Challenging Dogma - Fall 2009

Thursday, December 17, 2009

A Critique of Workplace Nutrition Interventions; The Answer May Be A Free Lunch – Kerry Coughlin

Obesity represents a national health problem which is increasingly prevalent, and has several comorbidities (1). Nutrition for weight management must therefore be considered an important public health objective. Many people spend the majority of their waking hours at work which makes the workplace an appropriate setting for an intervention (2). The workplace provides public health practitioners access to a captive and steady population (3). However, many workplace nutrition interventions are flawed due to their reliance on traditional public health models which focus on individual behavior. New interventions which aim to alter the environment and encourage healthy eating must be designed in order to address the issue of obesity.
The Healthy Worker Project, which was conducted in the late 1980’s in several Minnesota worksites, is an example of a failed weight management intervention. The Project consisted of both a smoking cessation program and a weight loss program, and employee participation in either component of the Project was voluntary. Those who opted in to the weight reduction program established goals and were invited to attend classes after work hours to learn behavior modifications for weight loss. Participants also selected a dollar amount to be withheld from each paycheck, which was refunded if weight goals were met (1). This intervention focused on the goal of weight reduction, using financial incentives to encourage participants and offering classes to target individual behavior modification. The program did not produce a significant change in BMI over the 2 year study period (1) which may be attributed to the poor design of the program, based upon inappropriate methodology.
First, the Healthy Worker Project was based on the assumption that overweight employees would make the logical choice to participate in the program in an effort to manage their weight as predicted by traditional theories such as the Health Belief Model. This decision was expected based on the knowledge that obesity has a high probability of causing severe health problems. However, employees likely believed that they were not as susceptible to the comorbidities of obesity, or that their personal health outcomes would be less severe. This is due to unrealistic optimism in which people underestimate their personal health risks relative to the actual risk for each aspect considered in theories such as the Health Belief Model, including perceived susceptibility and perceived severity (4).
Due in part to this optimism, the program suffered from poor participation rates and only 16% of employees participated in the weight loss program over 2 years (1). Participation rates for workplace health initiatives generally vary from 20-60%, and yet the employees who are most at risk for adverse outcomes are least likely to participate (3). The Healthy Worker Project had some success in targeting women and professional workers in the weight loss component of the program, but many of those who participated may have been willing to purchase other weight management programs (1) so the workplace initiative did not necessarily add value.
Another barrier to participation which was not considered is that employees may have been hesitant to reveal their weight to their employer, fearing possible employment discrimination (5). Weight is often considered a private matter, and reporting one’s weight or being labeled as overweight or obese within the context of a work environment is another obstacle which may be a factor in the decision to enroll in such a program (5). Potential participants may not have been comfortable talking about their weight in real terms with their employer and coworkers.
Second, the Healthy Worker Project used financial incentives to motivate participants to lose weight, presumably to reduce the perceived barrier to weight loss as suggested by the Health Belief Model. While financial incentives may have a positive effect in the short term, they have been proven to be ineffective as a tool to promote sustained weight loss (6). Short term behavior change can rely on extrinsic motivation, but the positive behaviors will not continue when the external incentive is removed. Changing dietary habits is much more difficult than changing behaviors which only need to be performed once or twice (7), and money cannot reasonably be utilized to provide continual reinforcement.
Economic incentives rely on the concept of loss aversion, but often the loss associated with a health program such as the Healthy Worker Project is minimal when compared to fluctuations in earnings and investments (6). The amount of money deducted from the employee’s pay may not have been meaningful, and therefore was not a potential motivator. A review of studies which used money to entice weight loss found that this method does not produce results in the 12-18 month timeframe, and only modestly works in a shorter timeframe if the incentive is greater than 1.2% of personal disposable income (8). This lends further support to the idea that financial incentives are not an effective means of reducing the barrier to weight loss in the long term, and are not cost effective.
Finally, the Healthy Worker Project was not successful because it primarily targeted individual behavior rather than changing the environment which influences that behavior. While genetics plays a role in the etiology of obesity, environmental conditions can directly contribute to the expression of this predisposition by encouraging a higher level of calorie consumption than required for the maintenance of a healthy weight (9). Individual food choices are frequently not rational; eating habits are often formed in response to observations of others (10). There has been an overall increase in the caloric density of foods which are sold, which has provided a strong influence on national eating patterns (9). Therefore, interventions which target individual behavior change and ignore the overall environment are often unsuccessful.
Even if individuals change their dietary habits for a short period of time with direct support, they will frequently fall back to their former eating habits when the support is no longer provided (10). People decide what to eat several times per day, and it is unrealistic to expect that a rational decision will be made every time based on potential health outcomes as traditional public health theories would suggest.
There are other environmental factors affecting employee nutrition which were not considered by the Healthy Worker Project. In many corporate cultures, employees are often encouraged to work through their lunch break (5). Similarly, they may feel pressured to spend additional time working rather than engaging in other activities such as exercise. Longer working hours often result in uneven meal patterns, and may also prevent the enjoyment of an evening meal in a relaxed setting (9). Especially in the current economic environment, there is often a high degree of job insecurity which also contributes to poor eating habits (5). These environmental issues must be addressed in order for a workplace nutrition intervention to be successful.
An alternative workplace nutrition intervention should focus on promoting healthy behaviors, rather than concentrating on the end goal of weight reduction. The American Dietetic Association supports the goal of improving eating behaviors as a valuable health objective aside from weight loss (9). Employees are more likely to accept and actively participate in a worksite program when the intervention focuses on behaviors such as healthy eating, rather than weight reduction (5). This approach eliminates the social stigma of being labeled as overweight, and places emphasis on practicing healthy behaviors. Previous studies have identified at least a weak trend of greater success when incenting people directly for behavior change, rather than weight loss (8). Participants are motivated when an outcome measure that is entirely distinct from weight is used, such as a sense of control over eating (9). While alternative outcome measures may be more difficult to quantify, they are nevertheless more meaningful in terms of addressing the causes of obesity.
In order to design such a program, a public health practitioner should perform a needs assessment of the worksite, meeting with key stakeholders at all levels of the organization to ensure adequate representation (3). The goal of this assessment is to identify one or two behaviors which are a risk factor for obesity, and to build consensus that these behaviors are a priority, and should be targeted by the intervention. A strong sense of ownership is encouraged when a subset of the target population is included in the formation of the intervention goals (3).
The needs assessment can determine both the appropriate behavior change and corresponding outcome measure. A nutritional assessment might be used to document current meal and snack patterns (9) and identify influences of food choice and areas of opportunity. Focus groups should also aim to determine the constraints which employees perceive in adopting new behaviors such as cost, lack of time, and lack of family support (9). It may also be useful to explore possible dissatisfaction with the outcome of prior attempts at behavior change. All of this information will allow a program to be designed which is both appropriate and acceptable for the target audience.
Enthusiasm for the program can be built this way by using formative research and involving a diverse group of employees to plan an intervention which focuses on a specific healthy behavior. This method creates a small group of early adopters of change, and sets the stage for the use of theories such as Diffusion of Innovation, which can effectively introduce the change in behavior to other members of the population (11). When a program is designed to fill the gaps identified in a needs assessment, employees will perceive the offer of the program as an advantage. In turn, this influences the rate of adoption of the behavior according to Diffusion of Innovation (12). Using the collected data which is specific to the target group will ensure that the program is tailored in a way to support diffusion and increase the likelihood of success.
The needs assessment may reveal the desire for a lunch option in the workplace which is nutritionally sound, convenient, and priced competitively. At many worksites, the only available options for food purchase are the meals sold in cafeterias and snacks which may be purchased from vending machines (13). Previous policy assessments in the workplace have determined that employees would like healthier foods options offered. These meals and snacks should provide nutritional value, convenience, and be sold at a reasonable cost (5).
Using this information might lead to an intervention which targets the availability of a healthy lunch. One idea would be to invite a locally known chef to design 4-5 different lunches, each containing 400-600 kcal and meeting specified nutrient goals within a budget. The intervention would promote this lunch to employees, provide the lunch free for a brief promotional period, and then offer the meal for purchase at a competitive price. Feedback on the quality and cost of the lunch should be collected, in order to make modifications to increase acceptance.
Rather than use financial incentives to promote change, the lunch program should leverage marketing theory. This requires attention to the four “Ps”: place, product, price, and promotion (7). The place must be the worksite, in order to meet the requirement of convenience. Taste is often the most important factor in food choice (13), so the product must be high quality, and should also be visually appealing.
The price must be competitive in consideration of other lunch options which are available, including fast food. Effective dietary interventions typically seek to alter the food marketplace (7). The economic aspects of food must be considered when less healthy options such as pizza are cheaper than a healthier option such as salad (5). An intervention must find the right balance among price, taste, and convenience (14).
The lunch designed as part of the intervention should be promoted as the solution to the problem of lack of convenient and healthy food options (7). However, food labeled as “healthy” may cause consumers to feel manipulated (15), or cause them to believe it is less tasty (13) so by using a locally known chef to effectively brand the lunch, this will be avoided. For instance, the program might be called the “Todd English Lunch”. Nutrition information for the meal contents should be provided however, because supplying this information does confer an advantage when the food meets generally accepted nutrition standards (15). There is a segment of the population which has interest in reviewing specific nutrient information when available (16).
A lunch program such as the “Todd English Lunch” should also include a component which addresses the environment. In fact, environmental interventions may also be less costly and less labor intensive (13). Effective nutrition interventions should focus on the social context of eating, and it is important to understand the collective eating patterns of the group (10). There may be social norms which dictate that the employees who eat food at their desks while working are considered higher performers. Given the pressures which may exist in the workplace including high demand for productivity and job insecurity, a reasonable intervention would be to encourage employees to take a 30 minute break to enjoy the new lunch which is available, and ensure that adequate physical space exists for this activity.
Social support from coworkers can have a significant effect in adoption of eating behaviors (2). If employees begin to enjoy the “Todd English Lunch” during their break, they will encourage others to take advantage of the lunch as well, which will increase the effectiveness of the intervention. Giddens Structuration Theory emphasizes the interdependency of voluntary actions and social practices, or the rules and resources which drive social action (10). If there is a new rule established which encourages taking the time to eat lunch, and resources such as a comfortable lunch room are provided, employees will begin to take advantage of the lunch break and a new social norm will emerge.
The needs assessment may reveal other opportunities to positively impact the environment. There may be common practices such as days on which donuts or cookies are provided, or a high frequency of celebrations in which cake is served. These items might be replaced with snacks which have more nutritional value, which would preserve an opportunity for communal eating, but support overall health objectives. Employees often report battling work stress with sweet treats, using the food as a reward (5). An organization may encourage managers and peers to provide verbal encouragement and recognition to help address the need for positive reinforcement.
Strong and visible management support for a workplace nutrition initiative is required, and organization leaders can reinforce the norms of healthy eating (14). Managers should actively participate in the “Todd English Lunch” and should also seek to change the notion that skipping lunch is a marker of a productive worker. These work breaks must have management support in order to overcome the barrier to participation, especially for blue collar workers (14) who may be more concerned that their work hours and productivity are being closely monitored. Organizational support can also be demonstrated by including health related goals in the company’s overall objectives, and providing adequate financial support and staffing for worksite health programs (14).
The Healthy Worker Project failed to produce a positive effect on obesity by focusing on weight loss using financial incentives to motivate individual behavior change. The concepts used to develop this workplace nutrition program were based on flawed models including the Health Belief Model, and the social context of eating was entirely ignored. An alternative work site program should be designed using formative research, and target specific employee behaviors. This program may include the availability of a healthy lunch, which would be extensively marketed along with the encouragement to take a regular lunch break. Corporations should seek to fund this type of program which has the potential to improve employee productivity, reduce health care costs (1) and reduce the costs of employee absenteeism (3).

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