Using FoodFlip© to Improve Food Choices Among Post-secondary Students

A Randomized Controlled Trial Using FoodFlip©, a Mobile Phone App, to Promote Healthier Diets and Food Choices Among Post-Secondary Students

Canada passed mandatory front-of-package labelling (FOPL) regulations where pre-packaged food and beverage products that are high in sugar, saturated fat, and/or sodium are required to display a 'high-in' front-of-pack nutrition symbol (NS). FOPL is an effective tool to inform consumers about products that can harm health and help guide their purchasing decisions. However, as the regulations are limited to the pre-packaged food supply and do not apply to restaurants and other food services, little is known about the potential impact of the NS in such settings. Therefore, the objective of the present study is to investigate the impact of the Canadian FOPL (i.e. the 'high-in' NS) as delivered through a mobile health (mHealth) app in a setting currently not subject to regulations. The study will take place on a post-secondary campus (University of Toronto) hosting students, a population vulnerable to poor dietary choices, nutritional knowledge, and associated weight gain. A 2-week long, randomized controlled trial with a 3-parallel arm study design will be conducted to explore the effect of the 'high-in' NS on students' purchasing behaviours and nutritional knowledge. Eligible participants will be randomly allocated into one of 3 intervention groups: no App control; App control with no NS; App with NS. Questionnaires will be used to assess nutritional knowledge, and receipts will be used to analyze purchasing behaviour.

Poor diets increase the risk of non-communicable diseases (NCDs), one of the major causes of disability and premature mortality in Canada. To help improve the diets of Canadians, Health Canada recently promulgated front-of-pack labelling (FOPL) regulations, which mandate pre-packaged foods and beverages meeting and/or exceeding the thresholds for nutrients of public health concern (i.e., sugars, saturated fat, and/or sodium) to display a 'high-in' front-of-pack nutrition symbol (NS). Moreover, previous studies have shown that FOPL can improve purchasing behaviours of consumers by decreasing purchases of nutrients of public health concern and/or foods carrying 'less healthy' FOPL and increase the nutritional knowledge of consumers. However, the FOPL regulations do not address restaurant foods, which are significant caloric contributors to the Canadian diet and are often high in nutrients of public health concern. Further, FOPL regulations do not address foods sold in other institutional settings, including schools, long-term care homes, and daycares. This policy gap may adversely affect the young adult population - a group notably vulnerable to poor diets and associated weight gain and poor nutritional knowledge. Emerging evidence suggests that FOPL can be an effective tool to communicate nutrition information to promote healthier food choices in food service settings; however, limited data exist on the effectiveness of FOPL on menu items available on post-secondary campuses to influence students' food purchasing behaviours on campus and to improve their nutritional knowledge. Furthermore, nutrition mobile health (mHealth) apps have been shown to have the potential to support behavioural change, improve nutrition knowledge, and develop skills to promote healthy eating behaviours through quick information-sharing capacity, customizable tracking abilities, and interactive components. The L'Abbe Lab has developed a mobile application, FoodFlip©, that provides nutrition information at the point of purchase to influence the decision-making process with high usability and functionality in grocery shopping settings. However, the application of FoodFlip© on purchasing behaviours in post-secondary campus settings is unknown. Therefore, the primary objective of the study is to investigate the effect of the Canadian FOPL (i.e., the 'high-in' nutrition symbol) on purchasing behaviours and nutritional knowledge of post-secondary students on campus, using the FoodFlip© App.

front-of-package labeling, post-secondary foods, university foods, universities, mobile applications, mobile health, smartphone

Participants will be allocated into one of 3 groups: (i) no App control; (ii) App without 'high-in' nutrition symbol; (iii) App with Canada's 'high-in' nutrition symbol

Intervention control: participants will have access to food information in the shape of a Nutrition Facts table through FoodFlip©. Participants will have access to a submission portal linked to their study ID through the app.

Intervention: Participants will have access to food information through FoodFlip© with Health Canada's 'high-in' nutrition symbol. ©. Participants will have access to a submission portal linked to their study ID through the app.

Intervention control: participants will have access to food information such as calories or the Nutrition Facts table through FoodFlip©

Intervention: Participants will have access to food information through FoodFlip© with Canada's 'high-in' NS

Purchasing behaviours will be assessed using receipts and/or records provided by participants over the 2-week study period. Nutritional quality of purchased menu items will be determined using a nutrient profiling model based on the thresholds for Canada's FOPL regulations. Menu items will be assigned a "Menu item score" on a scale of 0 (minimum) to 3 (maximum), with 0 indicating no 'high-in' nutrients and 3 being 'high-in' all 3 nutrients-of-concern. Scores of each menu item purchased will be summed and divided by the total number of purchases to derive the final score for each participant; higher scores mean lower nutritional quality (i.e. worse outcome) and lower scores mean higher nutritional quality (i.e. better outcome). The final scores will then be compared between intervention groups, and change in nutritional quality will be compared within intervention groups at 2 time points: early intervention (end of Week 1) and late intervention (end of study period).

Nutritional knowledge will be assessed using an online questionnaire developed and validated by the L'Abbe Lab. Questionnaire will be completed by participants at 1) baseline and 2) end-of-study. This short (10-15 min) survey of 30 short questions will include questions assessing health literacy and nutritional knowledge that have been adapted from validated questionnaires. Correct answers will be coded as "1" while incorrect answers will be coded as "0", with a maximum of 30 points. Higher scores indicate higher nutritional knowledge (i.e. better outcome), and lower scores indicate lower nutritional knowledge (i.e. worse outcome). Between intervention groups differences in nutritional knowledge will be assessed using ANOVA, while changes in nutritional knowledge from baseline to end-of-study will be compared within intervention groups using Mann-Whitney U-tests.

Inclusion Criteria: ≥18 years of age enrolled at UofT have regular access to either iPhone or Android purchases at least one meal a day on campus able to speak and read English not currently pregnant or in lactation Exclusion Criteria: <18 years of age not enrolled at UofT does not have access to a smartphone does not purchase at least one meal a day on campus unable to speak and read English currently pregnant or in lactation

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