1

Health in the Workplace - The role of theDietitian in Europe

Edited by Kerry Yuill and Anne de Looy

September 2012

2

EFADHealth in the Workplace the role of the Dietitian in Europe © 2012, EFAD secretariat@efad.org

This report is produced by the European Federation of Associations of Dietitians (EFAD) which has received funding from the European Union, in the framework of the Health Programme. Sole responsability for this publica-tion lies with EFAD and the Executive Agency is not responsible for any use that may be made of the information contained therein.

ALL RIGHTS RESERVED. Any unauthorized reprint or use of this material is prohibited. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system without ex-press written permission from the author / publisher.

3

ForewordDietitians are present in every European country. They are to be found in clinical environments, public health, administrative and those agencies and industries supporting health. The European Federation of the Associations of Dietitians (EFAD) which was founded in 1978 represents over half of the dietetic workforce in Europe or about 60,000 dietitians. As qualified health professionals and experts in nutrition dietitians are therefore very well place to advise and implement strategies to bring healthful nutrition to the workplace.

There is little doubt that a healthy and fit workforce can make a major contribution to productivity and thereby economic prosperity through industry in Europe. Dietitians being aware of their unique role in this area have over the past years made significant contributions to the promotion of better health through nutrition. It is therefore with great pleasure that I write this forward to present the endeavours of my colleagues in bring informed insights about healthful nutrition to people in the workplace. Although this report captures a unique point in time it also must be remembered that dietitians are continually working to promote better health through nutrition in all working environments.

Dietitians are therefore well prepared to meet the challanges of Health 2020 (WHO European Region, 2012) in building sustainable health promoting environments throughout Europe.

Anne de Looy

Honorary President European Federation of the Associations of Dietitians

Foreword

4

5

- Executivesummary 7

1 Introduction 9

1.1 Non-communicable diseases 1.2 Healthy workers, a part of Europe’s preventive health strategy1.3 The European working population; demographics, absence rates1.4 Health benefits of workplace physical activity and healthy eating

programmes: European and global evidence1.5 Economic benefits of workplace physical activity and healthy

eating programmes: Europe or European and global evidence1.6 The role of the dietitian and other health professionals.

2 EffectivestrategiesforHealthPromotionintheworkplace 17

2.1 Background2.2 Workplace defined2.3 Programmes by intervention setting/type2.4 Target populations2.5 Evaluation2.6 Additional dietetic contributions

3 Theroleofstakeholderswithintheworkplace 35

3.1 Evidence of effective interventions through a comprehensive approach to health promotion in the workplace.

3.2 Key elements for implementing workplace health promotion strategies; lessons from dietitians and others

3.3 Implications for the health of the European workforce and indicators to monitor health improvement through nutrition and health promotion in the workplace

4 Conclusionsandrecommendations 41

- References 43

- Listofabbreviations 46

- Listoftables 47

- Listoffigures 47

- Acknowledgements 47

6

7

Executive summaryThe health of the workforce is one of the key determinants to ensure economic growth and competitiveness in the global market. Optimal health is an indispensable element of social protection of workers, yet often absent from programmes to improve working conditions and occupational safety.

The incidence of obesity is nearing epidemic proportions and is a serious public health concern in Europe. Obesity is a major risk factor for the development of non-communicable diseases (NCD) such as diabetes (DM), certain cancers, cardiovascular disease (CVD), and respiratory disease. Globally, NCD are a leading cause of mortality in Europe, >36 million deaths in 2008. The European Heart Network’s report “Diet, Physical Activity and Cardiovascular Disease Prevention in Europe”, noted that the burden of cardiovascular disease (CVD) in the EU is estimated at 192 billion Euros - more than the entire EU budget. 12,000 Europeans die every day due to heart attacks, strokes, and other cardiovascular diseases. The cost of ill health amongst the UK working population, alone, exceeds £100 billion per year.

Dietitians have an integral part to play in health promotion (HP) in the workplace and have been encouraged to develop extended roles across professional and organisational boundaries. However, their full potential for HP may not be being realised or acknowledged by professional, organisational, or governmental bodies.

This report provides an overview of the activity of dietitians in Europe regarding workplace HP programmes and makes recommendations for future developments and activity.

Health promotion activities using the workplace as a venue to reach the workforce are common across Europe. These will include leaflets, displays in canteens and changing rooms, and are often linked to national campaigns like National stop Smoking Week – UK, National Healthy Eating Week - Ireland, Happy Heart at Work – Ireland, Happy Heart for Hospital Staff and Visitors – Ireland.

Healthy workplace policies are developed across departments/agencies and usually take a more holistic approach incorporating healthy eating and activity as part of a lifestyle approach. Depending on the setting it would be expected that a healthy eating message is demonstrated in food provided in restaurants, vending machines, and at meetings held on site, is taught at appropriate points in any teaching curricula and activity is promoted by, for example the provision of changing facilities, cycle storage, access/ reduced memberships fees for gyms and sports facilities and the promotion of walking and changes in lifestyle.

Executivesummary

8

9

1.1 Non-communicable diseases (NCD)

Globally, NCD are the leading cause of death, killing >36 million people in 2008 (WHO, 2011). There are four main killers: cancer, cardiovascular disease, respiratory disease, and diabetes. NCD are prevalent in high-income countries but now, as a result of economic growth, are on the increase in developing countries.

Twenty-five percent of NCD-related mortality occurs in individuals < 60 years, i.e. the workforce. Obesity-related morbidity accounts for 5-7% of total healthcare expenditure in Europe (Finkelstein et al, 2005). The cost of ill health amongst the UK working population exceeds 100 billion pounds per year; this is higher than the cost of the UK NHS (Eurofound, 2011).

In May 2011, the 64th World Health Assembly emphasized the requirement to urgently address the social determinants of NCD; poor nutrition, physical inactivity, smoking, and excess alcohol. There are various techniques available for this purpose, however, it is crucial that interventions which confer the greatest benefit for the minimum cost are identified and used. WHO refer to these as ‘best buys’ (WHO, 2011). This list of “best buy” interventions for NCD prevention and control can be complemented by efforts to reduce the burden of NCD on individuals and families. Design and implementation of more cost-effective models of care that are delivered by trained professionals may make a substantial difference to those most immediately affected by NCD.

Economic policy-makers are naturally concerned about economic growth. The evidence indicates that it would be illogical and irresponsible to care about economic growth and simultaneously ignore NCD. Interventions in this area will undeniably be costly, but inaction is likely to be far more costly (Bloom et al, 2011).

1Introduction

10

1.2 Healthy workers, a part of Europe’s preventive health strategy

The European Commission’s current strategy ‘Together for Health: A Strategic Approach for the EU 2008-2013’ aims to improve citizens’ prosperity, solidarity and security by:

1. Improving citizens’ health security

2. Promoting health to improve prosperity and solidarity

3. Producing and distributing health knowledge

4. The European Commission’s current strategy “Improving quality and productivity at work: the Community strategy 2007-2012 on health and safety at work” aims to achieve a sustained reduction of occupational accidents and diseases in the EU through various EU and national actions.

This will be achieved by the development and delivery of actions on tobacco, nutrition, alcohol, mental health and general environmental and socioeconomic factors affecting health.

1.3 The European working population; demographics, absence rates

The European Union today consists of 27 countries and, approximately, 493 million people. Total expenditure on health across the EU Member States has been estimated to account for 8,2% of GDP (OECD 2006). Expenditure for disability and sickness alone accounts for a large proportion of this. Country specific expenditure is detailed in Table 1.

One of the Europe 2020 headline targets is that 75% of the population aged 20-64 should be employed (Eurostat). In 2010, 64.2% of the EU population aged 15-64 was in employment (full-time or part-time): 39.2% were employed in market-oriented services, e.g. transportation, food/accommodation, financial services; 30.3% were employed in public administration services, education, arts, and human health; 25.4% in industry and construction; 5.2% in agriculture. Employees in a full-time position usually worked an average of 40.4 hours per week. Part-time employees in EU worked an average of 20.2 hours per week (Eurostat, 2010).

11

Of all Europeans between the ages of 15 and 65, 23 million people (8.6%) are affected by health problems caused or aggravated by work. Between 1999 and 2007 the number of working people affected by health problems was reported to have increased from 4.7% to 7.1%. This resulted in restricted performance, while 20% suffered serious limitations in daily work performance. 50% stayed off work due to health problems and approximately 20% stayed off work for more than a month. (Labour Force Survey, Eurostat, 2010).

There are two main types of health problem; physical (the chief reason cited by around 60% of the respondents with work-related complaints), and psychological – stress, depression and fear (14% of the respondents cited these reasons). Those workers with a better education tend to cite stress, fear or depression as the most serious health problem whereas those of a low and average educational background are more likely to cite physical problems. (Labour Force Survey, Eurostat, 2010).

Table1: Incapacity-related spending and trends in expenditure on morbidity (disability and sickness) programmes, in percentage of GDP by country (2005), % unemployment spending (2005) and % total public social spending (2005)

Country Morbidity-%GDP(2005) Morbidity-%unemploy-mentspending(2005)

Morbidity-%Publicsocialspending(2005)

Austria 2.4 221 9Belgium 2.1 72 8CzechRepublic 2.1 355 11Denmark 3.1 231 11Finland 3.1 194 12France 1.6 99 6Germany 2.2 148 8Greece 1.3 329 6Hungary 0.9 190 4Iceland 3.6 1183 22Ireland 1.5 163 9Italy 1.3 324 5Luxembourg 2.5 324 11Netherlands 4.6 303 22Norway 4.9 960 23Poland 2.3 821 11Portugal 1.8 157 8Slovakrepublic 1.2 672 7Spain 2.2 103 11Sweden 4.2 353 14Switzerland 3.2 339 16Turkey 0.1 232 1UK 2.3 904 11Source: OECD Social Expenditure database (www.oecd.org/els/social/expenditure).

12

1.4 Health benefits of workplace physical activity and healthy eating programmes: European and global evidence

Optimal health is an indispensable element of social protection of workers, yet often absent from programmes to improve working conditions and occupational safety (Wanjek 2005). The trend towards obesity is growing, with serious health implications. The obese are more likely to develop chronic health problems such as cardiovascular disease, diabetes, arthritis, breathing problems and some types of cancer. In Europe, obesity accounts for 5-7% of the total healthcare expense. Whilst in America, the burden of chronic diseases accounts for approximately 75% of the nation’s $2 trillion annual health care costs. In an attempt to reduce the economic and societal burden, a recent report, commissioned by CDC, made 17 recommendations. These included increased disease surveillance, further research, and federal support for the development of comprehensive, population-based initiatives to reduce chronic disease. An IOM committee expanded on this by recommending that government bodies develop incentives for businesses and employers to provide HP strategies which benefit people with chronic illness (IOM, 2012).

Childhood obesity is also rising at an alarming rate, therefore, NCD compromise future economic and human development. Poverty and ill health are frequently passed on from one generation to the next, e.g. inadequate nutrition, both over- and under-nutrition, and impaired foetal development, therefore, education for parents and children is crucial.

HP activity is equally important in the healthcare workplace. A recent report noted that physicians have identified that inadequate workplace nutrition has a significant negative impact on their personal wellness and professional performance (Lemaire, 2011).

There is strong evidence that multi-component workplace interventions that address physical activity, nutrition or both are effective for increasing physical activity, promoting healthy eating and preventing non-communicable illnesses such as obesity (Chau, 2009).

Exposure to work-related stress further increases the health risks, both, direct, as in hypertension, and indirect, as in unhealthy lifestyle choices such as overeating, lack of physical activity or excessive alcohol consumption.

13

Many adults spend a third of their day, or half their waking hours, at their place of work, therefore, it is a logical place to introduce a health intervention. The Marmot review (Marmot, 2010) recommended the effective promotion of wellbeing and physical and mental health at work. WHO and the Work Economic Forum highlight the workplace as an important setting for health promotion action and have produced a report on preventing non-communicable diseases in the workplace through diet and physical activity. This joint-report concluded that workplace health promotion programmes targeting physical activity and diet are effective in promoting lifestyle behaviours (Chau, 2009). This wealth of supportive evidence is further compounded by a recent systematic review which stated that there is enough evidence to implement nutrition interventions in the workplace (Maes et al, 2011). A key point found, both, educational and multimodal interventions are able to favourably change dietary behaviour and potential determinants of these behaviours.

The main health benefits of workplace HP programmes can be seen in Table 2.

The European diet could certainly be improved and local healthy nutrition programmes are pivotal here as there is some variation in the definition of fruit and vegetables between different countries in Europe. For example, in some countries potatoes are not included as a component of fruit and vegetable intake, however, in others, such as Norway, they can be counted. Similarly, with fruit juice, can be included as part of the daily fruit and vegetable intake in some areas but not in others. This complicates the interpretation of surveys on fruit and vegetable intakes, regardless, a wide range can be observed, 577g/day in Poland to 196g/day in Iceland (EFSA, 2008).

Table2: Possible health benefits of workplace health promotion programmes that target physical activity, diet or both. Adapted from Chau, 2009.

Intervention Physicalactivity Diet PhysicalactivityBenefits ê weight é fruit and vegetable intake ê weight

ê BMI ê dietary fat intake ê BMIê percentage body fat ê weight é lifestyle behaviour ê musculoskeletal disorders ê BMI ê NCD risk factors é cardiorespiratory fitness é wellbeing

14

1.5 Economic benefits of workplace physical activity and healthy eating programmes: European and global evidence

There is increasing evidence that ill health reduces individuals’ labour productivity and labour supply (Suhrke, 2008). Inadequate nutrition and poor health can lead to low productivity, low wages and lack of development. Lower productivity and labour supply have been proposed as prime reasons why Europe’s economy lags behind other major economies, e.g. United States (Suhrke, 2008). Economic reasons for investing in workplace health promotion (physical activity and/or nutrition) include enhanced worker productivity, improved workplace morale and workplace culture, reduced absenteeism, improved corporate image, improved staff retention, reduced work-related accidents and injuries, and reduced medical costs (McLaren, 1993).

The evidence of economic efficiency in the literature is mixed but it is accepted broadly that workplace health promotion programs have the potential to increase economic returns for employers and governments. Provision of adequate nutrition can increase national productivity by 20% (WHO, 2003). A review of studies on HP programmes by Aldana in 2001 noted that a reduction in absenteeism (range 12% to 36%) was a result which could have economic benefits and achieve a return on investment between 1:2.5 and 1:10.1 for absenteeism as well as a return on investment between 1:2.3 and 1:5.9 for medical costs However, the overall benefits may not be completely realised for some years after the health risks have been reduced which renders the observed short-term effects even more powerful.

15

1.6 The role of the dietitian

A dietitian has a qualification in nutrition & dietetics acknowledged by a national authority. There are approximately 60,000 practising dietitians in Europe and they have been encouraged to develop extended roles across professional and organisational boundaries. This new agenda requires them to promote health and wellbeing in, both, a clinical and administrative capacity, to educate patients, carers and other professionals, and to view every patient contact as an opportunity for health promotion.

The Ottawa Charter (WHO, 1986) identified three basic strategies for health promotion: advocate, enable and mediate, and emphasised that in order to enable individuals to take responsibility for their personal health it is necessary to provide HP agents. The charter proposed that the responsibility for HP should be shared amongst health professionals (WHO, 1986). However, as dietitians apply the science of nutrition to the feeding and education of groups and/or individuals in health and disease, they play a key role in public health nutrition and catering. They are pivotal in the promotion of healthy lifestyles and, therefore, in the campaign to promote health in the workplace and reduce the burden of non-communicable disease (NCD) in Europe.

It is thought, however, that their HP potential is unrealised, with their role limited to working with patients to alleviate the effects of illness or disability rather than promoting health and wellbeing in the population in general. Furthermore, relatively little is currently known about the roles they play in PH, HP, and administration. This report provides an overview of the activity of dietitians in Europe regarding workplace health promotion programmes to promote physical activity, healthy diet or both and prevent overweight and obesity.

16

17

2 Effective strategies for HP in the w

orkplace

2.1 Background

In 2005, EFAD joined the EU Platform on Diet, Physical Activity and Health. Both organizations have shared aims in improving the health of the European population. Following a workshop at the EFAD General meeting (2007), a mapping exercise was initiated during a conference. The workshop aimed to raise awareness of the work of the EU platform, to encourage EFAD members to develop and/or participate in local Platforms, and share good practice. EFAD member associations were invited to give details of examples of current good practice regarding health promotion/health in the workplace (HIW) activity.

16 EFAD membership countries (64%) responded, reporting active contribution to promotion of health in the workplace setting; Austria, Denmark, Finland, France, Germany, Greece, Holland, Ireland, Luxembourg, Norway, Poland, Portugal, Spain, Sweden, Switzerland, UK. A summary of activities is provided in Table 3.

The projects included initiatives which were innovative, often, multi-modal, and complied with current, evidence-based recommendations, and were introduced at local and national level. This report includes the details of good practice in HIW activities which were submitted to EFAD between Autumn 2007 and Summer 2009.

Table3: Best practice in workplace HP by dietitiansProjectTitle Association/Country Aim

Fit into Spring Dietitians Association of Austria Healthy diet; Increase exercise

Barnsley PCT Dining Room/Catering Project

British Dietetic Association Develop PCT staff catering as an example of healthy eating in the workplace

Project Plan for Health & Well-being Award

British Dietetic Association Achieve minimum standards for food hygiene, healthy diet, smoking cessation, PA

Promoting a ‘Healthy Workplace’ in Brad-ford Hospitals NHS Foundation Trust

British Dietetic Association Promote healthier foods/drinks via displays, collaboration with catering, reduced costs, free water

The Pleasant Everyday Meal The Danish Diet & Nutrition Association Enhance health and QoL; Enhanced professional profile

Heart symbol – a tool for promoting a healthier lunch at the workplace

The Association of Clinical and Public Health Nutritionists in Finland / Finnish Heart Association

Improve catering employees ‘knowledge of food quality; Healthy diet

Eat Right French Association of Nutritionist Dieti-tians

Improve knowledge re: food labeling

Seeking Balance French Association of Nutritionist Dieti-tians

Educate re:balanced diet

JOB&FIT Federal Ministry of Food, Agriculture and Consumer Protection and German Nutri-tion Society (DGE)

Healthy diet at work

Wellness Centre Nutrition Services Hellenic Dietetic Association Improve health status of college com-munity

Health in Workplace Hellenic Dietetic Association Healthy diet for employees

Balance op her work Dutch Association of Dietitians Create awareness of weight gain; Prevent weight gain

Covenant Overgewicht Dutch Association of Dietitians Encourage production of low energy foods; Disseminate healthy weight information

Food and Healthy Eating Policy for Staff of HSE West

Community Nutrition & Dietetic Service, HSE West, Ireland

Provide a supportive and sustainable environment for healthy diet

Happy Heart at Work Award Programme Irish Heart Foundation Facilitate healthy diet in workplaces; Support workplaces to maintain stand-ards

The Happy Heart Catering Award Community Nutrition & Dietetic Service, HSE West, Ireland

Encourage healthy food choices, incorpo-rating food safety guidelines

Happy Heart Eat Out at Work Irish Heart Foundation Promote healthy catering practice

Nutrition HP training to HSE staff HSE Performance & Development Promote healthy diet for retirees

Eating healthy and move more Luxembourg Dietetic Association Encourage PA and healthy diet

Healthy Choice Luxembourg Dietetic Association Promote healthy snacks at cinema

Administrative Dietitians at work Norwegian Dietetic Association Healthy nutrition

Promotion of knowledge on human nutrition & dietetics within the national forum

Polish Society of Dietetics Promote knowledge of human nutrition and dietetics

The efficacy of weight reduction programme for overweight and obese people covering all age groups

Department of Dietetics, Warsaw Univer-sity of Life Sciences

Educate 7-19 year-olds on role of poor nutrition and lack of PA in the develop-ment of chronic diseases and obesity

Table3: Best practice in workplace HP by dietitiansProjectTitle Association/Country AimFood for Life Portuguese Dietetic Association Promote healthy diet at private compa-

nies.

HP in the Workplace Portuguese Nutritionist Association Enable healthy food selection at work and home

Eat Well Spanish Dietetic Association -Balearic Islands Dietetic Association

Promote healthy eating habits in young people

Food and Catering Production Course (Curso de Produção Alimentar em Restauração)

Estoril Higher School for Hotel & Tourism Studies

Improve nutrition in food production

FOOD PRO-FIT The Official College of Dietitians – Nutri-tionists of Balearic Islands

Reformulate recipes

Healthy eating guides Spanish Dietetic Association -Balearic Islands Dietetic Association

Promote healthy eating guidelines, con-sidering cultural aspects

Strategic plan for prevention of child-hood obesity

Spanish Dietetic Association -Balearic Islands Dietetic Association

Analyse factors associated with child-hood obesity; Formulate proposal to control childhood obesity

HP in schoolchildren Spanish Dietetic Association Provide teaching materials for nutrition education

Not recorded Region Hospital of Borås, Region of Västra Götaland, Sweden

Promote better health

The Keyhole in restaurants Sweden Promote balanced meals in restaurants

Preventative health care for elderly citizens

Department of Food and Nutrition, Umea University, Sweden

Promote healthy diet to the elderly, in collaboration with other health profes-sionals

Student health at university Department of Food and Nutrition, Umea University, Sweden

Promote healthy diet to students

Fit at work/Fit for life Swiss Dietetic Association Ensure access to healthy meals at work.

Promoting Fruit & Vegetable Consump-tion

Swiss Dietetic Association & Swiss Cancer Association

Ensure daily availability of fruit & vegeta-bles for all employees

FOOD PRO-FIT The Official College of Dietitians – Nutri-tionists of Balearic Islands

Reformulate recipes.

Healthy eating guides Spanish Dietetic Association -Balearic Islands Dietetic Association

Promote healthy eating guidelines, con-sidering cultural aspects.

Strategic plan for prevention of child-hood obesity

Spanish Dietetic Association -Balearic Islands Dietetic Association

Analyse factors associated with child-hood obesity.

Formulate proposal to control childhood obesity.

HP in schoolchildren Spanish Dietetic Association Provide teaching materials for nutrition education.

Not recorded Region Hospital of Borås, Region of Västra Götaland, Sweden

Promote better health.

The Keyhole in restaurants Sweden Promote balanced meals in restaurants.

Preventative health care for elderly citizens

Department of Food and Nutrition, Umea University, Sweden

Promote healthy diet to the elderly, in collaboration with other health profes-sionals.

Student health at university Department of Food and Nutrition, Umea University, Sweden

Promote healthy diet to students.

Fit at work/Fit for life Swiss Dietetic Association Ensure access to healthy meals at work.

20

2.2 Workplace defined

This report has included the following settings under the definition of workplace:

• Healthcare - hospitals/clinics/nursing homes/residential care. Dietitians routinely provide clinical nutritional intervention for people being cared for but also work with all staff working in these establishments and visitors to these establishments.

• Education - schools, colleges and universities. Dietitians are employed on the teaching staff or in a research capacity where nutrition and/or dietetics are on the syllabus. Many also deliver the nutrition component of campaigns aimed at school children, students and staff and support teachers, school meal providers and school nurses to deliver the same message.

• Otherpublicsectorworkers - eg, police force, fire service. Campaigns aimed at promoting health to these workers have been developed.

• Industry - factories, food industry. Dietitians are employed in the food industry as part of product development or in the marketing department working on food labeling or producing marketing resources such as leaflets, posters, audio or video advertising. In many other industrial plants they work directly with employees in a health promotion capacity.

• Prisons. Dietitians are working in a clinical capacity with prisoners but are also in a position to influence the eating habits of both prisoners and prison staff.

• Military. Some Dietitians are employed as members of the armed forces to provide a dietetic service for the service personnel and their families through campaigns and individual referral or as part of the catering corp, where they can influence food provision. Others work in liaison with the Military Service, delivering the same range of services. Industry; manufacturing plants, food industry.

21

2.3 Programmes by intervention setting/ type

In the promotion of healthy lifestyles for the populations of EU/EFTA, European dietitians are extending their role beyond nutritional concerns. All countries who responded are adopting a multi-modal approach (Table 4). They are employing a wide variety of measures to reduce common risk factors for NCD; anti-smoking, physical activity, sensible use of alcohol, and mental health initiatives (Table 4).

Table4: Programmes by country

Initiati

ve

Anti-sm

oking

Food

provision

Dietary(group

)

Dietary(in

dividu

al)

Food

labe

lling

edu

catio

n

Food

safety

Lifestyle

Men

talh

ealth

PA(a

dvice)

PA(p

racti

cal)

Safealcoh

ol

Total

CountryAustria 1 1 1 3 6Denmark 1 1 1 3Finland 1 2 2 5France 1 4 1 3 9Germany 1 1 1 3Greece 1 1 1 1 1 5Holland 5 1 1 1 1 9Ireland 4 4 1 4 13Luxembourg 1 2 1 1 5Norway 1 1 2Poland 4 1 1 2 8Portugal 2 2 2 2 1 9Spain 1 5 2 2 1 11Sweden 1 1 3 1 2 1 1 1 1 12Switzerland 2 2 1 5UK 2 2 6 2 2 2 2 1 19

22

2.3.1 National level

Nearly all members reported programmes with a national aim. Spain reporting the highest contribution to national level initiatives at 19%. The Spanish Dietetic Association – Balearic Islands Dietetic Association have the support of the Autonomous government department to run on-line iterative workshops on healthy eating for young people within the general programme on healthy lifestyles for the young (http://www.codnib.es/pas/pas/inicio.html).

The Spanish initiative developed teaching materials and a structured education programme for use by dietitians when teaching healthy eating to school children. They were also asked by the local health ministry to produce guidelines for the production of healthy food to be used across the Balearic Islands in hospitals, health centres, social services and libraries. Figure 1 shows Interventions were applied at national while Figure 2 shows local level initiatives.

23

Figure 1 shows that many other NDA participated at national level, e.g. in the development of policy.

• In the Netherlands: Covenant Overgewicht - The Dutch Association of Dietitians are partners of the Covenant which is working on combined activities to create a less obesogenic environment. The aims are to encourage companies to produce low-energy foods/drinks and to disseminate information on the maintenance of a healthy weight in collaboration with partners.

• In the UK, the British Dietetic Association (BDA) has held an annual campaign related to obesity for a number of years, targeting different sections of the population. The NDA has produced materials for use by their members and information for members of the public which can be accessed via the BDA website. Materials were specifically designed for use in a “Weightwise at Work” campaign. The BDA also has a national media campaign at the start of the new academic year. This campaign is aimed at new university and college students and supported by direct involvement of dietitians in the universities and colleges and fact sheets on the website.

Several NDA are working with governments or other national agencies, providing dietary advice and specialist knowledge in the development of campaign materials, media information, or support for their members to enable them to participate in the campaign.

• The Netherlands Nutrition Centre provides scientifically reliable, honest information to consumers and use active communication campaigns to achieve changes in behaviour. An example of one of the campaigns is “Balansday op het werk” aimed at companies employing more than 250 staff. The companies are enabled to implement programmes designed to increase physical activity in combination with healthy-eating.

Figure1: National level initiatives (%)

24

2.3.2 Local level

UK dietitians contribute 27% of the total European local level initiatives (Figure 2). In the UK there are several dietitians working on city wide schemes involving a number of partner organizations from health and

the local authority, developing strategies for the provision of food in the workplace following healthy guidelines e.g. Leeds Food Matters and the Barnsley Food Strategy which is part of Barnsley’s Well Being @ work campaign. The Leicestershire Health and Well-being Award is targeting large workplaces that provide dining room facilities and is a co-ordinated approach to achieve minimum standards in four aspects that affect employees health – food hygiene, healthy food choices, smoking and physical activity.

• Administrative dietitians in Norway, Sweden and Denmark are employed in a variety of workplaces to develop and deliver policies for that workplace covering menus based on national guidelines and campaigns related to healthy food.

In many countries the dietetic department will advise on the nutritional content of the food served in hospitals.

• In Greece some hospital food service departments extend this to food and meals served to the staff.

• In the UK, the Barnsley Food Strategy which is part of Barnsley’s Well Being @ work campaign, aim to develop PCT catering staff as an example of excellence in the promotion of healthier eating choices.

• In Sweden some food shops employ dietitians for a few hours a week to offer advice on food and lifestyle directly to their consumers and to produce health promotion material for use in the shop. Health Promotion Campaigns motivate and encourage employees to adopt a healthy lifestyle.

• In Poland, dietitians from the Faculty of Human Nutrition and Consumer Sciences, Warsaw University of Life Sciences deliver nutrition education lessons for children and adolescents in 50 different primary and secondary schools in Warsaw, with the aim of improving nutrition and promoting lifestyle changes. In 1994 the Faculty created a Nutrition Forum for workers and students in the university but open to the public of Warsaw. They deliver 9 lectures/open discussions a year on all aspects of nutrition and lifestyle.

Figure2: Local level initiatives (%)

25

In many of the workplaces identified, dietitians are able to offer individual advice to employees or are involved in training other health professionals to enable them to work with individual employees. This may take the form of:

• Weight management groups

• Individual referral from Occupational Health departments

For example, at the American College of Greece a Wellness Centre has been established. Here, a MDT consisting of a dietitian, nurse, Health Educator and fitness professional are targeting college employees and students and offer counselling, workshops, general wellbeing and academic classes.

SpecificexamplesoftheDieteticcontributiontoHealthintheWorkplaceareprovidedhere.

2.3.3 Food safety

In France, an initiative for Banque Postale employees aimed to encourage individuals to read the labels on foods and to improve understanding of food labels, thereby, improving dietary habits.

2.3.4 Food provision

The Danish Diet and Nutrition Association are running a 3 year campaign which targets consumers who depend on professionals to provide daily meals –“Den gode hverdagsmad” (The Pleasant Everyday Meal), promoting the production of healthy food and meals.

2.3.5 Food labelling

A major role of administrative dietitians is to give advice on the food served in restaurants, dining rooms and in vending facilities. Other dietitians will be involved in this type of work as part of a wider role in for example a hospital or local authority. The Keyhole in Sweden is one example. It was developed as part of a community CVD prevention programme in Northern Sweden (Weinehall 2001). CVD risk factor screening and counselling by GP were carried out at the same time as the community intervention programme. A new food labelling system was introduced in the grocery stores, which after a few years became the official Swedish food labelling system. Sales statistics regarding dairy products showed a significant increase in sales of low fat products.

26

2.3.6 Childhood obesity

The Spanish Dietetic Association – Balearic Islands Dietetic Association are working with other healthcare agencies, education, sports and social activities to develop a strategic, multicentre approach for the prevention of childhood obesity. The programme includes education and promotional material for professionals and families, nutritional and dietary recommendations for menu development for school meals and foods sold in schools and a programme of subsidies for quality products from the region.

2.3.7 Multi-modal approach (EWalsh@Irishheart.ie)

The Irish Heart Foundation has a Happy Heart Award Programme, which consists of 3 elements:

• Health checks/health awareness days

• Physical activity in the workplace

• Healthy Eating Award

As the national charity fighting heart disease and stroke, the Irish Heart Foundation stresses the importance of the workplace as a key setting to tackle the rising problem of obesity in Ireland. The recently published guidelines from the European Heart Network, 2011, highlights workplaces as a key setting for action in improving diet and physical activity, and initiatives such as the Irish Heart Foundation’s Healthy Eating Award programme allows the workplace to play an important part in helping to tackle conditions like heart disease and obesity. One dietitian has responsibility for co-ordinating the Healthy Eating Award for workplaces. The objective of the catering audit undertaken as part of the process is to assist a staff restaurant/canteen to adopt healthier cooking practices and provide healthier food choices for staff, without incurring substantial cost. Recommendations given to the catering manager would meet the Irish Heart Foundation and the Department of Health’s ‘Healthy Eating’ Guidelines. The catering audit is carried out by a consultant Dietitian in conjunction with a catering manager. This audit is an independent assessment identifying the company’s individual needs. Over 300 companies are currently certified with the Healthy Eating Award. The Irish Heart Foundation Happy Heart at Work Award was developed over a 2 year period from 1990-1992, and has since been independently evaluated by the National University of Ireland, Galway (NUIG, 2001). This report showed that the Happy Heart at Work is a well-designed, flexible programme with high quality materials. The full report is available at:

http://www.irishheart.ie/media/pub/healthpromotionreports/hhawevaluation.pdf

AnEvaluationoftheHappyHeartatWorkProgrammeCentre for Health Promotion Studies, National University of Ireland, Galway

27

2.3.8 Recipe Reformulation (mmoninyo@gmail.com)

The Official College of Dietitians – Nutritionist of Balearics Island partnered the Department of Health and Consumer Affairs (Government of Balearic Islands) in leading the European initiative, FOOD PRO-FIT, from 2007-2010 . The objectives of this programme were:

• To evaluate nutritional risk in saturated fatty acids (SFA), free sugars (Fsu), and sodium (Na)

• To improve the nutritional profile of products and recipes

• To facilitate the use of nutritional claims

• To facilitate the selection of healthy choices

• To assess the impact on health

The online tool HANCP (Hazards Analysis and Nutritional Control Point) set thresholds for SFA, free sugars and sodium, enabling the evaluation of nutritional risk. Reformulations allow the use of the logo FOOD PRO-FIT, if reduced at least 50% of the risk. It also reports on nutritional claims possibilities on SFA, Fsu and Na. The nutritional risk has been assessed on 23 products in 7 food industries (3 meats, 3 dairy and 1 vegetarian products):12 products are in testing technology and 2 are in market; and in 10 establishments of HORECA channel (2 hotels, 2 hospitals 1 restaurant, 2 school catering, 1 canteen and 1 Faculty school and a University hostel). The reformulated recipes are 144. The dates show that the average reduction of risk in reformulated recipes is 2.78g of SFA, 6.65g of Fsu and 152.4mg of Na by 100g and 2.78g of SFA, 6.65g of Fsu and 152.4mg of Na by 100g of product. In addition, 56% customers foodservice establishments participants (n=339), selected a reformulated option and 85% seemed it good or very good, also the great majority (84%) would choose an establishment with this kind initiatives to improve nutritional quality of food.

CONCLUSIONS. The improvement of nutritional profile of foods in the food chain SME’s interface, acts on one of the most important sources of nutritional risk based on Na, SFA and Fsu, to evaluate the health impact of reduced exposure and availability to unhealthy food.

Figure3: FOOD PRO-FIT group.

THEFOODPRO-FITEUROPEANPROJECTQUICKSTARTGUIDE

• Create or log in to your account.

• Add a new recipe.

• Add ingredients or simply enter known nutrition values.

• See your analysis in real time.

• Print your Food Pro-Fit Certificate.

The HANCP tool will keep your product or original recipe formula and the resulting reformulations, allowing you to self-monitor their nutritional risk.

28

2.4 Target populations

The comprehensive range of strategies employed by dietitians in their contributions to HP in the workplace has operated at, both, national and local level. These strategies have been aimed at different groups within the population and cover all life stages; expectant mothers, infants, children, young adults, adults, the elderly, and entire populations. Figures 4-7 display the percentage of each strategy apportioned to each target group.

Increasing physical activity participation and improving nutritional choices reduce the risk factors for non-communicable diseases (e.g., reducing BMI, reducing blood pressure); and facilitating organisational-level changes (e.g., reducing absenteeism).

Health benefits of workplace HP programmes can be seen in Table 2. The benefits of physical activity initiatives include increased physical activity levels, reduced relative body fat percentage, decrease musculoskeletal disorders and improvements in cardiorespiratory fitness (Table 2). For those programmes that target healthy diet, beneficial outcomes include increased fruit and vegetable intake, decreased intake of unhealthy dietary fat, significant reduction in BMI, overweight and obesity (Table 2).

2.4.1 Expectant mothers

Three percent of all dietary advice initiatives and 17% weight-management initiatives are directed specifically at expectant mothers (Figures 4 & 5).

The impact of intervention at this crucial stage can confer benefits, current and future, for the expectant mother, unborn child and immediate family.

29

Figure4&5 : Nutritional advice initiatives

2.4.2 General Population

Twenty-seven percent of all initiatives dealing with PA were directed at the population in general (Figure 6). Others included; food safety (47%), mental health (50%), anti-smoking (50%), and sensible use of alcohol (50%).

2.4.3 Adults

Forty-seven percent of all European food safety initiatives are aimed at adults (Figure 7). Other initiatives directed specifically at adults; mental health (50%), sensible alcohol use (50%), anti-smoking (50%), PA (27%), anti-obesity (17%), general nutrition (31%).

2.4.4 Elderly

Five percent of the total number of nutritional advice initiatives were designed specifically for the elderly (Figure 4). A very important activity, not least, because of the increase in the number of Europeans in this age group.

Figure6: Physical activity initiatives

Figure7: Food safety initiatives

30

2.4.5 Young adults

A good proportion of the specific initiatives was aimed at young adults; nutritional advice (15%), PA (18%) and food safety (6%). Thereby, addressing the unique requirements of this generation, enabling a NCD-free future.

2.4.6 Infants & children

Nutritional advice (13%) and healthy weight/anti-obesity (34%) strategies were directed specifically at infants and children. Interventions aimed at schools and nurseries can foster healthy lifelong habit. Furthermore, the opportunity to provide access to nutritious food should not be missed.

2.5 Evaluation

Improved data collection and measurement can impact on the health of local, regional, and national communities as it facilitates the construction of robust policies and guidelines. Governments and policy-makers frequently lack appropriate information to ensure optimal use of resources, thereby, achieving the most beneficial outcomes for their communities. Population health statistics needs greater coordination, integration, coherence, and enhanced capabilities at all levels if they are to provide robust, comprehensive evidence (IOM, 2010). A recent IOM report recommended that the CDC should develop policy goals aimed at decreasing suffering from chronic disease, rigorously evaluate the effectiveness of chronic disease prevention programmes that it funds, and routinely evaluate policies to ensure they comply with current healthcare systems (IOM, 2012). It is of paramount importance to measure the effect of HP activity, therefore, evaluation methods must be incorporated into all interventions. Table 5 shows the evaluation strategies employed by dietitians in their workplace interventions.

However, although the gap in the evaluation of activities needs to be addressed, it is important to highlight that this should not prevent the development and implementation of HP programmes. Identifying and publishing case reports and examples of HP programmes can also build supportive evidence and can help stakeholders and planners better understand how to develop HP programmes that fit different workplace contexts (WHO/WEF, 2008).

31

Table5: Findings from reviews of workplace interventions to promote physical activity and healthy eating and to prevent obesity.Project Setting Association FindingsPromoting a ‘Healthy Workplace’ in Bradford Hospitals NHS Founda-tion Trust

Bradford Hospitals NHS Foundation Trust

BDA Improved availability/sales of ‘healthy options’. Positive feedback from employees. Evaluation ongo-ing.

Heart symbol – a tool for promoting a healthier lunch at the workplace

Food services (e.g. at schools, personnel restaurants), food ser-vice employees, food industry

The Association of Clini-cal and Public Health Nutritonists in Finland / Finnish Heart Associa-tion

Stake holders, at food industry and catering sector, are interested in improving the nutritional quality of the food they serve. They are keen that they can highlight to consumers their efforts on develop-ing healthier food. 84% population recognise the symbol. The reported use of healthier products increased in all age and educational groups, especially among the less edu-cated.

Eat Right Employees - Banque Postale- France

AFDN Evaluation planned in 6 months

Seeking Balance Adults in the workplace AFDN Improvement in healthy food choices

JOB&FIT Employees, employers and staff canteen

Federal Ministry of Food, Agriculture and Consumer Protection and German Nutrition Society (DGE)

Website developed (www.jobund-fit.de), (www.in-form.de)

Food and Healthy Eat-ing Policy for Staff of HSE West

HSE West employees Community Nutrition & Dietetic Service, HSE West, Ireland

Recommendations being made

Happy Heart at Work Award Programme

Adults in the workplace Irish Heart Foundation No formal outcome evaluations or risk factor profiles were undertaken but a series of detailed process evaluations were conducted. Cater-ing audit and monitoring. Biannual update on healthy nutrition, aimed at retirees/mid-career employees.

The efficacy of weight reduction programme for overweight and obese people covering all age groups

Overweight/obese of all ages

Department of Dietet-ics. Warsaw University of Life Sciences

Reduction in body weight, mainte-nance of REE, improvement in CHO and lipid metabolism.

32

Table5: Findings from reviews of workplace interventions to promote physical activity and healthy eating and to prevent obesity.Project Setting Association FindingsEat Well Secondary school

pupilsSpanish Dietetic Asso-ciation -Balearic Islands Dietetic Association

4,500 secondary school pupils given healthy lifestyle advice. Parents, teachers and leisure activ-ity monitors enabled to promote healthy eating in school.

FOOD PRO-FIT Population The Official College of Dietitians – Nutrition-ists of Balearic Islands

Mean reduction of risk in refor-mulated recipes: 2.78g SFA, 6.65g Fsu, 152.4mg Na per 100g, 56% consumers (n=339), selected re-formulated option, 85% consum-ers ranked reformulated recipe good/very good, 84% consumers would choose an establishment of-fering reformulated recipes.

Healthy eating guides General population Spanish Dietetic Asso-ciation -Balearic Islands Dietetic Association

Healthy eating guidelines used nationally. Web page developed where there is an online query facility which is answered by dieti-tians.

Not recorded Hospital patients, hos-pital employees, local population

Region Hospital of Borås, Region of Västra Götaland, Sweden

Focus group for food habits. Series of public presentations regarding food habits.

Fit at work/Fit for life Employee customers of staff canteens

Swiss Dietetic Associa-tion

Approximately 3,000 people have the opportunity to have a healthy meal at their place of work.

Promoting Fruit & Veg-etable Consumption

Employees & Farmers Swiss Dietetic Asso-ciation & Swiss Cancer Association

Daily fruit-availability for all em-ployees

33

2.6 Additional dietetic contributions

Awareness and use of the Heart Symbol by Finnish consumers (Lahti-Koski et al, 2012).

• This study looked at the awareness of the Finnish Heart Symbol in different age and educational groups amongst Finnish adults, examined changes in awareness over a 9-year period, and the reported use of products displaying the symbol.

• The study concluded that majority of Finnish adults are familiar with the Heart Symbol, and the reported use of such products increased in all age and educational groups. This increase was particularly prominent among the less educated. The symbol may work as an effective measure to reduce nutrition-related health inequalities.

Kellogg’s Belgian Prize for Dietetics (CIAA 1206)

• In partnership with the Belgian Dietetic Association, Kellogg sponsors a yearly award for the best dissertation in dietetics. The objective is to support the profession and encourage scientific research in the area of nutrition. This commitment aligns with the general aims of the Platform.

• Facilitate the promotion of healthy diets and lifestyles in various areas (Danish Chamber of Commerce 727). Coordination of the retailers’ voluntary 13-point plan to fight obesity by holding meetings with different stakeholders and trying to reach a consensus. However, there are no explicit outcome impact indicators for this commitment.

34

Commitments made by the European Federation of the Associations of Dietitans and its members. This Platform member submitted two continuing commitments in this area. Through these commitments, the following was achieved in 2010:

• Dietitians Improving Education and Training Standards (DIETS) (EFAD, 282). A network of professional dieticians, academic dieticians and nutritionists and other European agencies’ aimed at sharing and disseminating dietetic knowledge, best practice and to encourage evidence based dietetic practice (EACEA). Now complemented by (DIETS2) as a ‘means for working with both academics and professionals as well as NGO to ‘facilitate the sharing of best practices with respect to promoting nutritional health’.

• Improving medical and health professional skills to counteract obesity (IOTF International Obesity Task Force, 810).The IOTF continued to organise and deliver face-to-face and online education in obesity for health care professionals throughout the EU.

35

3.1 Evidence of effective interventions through a comprehensive approach to health promotion in the workplace

It will be essential to involve a wide range of stakeholders in the implementation of interventions. Commitment and interest from central government, political parties local government, the health services, the third sector and the private sector is crucial here (Marmot, 2010). The private sector, in particular, has a key role to play. For example, private industry can develop new technologies to prevent, diagnose and treat NCD, market healthy products and make existing food products healthier. Also, setting priorities is a must, given that in most countries resources for health are very limited. For policy-makers, that will mean taking into consideration the current and projected burden of disease, cost-effectiveness of proposed interventions, the equity of and relative feasibility of competing options and short-term political considerations (Bloom et al, 2011).

Stakeholders within the workplace include the following:

• employees

• employers, owners, managers

• health and safety committee representatives

• professionals who provide health and/or safety services to employees such as dietitians, ergonomists and fitness professionals

• occupational health professionals

• human resource professionals

• union representatives

• company physician

• cafeteria/food service supervisors

• social committees

3 The role of stakeholders w

ithin the workplace

36

Stakeholders and partners outside the workplace include:

• public health departments

• community health centres

• NGO

• Ministry of Labour

• Employee Assistance Program providers

• Industrial Accident Prevention Association (IAPA)

• Workplace Safety and Insurance Board (WSIB)

• Health Professional Associations

• Hospitals

• union associations

• private sector consultants (workplace wellness

• providers, occupational health consultants,

• organizational change consultants)

• private insurance providers

• food distributors

• catering companies (WHO/WEF, 2008).

The following are two examples of successful collaboration of stakeholder groups.

• Take a step for your health – MOL. The programme, started in 2006, is a long-term cultural change programme which incorporates; individual health plans, screening, healthy diet information/provision. A single organisation manages health, safety and environmental protection within the MOL oil and gas group, which has around 35,000 employees. ‘Dr István Miniska, Group Medical Advisor, outlined the steps that MOL has taken to promote employee health. ‘Health protection is an integral part of the management philosophy’ he said. ‘We focus on healthy working conditions to improve the overall health and life conditions of all our employees, with special attention to selected target groups. We are investing in reorientation towards prevention and health promotion.’

37

• The Norsjo health programme was launched in 1985. When it was developed it was considered quite a new approach. The model integrated voluntary organizations, municipal executives, healthcare employees, and researchers from Umea University. Broad support for the health initiative was demonstrated when representatives of some 100 voluntary organizations, together with politicians, planners, primary care personnel, and researchers came together to plan a model for community intervention for the prevention of CVD (Weinehall et al, 2001).

3.2 Key elements for implementing workplace health promotion strategies; lessons from dietitians and others

A number of factors will adversely affect the overall success of the HP strategy:

• lack of management support

• lack of participant motivation

• changing priorities of the workplace

• low participation rates

• poor retention in program

• lack of professional staff to deliver the intervention

• financial resource limitations

• timing/other organizational labour disruptions

• competing interests between public and private, between employee and employer

Several factors have been identified as essential elements to consider when implementing HP and healthy diet strategies in the workplace. Table 6 presents these key elements, from organisational to environmental to individual employee levels. A recent report by Needle et al (2011) emphasises the importance of the conceptualisation and evaluation of initiatives.

38

Table6:KeyelementsforimplementationofworkplaceHPstrategies:AdaptedfromChau,2009.Level KeyelementsOrganisational level HP programmes and policies linked to organisational objectives and values.

HP strategies integrated with business practices. Organisational policies that support healthy lifestyle to ensure long-term commit-ment, resources and sustainability.

Management level Support and involvement, from senior to middle management, to ensure equal ac-cess and support to all workers. Optimise use of resources; adequate staff, time and resources for programme devel-opment and implementation. Set goals and indicators of success within realistic timeframes. Ensure long-term commitment to the programme.

Environmental level Supportive organisational environment. Ensure access to resources and support. Give employees time to learn how to deliver and/or use the programme compo-nents. Programme accessible and easy to use.Redesign of work processes/patterns to increase opportunities and facilitate healthy physical activity and diet choices.

Cultural level Communication, marketing and promotion of programmes to employees. Regular, concise messages via multiple communication channels.

Individual/ employee level Participatory planning; involve, engage and consult employees. Conduct needs assessments as part of project planning to identify employee needs, likes, dislikes; help tailor programmes to their needs.

Programme level Multi-modal programmes across the individual to environment continuum, to simul-taneously address factors that affect health and productivity at individual, environ-mental, policy and cultural levels. Develop and implement multi-component programmes that target several health issues. Achieve/maintain high participation rates. Programmes with the focus on employees’ needs. Evaluate programme and policies to provide indication of whether programmes are achieving their goals; demonstrate value of programme and provide accountability to management to influence support and funding for future implementation and sustainability. Dissemination of outcomes and findings to stakeholders.

39

3.3 Implications for the health of the workforce in Europe and indicators to monitor health improvementthrough nutrition and health promotion in the workplace

• improved health status

• improved mental health

• improved self-esteem

• improved nutrition knowledge or awareness

• improved nutrition attitudes and intentions

• improved perception of health status

• improved nutrition behaviour

• improved skills/confidence around making and preparing healthier food choice

• reduced sickness absence rates

• reduced short- and long-term disability rates

40

41

4 Conclusions and recommendations

This evidence snapshot has identified the following research areas that need to be implemented and improved:

Policy

• All workplaces should establish a policy with respect to health promotion especially as concerns nutrition and physical activity, to ensure a health promoting environment.

• A reporting frame of specific initiatives in the workplace, to be established to indicate the reduction in burden of the four principal non-communicable diseases thereby contributing to Health 2020.

• Dietitians as health professionals and experts in nutrition to be fully involved in policy formation, implementation and evaluation monitoring and reporting

Research

• More European studies are needed to help design, implement, and evaluate effective workplace health promotion interventions fully utilizing the contribution that dietitians can make to these initiatives.

• Translational research should be conducted to examine the degree to which trialled programmes may be implemented and sustained across different working contexts and roles, such as part-time, casual, blue collar and rural workforce groups.

• Evidence on the sustainability of interventions over longer periods of time and the cost-effectiveness of interventions that address physical activity and nutrition.

4 Conclusions and recom

mendations

42

43

References

Aldana SG, Financial Impact of Health Promotion Programs. A Comprehensive Review of the Literature. American Journal of Health Promotion. 15(5):296-320. (2001).

Bloom DE, Cafiero ET, Jané-Llopis E., Abrahams-Gesse, S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B, Stein A, Weinstein C. (2011). The Global Economic Burden of Non-communicable Diseases. Geneva: World Economic Forum.

Chau J. (2009) Evidence module: Workplace physical activity and nutrition interventions. Physical Activity Nutrition and Obesity Research Group, University of Sydney.

Eurofound (2010) Arrangements for workers with care responsibilities for sick or dependent relatives: the situation in the EU. Eurofound, Dublin. Available at: http://www.eurofound.europa.eu

Europe 2020 Headline indicators. Available at http://epp.eurostat.ec.europa.eu/portal/page/portal/europe_2020_indicators/headline

European Commission. Improving quality and productivity at work: Community strategy 2007–2012 on health and safety at work. SEC(2007) 216/2, Brussels, 2007. Available at http://ec.europa.eu/employment_social/news/2007/feb/executivesummary_en.pdf

European Commission. Labour force survey in the EU, candidate and EFTA countries — Main characteristics of national surveys, 2009. Luxembourg: Publications Office of the European Union 2011. Available through: http://bookshop.europa.eu

European Commission (2007). Together for Health: A Strategic Approach for the EU 2008-2013. Available at: http://ec.europa.eu/health-eu/doc/whitepaper_en.pdf

European Food Safety Authority (2008). Concise Database summary statistics - Total population. Available at: http://www.efsa.europa.eu/en/datexfoodcdb/datexfooddb.htm

European Union Labour Force Survey – Annual results 2010. Eurostat. Available at: http://epp.eurostat.ec.europa

Foundation Focus - Health and work: a difficult relationship? February 2011; Issue 9. Available at : www.eurofound.europa.eu

Finkelstein EA, Ruhm CJ, Kosa, KM. (2005) Economic causes and consequences of obesity. Annual Review Public Health; 26: 239-257.

References

44

IOM. For the Public’s Health: The Role of Measurement in Action and Accountability. December 2010.

IOM Living Well with Chronic Illness: A Call for Public Health Action. Jan. 31 2012 (www.iom.edu/reports/2012/living-well-with-chronic-illness.aspx)

Lahti-Koski M, Helakorpi S, Olli M, Vartiainen E, Puska P. (2012). Awareness and use of the Heart Symbol by Finnish consumers. Public Health Nutrition Mar;15(3): 476-82. Epub 2011 Aug 11.

Lemaire JB, Wallace JE, Dinsmore K, Roberts D. (2011). Food for thought: an exploratory study of how physicians experience poor workplace nutrition. Nutr J Feb 18;10(1): 18.

Mc Laren J. (1993) Creating The Health Promoting Workplace. The Scottish Office (Unpublished report).

Maes L, Van Cauwenberghe E, Van Lippevelde W, Spittaels H, De Pauw E, Oppert JM, Van Lenthe FJ, Brug J, De Bourdeaudhuij I. (2011). Effectiveness of workplace interventions in Europe promoting healthy eating: a systematic review. European Journal of Public Health. Published online July 23, 2011. doi:10.1093/eurpub/ckr098

Marmot M. Fair society, healthy lives : the Marmot review ; strategic review of health inequalities in England post-2010. [S.l.] : The Marmot Review, 2010.

Mazzuco S, Suhrcke M (2010). What does Eurostat’s Labour Force Survey say about health and health inequalities in the European Union? Copenhagen, WHO Regional Office for Europe.

Miniska I. (2010) ‘Workplace health promotion in the Mol company’, Working longer through better working conditions and new modes of work and career organization, Conference, 16-17 november 2010, Brussels, Belgium. Available at: http://www.eurofound.europa.eu/events/2010/ewcs1110/documentation.htm.

Needle JJ, Petchey RP, Benson J, Scriven A, Lawrenson J, Hilari K. The allied health professions and health promotion: a systematic literature review and narrative synthesis. Final report. NIHR Service Delivery and Organisation programme; 2011.

OECD. (2006). www.oecd.org/els/social/expenditure

Suhrke M, ArceRS, McKee M, Rocco L. (2008). The economic costs if ill health in the European Region. Copenhagen, WHO Regional Office for Europe.

45

Wanjek C. (2005) Food at work: Workplace solutions for malnutrition, obesity and chronic diseases Geneva, International Labour Office, 2005.

Weinehall L, Hellsten G, Boman K, Hallmans G. (2001). Prevention of cardiovascular disease in Sweden: The Norsjö community intervention programme --Motives, methods and intervention components. Scand J Public Health 29: 13.

WHO (2004) Battling iron deficiency anaemia, available online: http://www.who.int/nut/ida.htm.

WHO (2011) From burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle-income countries. Available through: http://www.who.int/nmh/publications/best_buys

WHO (2011). Global status report on noncommunicable diseases, 2010. Geneva, World Health Organization.

WHO (2012). Health 2020: a European policy framework supporting action across government and society for ealth and well-being. EUR/RDC62/9. WHO Regional Office for Europe; Denmark

WHO (1986). Ottawa Charter for Health Promotion. First International Conference on Health Promotion, Ottawa, 21 November 1986.

WHO (2011). Scaling up action against noncommunicable diseases: How much will it cost? Available through: http://www.who.int/nmh/publiations

WHO/WEF (2008). Preventing noncommunicable diseases in the workplace through diet and physical activity: WHO/World Economic Forum report of a joint event. Geneva: World Health Organisation / World Economic Forum.

46

Abbreviations

AHP Allied Health Profession/Professional

BDA British Dietetic Association

BMI Body Mass Index

CDC Centres for Disease Control and Prevention

CHO carbohydrate

CPD continuing professional development

CVD cardiovascular disease

DA Dietetic Association

DM Diabetes mellitus

EC European Commission

EFAD European Federation of Associations of Dietitians

EFTA European Free Trade Association

EHN European Heart Network

ESHTE Estoril Higher School for Hotel & Tourism Studies

EU European Union

EFSA European Food Safety Authority

HP health promotion

HPC Health Professions Council

ILO International Labour Organisation

IOM Institute of Medicine of the National Academies

MDT multi-disciplinary team

NCD non-communicable disease/s

NDA National Dietetic Association/s

NGO Non-governmental Organisations

NHS National health Service

NICE National Institute for Health and Clinical Excellence

OECD Organisation for Economic Co-operation and Development

PA physical activity

PCT Primary Care Trust

PH Public Health

QoL quality of life

REE Resting energy expenditure

WEF World Economic Forum

WHO World Health Organisation

47

List of tables

Table 1 Incapacity-related spending and trends in expenditure on morbidity programmes. Table 2 Possible health benefits of workplace health promotion programmes that target physical activity, diet or both.

Table 3 Best practice in workplace HP by dietitians.

Table 4 Programmes by country.

Table 5 Findings from reviews of workplace interventions to promote physical activity and healthy eating and to prevent obesity.

Table 6 Key elements for implementation of workplace HP strategies.

List of figures

Figure 1 National level initiatives.

Figure 2 Local level initiatives.

Figure 3 FOOD PRO-FIT group.

Figure 4 Nutritional advice initiatives.

Figure 5 Weight-management initiatives.

Figure 6 Physical activity initiatives.

Figure 7 Food safety initiatives.

Acknowledgements

It is a great pleasure to acknowledge the creativity and innovations shown by all the dietitians and their host National Associations in providing the information about healthy eating initiatives in the workplace. Carole Middleton from the British Dietetic Association undertook the preliminary analysis and we are grateful to her for these insights. The University of Plymouth generously enabled the writing of this full report and the Executive Agency for Health and Consumers (EAHC) have provided support for its dissemination and promotion amongst key stakeholders. Finally we are grateful to Marcel Smeets and others who have been involved in the final layout and publication.

48

FormoreinformationaboutEFAD

JudithLiddell,Secretary-general

A Ziegeleiweg4,D-46446Emmerich(Germany)

T +49282268367

E secretariat@efad.org

I www.efad.org