Emoticons and Small Prizes to Improve Food Selection in an Elementary School Cafeteria: A 15 Month Experience

Background: Poor food selection in school cafeterias is a risk factor for childhood obesity. With this study, we describe improved food selection by students in an inner city elementary school cafeteria by the placement of emoticons and giving small prizes to encourage healthier choices over 15 months. Methods: Emoticons and small prizes were introduced sequentially over a three month period. The “Green Smiley Faced” Emoticons were posted near the 4 most healthful foods: fruits, vegetables, plain fat free milk (PFFM) and entree with whole grains. Three months later in addition to the emoticons, students were rewarded with a small prize if they selected a Power Plate (PP) which consisted of the four healthful foods. Purchase of the healthful foods was determined by cash register receipts. Results: Baseline purchase of PFFM was 7.3%, increased to 53% during the initial PP phase and leveled off at 26% over 15 months. This represents an increase of 256% in PFFM milk sales. Chocolate milk showed a parallel decline in sales starting with a baseline of 86% of students and decreased to 65%. Up to two fruits and vegetables were offered with lunch daily. Vegetables increased from 78 to 93% (a 19% increase in sales) over the 15 months. Fruit selection was 108% initially and increased to 121% during the program (a 12% increase). The increases were significant by Statistical Control Process Methods. Conclusion: A two-tiered approach of emoticons followed by small prizes as incentives for better food choice leads to significant and sustained improvement.