A Scoping Review of Choice Architecture to Promote Healthy Nutrition in Health and Care Settings.

introductionPoor diets are a remediable risk factor for non-communicable diseases. Sickness absence rates for national health service (NHS) staff are substantially higher than the public sector average (5.6% vs. 3.6%). Hospital inpatients are often being treated for the downstream consequences of poor diets. Systematic reviews and meta-analyses support national health recommendations for plant-based diets that emphasise consumption of varied whole plant-source foods with minimal consumption of animal products. These diets are increasingly recognised as compatible with planetary health and are associated with lower greenhouse gas emissions. There is increasing interest in using choice architecture interventions (subtly changing the environment in which individuals make decisions) to encourage healthier plant-based food choices in health and care settings. This approach may prove cost effective, encouraging better choices for staff and inpatients with minimal upfront investment.

objectiveTo summarise evidence for choice architecture interventions aimed at changing dietary choices made by staff and inpatients in high-income health and care settings. This review aims to inform decision making on food service provision in health and care organisations.

methodsMedline, CINAHL PLUS, GreenFile, and Web of Science were searched for studies which examined choice architecture on dietary choices in high-income health and care settings. Studies referenced in systematic reviews were examined for inclusion from 4th to 10th June 2024. A typology used in a previous review conducted by Public Health England (categories: availability, positioning, pricing, functionality, presentation, information, sizing) was modified to include a category for using defaults (the action that occurs when no choice is made). Randomised experimental, quasi-experimental, interrupted time series and before and after studies reporting on nutritional measures or a measure of healthy food purchases were included. Studies from non-healthcare settings were excluded.

resultsNone of the studies explicitly encouraged plant-based diets or measured environmental impact although 12 studies measured change in plant-based choices using measures such as fruit and vegetable servings. A total of 51 studies were included focused on other healthy dietary interventions. A total of 31 of these studies implemented more than one type of choice architecture. Twenty studies were conducted in cafeterias, eight on hospital vending machines, six in hospital retail stores, three in residential care homes, and five in an inpatient setting. A further nine studies either implemented changes across multiple aspects of healthcare food provision, included non-healthcare workplaces, or examined hospital office-based interventions. Overall, 34 of the 51 studies reported a positive change in healthy food choices and only six studies reported no significant change or an adverse change. Availability, pricing and positioning of items are associated with a change in dietary choices. Evidence for informational changes was mixed and at worst, had a negative reaction, increasing unhealthy purchasing. Few studies used sizing or presentation elements and none of the studies evaluated functionality or default elements. None of the inpatient studies examined persistent change in dietary choices for long-term health.

conclusionsIn this review, the evidence indicates that choice architecture interventions can support healthier food choices in health and care settings. However, there is limited research and nutritional evaluation of choice architecture interventions that encourage plant-based diets. Further well-conducted studies are needed in health and care settings to determine optimal typologies, or combined approaches, for making healthier dietary choices. Given the established evidence of plant-based diets for long-term health, and the lower environmental impact of these diets, studies using choice architecture to encourage plant-based choices in health and care settings should be conducted and should evaluate nutritional, financial, and environmental outcomes. The effectiveness of choice architecture techniques in inpatient catering to encourage and role model healthier diets should be investigated to tackle dietary inequality and the burden of diet-related chronic disease.