Cost-free and sustainable incentive increases healthy eating decisions during elementary school lunch.

We aimed to develop a cost-free and sustainable program to influence healthier eating decisions during elementary school lunch. Baseline food and beverage choices were assessed for 9 days during lunch service at two racially and economically diverse elementary schools in Spartanburg County, SC, USA. After being informed that the labeled items on the daily lunch menu represented the healthiest choice, students were allowed to ring a call bell in the cafeteria for public recognition when they chose all of the identified healthiest food and beverage items during lunch service. Using menus matched to the baseline phase, food and beverage choices were measured during a 9-day intervention phase. After 30 days, food and beverage choices were reassessed during a 3-day follow-up phase. Healthiest food & beverage choices increased 49% with >60% of students choosing non-flavored milk over flavored milk during the intervention phase. There was no difference in the success of the program between the two schools. The program continued and healthy eating decisions were significantly sustained at a 30-day follow-up assessment. Public recognition through bell ringing appears to be an effective practice to sustain increases in healthy eating decisions during elementary school lunch and warrants expansion to larger scale, longitudinal trials.