Green for Go: How to steer HCWs to healthy food

Cafeteria changes boost healthy choices

If you want employees to make healthier food choices in your cafeteria, keep it simple.

That is the strong message from the successful Choose Well, Eat Well program at Massachusetts General Hospital in Boston. The program uses red, yellow and green stickers to convey which foods are the healthiest. Placing healthier foods at eye level or in convenient locations also significantly improved the choices, according to a study of the program.1

“Our employees are very busy. When they go to the cafeteria they don’t want to spend a lot of time looking at labels,” says Anne Thorndike, MD, MPH, assistant professor of medicine at Harvard Medical School, who studied the program. “There are also impulsive purchases. We wanted to create a system that would be quickly understood and that didn’t require people to do a lot of thinking.”

The healthy food program began as a part of the hospital’s Be Fit wellness program, which includes nutritional counseling. “You want your employees have every opportunity to be healthy while at work,” says Andrew Gottlieb, NP, FNP-BC, director of Occupational Health Services at Mass General. “We want to take every opportunity we can to help people make the right choice.”

Restaurants have used various methods to steer people toward the healthier menu options, from heart symbols for “heart-healthy” to calorie counts. Those are not always effective, says Thorndike. “We looked at what hadn’t worked [in other studies] and needed to try something new,” says Gottlieb.

People need an easy way to make the right choice, says Thorndike. “Sometimes people are either not knowledgeable about what the calories mean or they don’t know how to put that into context,” she says. “Sometimes people just don’t notice it. It’s just another number up there. That’s why I like the colors. It’s a very gut reaction you have toward seeing it.”

First, nutritionists designed a food labeling system:

Green items (“choose often”) contain fruits, vegetables, whole grains and/or lean proteins. Green foods contain a limited amount of calories and unhealthy fats. Green entrées have less than 500 calories and less than 5 grams of saturated fat. Green side items have less than 200 calories and less than 2 grams of saturated fat. Green beverages have less than 100 calories and less than 2 grams of saturated fat. (Bottled water, low-fat milk and diet drinks were marked green.)

Yellow items (“choose less often”) may contain fruit, vegetables, whole grains and/or lean proteins. They may also contain additional calories or additional sources of unhealthy fat. Entrees may contain more than 500 calories or more than 5 grams of saturated fat, but usually not both. Side items may contain more than 200 calories or more than 2 grams of saturated fat, but usually not both. Beverages may contain more than 100 calories or more than 2 grams of saturated fat but usually not both. (Juices and sugar-sweetened drinks of less than 200 calories were labeled yellow.)

Red items (“There’s a better choice”) contain little or no fruits or vegetables, whole grains and/or lean proteins and contain additional calories and additional sources of unhealthy fats. Entrees contain more than 500 calories and more than 5 grams of saturated fat. Side items contain more than 200 calories and more than 2 grams of saturated fat. Beverages contain more than 200 calories and/or more than 2 grams of saturated fat. (Sugary drinks and sodas with more than 200 calories were red, as were whole milk dairy drinks of more than 100 calories and 5 grams of saturated fat.)

Thorndike and colleagues collected three months of baseline data, then made the change. Signs in the cafeteria explained the color coding, but the red-yellow-green was easily identifiable as similar to the traffic signals. “A lot of times people just don’t know what they’re getting and would make a different choice if they knew,” she says.

The codes made an immediate difference. Consumption of red items declined by 9.4% and purchase of sodas declined by 23%.

“My first goal in this project, from a research perspective, was to demonstrate that these labels do make a difference. People are paying attention to them,” says Thorndike. “It is impacting the way people are choosing.”

Then the hospital added another intervention. Thorndike and her colleagues rearranged items. Healthier pre-made sandwiches were placed at eye level, and yellow and red versions were below or above eye level. Chips were moved lower. “They didn’t have to do a lot of looking for what were healthier options,” she says.

In the first intervention, bottle water sales actually declined slightly. The bottled water was in a refrigerated display off to the side. This time, “we put the water in every beverage refrigerator and we put baskets of water at each food station,” says Thorndike. “It would be the first choice for someone to just grab a bottle of water.”

The reorganization worked. Bottled water sales jumped by about 26%. Red items declined even further. With both interventions, all types of employees improved their healthy choices — regardless of education or ethnic background.

Labeling is just one way to encourage healthy habits, says Thorndike. But it is an important part of creating a healthy environment, she says.


1. Thorndike AN, Sonnenberg L, Riis J et al. A 2-phase labeling and choice architecture intervention to improve healthy food and beverage choices. Am J Public Health 2012; 102:527-533.