Creating healthy food environments in recreation and sport settings using choice architecture: a scoping review

Abstract Recreation and sport settings (RSS) are ideal for health promotion, however, they often promote unhealthy eating. Choice architecture, a strategy to nudge consumers towards healthier options, has not been comprehensively reviewed in RSS and indicators for setting-based multi-level, multi-component healthy eating interventions in RSS are lacking. This scoping review aimed to generate healthy food environment indicators for RSS by reviewing peer-reviewed and grey literature evidence mapped onto an adapted choice architecture framework. One hundred thirty-two documents were included in a systematic search after screening. Data were extracted and coded, first, according to Canada’s dietary guideline key messages, and were, second, mapped onto a choice architecture framework with eight nudging strategies (profile, portion, pricing, promotion, picks, priming, place and proximity) plus two multi-level factors (policy and people). We collated data to identify overarching guiding principles. We identified numerous indicators related to foods, water, sugary beverages, food marketing and sponsorship. There were four cross-cutting guiding principles: (i) healthy food and beverages are available, (ii) the pricing and placement of food and beverages favours healthy options, (iii) promotional messages related to food and beverages supports healthy eating and (iv) RSS are committed to supporting healthy eating and healthy food environments. The findings can be used to design nested, multipronged healthy food environment interventions. Future research is needed to test and systematically review the effectiveness of healthy eating interventions to identify the most promising indicators for setting-based health promotion in RSS.


INTRODUCTION
Setting-based interventions are accepted approaches to promote health in populations (World Health Organization (WHO), 2022; Poland et al., 2009).Setting-based approaches embed health promotion in physical, organizational and social contexts in which health occurs and use multi-level interventions to comprehensively support health (Poland et al., 2009).Settings range from microenvironments such as families and homes to large-scale settings such as workplaces, schools or cities (WHO, 2022).Recreation and sport settings (RSS), such as sports clubs and recreation facilities, are ideal settings for health promotion (Geidne et al., 2013(Geidne et al., , 2019;;Kokko et al., 2014;Van Hoye et al., 2021) due to their wide reach to children, educational focus, healthy living mandate and multi-level structure (Geidne et al., 2019;Van Hoye et al., 2021).
Setting-based interventions enable communities to move away from one-size-fits-all interventions to tailored, capacity-building interventions (Poland et al., 2009;Kokko et al., 2014).The success of implementing evidence-based interventions requires adapting to the context (Leeman et al., 2017) thus tailored interventions may be particularly important for RSS in Canada, where these settings tend to be highly diverse with varied ownership and funding models, sport types, geography, food services and users.Naylor et al. created a framework of operational areas to support healthy eating in RSS which has guided experimental tailored interventions (Naylor et al., 2010;Olstad et al., 2019).Some Canadian provinces developed voluntary provincial nutrition guidelines for RSS which had limited, but positive, impacts on healthy food availability in concessions and vending machines (Olstad et al., 2020).In provinces with voluntary nutrition guidelines, food environments in RSS were further improved after an intensive, tailored 18-month capacity-building intervention that facilitated guideline implementation (Olstad et al., 2019).Other research found, however, that this capacity-building intervention was unsuccessful at improving food marketing in the same facilities, presumably related to vague intervention goals (i.e.'market healthy choices') set by intervention facilities (Prowse et al., 2020).Applying principles of choice architecture to design environments to nudge consumers towards healthier options may improve the success of setting-based healthy eating interventions in RSS.Choice architecture has been studied in a variety of settings, including food retailers (Kraak et al., 2017;Houghtaling et al., 2019;Lindstrom et al., 2022), workplaces (Al-Khudairy et al., 2019;Rantala et al., 2021), schools (Skov et al., 2013;Nørnberg et al., 2016) and health care settings (Al-Khudairy et al., 2019), however, it has not been comprehensively reviewed in RSS.
Prowse et al. noted that the multiple levels that impact food environments in RSS, namely, individual factors (e.g.consumers), interpersonal factors (e.g.coaches and teams), institutional factors (e.g.food service providers, sports leagues,), community factors (e.g.sponsors, regional sport associations) and policy factors (provincial nutrition guidelines, municipal policies), were not collectively considered in the capacity-building intervention to improve food environments which may have curtailed the intervention's impact (Prowse et al., 2020).Given the diversity of RSS in Canada, it is important to consider the 'added value' of multi-level systems as a whole (Dooris, 2006).Multi-component and multi-level interventions in RSS are noted as promising interventions (Geidne et al., 2019), however, currently only broad theories and conceptual frameworks exist; indicators for setting-based multi-level/-component healthy eating interventions in RSS are lacking (Prowse et al., 2020).
Active living, as well as other health-related behaviours such as tobacco and alcohol use (Geidne et al., 2019;Van Hoye et al., 2021), and more recently healthy eating (Pluim et al., 2014;Wolfenden et al., 2015;Westberg et al., 2022), have been targets in health promotion interventions in RSS around the world.Setting-based approaches have been applied in RSS in Australia, Europe, Canada and the USA, however, few have focussed on nutrition (Geidne et al., 2019).Guidance for setting-based health promotion initiatives for RSS have been developed, but multi-level setting-based healthy eating interventions are not common in the literature (Geidne et al., 2019;Van Hoye et al., 2021).
Canada recently released new national dietary guidelines which encourage public institutions, such as RSS, to adopt its key recommendations and support healthy food environments (Health Canada, 2022).To support the implementation of such broad health promotion recommendations, more information is needed for communities, practitioners and policy-makers to design, implement and evaluate interventions in RSS.We sought to identify indicators of healthy food environments, defined as measures of success described by goals, outcomes, indicators or targets, from peerreviewed and grey literatures that can be used as a foundation to build tailored multi-level/-component interventions in RSS to promote healthy eating.

Objective
This scoping review aimed to generate indicators of healthy food environments in RSS by reviewing interventions and outcomes in peer-reviewed and grey literature evidence.We aimed to explore indicators of healthy food environments based on principles of choice architecture (Kraak et al., 2017) and multi-level setting-based health promotion approaches (Geidne et al., 2019).

Approach
We conducted a scoping review to systematically search and narratively describe existing evidence.Scoping reviews are valid approaches to literature reviews intending to provide an overview, clarify key concepts and identify key factors of a phenomenon (Munn et al., 2018).This scoping review is reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).In September-October 2021, we searched Google for grey literature in English and French, such as existing nutrition guidelines, policies, practices, toolkits and other resources to support healthy eating and food environments in RSS.Searches strings were run with and without regional (Canada, Australia, New Zealand, USA and UK) and file type ('pdf') restrictions.These regions were previously identified as developing and evaluating healthy eating interventions in RSS (Geidne et al., 2019).We conducted targeted hand searching of relevant government and organizational websites from Canada (n = 15), Australia (n = 12), the UK (n = 3) and the USA (n = 3) (Supplementary File 1).

Selection process
Titles and abstracts of peer-reviewed articles were screened by N.L. and R.P. The first five pages of Google search results were screened by N.L. and R.P. The page limit was chosen a priori considering the Google Search ranking of most relevant results in the first pages, and to keep the number of results to review manageable (Godin et al., 2015;Lefebvre et al., 2022).
Our selection strategy was informed by understanding indicators (i.e.measures of 'success') of healthy food interventions in RSS, where, • 'Healthy food interventions' included any implemented or recommended change to food provision, promotion or sale; • 'RSS' included all types of single sport and multi-sport centres as well as the events and programs that may take place in those centres (e.g.tournaments, camps and leagues); and • 'Success' represents primary and secondary outcomes, or recommended targets or goals related to food environments, food policy, food purchases and dietary intake to measure change as a result of 'healthy food interventions' Documents were included if they had detailed quantitative or qualitative methods or results related to food environment characteristics, actions and supports that were considered goals, targets, outcomes or indicators of healthy eating or healthy food environments in RSS.Only resources produced in Canada, USA, Australia, New Zealand, UK and the European Union were included; the RSS across these regions are likely to have more established health promotion initiatives and be reasonably comparable.See Supplementary File 2 for detailed inclusion/exclusion criteria.
Full text of relevant resources was obtained for review.Twenty per cent of full-text articles were double screened, with discrepancies resolved by the first author.The research team met after double screening to discuss differences in screening outcomes.Research assistants were provided with further training on inclusion/exclusion criteria based on consensus after discussing screening results to improve consistency; the remaining resources were screened by a single research assistant.

Data extraction and synthesis
Documents were classified as formal policies (i.e. official or endorsed practices), guidelines/recommendations (i.e.suggested, but not mandatory, implemented or evaluated policies or practices), toolkits (i.e.resources to help implement policies and practices) or real-life practices (i.e.pilots or experiments).Three steps were completed to extract and synthesize data, moving from individual pieces of data from single studies and documents towards general themes.First, data were extracted and coded by Canada's national dietary guideline key messages.Data extracted included document type, country, as well as outcomes, indicators and targets (i.e.measures of success).It is common for policy guidance from higher jurisdictions (e.g.national) to be used to inform local action (e.g.provincial, municipal, institutional).Canada's Food Guide is recommended to be implemented in public institutions, such as RSS, therefore, we used Canada's Food Guide to guide data extraction to increase the policy relevance of the data and demonstrate how national policies can be operationalized at a local level.Each of the measures of success was coded according to key message topics of Canada's Food Guide (Health Canada, 2022): 1. Make water your drink of choice.2. Make it a habit to eat a variety of healthy foods each day.3. Have plenty of vegetables and fruits.4. Choose whole grains.5. Eat protein foods.6. Choose protein foods that come from plants more often.7. Limit highly processed foods and beverages.8. Be aware that food marketing can influence your choices.9. Be mindful of your eating habits.10.Cook more often.11.Enjoy your food.12. Eat meals with others.
Third, through a series of consensus-building meetings with research staff, we mapped extracted data in each set onto eight nudging strategies adapted from a multi-component evidence-based framework for generating healthy food environments by Kraak et al. (Kraak et al., 2017) (Table 1).The mix of nudging strategies to create a healthy food environment is often referred to as 'choice architecture' where settings are designed to nudge consumers towards a healthy option (Hollands et al., 2013).Choice architecture has emerged in the evidence as a strategy to support healthy eating (Hollands et al., 2013), and enhance the adoption of nutrition guidelines in populations (Enstaff, 2021).We added two new categories, Policy and People, to capture multi-level influences on healthy settings in recreation and sport (Kokko et al., 2014).The adapted framework is henceforth referred to as the Healthy Eating Environments in Recreation and Sport Settings (HEERSS) Framework (Table 1).The data synthesized in the HEERSS Framework represent indicators for achieving healthy food environments in RSS which can be embedded into programs, practices or policies to promote healthy eating through multi-level/-component interventions.Finally, we categorized indicators that were collated within and between Canada's Food Guide data sets and the HEERSS framework to develop general principles for action.

Document characteristics
The systematic search resulted in 762 peer-reviewed articles, of which 128 were reviewed in full text; 165

Profile
The nutritional content, or healthfulness of foods and beverages provided, offered or sold in food outlets, through catering and in sports

Portion
The portion size of foods and beverages provided, offer or sold in food outlets, through catering and in sports

Pricing
The relative prices of foods and beverages sold in vending and concession.The provision of free foods or beverages at recreation and sport events, and around sport training and competition.Pricing strategies used to increase the value of foods and beverages.

Promotion
Commercial marketing practices to increase awareness, preference and choice of promoted foods and beverages in food outlets

Picks
Environmental changes to food outlets that normalize healthy default choices (e.g.salad as side) Priming Social marketing and healthy eating promotion undertaken by the facility, sport clubs, sports teams (coaches, players), staff and/or parents Place Changes to the facilities' amenities to increase awareness of healthy food options (e.g.install water fountains or bottle filling stations) Proximity Placement of food and beverage options to increase the visibility of healthy options and decrease the visibility of less healthy options (e.g.placement of vending machines and water fountains, eye level of products).

Policy
Formalized written commitments to supporting healthy eating and food environments in recreation and sport facilities People Agents of change in recreation and sport facilities Food outlets = vending and concession.
In sports = at recreation and sport events, and around sport training and competition.
We identified numerous indicators for healthy food and beverage environments which are summarized in Tables 2 and 3, respectively, organized by HEERSS component (see Supplementary File 2 for marketing data).We excluded the social environment from further analysis due to gaps in data using the HEERSS framework (see Supplementary File 2 for social environment data).From the indicators, we identified eight main indicator types, which fall into four guiding principles (Table 4).We review the data informing indicators for each guiding principle below.

Indicators for water
Indicators for sugar-sweetened beverages (SSBs)

Indicators for water
Indicators for sugar-sweetened beverages (SSBs)
• Provide free water • Improve relative affordability of healthy vs unhealthy items • Change price promotions (e.g.combo deals, sales and loyalty discounts) • Improve relative visibility of healthy vs unhealthy (e.g.eye level vs 'out of sight') • Change proximity of healthy food access (e.g.vending) and options (e.g.point-of-purchase) to consumers 3. Promotional messages related to food and beverages supports healthy eating v. Messages related to foods and beverages encourage healthy food and beverage practices.vi.Partnerships with businesses supports health rather than commercial motives.
• Use social marketing to promote healthy foods (e.g.traffic light labelling) • Restrict commercial unhealthy food marketing (e.g.sponsorship) 4. Facilities are committed to supporting healthy eating and healthy food environments.
vii.Healthy food availability and promotion are institutionalized through policies, contracts or other written documents.viii.The physical environment of facilities supports healthy food availability.

Guiding Principle 2: The pricing and placement of food and beverages favours healthy options
Water was recommended to be priced lower than sugar-sweetened beverages (23,60,89), and water was encouraged to be used in combo deals rather than sugar-sweetened beverages (5,60).Water was to be more visible than other beverages by placing it at eye level (60), offering it at food outlets (22,79) and by moving less healthy beverages out of sight (11,17,46,60,64,92).
Social marketing activities were recommended to encourage water consumption including encouraging use of reusable water bottles (18,92,115,117) and promoting water consumption in children participating in sports and activities at the facility (2,12,77,92,97,116).Social marketing of healthy snacks, such as fruits and vegetables, by sports leagues, clubs and coaches were mentioned including the provision of free healthy snacks to youth players (73,82,95) and encouraging parents and coaches to bring healthy snacks to sporting events (2,22,64,116,121).

DISCUSSION
This review aimed to generate indicators of healthy food environments in RSS by summarizing peerreviewed and grey literature on indicators of healthy eating and food environments in RSS.Numerous indicators related to foods, water and sugary beverages, as well as food marketing and sponsorship, were identified from the literature with a considerable amount from grey literature.We identified four principles for multi-level/-component healthy food environment interventions in RSS: 1. Healthy food and beverages are available.2. The pricing and placement of food and beverages favours healthy options.3. Promotional messages related to food and beverages supports healthy eating.4. Facilities are committed to supporting healthy eating and healthy food environments.
Over the past decade, interventions to support healthy eating in RSS have focussed on three areas: guidelines/policy, organizational capacity-building and availability of healthy food and beverages (Westberg et al., 2022).Guidelines/policy interventions have had limited impact without additional supports, such as capacity-building and tailored intervention planning (Westberg et al., 2022).For example, recreation facilities in provinces with voluntary nutrition guidelines had significantly lower proportions of least healthy snacks and beverages compared to RSS in provinces without guidelines (76.5% vs 91.1% and 64.5% vs 80.8%, respectively).However, the majority of snacks and beverages were still considered unhealthy in both groups (Olstad et al., 2020).Facilities that received a capacity-building intervention with tailored food environment changes further reduced the proportion of least healthy vending machine snacks by almost 30 percentage points, significantly greater than in the facilities that had nutrition guidelines but did not receive capacity-building support (Olstad et al., 2019).
Implementing a variety of activities in RSS may mutually reinforce healthy eating practices.Nested, multipronged tailored interventions, supported by capacity-building are recommended as promising approaches to healthy food environments in RSS, which can be operationalized through a setting-based approach to health promotion (Von Hoye et al., 2021).By collating together documents that relate to health promotion in RSS to identify indicators of healthy food environments that can be used to inform intervention design and evaluation, this review reinforces the promise of multi-level/-component interventions.By combining principles of choice architecture with settings approaches, it is possible that recreation and sport facilities and clubs may be able to more comprehensively promote health in their setting.Both choice architecture and setting-based approaches are known health promotion strategies (Hollands et al., 2013;Geidne et al., 2019); this is the first review to explicitly combine the two strategies in order to explore how food environments in RSS could be designed to support health.
Multi-level/-component setting-based approaches to healthy food environments may be more productive in creating and sustaining healthy food environments than singular interventions, regardless of if they are top-down or bottom-up.A limitation of provincial nutrition guidelines for RSS, and their use in capacity-building interventions, was that the guidelines were focussed on food and beverage availability and did not include many recommendations related to marketing (pricing, placement and promotion), or sponsorship (Prowse et al., 2020), which could reinforce or oppose healthy food availability interventions.
Although this review does not identify the preferred mix of intervention indicators, our findings represent a menu of options from which a multi-level/-component intervention can be designed.Multi-level/-component interventions may help address real or perceived factors that influence healthy eating environments in RSS, including potential revenue loss of removing unhealthy food sponsors, lack of organizational capabilities and resources, and consumer preferences (Kirk et al., 2021;Westberg et al., 2022).Kirk et al. explain that barriers and facilitators of change to food environments in RSS are contextual and multi-level such as lack of champion for healthy eating environments (individual), staff support for initiative (interpersonal), capacity (organizational), demand for healthy options (community) and top-down mandatory guidelines (policy) (Kirk et al., 2021).Progress towards healthy food environments in RSS is slowed due to the complexity of policy implementation, inadequate organizational support, social acceptability of unhealthy food in RSS, existing contracts with food service providers and sponsors and perceived financial challenges (Olstad et al., 2011(Olstad et al., , 2012;;Kirk et al., 2021).Our findings, grounded in choice architecture and setting-based approaches to health promotion, can help change agents in RSS create tailored interventions to best suit their context, capitalize on opportunities and manage barriers.
Future research is needed to test and systematically review the effectiveness of healthy eating interventions in RSS to identify the most promising indicators, and strategies to achieve those indicators.Randomized controlled trials and natural experiments of food environment interventions for RSS are required to reduce the uncertainty of which types of interventions work best under which circumstances.Systematic reviews are required of indicators identified here (individually and in combination), such as the proportionate availability of healthy/unhealthy foods and beverages, traffic light labelling and restricting unhealthy food and beverage marketing, to identify best practices.Most of the evidence reviewed here was from grey literature, however, so it may be necessary to complete more primary research with common interventions and evaluation methods to facilitate a robust systematic review or meta-analysis.When underpinned by implementation science, experiments and evaluations of setting-based healthy food environment initiatives in RSS can provide valuable practice-and policy-relevant knowledge to adapt indicators to their context and create supportive physical, social, economic and political environments for healthy eating.Future research should explore how the social environment can support healthy eating in RSS-a gap identified here.

Strengths and limitations
This scoping review included data from 132 peerreviewed and grey literature resources.Since the literature search was limited to countries and years deemed most appropriate, there may be other relevant international or older research that was excluded.We searched the first five pages of Google search results; there may have been additional resources in later pages that would have been relevant.However, we found that resources were duplicated in later pages and between searches which suggests the grey search was comprehensive.
The review was informed by the components of the Canadian national guidelines, as well as literature on healthy food environments (Kraak et al., 2017) and healthy settings in RSS (Kokko et al., 2014;Geidne et al., 2019).Using the choice architecture and multi-level influence frameworks to guide data extraction and interpretation increased the comprehensiveness and relevance of findings.Aligning data extraction with national dietary guidelines helped generate relevant indicators, enhances consistency in understanding and application of the guidelines and supports uptake of the guidelines by settings that influence diets at a population level.
Due to the volume and length of documents, data were extracted by a single research assistant which may have caused some errors or exclusion of relevant data.The peer-reviewed literature was screened and extracted by a single researcher.We were able to create a comprehensive list of indicators of healthy food environments in recreation and sport but did not assess the quality of the literature nor the effectiveness of individual indicators or mixes of indicators.Nonetheless, many documents included policies or practices that were recommended, trialled or implemented in reallife settings which enhances the applicability of the findings.

CONCLUSIONS
This scoping review identified indicators of healthy food environments for RSS related to food and beverage availability and marketing from peer-reviewed and grey literature.The proposed indicators can be used as goals for RSS to design healthy eating interventions; they represent a collection of interventions that could be mixed and adapted to different contexts.Since improving food environments in RSS can be complex, challenging and slow, it may be important to allow flexibility in designing interventions to support healthy eating.
Local context impacts the effectiveness of public health interventions, thus the mix of interventions within a setting may be more important than the effectiveness of singular interventions.By exploring the 'added value of the whole system approach' (Dooris, 2006) in setting-based health promotion in RSS in future research, RSS may improve its contribution to health through healthy eating.

Table 1 :
Healthy eating environments in recreation and sport settings (HEERSS) framework

Table 2 :
Indicators for Healthy Beverage Environments in Recreation and Sport Settings according to the HEERSS framework

Table 2 .
References are document identification numbers (ID) as per Table1in Supplementary File 2. Continued

Table 3 :
Indicators for Healthy Food Environments in Recreation and Sport Settings according to the HEERSS framework

Table 3 .
References are document identification numbers (ID) as per Table1in Supplementary File 2. Continued

Table 4 :
Guiding principles, indicators and potential actions to promote healthy eating and food environments in RSS