The food choice at work study: effectiveness of complex workplace dietary interventions on dietary behaviours and diet-related disease risk - study protocol for a clustered controlled trial

Background: Dietary behaviour interventions have the potential to reduce diet-related disease. Ample opportunity exists to implement these interventions in the workplace. The overall aim is to assess the effectiveness and cost-effectiveness of complex dietary interventions focused on environmental dietary modification alone or in combination with nutrition education in large manufacturing workplace settings. Methods/design: A clustered controlled trial involving four large multinational manufacturing workplaces in Cork will be conducted. The complex intervention design has been developed using the Medical Research Council's framework and the National Institute for Health and Clinical Excellence (NICE) guidelines and will be reported using the TREND statement for the transparent reporting of evaluations with non-randomized designs. It will draw on a soft paternalistic 'nudge' theoretical perspective. It will draw on a soft paternalistic "nudge" theoretical perspective. Nutrition education will include three elements: group presentations, individual nutrition consultations and detailed nutrition information. Environmental dietary modification will consist of five elements: (a) restriction of fat, saturated fat, sugar and salt, (b) increase in fibre, fruit and vegetables, (c) price discounts for whole fresh fruit, (d) strategic positioning of healthier alternatives and (e) portion size control. No intervention will be offered in workplace A (control). Workplace B will receive nutrition education. Workplace C will receive nutrition education and environmental dietary modification. Workplace D will receive environmental dietary modification alone. A total of 448 participants aged 18 to 64 years will be selected randomly. All permanent, full-time employees, purchasing at least one main meal in the workplace daily, will be eligible. Changes in dietary behaviours, nutrition knowledge, health status with measurements obtained at baseline and at intervals of 3 to 4 months, 7 to 9 months and 13 to 16 months will be recorded. A process evaluation and cost-effectiveness economic evaluation will be undertaken. Discussion: A 'Food Choice at Work' toolbox (concise teaching kit to replicate the intervention) will be developed to inform and guide future researchers, workplace stakeholders, policy makers and the food industry. Trial registration: Current Controlled Trials, ISRCTN35108237.

The effect of complex workplace dietary interventions on employees dietary behaviours, nutrition knowledge and health status

Background The growing prevalence and associated burden of diet-related non-communicable diseases is a global public health concern. The environments in which people live and work influences their dietary behaviours. Aim The focus of this thesis was on the effectiveness of complex workplace dietary interventions. The comparative effectiveness of a complex workplace environmental dietary modification intervention and an educational intervention were assessed both alone and in combination relative to a control workplace setting. Methods The systematic review was guided by the PRISMA statement. In a cluster controlled trial, four workplaces were purposively allocated to control, nutrition education alone (Education), environmental dietary modification alone (Environment) and nutrition education and environmental dietary modification (Combined intervention). The interventions were guided by the MRC framework. In the control workplace, data were collected at baseline and follow-up. In the intervention related sub-study, the relationships between nutrition knowledge, diet quality and hypertension were examined. Results The systematic review provided limited evidence. In the FCW study, 850 employees aged 18-64 years were recruited at baseline with N(response rate %) in each workplace as follows: Control: 111(72%), Education: 226(71%), Environment: 113(91%), Combined intervention: 400(61%). Complete follow-up data was obtained for 517 employees (61%). There were significant positive changes in dietary intakes of saturated fat(p=0.013), salt(p=0.010) and nutrition knowledge(p=0.034) between baseline and follow-up at 7-9 months in the combined intervention versus the control workplace in the fully adjusted multivariate analysis. Small but significant changes in BMI(-1.2kg/m2 (p=0.047) were also observed in the combined intervention. In the sub-study, nutrition knowledge was positively significantly associated with diet quality and blood pressure but no evidence of a mediation effect of the DASH score was detected between nutrition knowledge and blood pressure. Conclusion This thesis provides critical evidence on the effectiveness of complex workplace dietary interventions in a manufacturing working population.

A systematic review of environmental factors and obesogenic dietary intakes among adults : are we getting closer to understanding obesogenic environments?

This study examined whether physical, social, cultural and economical environmental factors are associated with obesogenic dietary behaviours and overweight/obesity among adults. Literature searches of databases (i.e. PubMed, CSA Illumina, Web of Science, PsychInfo) identified studies examining environmental factors and the consumption of energy, fat, fibre, fruit, vegetables, sugar-sweetened drinks, meal patterns and weight status. Twenty-eight studies were in-scope, the majority (n= 16) were conducted in the USA. Weight status was consistently associated with the food environment; greater accessibility to supermarkets or less access to takeaway outlets were associated with a lower BMI or prevalence of overweight/obesity. However, obesogenic dietary behaviours did not mirror these associations; mixed associations were found between the environment and obesogenic dietary behaviours. Living in a socioeconomically-deprived area was the only environmental factor consistently associated with a number of obesogenic dietary behaviours. Associations between the environment and weight status are more consistent than that seen between the environment and dietary behaviours. The environment may play an important role in the development of overweight/obesity, however the dietary mechanisms that contribute to this remain unclear and the physical activity environment may also play an important role in weight gain, overweight and obesity.

A systematic review of studies on socioeconomic inequalities in dietary intakes associated with weight gain and overweight/obesity conducted among European adults

This Review examined socioeconomic inequalities in intakes of dietary factors associated with weight gain, overweight/obesity among adults in Europe. Literature searches of studies published between 1990 and 2007 examining socioeconomic position (SEP) and the consumption of energy, fat, fibre, fruit, vegetables, energy-rich drinks and meal patterns were conducted. Forty-seven articles met the inclusion criteria. The direction of associations between SEP and energy intakes were inconsistent. Approximately half the associations examined between SEP and fat intakes showed higher total fat intakes among socioeconomically disadvantaged groups. There was some evidence that these groups consume a diet lower in fibre. The most consistent evidence of dietary inequalities was for fruit and vegetable consumption; lower socioeconomic groups were less likely to consume fruit and vegetables. Differences in energy, fat and fibre intakes (when found) were small-to-moderate in magnitude; however, differences were moderate-to-large for fruit and vegetable intakes. Socioeconomic inequalities in the consumption of energy-rich drinks and meal patterns were relatively under-studied compared with other dietary factors. There were no regional or gender differences in the direction and magnitude of the inequalities in the dietary factors examined. The findings suggest that dietary behaviours may contribute to socioeconomic inequalities in overweight/obesity in Europe. However, there is only consistent evidence that fruit and vegetables may make an important contribution to inequalities in weight status across European regions.

Trading off dietary choices, physical exercise and cardiovascular disease risks

Despite several decades of decline, cardiovascular diseases are still the most common causes of death in Western societies. Sedentary living and high fat diets contribute to the prevalence of cardiovascular diseases. This paper analyses the trade-offs between lifestyle choices defined in terms of diet, physical activity, cost, and risk of cardiovascular disease that a representative sample of the population of Northern Ireland aged 40-65 are willing to make. Using computer assisted personal interviews, we survey 493 individuals at their homes using a Discrete Choice Experiment (DCE) questionnaire administered between February and July 2011 in Northern Ireland. Unlike most DCE studies for valuing public health programs, this questionnaire uses a tailored exercise, based on the individuals’ baseline choices. A “fat screener” module in the questionnaire links personal cardiovascular disease risk to each specific choice set in terms of dietary constituents. Individuals are informed about their real status quo risk of a fatal cardiovascular event, based on an initial set of health questions. Thus, actual risks, real diet and exercise choices are the elements that constitute the choice task. Our results show that our respondents are willing to pay for reducing mortality risk and, more importantly, are willing to change physical exercise and dietary behaviours. In particular, we find that to improve their lifestyles, overweight and obese people would be more likely to do more physical activity than to change their diets. Therefore, public policies aimed to target obesity and its related illnesses in Northern Ireland should invest public money in promoting physical activity rather than healthier diets.

Review of dietary assessment methods in public health

This report provides a descriptive summary of tools to measure dietary intake and dietary behaviours - exploring the application, reliability and validity of the various tools.

Socioeconomic differences in takeaway food consumption among adults

Background In Australia and other developed countries, there are consistent and marked socioeconomic inequalities in health. Diet is a major contributing factor to the poorer health of lower socioeconomic groups: the dietary patterns of disadvantaged groups are least consistent with dietary recommendations for the prevention of diet-related chronic diseases compared with their more advantaged counterparts. Part of the reason that lower socioeconomic groups have poorer diets may be their consumption of takeaway foods. These foods typically have nutrient contents that fail to comply with the dietary recommendations for the prevention of chronic disease and associated risk factors. A high level of takeaway food consumption, therefore, may negatively influence overall dietary intakes and, consequently, lead to adverse health outcomes. Despite this, little attention has focused on the association between socioeconomic position (SEP) and takeaway food consumption, with the limited number of studies showing mixed results. Additionally, studies have been limited by only considering a narrow range of takeaway foods and not examining how different socioeconomic groups make choices that are more (or less) consistent with dietary recommendations. While a large number of earlier studies have consistently reported socioeconomically disadvantaged groups consume a lesser amount of fruit and vegetables, there is limited knowledge about the role of takeaway food in socioeconomic variations in fruit and vegetable intake. Furthermore, no known studies have investigated why there are socioeconomic differences in takeaway food consumption. The aims of this study are to: examine takeaway food consumption and the types of takeaway food consumed (healthy and less healthy) by different socioeconomic groups, to determine whether takeaway food consumption patterns explain socioeconomic variations in fruit and vegetable intake, and investigate the role of a range of psychosocial factors in explaining the association between SEP and takeaway food consumption and the choice of takeaway food. Methods This study used two cross-sectional population-based datasets: 1) the 1995 Australian National Nutrition Survey (NNS) which was conducted among a nationally representative sample of adults aged between 25.64 years (N = 7319, 61% response rate); and 2) the Food and Lifestyle Survey (FLS) which was conducted by the candidate and was undertaken among randomly selected adults aged between 25.64 years residing in Brisbane, Australia in 2009 (N = 903, 64% response rate). The FLS extended the NNS in several ways by describing current socioeconomic differences in takeaway food consumption patterns, formally assessing the mediated effect of takeaway food consumption to socioeconomic inequalities in fruit and vegetable intake, and also investigating whether (and which) psychosocial factors contributed to the observed socioeconomic variations in takeaway food consumption patterns. Results Approximately 32% of the NNS participants consumed takeaway food in the previous 24 hours and 38% of the FLS participants reported consuming takeaway food once a week or more. The results from analyses of the NNS and the FLS were somewhat mixed; however, disadvantaged groups were likely to consume a high level of �\less healthy. takeaway food compared with their more advantaged counterparts. The lower fruit and vegetable intake among lower socioeconomic groups was partly mediated by their high consumption of �\less healthy. takeaway food. Lower socioeconomic groups were more likely to have negative meal preparation behaviours and attitudes, and weaker health and nutrition-related beliefs and knowledge. Socioeconomic differences in takeaway food consumption were partly explained by meal preparation behaviours and attitudes, and these factors along with health and nutrition-related beliefs and knowledge appeared to contribute to the socioeconomic variations in choice of takeaway foods. Conclusion This thesis enhances our understanding of socioeconomic differences in dietary behaviours and the potential pathways by describing takeaway food consumption patterns by SEP, explaining the role of takeaway food consumption in socioeconomic inequalities in fruit and vegetable intake, and identifying the potential impact of psychosocial factors on socioeconomic differences in takeaway food consumption and the choice of takeaway food. Some important evidence is also provided for developing policies and effective intervention programs to improve the diet quality of the population, especially among lower socioeconomic groups. This thesis concludes with a discussion of a number of recommendations about future research and strategies to improve the dietary intake of the whole population, and especially among disadvantaged groups.

Using photography in ‘The Restaurant of the Future’. A useful way to assess portion selection and plate cleaning?

Laboratory-based studies of human dietary behaviour benefit from highly controlled conditions; however, this approach can lack ecological validity. Identifying a reliable method to capture and quantify natural dietary behaviours represents an important challenge for researchers. In this study, we scrutinised cafeteria-style meals in the ‘Restaurant of the Future.’ Self-selected meals were weighed and photographed, both before and after consumption. Using standard portions of the same foods, these images were independently coded to produce accurate and reliable estimates of (i) initial self-served portions, and (ii) food remaining at the end of the meal. Plate cleaning was extremely common; in 86% of meals at least 90% of self-selected calories were consumed. Males ate a greater proportion of their self-selected meals than did females. Finally, when participants visited the restaurant more than once, the correspondence between selected portions was better predicted by the weight of the meal than by its energy content. These findings illustrate the potential benefits of meal photography in this context. However, they also highlight significant limitations, in particular, the need to exclude large amounts of data when one food obscures another.

Impact of a school-based food garden on attitudes and identification skills regarding vegetables and fruit : a 12-month intervention trial

Objective To determine changes in ability to identify specific vegetables and fruits, and attitudes towards vegetables and fruit, associated with the introduction of a school-based food garden. Design A 12-month intervention trial using a historical control (control n 132, intervention n 120), class-based, self-administered questionnaires requiring one-word answers and 3-point Likert scale responses. Setting A state primary school (grades 4 to 7) in a low socio-economic area of Brisbane, Australia. Intervention The introduction of a school-based food garden, including the funding of a teacher coordinator for 11 h/week to facilitate integration of garden activities into the curriculum. Main outcome measures Ability to identify a series of vegetables and fruits, attitudes towards vegetables and fruit. Analysis Frequency distributions for each item were generated and χ2 analyses were used to determine statistical significance. Exploratory factor analysis was employed to detect major trends in data. Results The intervention led to enhanced ability to identify individual vegetables and fruits, greater attention to origins of produce (garden-grown and fresh), changes to perceived consumption of vegetables and fruits, and enhanced confidence in preparing fruit and vegetable snacks, but decreased interest in trying new fruits. Conclusions The introduction of this school-based food garden was associated with skill and attitudinal changes conducive to enhancing vegetable and fruit consumption. The ways in which such changes might impact on dietary behaviours and intake require further analysis.

Reported consumption of takeaway food and its contribution to socioeconomic inequalities in body mass index

The aim of this study was to examine whether takeaway food consumption mediated (explained) the association between socioeconomic position and body mass index (BMI). A postal-survey was conducted among 1500 randomly selected adults aged between 25 and 64 years in Brisbane, Australia during 2009 (response rate 63.7%, N=903). BMI was calculated using self-reported weight and height. Participants reported usual takeaway food consumption, and these takeaway items were categorised into "healthy" and "less healthy" choices. Socioeconomic position was ascertained by education, household income, and occupation. The mean BMI was 27.1kg/m(2) for men and 25.7kg/m(2) for women. Among men, none of the socioeconomic measures were associated with BMI. In contrast, women with diploma/vocational education (β=2.12) and high school only (β=2.60), and those who were white-collar (β=1.55) and blue-collar employees (β=2.83) had significantly greater BMI compared with their more advantaged counterparts. However, household income was not associated with BMI. Among women, the consumption of "less healthy" takeaway food mediated BMI differences between the least and most educated, and between those employed in blue collar occupations and their higher status counterparts. Decreasing the consumption of "less healthy" takeaway options may reduce socioeconomic inequalities in overweight and obesity among women but not men.

Psychological distress may affect nutrition indicators in Australian adults

- Objective The purpose of this research was to explore which demographic and health status variables moderated the relationship between psychological distress and three nutrition indicators: the consumption of fruits, vegetables and takeaway. - Method We analysed data from the 2009 Self-Reported Health Status Survey Report collected in the state of Queensland, Australia. Adults (N = 6881) reported several demographic and health status variables. Moderated logistic regression models were estimated separately for the three nutrition indicators, testing as moderators demographic (age, gender, educational attainment, household income, remoteness, and area-level socioeconomic status) and health status indicators (body mass index, high cholesterol, high blood pressure, and diabetes status). - Results Several significant interactions emerged between psychological distress, demographic (age, area-level socioeconomic status, and income level), and health status variables (body mass index, diabetes status) in predicting the nutrition indicators. Relationships between distress and the nutrition indicators were not significantly different by gender, remoteness, educational attainment, high cholesterol status, and high blood pressure status. - Conclusions The associations between psychological distress and several nutrition indicators differ amongst population subgroups. These findings suggest that in distressed adults, age, area-level socio-economic status, income level, body mass index, and diabetes status may serve as protective or risk factors through increasing or decreasing the likelihood of meeting nutritional guidelines. Public health interventions for improving dietary behaviours and nutrition may be more effective if they take into account the moderators identified in this study rather than using global interventions.

Exploring food choice as social practice : appreciating the context of family feeding in Kahnawake, Québec, Canada

De nous jours, les modèles se référant aux comportements individuels représentent la pensée dominante pour comprendre les choix alimentaires dans le domaine de la nutrition en santé publique. Ces modèles conceptualisent les choix alimentaires comme un comportement de consommation décidé de façon rationnelle par des individus, en réponse aux multiples déterminants personnels et environnementaux. Même si ces modèles sont utiles pour décrire les déterminants des comportements individuels d’alimentation, ils ne peuvent expliquer les choix alimentaires en tant que processus social façonné en fonction des individus et des lieux, dans des contextes diversifiés. Cette thèse élabore le Cadre Conceptuel sur la Pratique des Choix Alimentaires afin d’explorer les choix alimentaires comme phénomène social. En utilisant le concept de pratique sociale, les choix alimentaires des individus symbolisent une relation récursive entre la structure sociale et l’agence. Ce cadre conceptuel nous donne un moyen d’identifier les choix alimentaires comme des activités sociales modelées sur la vie de tous les jours et la constituant. Il offre des concepts pour identifier la manière dont les structures sociales renforcent les activités routinières menant aux choix alimentaires. La structure sociale est examinée en utilisant les règles et les ressources de Giddens et est opérationnalisée de la façon suivante : systèmes de significations partagées, normes sociales, ressources matérielles et ressources d'autorité qui permettent ou empêchent les choix alimentaires désirés. Les résultats empiriques de deux études présentées dans cette thèse appuient la proposition que les choix alimentaires sont des pratiques sociales. La première étude examine les pratiques de choix alimentaires au sein des familles. Nous avons identifié les choix alimentaires comme cinq activités routinières distinctes intégrées dans la vie familiale de tous les jours à partir d’analyses réalisées sur les activités d’alimentation habituelles de 20 familles avec de jeunes enfants. Notre seconde étude a élaboré les règles et les ressources des pratiques alimentaires à partir des familles de l’étude. Ensuite, nous avons analysé la façon dont les règles et les ressources pouvaient expliquer les pratiques de choix alimentaires qui sont renforcées ou limitées au sein des familles lors de la routine spécifique à la préparation des repas et de la collation. Les ressources matérielles et d'autorité suffisantes ont permis d’expliquer les pratiques de choix alimentaires qui étaient facilitées, alors que les défis pouvaient être compris comme etant reliés à des ressources limitées. Les règles pouvaient empêcher ou faciliter les pratiques de choix alimentaires par l’entremise de normes ou de significations associées à la préparation de repas. Les données empiriques provenant de cette thèse appuient les choix alimentaires comme étant des activités routinières qui sont structurées socialement et qui caractérisent les familles. Selon la théorie de la structuration de Giddens, les pratiques routinières qui persistent dans le temps forment les institutions sociales. Ainsi, les pratiques routinières de choix alimentaires façonnent les styles d’habitudes alimentaires familiales et contribuent par ailleurs à la constitution des familles elles-mêmes. Cette compréhension identifie de nouvelles directions concernant la façon dont les choix alimentaires sont conceptualisés en santé publique. Les programmes de promotion de la santé destinés à améliorer la nutrition sont des stratégies clés pour prévenir les maladies chroniques et pour améliorer la santé populationnelle. Les choix alimentaires peuvent être abordés comme des activités partagées qui décrivent des groupes sociaux et qui sont socialement structurés par des règles et des ressources présentes dans les contextes de pratiques de choix alimentaires.

Association entre l'insécurité alimentaire et les apports en nutriments chez les Premières Nations de la Colombie-Britannique

Cette étude a pour but de vérifier l’association entre l’insécurité alimentaire et les apports nutritionnels des Premières Nations vivant sur les réserves de la Colombie-Britannique, ainsi que la présence d’interactions de la nourriture traditionnelle dans la relation entre l’insécurité alimentaire et les apports nutritionnels. Un rappel de 24h et le questionnaire sur l’insécurité alimentaire du HFSSM adapté par Santé Canada provenant de la First Nations Food, Nutrition and Environment Study (FNFNES) ont servi pour les analyses statistiques chez 493 femmes et 356 hommes dans 21 communautés de Premières Nations de la Colombie-Britannique. Aucune association entre l’insécurité alimentaire et les apports nutritionnels totaux n’a été observée dans notre échantillon. Par contre, la nourriture traditionnelle interagissait dans la relation entre l’insécurité alimentaire et les apports nutritionnels pour plusieurs nutriments chez les hommes et chez les femmes. Chez les femmes, la qualité nutritionnelle pourrait jouer un rôle important dans la relation entre l’insécurité alimentaire et les apports nutritionnels. Chez les hommes, des différences dans les comportements alimentaires pourraient être associées au manque de nourriture traditionnelle chez ceux ayant manifesté une insécurité alimentaire grave. Enfin, les interactions de la nourriture traditionnelle dans la relation entre l’insécurité alimentaire et les apports nutritionnels laissent croire que les hommes et les femmes souffrant peu ou pas d’insécurité alimentaire ajoutent ce type d’alimentation à leurs apports quotidiens. À l’inverse, ceux et celles qui souffrent d’insécurité alimentaire grave utiliseraient la nourriture traditionnelle pour remplacer la nourriture commerciale.

Évolution des pratiques alimentaires en cours de vie : une étude isotopique multi-matérielle de la population du cimetière Saint-Matthew (Québec, 1771-1860)

En tant que population majoritairement immigrante, les protestants inhumés au cimetière Saint-Matthew, ville de Québec (1771-1860) ont dû s'adapter à un nouvel environnement à leur arrivée au Québec, et donc à de nouvelles ressources. Parallèlement, les 18e et 19e siècles sont marqués par un contexte socio-économique en pleine mutation avec l'arrivée graduelle de la période industrielle, et la ville de Québec, avec son contexte portuaire, a ainsi été au coeur de ces changements. L'objectif de ce mémoire est d'évaluer si la géochimie des isotopes stables appliquée à plusieurs matériaux du squelette humain (collagène et apatite de l'os, collagène de la dentine, et carbonate de l'émail) permet de mieux comprendre comment les comportements alimentaires des individus analysés provenant de ce cimetière cosmopolite (n=40) ont évolué en cours de vie. L'alimentation étant influencée par des conditions socio-économiques, culturelles et environnementales, cela peut nous informer indirectement sur les processus d'adaptation et l'identité d'un individu. C'est dans cette perspective d'écologie culturelle que nous avons interprété les données recueillies lors de ce projet, en complément aux analyses effectuées précédemment par Morland (2009) et Caron (2013). Nos résultats corroborent les tendances déjà observées, soit des pratiques alimentaires semblables à celles que l'on retrouve en Europe, et des immigrants provenant majoritairement des Îles Britanniques. Ils démontrent également une légère augmentation de la consommation de ressources C4, comme le maïs et la canne à sucre, à l'âge adulte pour 90% des individus analysés, de même qu'une baisse du niveau de protéines. Par ailleurs, les individus étudiés ont généralement eu tendance à conserver le même niveau alimentaire les uns par rapport aux autres tout au cours de leur vie, même si les pratiques étaient moins diversifiés à l'âge adulte. Finalement, on constate des similarités de comportements avec les populations irlandaises et britanniques plus pauvres durant l'enfance, alors qu'ils ressemblent davantage à ceux visibles dans la vallée laurentienne en fin de vie, notamment en ce qui concerne l'apport en protéines. Nos résultats suggèrent donc des changements alimentaires significatifs, fort possiblement liés aux processus de migration et à une adaptation constante à un nouvel environnement de la part des individus étudiés.

Risk-taking behaviours in adolescent boys and girls : sexuality and dietary health

This study examined adolescents' reported sexual and dietary health-risk behaviours and perceptions. Specifically, this study analyzed the data of 600 students (300 male~ 300 female) in grades 9, I 1, and OAC (mean, standard deviation). The mean age of the students in the sample is 16 with a standard deviation of 1.6. The study was a secondary analysis ofthe first-year data of a 3-year longitudinal study conducted by Youth Lifestyle Choices-Community University Research Alliance (YLC-CURA) on adolescents. To explore sexuality and dietary health, this study purposefully selected sections of the survey that represented sex and dieting behaviours of adolescents. Separate gender and age data analyses revealed different patterns among the variables. Specifically., findings revealed that adolescents who engaged in recent sexual activities were more likely to have a relatively more positive body image perception and were relatively more likely to engage in disordered eating. Across both genders and 3 age levels, adolescents reported that despite their unhealthy dietary habits they felt that dieting was not a high-risk behaviour. Results were discussed in terms of educational implication for sexual health programs.