Behavioral economics to implement a traffic light nutrition ranking system in a network of food pantries

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Approximately one in 10 US households experience food insecurity, which is associated with cardiometabolic disease risk. Federal food assistance programs are often insufficient, and therefore the charitable food system, largely comprised of food banks that distribute food to partner agencies (e.g., pantries), is a regular food source for 53 million people a year. The quality of food offered in pantries and consumed by clients often does not align with US dietary guidelines. Pantry interventions to promote healthier food choices can improve clients’ health but have not been widely adopted due to implementation barriers. The project’s overall objective is to use multi-level behavioral economics (BE) interventions to implement evidence-based strategies to improve the dietary quality of food offered by pantries and selected and consumed by clients. Traffic light nutrition ranking is an evidence-based BE strategy for increasing healthy food choices in multiple settings. Feeding America, the largest U.S. private hunger relief organization, released recommendations in 2021 for food banks to implement traffic light nutrition ranking on their ordering platforms. Supporting Wellness at Pantries (SWAP) is a program to guide both traffic light labeling for use on ordering platforms and pantry shelves, as well as food pantry layout to inform clients and encourage healthy food choice. Nevertheless, widespread implementation of SWAP is challenging due to barriers such as time constraints and competing priorities. The proposed project is a collaboration with the Greater Boston Food Bank (GBFB) to test BE strategies (choice architecture, framing, social norms, and incentives) for implementation of an evidence-based intervention (traffic light nutrition ranking, SWAP) at two levels of the charitable food system: a food bank and food pantries. We will conduct a Hybrid Type II effectiveness-implementation study, guided by the Practical, Robust, Implementation, and Sustainability Model (PRISM) to examine Reach Effectiveness Adoption Implementation Maintenance (RE- AIM) domains. Aim 1 is a randomized controlled trial of 600 GBFB partner agencies to determine if using BE strategies on the GBFB ordering platform will increase agencies’ utilization of the platform’s traffic light nutrition labels (Reach) and their orders of healthy food over 12 months (Effectiveness and Maintenance). Aim 2 is a waitlist-control randomized trial of 30 GBFB pantries to determine if BE interventions will increase pantries’ implementation of SWAP (Implementation, Adoption) and improve clients’ food selection and dietary intake, assessed with the PRIME diet screener and Veggie Meter skin carotenoid measure over 24 months (Effectiveness, Maintenance). Aim 3 will evaluate the budget impact and cost-effectiveness of BE strategies (Implementation, Effectiveness) from the food bank’s and pantries’ perspectives. Results of this research will inform Feeding America and other national and local hunger relief organizations about the implementation and dissemination of evidence-based nutrition recommendations that can improve the diet and health of marginalized families at highest risk for cardiometabolic diseases.