Background
Objectives
Methods
Search strategy
Exclusion criteria
Data collection and assessment of quality of studies
Data analysis/synthesis
Results
Description of studies
Characteristic | Study 1 | Study 2 | Study 3 |
---|---|---|---|
Reference no. | 33 | 34 | 35 |
Author | Vermeer et al. | Lowe et al. | Thorndike et al. |
Year | 2011 | 2010 | 2016 |
Country | Netherlands | USA (Philadelphia) | USA (Massachusetts) |
Type of study | Cluster RCT | RCT | RCT |
Participants | Hospital: N = 15, company: N = 5, university: N = 3, police department: N = 2 | Hospital: N = 2 cafeterias in hospital or university employees | Hospital: N = 2 cafeterias in hospital where employees were working |
Total study population (I/C) | Pre: 499 (184, 135/180) Post: 308 (129, 75/104) | 96 (47/49) | |
Sex | Males and females; male 50% | Males and females (18, 78), EC (11, 38), ECPls (7, 40) | Male and females; feedback incentive (72, 28), feedback only (73,27), control (72, 28) |
Age | 18–79 years; mean (SD) = 39.18 (11.26) | 21–65 years | 18–50 and over |
Intervention duration | 3 months | 3 months | 3 months |
Follow-up | – | 6 months, 12 months | 1 month, 2 months, 3 months |
Intervention program | 1. Intervention group 1 (N = 9): price was 65% of the standard price. About 2/3 of the size of the standard portion was offered. 2. Intervention group 2 (N = 8); price was 80% of the standard price. A smaller portion size was added to the assortment and value-size pricing (a lower price per unit for large portions than for small portions). | 1. Intervention group (density education and incentive): environmental change (EC)-plus ・Financial discounts: 15% discount (low-energy density) or 25% discount (very low-energy density) for cafeteria food items which were lower in energy density (e.g., soups, salads, diet soda, any entrees or side dishes etc., labeled as low or very low in energy density) *Green: very low in energy density (< 0.6 kcal/g) *Yellow: low in energy density (< 0.6–1.5 kcal/g) *Orange: medium in energy density: (< 1.6–3.9 kcal/g) *Red: high in energy density: (< 4.9–9.0 kcal/g) ・Group sessions (four time × 60 min) during which subjects were informed about the energy density of different food items. | 1. Intervention group 1 (feedback incentive): ・Rewards for achieving “green goal” (40%, 60%, 80%) of all cafeteria purchases. Each time the goal was achieved in a month, $10 was earned as a reward. ・Same as feedback-only group |
Control program | 1. The control group (N = 8): the standard size of hot meal was offered. | 1. Control group (only environmental changes): EC・(same as EC-plus)・No financial discounts No group session | 1. Control group (no contact) 2. Feedback only (four letters sent over a period of 3 months; explanation of traffic light system or the proportion of employee’s traffic light group purchases) |
ITT* | No; pre-post | Yes | No; pre-post |
Outcome | Primary outcome: BMI Secondary outcome: Fried snacks | Primary outcome: weight change Secondary outcomes: Cholesterol (TC, HDL, LDL), blood pressure (no outcome data), food intake (fruits, meats, dairy, breads, dairy products, fat and sweets), nutritional intake (total energy kcal), sales data (purchased energy [kcal] and purchased proportion of calories from fat, protein, and carbohydrate) | Primary outcome: none Secondary outcomes: inappropriate |
Characteristic | Study 1 | Study 2 | Study 3 |
---|---|---|---|
Reference no. | 36 | 37 | 38, 39 |
Author | Lachat et al. | French et al. | French et al., French et al. |
Year | 2009 | 2001 | 2010, 2010 |
Reason for exclusion | Participants were not only employees but also university students | Participants were not only worksite employees but also secondary school students | Interventions included fitness facility environmental interventions or physical activity enhancement like yoga or walking class interventions. |
Country | Belgium | USA: Minneapolis-St. Paul, Minneapolis | USA: Metropolitan Minneapolis-St Paul area |
Type of study | RCT | RCT | Cluster RCT |
Participants | Regular (i.e., at least 3 meals/week) customers of a university cafeteria, essentially students and university staff | Secondary schools (adolescents) and worksites (adults) | Transportation workers (n = 190,488) |
Total study population (I/C) | 209 (104/105), 156 (84/72) | Secondary school: N = 12, Worksite: N = 12 | |
Sex | 36% male | ? | 79% male |
Age | Mean (SD): 22.8 (3.5) years | ? | 19–79 years |
Intervention duration | 3 weeks | 12 months | 18 months |
Follow-up | 2 years | ||
Intervention program | One portion of vegetables and two portions of fruit for free at lunchtime. | The overall design: Two kinds of setting: worksite and school Three levels of pricing: discounts of 10%, 25%, and 50% for low-fat snacksTwo levels of promotion: only label, label with sign | ・Lower prices for healthy vending machine choices with 10% discount ・Low-priced fruit available from farmers’ markets held 1 day/month ・Availability (50% healthy foods; the goal of the vending machine intervention was to ensure 50% of the available vending machine offerings met healthy food criteria) ・Physical activity enhancement and fitness facilities, yoga ・Group behavioral programs (calculating calories) ・Advisory groups based at the workplace ・Self-weighing team competition |
Control program | No intervention | Pricing: equal pricePromotion: no labels and no signs | Control group |
ITT* | ITT analysis: 209 ⇒ 156 | ? | Pre-post: 78%⇔74% |
Outcome | Secondary outcomes: ・Fruit (g) ・Vegetables (g) ・Energy intake (kJ) ・Energy density (kJ/100 g) ・Energy from fat (%) ・Na (mg) | Secondary outcome: Low-fat snack sale data (%) | Primary outcome: ・BMI, weight change Secondary outcomes: ・Sugar-sweetened beverages ・Fruit and vegetables (SV/day) ・Snacks, sweets (SV/day) ・Energy (kcal/day) ・Vending machine use |
Results of the search
Participants
Interventions
Excluded studies
Risk of bias in included studies
Allocation (selection bias)
Sequence generation
Allocation concealment
Blinding (performance bias and detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other potential sources of bias
Effects of interventions
Outcome | Mean difference IV, Fixed, (95% CI) | p value | Effect size (η2p) | p value | Intervention Mean (SD) | No intervention Mean (SD) | No. participants (studies) | Authors | Others | Quality of evidence (GRADE) | ||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Pre | Post | Pre | Post | |||||||||
Weight changes (kg) | 0.0 (−11.69, 11.69) | 1.00*1 | 0.04*2 | 0.11*2 | 85.5 (16.2) | 85.9 (16.8) | 78.7 (21.0) | 79.1 (20.5) | 96 (1) | Lowe et al. | ⊕very low 1,2,3,5 | |
Body mass index (kg/m2) | – | – | – | – | – | – | – | 308 (1) | Vermeer et al. | Self-assessment | ⊕ ⊕ low 1,2,3 | |
HbA1c (%) | – | – | – | – | – | – | – | – | – | ⊕very low 1,2,3,5 | ||
Blood pressure (mmHg) | – | – | – | – | – | – | – | – | Lowe et al. | ⊕very low 1,2,3,5 | ||
Cholesterol | ||||||||||||
Total cholesterol (mg) | 16.1 (−4.67, 36.87) | 0.13*1 | 0.07*2 | < 0.05*2 | 192.4 (32.4) | 201.8 (28.9) | 204.1 (41.8) | 197.4 (42.3) | 96 (1) | Lowe et al. | ⊕very low 1,2,3,5 | |
High-density lipoprotein (mg) | 4.2 (−5.66, 14.06) | 0.40*1 | 0.06*2 | < 0.05*2 | 58.4 (16.6) | 60.9 (16.6) | 58.7 (19.5) | 57.0 (16.9) | 96 (1) | Lowe et al. | ⊕very low 1,2,3,5 | |
Low-density lipoprotein (mg) | 10.1 (−9.00, 29.20) | 0.30*1 | 0.05*2 | 0.08*2 | 115.4 (31.6) | 121.5 (31.3) | 124.1 (34.4) | 120.1 (37.5) | 96 (1) | Lowe et al. | ⊕very low 1,2,3,5 | |
Fruit | – | 0.07*2 | < 0.05*2 | 0.77SV | 0.98SV | 1.41SV | 0.96SV | 96 (1) | Lowe et al. | 24-h dietary recall | ⊕ ⊕ low 1,3,4 |
Financial incentive interventions using discounting strategies and a reward system
Discussion
Summary of main results
Overall completeness and applicability of evidence
Quality of the evidence
Potential biases in the review process
Agreements and disagreements with other studies or reviews
Authors’ conclusions
Implications for practice
Implications for research
Participants | Employees at any worksite, including both men and women |
Intervention | Organizational-based, food-based incentive-pricing strategies or social marketing in workplace cafeterias, vending machines, and kiosks |
Comparison | Any other treatment, other interventions, or placebo |
Outcome | Primary outcomes (continuous variables): |
1. Changes in weight (kg) | |
2. Body mass index (BMI) (kg/m2) | |
3. Changes in HbA1c (%) | |
Secondary outcomes: | |
1. Blood pressure (mmHg) | |
2. Changes in cholesterol levels (mg) | |
3. Food consumption (changes in consumption of vegetables [g or serving (SV)], fruit [g or SV], fruit and vegetables [g or SV], sugary beverages [g], sweets [g], and other foods) | |
4. Nutritional intake (changes in fat and oil intake [g]) | |
5. Changes in fiber intake (g) | |
6. Changes in energy intake (kcal) | |
Setting | Worksite |