Health in the Workplace - The role of the Dietitian in Europe - Edited by Kerry Yuill and Anne de Looy - Efad
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Health in the Workplace -
The role of the
Dietitian in Europe
Edited by Kerry Yuill and Anne de Looy
September 2012
1
EFAD
Health 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.
2
Foreword
Foreword
Dietitians 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
34
- Executive summary 7
1 Introduction 9
1.1 Non-communicable diseases
1.2 Healthy workers, a part of Europe’s preventive health strategy
1.3 The European working population; demographics, absence rates
1.4 Health benefits of workplace physical activity and healthy eating
programmes: European and global evidence
1.5 Economic benefits of workplace physical activity and healthy
eating programmes: Europe or European and global evidence
1.6 The role of the dietitian and other health professionals.
2 Effective strategies for Health Promotion in the workplace 17
2.1 Background
2.2 Workplace defined
2.3 Programmes by intervention setting/type
2.4 Target populations
2.5 Evaluation
2.6 Additional dietetic contributions
3 The role of stakeholders within the workplace 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 Conclusions and recommendations 41
- References 43
- List of abbreviations 46
- List of tables 47
- List of figures 47
- Acknowledgements 47
56
Executive summary
Executive summary
The 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.
78
1 Introduction
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).
91.2 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).
10Of 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).
Table 1: 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- Morbidity -% Public social
ment spending (2005) spending (2005)
Austria 2.4 221 9
Belgium 2.1 72 8
Czech Republic 2.1 355 11
Denmark 3.1 231 11
Finland 3.1 194 12
France 1.6 99 6
Germany 2.2 148 8
Greece 1.3 329 6
Hungary 0.9 190 4
Iceland 3.6 1183 22
Ireland 1.5 163 9
Italy 1.3 324 5
Luxembourg 2.5 324 11
Netherlands 4.6 303 22
Norway 4.9 960 23
Poland 2.3 821 11
Portugal 1.8 157 8
Slovak republic 1.2 672 7
Spain 2.2 103 11
Sweden 4.2 353 14
Switzerland 3.2 339 16
Turkey 0.1 232 1
UK 2.3 904 11
Source: OECD Social Expenditure database (www.oecd.org/els/social/expenditure).
111.4 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.
12Many 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.
Table 2: Possible health benefits of workplace health promotion programmes that target physical activity, diet or
both. Adapted from Chau, 2009.
Intervention Physical activity Diet Physical activity
Benefits ê weight é fruit and vegetable intake ê weight
ê BMI ê dietary fat intake ê BMI
ê percentage body fat ê weight é lifestyle behaviour
ê musculoskeletal disorders ê BMI ê NCD risk factors
é cardiorespiratory fitness é wellbeing
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).
131.5 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.
141.6 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.
1516
2 Effective strategies for HP in the workplace
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.
17Table 3: Best practice in workplace HP by dietitians
Project Title Association / Country Aim
Fit into Spring Dietitians Association of Austria Healthy diet; Increase exercise
Barnsley PCT Dining Room/Catering British Dietetic Association Develop PCT staff catering as an example
Project of healthy eating in the workplace
Project Plan for Health & Well-being British Dietetic Association Achieve minimum standards for food
Award hygiene, healthy diet, smoking cessation,
PA
Promoting a ‘Healthy Workplace’ in Brad- British Dietetic Association Promote healthier foods/drinks via
ford Hospitals NHS Foundation Trust 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 The Association of Clinical and Public Improve catering employees ‘knowledge
healthier lunch at the workplace Health Nutritionists in Finland / Finnish of food quality; Healthy diet
Heart Association
Eat Right French Association of Nutritionist Dieti- Improve knowledge re: food labeling
tians
Seeking Balance French Association of Nutritionist Dieti- Educate re:balanced diet
tians
JOB&FIT Federal Ministry of Food, Agriculture and Healthy diet at work
Consumer Protection and German Nutri-
tion Society (DGE)
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 Community Nutrition & Dietetic Service, Provide a supportive and sustainable
of HSE West HSE West, Ireland 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, Encourage healthy food choices, incorpo-
HSE West, Ireland 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 Polish Society of Dietetics Promote knowledge of human nutrition
nutrition & dietetics within the national and dietetics
forum
The efficacy of weight reduction Department of Dietetics, Warsaw Univer- Educate 7-19 year-olds on role of poor
programme for overweight and obese sity of Life Sciences nutrition and lack of PA in the develop-
people covering all age groups ment of chronic diseases and obesityTable 3: Best practice in workplace HP by dietitians
Project Title Association / Country Aim
Food 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 Promote healthy eating habits in young
Islands Dietetic Association people
Food and Catering Production Course Estoril Higher School for Hotel & Tourism Improve nutrition in food production
(Curso de Produção Alimentar em Studies
Restauração)
FOOD PRO-FIT The Official College of Dietitians – Nutri- Reformulate recipes
tionists of Balearic Islands
Healthy eating guides Spanish Dietetic Association -Balearic Promote healthy eating guidelines, con-
Islands Dietetic Association sidering cultural aspects
Strategic plan for prevention of child- Spanish Dietetic Association -Balearic Analyse factors associated with child-
hood obesity Islands Dietetic Association 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 Promote better health
Västra Götaland, Sweden
The Keyhole in restaurants Sweden Promote balanced meals in restaurants
Preventative health care for elderly Department of Food and Nutrition, Promote healthy diet to the elderly, in
citizens Umea University, Sweden collaboration with other health profes-
sionals
Student health at university Department of Food and Nutrition, Promote healthy diet to students
Umea University, Sweden
Fit at work/Fit for life Swiss Dietetic Association Ensure access to healthy meals at work.
Promoting Fruit & Vegetable Consump- Swiss Dietetic Association & Swiss Cancer Ensure daily availability of fruit & vegeta-
tion Association bles for all employees
FOOD PRO-FIT The Official College of Dietitians – Nutri- Reformulate recipes.
tionists of Balearic Islands
Healthy eating guides Spanish Dietetic Association -Balearic Promote healthy eating guidelines, con-
Islands Dietetic Association sidering cultural aspects.
Strategic plan for prevention of child- Spanish Dietetic Association -Balearic Analyse factors associated with child-
hood obesity Islands Dietetic Association 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 Promote better health.
Västra Götaland, Sweden
The Keyhole in restaurants Sweden Promote balanced meals in restaurants.
Preventative health care for elderly Department of Food and Nutrition, Promote healthy diet to the elderly, in
citizens Umea University, Sweden collaboration with other health profes-
sionals.
Student health at university Department of Food and Nutrition, Promote healthy diet to students.
Umea University, Sweden
Fit at work/Fit for life Swiss Dietetic Association Ensure access to healthy meals at work.2.2 Workplace defined
This report has included the following settings under the definition of
workplace:
• Health care - 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.
• Other public sector workers - 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.
202.3 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).
Table 4: Programmes by country
Food labelling education
Dietary (individual)
Dietary (group)
Food provision
Mental health
Anti-smoking
PA (practical)
Safe alcohol
Food safety
PA (advice)
Lifestyle
Initiative
Total
Country
Austria 1 1 1 3 6
Denmark 1 1 1 3
Finland 1 2 2 5
France 1 4 1 3 9
Germany 1 1 1 3
Greece 1 1 1 1 1 5
Holland 5 1 1 1 1 9
Ireland 4 4 1 4 13
Luxembourg 1 2 1 1 5
Norway 1 1 2
Poland 4 1 1 2 8
Portugal 2 2 2 2 1 9
Spain 1 5 2 2 1 11
Sweden 1 1 3 1 2 1 1 1 1 12
Switzerland 2 2 1 5
UK 2 2 6 2 2 2 2 1 19
212.3.1 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.
22Figure 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 Figure 1: National level initiatives (%)
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.
232.3.2 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,
Figure 2: Local level initiatives (%) 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.
24In 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.
Specific examples of the Dietetic contribution to Health in the
Workplace are provided here.
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.
252.3.6 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,
An Evaluation of the which consists of 3 elements:
Happy Heart at Work • Health checks/health awareness days
Programme
• Physical activity in the workplace
Centre for Health Promotion
Studies, National University of • Healthy Eating Award
Ireland, Galway
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
262.3.8 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)
THE FOOD PRO-FIT
• To improve the nutritional profile of products and recipes EUROPEAN PROJECT
• To facilitate the use of nutritional claims QUICK START GUIDE
• To facilitate the selection of healthy choices • Create or log in to your
account.
• To assess the impact on health
• Add a new recipe.
The online tool HANCP (Hazards Analysis and Nutritional Control Point) • Add ingredients or simply
set thresholds for SFA, free sugars and sodium, enabling the evaluation enter known nutrition values.
of nutritional risk. Reformulations allow the use of the logo FOOD PRO-
• See your analysis in real time.
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 • Print your Food Pro-Fit
assessed on 23 products in 7 food industries (3 meats, 3 dairy and 1 Certificate.
vegetarian products):12 products are in testing technology and 2 are The HANCP tool will keep your
in market; and in 10 establishments of HORECA channel (2 hotels, product or original recipe
2 hospitals 1 restaurant, 2 school catering, 1 canteen and 1 Faculty formula and the resulting
reformulations, allowing you to
school and a University hostel). The reformulated recipes are 144. The
self-monitor their nutritional risk.
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.
Figure 3: FOOD PRO-FIT group.
272.4 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.
282.4.2 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
Figure 4 & 5 : Nutritional advice initiatives
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 Figure 6: Physical activity initiatives
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.
Figure 7: Food safety initiatives
292.4.5 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).
30Table 5: Findings from reviews of workplace interventions to promote physical activity and healthy eating and to
prevent obesity.
Project Setting Association Findings
Promoting a ‘Healthy Bradford Hospitals NHS BDA Improved availability/sales of
Workplace’ in Bradford Foundation Trust ‘healthy options’. Positive feedback
Hospitals NHS Founda- from employees. Evaluation ongo-
tion Trust ing.
Heart symbol – a Food services (e.g. at The Association of Clini- Stake holders, at food industry and
tool for promoting a schools, personnel cal and Public Health catering sector, are interested in
healthier lunch at the restaurants), food ser- Nutritonists in Finland improving the nutritional quality
workplace vice employees, food / Finnish Heart Associa- of the food they serve. They are
industry tion 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 AFDN Evaluation planned in 6 months
Postale- France
Seeking Balance Adults in the workplace AFDN Improvement in healthy food
choices
JOB&FIT Employees, employers Federal Ministry of Website developed (www.jobund-
and staff canteen Food, Agriculture and fit.de), (www.in-form.de)
Consumer Protection
and German Nutrition
Society (DGE)
Food and Healthy Eat- HSE West employees Community Nutrition Recommendations being made
ing Policy for Staff of & Dietetic Service, HSE
HSE West West, Ireland
Happy Heart at Work Adults in the workplace Irish Heart Foundation No formal outcome evaluations or
Award Programme 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 Overweight/obese of Department of Dietet- Reduction in body weight, mainte-
reduction programme all ages ics. Warsaw University nance of REE, improvement in CHO
for overweight and of Life Sciences and lipid metabolism.
obese people covering
all age groups
31Table 5: Findings from reviews of workplace interventions to promote physical activity and healthy eating and to
prevent obesity.
Project Setting Association Findings
Eat Well Secondary school Spanish Dietetic Asso- 4,500 secondary school pupils
pupils ciation -Balearic Islands given healthy lifestyle advice.
Dietetic Association Parents, teachers and leisure activ-
ity monitors enabled to promote
healthy eating in school.
FOOD PRO-FIT Population The Official College of Mean reduction of risk in refor-
Dietitians – Nutrition- mulated recipes: 2.78g SFA, 6.65g
ists of Balearic Islands 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- Healthy eating guidelines used
ciation -Balearic Islands nationally. Web page developed
Dietetic Association where there is an online query
facility which is answered by dieti-
tians.
Not recorded Hospital patients, hos- Region Hospital of Focus group for food habits. Series
pital employees, local Borås, Region of Västra of public presentations regarding
population Götaland, Sweden food habits.
Fit at work/Fit for life Employee customers of Swiss Dietetic Associa- Approximately 3,000 people have
staff canteens tion the opportunity to have a healthy
meal at their place of work.
Promoting Fruit & Veg- Employees & Farmers Swiss Dietetic Asso- Daily fruit-availability for all em-
etable Consumption ciation & Swiss Cancer ployees
Association
322.6 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.
33Commitments 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.
343 The role of stakeholders within the workplace
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
35Stakeholders 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.’
36You can also read
