RETHINKING HEALTHY EATING

RETHINKING HEALTHY EATING IN THE WORKPLACE A Toolkit for Employers Ellen Gregg RD MSc Public Health Nutritionist Region of Waterloo Public Health C...
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RETHINKING HEALTHY EATING IN THE WORKPLACE A Toolkit for Employers

Ellen Gregg RD MSc Public Health Nutritionist Region of Waterloo Public Health

Copyright Acknowledgment Written permission is required if any adaptations or changes are made to this resource. No part of this resource may be used or reproduced for commercial purposes or to generate monetary profits. Copies of this resource, in its entirety, may be created for non-commercial use provided the source is fully acknowledged © Region of Waterloo Public Health, 2011 (updated July 2014)

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PART I

RETHINKING HEALTHY EATING IN THE WORKPLACE The Cost of Doing Nothing: The Business Case

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THE BUSINESS CASE

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Table of Contents

PART I - THE COST OF DOING NOTHING: THE BUSINESS CASE

Introduction Workplaces are often looking for ways to improve the health and quality of life for their employees. It is not uncommon for healthy eating to be listed as a top choice on employee interest surveys. The rationale for this business case is to provide evidence to workplaces on the importance of creating a supportive healthy eating environment. A supportive healthy eating environment is much more than simply making healthy choices available to employees. In a truly supportive environment, the onus is not placed on employees to consistently resist an unhealthy food environment in order to maintain good health. Instead, a supportive environment provides surroundings and conditions that foster good health and support healthy eating.

Before planning your workplace healthy eating strategy, review: PART I – ‘THE COST OF DOING NOTHING: THE BUSINESS CASE’ 

Provides information for workplaces in Waterloo Region about the benefits of creating a comprehensive workplace healthy eating strategy.



Outlines the current costs of unhealthy eating for workplaces.

PART II – ‘EXAMINING THE EVIDENCE: ADDRESSING THE LIMITATIONS OF CURRENT INTERVENTIONS’ 

Presents an overview of the current evidence on the barriers individuals face when trying to maintain healthy eating behaviours.

PART III – ‘MAKING THE SHIFT: COMPREHENSIVE STRATEGIES TO PROMOTE HEALTHY EATING’ 

Guides workplaces in planning, implementing and evaluating evidencebased comprehensive healthy eating strategies.

This resource can be downloaded from: http://www.projecthealth.ca under ‘Toolkits’. For more information or to schedule a consultation, please call: 519-575-4400 or visit: http://www.projecthealth.ca. TTY phone line: 519-575-4608.

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Healthy eating refers to following the recommendations in Canada’s Food Guide, which describes the type and amount of food people need to eat to support good health.1 Following the recommendations in Canada’s Food Guide will help your employees get enough vitamins, minerals and other nutrients, as well as reduce the risk of developing nutrition-related chronic disease.1 Canada’s Food Guide recommends the average number of servings from each food group that Canadians should try to eat each day.1 All Canadians are encouraged to consume more vegetables, fruit and whole grains while limiting or avoiding food and beverages that contain trans fat or that have high levels of added fat, sugar and salt.1 Canada’s Food Guide recommends limiting food and beverages that are high in calories,

fat, sugar and salt such as: cakes, pastries, chocolate, candies, cookies, granola bars, doughnuts, muffins, ice cream, frozen desserts, french fries, potato chips, nachos, salty snacks, alcohol, fruit flavoured drinks, soft drinks, sports drinks, energy drinks and sweetened hot and cold drinks.1 Consuming these “Foods to Limit” on a regular basis means that nutritious foods are displaced from the diet and that individuals are eating too many foods high in calories, fat, sugar or salt, which can contribute to the development of chronic disease. Canada’s Food Guide also recommends drinking water regularly to meet hydration needs. Additional water is needed during hot weather or when employees are physically active.1 Some very active individuals may require more calories and should eat extra servings of food from the four food groups.1

Tools: CANADA’S FOOD GUIDE Visit the Health Canada website for tools that will help your employees follow Canada’s Food Guide http://healthcanada.gc.ca/foodguide.

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Business Case

What is Healthy Eating?

Who is at Risk for Nutrition-Related Chronic Disease? Virtually all Canadians require significant improvements to their dietary intakes. Less than one per cent of Canadians follow a diet consistent with Canada’s Food Guide.2

Overall, Canadians’ diets scored a 58.8 on the Healthy Eating Index with 50 being the cut off for ‘poor diet’ and above 80 being the cut off for ‘good diet’.2 This indicates that the average Canadian diet is much closer to the ‘poor’ diet category than to the ‘good’ diet category.2

The Business Case for Healthy Eating Healthy Eating: A Health and Safety Issue Healthy eating is associated with a lower risk of developing chronic diseases such as obesity, type 2 diabetes, certain types of cancer, heart disease and osteoporosis.1 In addition, healthy eating can contribute to the overall health and vitality of employees.1 Most employed Canadian adults spend at least 60% of their waking hours at work.3 This makes the workplace an ideal setting to promote healthy eating. Workplace environments that support healthy eating may be particularly effective to reach worksite populations typically resistant to health education since employees do not have to actively choose to participate.4-6 An example of this includes reducing employee exposure to food and beverages described as “Foods to Limit” by Canada’s Food Guide.1

Historically, workplaces have taken responsibility for removing environmental safety hazards in the workplace, while the onus has been on employees to be responsible for maintain a healthy diet.4 However, the workplace food environment and the demands of work may negatively impact eating and physical activity behaviours, which may lead to employees developing nutrition-related chronic diseases.4 Employees who have the benefit of optimal health are more likely to be at work and perform well.7 They are also more likely to remain with an employer who values their health.8 Employers should consider the resources spent to improve the productivity and health of employees similar to how they would consider investments in workplace facilities.8-10 After all, investing in healthy eating helps to protect the vitality of a workplace’s greatest assets, its employees!

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Employer Costs Related to Chronic Disease The presence of chronic diseases among employees creates a burden on workplaces in terms of depleting human resources and increasing financial losses related to increased medical expenses, drug costs, higher rates of injury, disability and workers compensation, increased absenteeism, decreased productivity, higher insurance costs, higher rates of employee turnover and early retirement.4,5,11-23 When individuals have a chronic medical condition they often have mental health issues such as depression that either preceded the condition or has occurred as a result of having a chronic disease.24,25 As a result, mental health issues related to the development of chronic disease may also increase workplace costs.23

Overall Costs Overall workplace financial losses related to chronic disease range from as low as a few hundred dollars22,23,26,27 to several thousand dollars affected employee per year, (i.e., combined costs of $3000 to $15000 higher than employees without chronic health conditions).20,23,28,29 A supportive healthy eating environment may prevent employees from developing chronic diseases and may also assist individuals who have chronic disease to manage their conditions, both of which will help to contain health-related workplace expenditures.

Workplace Example: Scotiabank In 2001, none of the top 10 drugs covered by Scotiabank’s drug plan were related to poor diet quality. By 2007, three of the top 10 prescription drugs were for medical conditions related to poor diet quality. To address this growing problem Scotiabank has created a supportive environment by implementing healthier menus, setting nutrition guidelines for food and beverages served at work functions and by providing nutrition counselling for employees.30 Project Health – Healthy Eating Business Case for Employers

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Promoting Healthy Eating in the Workplace The goal of your healthy eating initiative should be to help your employees to follow Canada’s Food Guide, which translates the science of nutrition and health into a healthy eating pattern.1 By following Canada’s Food Guide, employees will be able to meet their nutrient needs and reduce their risk of developing nutrition-related chronic diseases.

Creating a supportive healthy eating environment may also help individuals who have developed chronic diseases to manage their conditions. In addition to providing awareness raising and skill building activities in the workplace, dietary improvements can be achieved by:   

Offering more vegetables, fruit and whole grains Reducing the sodium, sugar and trans fat content in food offerings Limiting “Foods to Limit” in the workplace

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What about personal ‘choice’? Often the argument against limiting certain food and beverages is that “people need to have choices.” This feeling is especially strong when it comes to food. However, is it an individual’s personal right to have less healthy food options available to them in the workplace? Workplaces should not feel obligated to offer “Foods to Limit” to their employees. Employees always have the right to pack preferred food options in their lunch bag or to purchase food from other locations. Therefore, by not offering some choices you will not violate anyone’s personal rights to choose what they eat. People by nature are not fond of changes, especially imposed changes.31 As a result, when making any changes in the workplace, it should be expected that there will be some opposition. It is possible that the individuals who are most opposed to changes are in the minority. By using workplace committees and conducting needs assessments, you can involve stakeholders in decision-making and give all employees an equal opportunity to identify their personal preferences and priorities. Studies on choices show that people most often make day-to-day choices that serve a purpose such as providing energy or nutrition,

(e.g., what to have for lunch at work).32-34 This may mean that people accept having choices in the workplace limited to more nutritious food and beverages. However, when people have expectations of fun, excitement or reward attached to food occasions, they tend to desire and expect more indulgent food choices.32-34 When offered indulgent choices, people often look for reasons to justify making a more indulgent choice (e.g., “it was a hard day at work today”, or “I’m going to the gym later”).34 Many people struggle to make healthy choices when offered tempting food options.32,35-38 These people will benefit the most from interventions that reduce exposure to tempting food. In studies that used focus groups to ask employees what changes should be made to their work environment, it has been individuals in management positions who are most reluctant to limit the types of food and beverages offered to employees.37,39 Some employees may also be initially resistant to the idea of not being offered “Foods to Limit”, however, in time they will probably adjust to changes as long as they have a reasonable amount of healthy choices that are tasty, appealing and reasonably priced.33,40

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Return on Investment (ROI) A systematic review of nutrition focused workplace health promotion programs found a return on investment in some studies but not others.41,42 The majority of healthy eating interventions have included health-related print materials, emails and websites; healthy eating challenges; incentives; group or one-on-one education; point-of-purchase messages; health screening and referrals; and environmental support strategies such as offering healthier options in cafeterias and vending machines. These strategies focus most on changing individual behaviours. Workplace wellness programs in general, have been shown to reduce medical costs by about $3.27 and absenteeism costs by about $2.73 for every dollar spent.42,43

Considerations: Although some studies have shown a positive ROI, none have investigated long term effects. It is not clear if ROI is ongoing over several years or if the interventions have a diminishing effectiveness over time. Also, it may be difficult to evaluate ROI data. For example, absenteeism may be influenced by several variables; not solely related to sickness, such as job satisfaction or work/life conflicts, making it a less than perfect measure of the effectiveness of healthy eating interventions.44 Therefore, it is important to evaluate several aspects of your healthy eating initiative in order to determine its effectiveness.

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Business Case References 1. Health Canada. Eating Well with Canada's Food Guide: A resource for educators and communicators. Ottawa: Health Canada; 2007. 2. Garriguet D. Diet quality in Canada. Health Rep 2009 Sep;20(3):41-52. 3. Health Canada. Workplace health system: Overview booklet. Ottawa: ON. 2004. 4. Schulte PA, Wagner GR, Ostry A, Blancforti LA, Cutlip RG, Krajnak KM, et al. Work, obesity, and occupational safety and health. Am J Public Health 2007;97(3):428-436. 5. Thompson DL. The costs of obesity: What occupational health nurses need to know. AAOHN J 2007 Jul;55(7):265-270. 6. Biener L, Glanz K, McLerran D, Sorensen G, Thompson B, Basen-Engquist K, et al. Impact of the Working Well Trial on the worksite smoking and nutrition environment. Health Educ Behav 1999 Aug;26(4):478-494. 7. Wolf AM, Woodworth KA. Obesity prevention: Recommended strategies and challenges. Am J Med 2009;122:S19-S23. 8. Hawkins C, O’Garro MA, Wilmsett K. Engaging employers to develop healthy workplaces: The Workwell Initiative of Steps to a Healthier Washington in Thurston County. Prev Chronic Dis 2009;6(2):1-7. 9. Goetzel RZ, Ozminkowski RJ, Baase CM, Billotti GM. Estimating the return-on-investment from changes in employee health risks on the Dow Chemical Company’s health care costs. J Environ Med 2005;47(8):759-768. 10. Raulio S, Roos E, Mukala K, Prattala R. Can working conditions explain differences in eating patterns during working hours? Public Health Nutr 2008 Mar;11(3):258-270. 11. J. Park. Obesity on the job. 2009. 12. Cawley J, Rizzo JA, Haas K. Occupation-specific absenteeism costs associated with obesity and Grade III obesity. J Occup Environ Med 2007;49(12):1317-1324. 13. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health 2008;29:303-323. 14. Ostbye T, Dement JM, Krause KM. Obesity and workers' compensation: Results from the Duke Health and Safety Surveillance System. Arch Intern Med 2007 Apr 23;167(8):766-773. 15. Renaud L, Kishchuk N, Juneau M, Nigam A, Tereault K, Leblanc MC. Implementation and outcomes of a comprehensive worksite health promotion program. Can J Public Health 2008 Jan-Feb;99(1):73-77. 16. Pollack KM, Sorock GS, Slade MD, Cantley L, Sircar K, Taiwo O, et al. Association between body mass index and acute traumatic workplace injury in hourly manufacturing employees. Am J Epidemiol 2007 Jul 15;166(2):204-211. 17. Arena VC, Padiyar KR, Burton WN, Schwerha JJ. The impact of body mass index on short-term disability in the workplace. J Occup Environ Med 2006 Nov;48(11):1118-1124.

18. Henke RM, Carls GS, Short ME, Pei X, Wang S, Moley S, et al. The relationship between health risks and health and productivity costs among employees at Pepsi Bottling Group. J Occup Environ Med 2010 May;52(5):519-527. 19. Henke RM, Goetzel RZ, McHugh J, Isaac F. Recent experience in health promotion at Johnson & Johnson: Lower health spending, strong return on investment. Health Aff (Millwood) 2011 Mar;30(3):490-499. 20. Burton WN, Chen CY, Schultz AB, Edington DW. The prevalence of metabolic syndrome in an employed population and the impact on health and productivity. J Occup Environ Med 2008 Oct;50(10):1139-1148. 21. Goetzel RZ, Carls GS, Wang S, Kelly E, Mauceri E, Columbus D, et al. The relationship between modifiable health risk factors and medical expenditures, absenteeism, short-term disability, and presenteeism among employees at Novartis. J Occup Environ Med 2009 Apr;51(4):487-499. 22. Schultz AB, Chen CY, Edington DW. The cost and impact of health conditions on presenteeism to employers: A review of the literature. Pharmacoeconomics 2009;27(5):365-378. 23. Goetzel RZ, Long SR, Ozminkowski RJ, Hawkins K, Wang S, Lynch W. Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers. J Occup Environ Med 2004 Apr;46(4):398-412. 24. Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis 2005 Jan;2(1):A14. 25. Anesetti-Rothermel A, Sambamoorthi U. Physical and mental illness burden: Disability days among working adults. Popul Health Manag 2011 Apr 20. 26. Benedict MA, Arterburn D. Worksite-based weight loss programs: A systematic review of recent literature. Am J Health Promot 2008 Jul-Aug;22(6):408-416. 27. Schultz AB, Edington DW. Metabolic syndrome in a workplace: Prevalence, co-morbidities, and economic impact. Metab Syndr Relat Disord 2009 Oct;7(5):459468. 28. American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care 2008;31:596615. 29. Sasser AC, Rousculp MD, Birnbaum HG, Oster EF, Lufkin E, Mallet D. Economic burden of osteoporosis, breast cancer, and cardiovascular disease among postmenopausal women in an employed population. Womens Health Issues 2005 May-Jun;15(3):97-108. 30. Thanasse L. HR leaders talk: Obesity in the workplace. Canadian HRReporter 2009 January 26, 2009. 31. Fleming SM, Thomas CL, Dolan RJ. Overcoming status quo bias in the human brain. Proc Natl Acad Sci U S A 2010 Mar 30;107(13):6005-6009. 32. Weijzen PL, de Graaf C, Dijksterhuis GB. Discrepancy between snack choice intentions and behavior. J Nutr Educ Behav 2008 Sep-Oct;40(5):311316.

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33. Botti S, McGill AS. The locus of choice: Personal causality and satisfaction with hedonic and utilitarian decisions. The Journal of Consumer Research 2011;37(6):1065-1078.

39. Gates D, Brehm B, Hutton S, Singler M, Poeppelman A. Changing the work environment to promote wellness: A focus group study. AAOHN J 2006 Dec;54(12):515520.

34. Sela A, Berger J, Liu W. Variety, vice, and virtue: How assortment size influences option choice. Journal of Consumer Research 2009;35(6):941-951.

40. Stice E, Yokum S, Blum K, Bohon C. Weight gain is associated with reduced striatal response to palatable food. J Neurosci 2010 Sep 29;30(39):13105-13109.

35. Bryant EJ, King NA, Blundell JE. Disinhibition: Its effects on appetite and weight regulation. Obes Rev 2008 Sep;9(5):409-419. 36. Zimmerman FJ. Using marketing muscle to sell fat: The rise of obesity in the modern economy. Annu Rev Public Health 2011 Apr 21;32:285-306.

41. van Dongen JM, Proper KI, van Wier MF, van der Beek AJ, Bongers PM, van Mechelen W, et al. Systematic review on the financial return of worksite health promotion programmes aimed at improving nutrition and/or increasing physical activity. Obes Rev 2011 Dec;12(12):1031-1049.

37. Devine CM, Nelson JA, Chin N, Dozier A, Fernandez ID. "Pizza is cheaper than salad": Assessing workers' views for an environmental food intervention. Obesity (Silver Spring) 2007 Nov;15 Suppl 1:57S-68S.

42. Ontario Society of Nutrition Professionals in Public Health Workplace Nutrition Advisory Group. Call to action: Creating a healthy workplace nutrition environment. 2012.

38. Wilcox K, Vallen B, Block L, Fitzsimons GJ. Vicarious goal fulfillment: When the mere presence of a healthy option leads to an ironically indulgent decision. Journal of Consumer Research 2009;36:380-393.

43. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Affairs 2010;29(2):1-8. 44. Wolf K. Health and productivity management in Europe. International Journal of Workplace Health Management 2008;1(2):136-144.

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PART II

RETHINKING HEALTHY EATING IN THE WORKPLACE Examining the Evidence: Addressing the Limitations of Current Interventions

ADDRESSING THE LIMITATIONS OF CURRENT INTERVENTIONS 2.0

MAKING CHANGES

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3.0

BARRIERS TO HEALTHY EATING

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4.0

CONCLUSION

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Table of Contents

PART II - EXAMINING THE EVIDENCE:

Introduction Is it time for change? Despite education efforts to promote healthy eating, eating habits do not seem to be improving. There is also evidence that current methods to promote healthy eating and healthy weights may be doing some harm (e.g., lowering self-esteem, creating weight bias, increasing disordered eating). Good decisions are based on good information. Before taking action to promote healthy eating in your workplace, consider the information in this resource. PART II - EXAMINING THE EVIDENCE: ADDRESSING THE LIMITATIONS OF CURRENT INTERVENTIONS: 

Makes the case that healthy eating is not just an individual issue.



Highlights the current barriers to healthy eating in a workplace context.

The previous section PART I – ‘THE COST OF DOING NOTHING: THE BUSINESS CASE’ 

Outlined the current costs of unhealthy eating for workplaces.

The next section: PART III – ‘MAKING THE SHIFT: COMPREHENSIVE STRATEGIES TO PROMOTE HEALTHY EATING’ 

Guides workplaces in planning, implementing and evaluating evidence-based comprehensive healthy eating strategies.

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Canadians say that nutrition is an important factor in their food choices; however, this is not reflected in their actual food choices.1 Eating habits have been getting worse over the years, despite efforts and campaigns aimed at helping people to make healthy choices.2

Healthy Eating Toolkit for Workplaces

We often think of eating as a personal choice which can be influenced by education and individual counselling. Nutrition education can improve nutrition knowledge; however, it does not necessarily influence food choices.3-6

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Making Changes

Can People Change?

Why Do People Resist Change? Workplaces often report that employee resistance is one of the major barriers to making changes in the workplace. Unfortunately, people are often opposed to changes in the food environment because food choice is considered to be a personal responsibility. Lack of willpower is a common explanation for failing to maintain a healthy diet.4 However, food and eating decisions involve a very complex mix of social, psychological, physiological and environmental factors, most of which affect us without our conscious awareness. Awareness-raising efforts are often directed at individual behaviour change. As a result, most people attribute the development of nutrition related chronic conditions to individual lifestyle factors and are resistant to interventions and policies meant to address the unhealthy food available in the environment. Typically, such initiatives are perceived as “taking away choices.”7 However, an environment with an increased availability of inexpensive (or free), convenient, calorie-dense foods is most likely the reason that the population continues to consume less healthy food and beverages.4

Healthy Eating Toolkit for Workplaces

Weight Bias The belief that weight is easily modifiable and weight loss is a matter of personal effort and self-control is shared by the media, regulatory agencies, consumer groups and health practitioners.6,8,9 As a result, people who are overweight or obese are stigmatized, ridiculed and discriminated against in our society, which lowers the quality of life for overweight and obese individuals.9-12 In the workplace, overweight and obese workers can face disadvantages in wages, hiring, promotions and job termination because of their weight status.9-11,13-17 Negative attitudes toward overweight individuals are accepted and sometimes encouraged. It is even common in popular media to make fun of overweight characters.14 In addition, it is not uncommon for overweight and obese individuals to describe other overweight individuals as stupid, unmotivated and lazy.13,14 People struggling with their weight often internalize this weight bias and believe that they simply lack the motivation and willpower to overcome their weight problem. When overweight people try and fail to lose weight, they reinforce these stereotypes to themselves and others.14

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Unfortunately, individuals who experience weight stigma are more likely to engage in binge eating, maladaptive eating behaviours and low levels of physical activity.13 Therefore, the stigma due to weight bias may actually contribute to the risk of becoming obese.18 Individuals facing weight stigma are also at a higher risk of low selfesteem, depression and suicide.13 Weight bias may be the result of another bias known as the ‘just world’ bias – which implies that people "get what they deserve" and that “there is a reason for everything.”13,15 In a ‘just world’, hard work results in success, meaning that any failure is likely the fault of the individual.15 As a result, we rely on education and individual behaviour change initiatives to help individuals lose weight. We expect that this is enough to address the problem, while disregarding the need to change the external factors that influence eating habits.15

Reducing Weight Bias Unfortunately, when people are educated on lifestyle aspects of weight gain alone (i.e., individual responsibility for diet and exercise), they tend to display higher rates of weight bias.7 However, education on environmental, genetic and social influences on weight status decreases the belief that obesity is solely an individual issue and increases support for initiatives addressing supportive environments and policy development.16,17,19,20

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Making Changes References 1. Hamelin AM, Lamontagne C, Ouellet D, Pouliot N, O'Brien HT. Healthful eating: Beyond food, a global concept. Can J Diet Pract Res 2010 Summer;71(2):98.

12. MacLean L, Edwards N, Garrard M, Sims-Jones N, Clinton K, Ashley L. Obesity, stigma and public health planning. Health Promot Int 2009 Mar;24(1):88-93.

2. Slater J, Green CG, Sevenhuysen G, Edginton B, O'Neil J, Heasman M. The growing Canadian energy gap: More the can than the couch? Public Health Nutr 2009 Nov;12(11):2216-2224.

13. Puhl RM, Heuer CA. Public opinion about laws to prohibit weight discrimination in the United States. Obesity (Silver Spring) 2011 Jan;19(1):74-82.

3. Chandon P, Wansink B. The biasing health halos of fast-food restaurant health claims: Lower calorie estimates and higher side-dish consumption intentions. Journal of Consumer Research 2007 October 2007;34:301-314. 4. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis 2008 Jan;5(1):A23. 5. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point-of-purchase behavior in adults: A review. Prev Med 2004 Sep;39 Suppl 2:S108-36. 6. Wansink B, Huckabee M. De-marketing obesity. California Management Review 2005 Summer 2005;47(4):1-13. 7. Tillotson JE. America's obesity: Conflicting public policies, industrial economic development, and unintended human consequences. Annu Rev Nutr 2004;24:617-643. 8. Brownell KD, Kersh R, Ludwig DS, Post RC, Puhl RM, Schwartz MB, et al. Personal responsibility and obesity: A constructive approach to a controversial issue. Health Aff (Millwood) 2010 Mar-Apr;29(3):379387. 9. Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity (Silver Spring) 2009 May 2009;17(5):941-964.

14. Wang SS, Brownell KD, Wadden TA. The influence of the stigma of obesity on overweight individuals. Int J Obes Relat Metab Disord 2004 Oct;28(10):1333-1337. 15. Puhl RM, Brownell KD. Psychosocial origins of obesity stigma: Toward changing a powerful and pervasive bias. Obes Rev 2003 Nov;4(4):213-227. 16. O'Brien KS, Puhl RM, Latner JD, Mir AS, Hunter JA. Reducing anti-fat prejudice in preservice health students: A randomized trial. Obesity (Silver Spring) 2010 Nov;18(11):2138-2144. 17. Harris JL, Bargh JA, Brownell KD. Priming effects of television food advertising on eating behavior. Health Psychol 2009 Jul;28(4):404-413. 18. Klarenbach S, Padwal R, Chuck A, Jacobs P. Population-based analysis of obesity and workforce participation. Obesity (Silver Spring) 2006 May;14(5):920-927. 19. Alvaro C, Jackson LA, Kirk S, McHugh TL, Hughes J, Chircop A, et al. Moving governmental policies beyond a focus on individual lifestyle: Some insights from complexity and critical theories. Health Promot Int 2010 Aug 13. 20. Barry CL, Brescoll VL, Brownell KD, Schlesinger M. Obesity metaphors: How beliefs about the causes of obesity affect support for public policy. Milbank Q 2009 Mar;87(1):7-47.

10. Judge TA, Cable DM. When it comes to pay, do the thin win? The effect of weight on pay for men and women. J Appl Psychol 2010 Sep 20. 11. Schulte PA, Wagner GR, Ostry A, Blancforti LA, Cutlip RG, Krajnak KM, et al. Work, obesity, and occupational safety and health. Am J Public Health 2007;97(3):428-436.

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Food Availability

Taste and Price

There were up to 530 more calories available for each Canadian to consume in 2002 than there were in 1985.1

Taste is the most important factor influencing food choice, followed by food cost.2-9 Studies show that price modifications are more effective than educational health messages to motivate people to purchase healthier foods.6,10

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Barriers to Healthy Eating

How the Environment Impacts Individual Choice

Portion Sizes Portion size appears to be a major factor for how much food people consume; as the amount of food served suggests that it is an appropriate amount to eat.9,11-14 Educating people about the effects of portion size seems to have little to no effect on their food consumption.15 In an experiment, a group of university graduate students were educated on the effects of portion sizes on food consumption. Six weeks later these students were invited to a party where they knew they would be part of a study. The students were divided into two groups, with each group receiving different sized bowls. The students were allowed to consume as many snacks as they wanted. The group with the larger bowls served themselves 55 per cent more food compared to the group with smaller bowls. When the students were informed of this effect, the typical response was “maybe that happens to other people, but not to me”.16

Food For Thought: PORTION SIZE People who are served larger portion sizes consume more food but do not report greater feelings of fullness. This is true even when it involves food that tastes bad. In one study, people were given stale 14-day old popcorn in boxes twice the normal size. Even though they complained about the taste, the participants who were given the larger boxes of stale popcorn ate 34 per cent more popcorn than participants given stale popcorn in normal sized boxes.12 The bottom line: Larger portion sizes cause people to eat more

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Television, Media and Advertising The nutrient content of the majority of advertised foods goes against nutrition education and guidelines and may encourage the development of chronic disease.17 The pattern of nutrition imbalance found in advertised food mimics the pattern of imbalance in the common North American diet, leading researchers to believe that television commercials have a direct impact on what consumers eat. Approximately 85 per cent of foods advertised in Canada are for food and beverages designated as “Foods to Limit” by Canada’s Food Guide.18 Social modelling theory predicts that we will mimic the behaviours of other people. This effect was shown when people watched soft

drinks commercials and then drank more pop.19 Similar effects have also been shown after people are shown fast food commercials.20 Advertised foods do not have to be present in order to have an effect. Adults shown food commercials ate more food overall even though the food they ate was not presented in any advertisements they watched.31 Food commercials may act as a stimulus that can trigger a desire to eat, even when the viewer is not hungry.21 Other forms of advertising such as brand logos may also act as food cues, which can also subsequently affect food consumption patterns.21

Convenience “Effort is not required to continue eating when food is present; effort is required to refrain from eating when food is present.”12 Many studies have examined the relationship between the food environment and weight. A high ratio of fast food restaurants and convenience stores in a neighbourhood is associated with increased weight.22-25 The availability of poor nutritional choices has a profound impact on what people eat.26 For example, many stores sell unhealthy ‘snack’ foods placed near the cash register.26

The mere presence of convenient ready-toeat foods increases the likelihood that people will consume them, leading to higher overall energy intakes.26 Therefore, the impact of vending machines, food in common areas and foods placed at influential locations such as near cash registers in cafeteria lines should be carefully considered.

Food For Thought: THE LAW OF LEAST EFFORT In one study, secretaries who had chocolates placed on their desk ate twice as many as secretaries that had chocolates placed only six feet away.27 The bottom line: As effort goes up, food consumption goes down.

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Time Pressures Forty-one per cent of Canadians say that their life is so hectic that they find it hard to include healthier foods in their diets.28 The feeling that there is not enough time in the day to do everything has been implicated in the decline of family meals and the increased consumption of convenience and fast foods.29,30 When asked, people admitted making ‘quick’ foods because they did not have the time or energy to cook, despite knowing that it was not ‘good’ for them.29

Common barriers to making family meals include: being a single parent, working an inflexible job and working a schedule that interferes with family time such as evening and night shifts.29 People are more likely to cook meals at home if they have cooking skills and flexible or reduced work schedules (i.e., they can be home in the afternoon).29,30

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Point-of-Purchase Nutrition Information Providing nutrition information when people are making food decisions gives consumers an opportunity to improve their diet quality.2,31-34 However, nutrition information has to be readily available at the point-of-purchase, as only 0.1 per cent of people look for nutrition information before making their purchase. Websites, pamphlets and tray liners are not an effective format to promote behaviour change.35 In order to prevent indulgence at a later point in the day, it is also important that nutrition information be provided along with an average estimate of how many calories people need for the day.36,37 For example, “this menu item has 500 calories; the average person needs 2000 calories a day.” Consumers welcome information in the form of nutrition labels and logos.38 However, providing nutrition information is not always an effective way to improve dietary intakes.3,13,39-41

Most Canadians report being interested in nutrition, however, 61 per cent think that there are so many different things to consider when buying foods, (e.g., fat, trans fat, sugar, calories, fibre, locally produced, organic, etc.), that it is impossible for an ordinary person to figure out what to eat.28 Consumers report that nutrition logos assigned to products that meet specific nutrition criteria influence their food choices.42 However, studies on this type of labelling fail to show substantial positive effects on actual food choice when logos are placed on healthier food items.43 To complicate matters, nutrition labels are not always accurate. One study analyzed foods in a lab found that the calorie content of packaged food was an average of 18 per cent higher than what was stated on the label.44 Therefore, providing nutrition information is probably not effective as a stand-alone intervention but may be useful as part of a comprehensive strategy.13

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Stress A stressful work environment where workers experience high demand, low job control and low social support can negatively influence eating behaviours and often leads to skipping meals, eating at workstations, extra snacking and a preference for calorie dense foods.11,45,46 In this type of work environment, health problems are more likely to occur.11,47,48

“It’s like a quick pat on the shoulder or something like that. You’ve kept up with your day; you’ve done a great job, here have a cookie”.11 - Manufacturing Worker

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Social Norms and Cues Eating food with other people can create a sense of belonging and social norms can dictate individual behaviours.49,50 Therefore, individual employee behaviour can be influenced by the health-related norms and values of other co-workers.47,51 Having other people present while eating can influence both the amount and types of food people eat. Eating with others, especially familiar people, can extend eating occasions and suppress self-monitoring.14 Individuals use social cues to decide what to eat and how much to eat without attracting

negative judgment from others.52,53 It has been shown that individuals will eat more when eating companions eat more and vice versa.54 This effect can be profound, with one researcher finding that meal size almost doubled when subjects ate with seven or more people.14 Work related activities that revolve around eating and drinking can promote poor diet quality. Such activities include workplace celebrations, fundraisers, social events and entertaining clients.24

Food For Thought: SOCIAL INFLUENCE In one study, two different bowls of crackers were provided to participants. Subjects unknowingly copied another person’s behaviour by eating whichever type of cracker the other person ate.12 The bottom line: Eating behaviours are unknowingly influenced by others.

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Holidays “Corporate break rooms need not become repositories for unused Halloween candy and holiday leftovers.” 55 The holidays are a time when cultural and social influences such as such as eating with others, longer meal times, easy access to food, large portion sizes and an increase in alcoholic beverages combine to create high risk environments that promote poor diet quality.56

Implications for Workplaces Many of the environmental factors that influence food choice are outside the control of individual employees. This highlights the need to create a supportive healthy eating environment in the workplace. There are many strategies and policies that workplaces can implement to help improve employee’s eating habits.

Refer to the section ‘Part III - Making the Shift: Comprehensive Strategies to Promote Healthy Eating’ for strategies to improve the food environment in your workplace. This resource is available for download at: http://www.projecthealth.ca under ‘Toolkits’.

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Environmental Influence References 1. Bleich S, Cutler D, Murray C, Adams A. Why is the developed world obese? Annu Rev Public Health 2008;29:273-295. 2. Howlett E, Burton AS, Bates K, Huggins K. Coming to a restaurant near you? Potential customer responses to nutrition information disclosure on menus. Journal of Consumer Research 2009;36(3):494-503. 3. Harnack LJ, French SA, Oakes JM, Story MT, Jeffery RW, Rydell SA. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trial. Int J Behav Nutr Phys Act 2008 Dec 5;5:63. 4. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point-of-purchase behavior in adults: A review. Prev Med 2004 Sep;39 Suppl 2:S108-36. 5. Eertmans A, Baeyens F, & Van den Bergh, O. Food likes and their relative importance in human eating behavior: Review and preliminary suggestions for health promotion. Health Education Research 2001;16(4):443-456. 6. Elinder LS, Jansson M. Obesogenic environments – aspects on measurement and indicators. Public Health Nutr 2008;12(3):307-315. 7. French SA. Pricing effects on food choices. J Nutr 2003 Mar;133(3):841S-843S. 8. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health 2008;29:253-272. 9. Vermeer WM, Alting E, Steenhuis I, Seidell JC. Value for money or making the healthy choice: The impact of proportional pricing on consumers' portion size choices. Eur J Public Health 2009 July 8. 10. Block JP, Chandra A, McManus KD, Willett WC. Point-of-purchase price and education intervention to reduce consumption of sugary soft drinks. Am J Public Health 2010 Aug;100(8):1427-1433. 11. Devine CM, Nelson JA, Chin N, Dozier A, Fernandez ID. "Pizza is cheaper than salad": Assessing workers' views for an environmental food intervention. Obesity (Silver Spring) 2007 Nov;15 Suppl 1:57S-68S. 12. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis 2008 Jan;5(1):A23. 13. Krukowski RA, Harvey-Berino J, Kolodinsky J, Narsana RT, Desisto TP. Consumers may not use or understand calorie labeling in restaurants. J Am Diet Assoc 2006 Jun;106(6):917-920. 14. Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annu Rev Nutr 2004;24:455-479. 15. Wansink B, van Ittersum K. Portion size me: downsizing our consumption norms. J Am Diet Assoc 2007 Jul;107(7):1103-1106. 16. Wansink B, Cheney MM. Super Bowls: Serving bowl size and food consumption. JAMA 2005 Apr 13;293(14):1727-1728. 17. Mink M, Evans A, Moore CG, Calderon KS, Deger S. Nutritional imbalance endorsed by televised food advertisements. J Am Diet Assoc 2010 Jun;110(6):904910.

18. Kelly B, Halford JC, Boyland EJ, Chapman K, Bautista-Castano I, Berg C, et al. Television food advertising to children: A global perspective. Am J Public Health 2010 Sep;100(9):1730-1736. 19. Koordeman R, Anschutz DJ, van Baaren RB, Engels RC. Exposure to soda commercials affects sugar-sweetened soda consumption in young women. An observational experimental study. Appetite 2010 Jun;54(3):619-622. 20. Scully M, Dixon H, Wakefield M. Association between commercial television exposure and fast-food consumption among adults. Public Health Nutr 2009 Jan;12(1):105-110. 21. Harris JL, Bargh JA, Brownell KD. Priming effects of television food advertising on eating behavior. Health Psychol 2009 Jul;28(4):404-413. 22. Spence JC, Cutumisu N, Edwards J, Raine KD, Smoyer-Tomic K. Relation between local food environments and obesity among adults. BMC Public Health 2009 Jun 18;9:192. 23. Inagami,S., Cohen, D.A., Brown, A.F., Asch, S.M. Body Mass Index, Neighbourhood Fast Food and Restaurant Concentration, and Car Ownership. Journal of Urban Health 2009;86(5):683-695. 24. Sharma AM, Padwal R. Obesity is a sign - overeating is a symptom: An aetiological framework for the assessment and management of obesity. Obes Rev 2010 May;11(5):362-370. 25. Freedman DA. Local food environments: They're all stocked differently. Am J Community Psychol 2009 Dec;44(3-4):382-393. 26. Farley TA, Baker ET, Futrell L, Rice JC. The ubiquity of energy-dense snack foods: A national multicity study. Am J Public Health 2010 Feb;100(2):306-311. 27. Wansink B, Huckabee M. De-marketing obesity. California Management Review 2005 Summer 2005;47(4):1-13. 28. Dietitians of Canada. 2006 Nutrition Month Campaign, "Make Wise Food Choices Wherever You Go!" Backgrounder. 2006. 29. Jabs J, Devine CM, Bisogni CA, Farrell TJ, Jastran M, Wethington E. Trying to find the quickest way: employed mothers' constructions of time for food. J Nutr Educ Behav 2007 Jan-Feb;39(1):18-25. 30. Welch N, McNaughton SA, Hunter W, Hume C, Crawford D. Is the perception of time pressure a barrier to healthy eating and physical activity among women? Public Health Nutr 2009 Jul;12(7):888-895. 31. Bassett MT, Dumanovsky T, Huang C, Silver LD, Young C, Nonas C, et al. Purchasing behavior and calorie information at fast-food chains in New York City, 2007. Am J Public Health 2008 Aug;98(8):14571459. 32. Bleich S, Pollack K. The publics' understanding of daily caloric recommendations and their perceptions of calorie posting in chain restaurants. BMC Public Health 2010;10(1):121.

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33. Post RE, Mainous AG,3rd, Diaz VA, Matheson EM, Everett CJ. Use of the nutrition facts label in chronic disease management: Results from the National Health and Nutrition Examination Survey. J Am Diet Assoc 2010 Apr;110(4):628-632. 34. Temple JL, Johnson K, Recupero K, Suders H. Nutrition labels decrease energy intake in adults consuming lunch in the laboratory. J Am Diet Assoc 2010 Jul;110(7):1094-1097. 35. Roberto CA, Hoffnagle E, Bragg MA, Brownell KD. An observational study of consumer use of fastfood restaurant drive-through lanes: implications for menu labelling policy. Public Health Nutrition 2010. 36. Roberto CA, Larsen PD, Agnew H, Baik J, Brownell KD. Evaluating the impact of menu labeling on food choices and intake. Am J Public Health 2010 Feb;100(2):312-318. 37. Berman M, Lavizzo-Mourey R. Obesity prevention in the information age: caloric information at the point of purchase. JAMA 2008 Jul 23;300(4):433-435. 38. Mackison D, Wrieden WL, Anderson AS. Making an informed choice in the catering environment: What do consumers want to know? J Hum Nutr Diet 2009 Dec;22(6):567-573. 39. Piron J, Smith LV, Simon P, Cummings PL, Kuo T. Knowledge, attitudes and potential response to menu labelling in an urban public health clinic population. Public Health Nutr 2010 Apr;13(4):550-555. 40. Ellis S, Glanville NT. Trans fat information on food labels: Consumer use and interpretation. Can J Diet Pract Res 2010 Spring;71(1):6-10. 41. Elbel B, Kersh R, Brescoll VL, Dixon LB. Calorie labeling and food choices: A first look at the effects on low-income people in New York City. Health Aff (Millwood) 2009 Nov-Dec;28(6):w1110-21. 42. Driskell JA, Schake MC, Detter HA. Using nutrition labeling as a potential tool for changing eating habits of university dining hall patrons. J Am Diet Assoc 2008 Dec;108(12):2071-2076. 43. Vyth EL, Steenhuis IH, Heymans MW, Roodenburg AJ, Brug J, Seidell JC. Influence of placement of a nutrition logo on cafeteria menu items on lunchtime food Choices at Dutch work sites. J Am Diet Assoc 2011 Jan;111(1):131-136.

44. Urban LE, Dallal GE, Robinson LM, Ausman LM, Saltzman E, Roberts SB. The accuracy of stated energy contents of reduced-energy, commercially prepared foods. J Am Diet Assoc 2010 Jan;110(1):116-123. 45. Schulte PA, Wagner GR, Ostry A, Blancforti LA, Cutlip RG, Krajnak KM, et al. Work, obesity, and occupational safety and health. Am J Public Health 2007;97(3):428-436. 46. Raulio S, Roos E, Mukala K, Prattala R. Can working conditions explain differences in eating patterns during working hours? Public Health Nutr 2008 Mar;11(3):258-270. 47. Lemon SC, Zapka J, Li W, Estabrook B, Magner R, Rosal MC. Perceptions of worksite support and employee obesity, activity and diet. American Journal of Health Behaviours 2009;33(3):299-308. 48. Nishitani N, Sakakibara H, Akiyama I. Eating behaviour related to obesity and job stress in male Japanese workers. Nutrition 2009;25(1):45-50. 49. Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: the potential health benefits of providing nutrition information in restaurants. Am J Public Health 2006 Sep;96(9):1669-1675. 50. Raine KD. Determinants of healthy eating in Canada: An overview and synthesis. Can J Public Health 2005 Jul-Aug;96 Suppl 3:S8-14, S8-15. 51. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007 Jul 26;357(4):370-379. 52. Polivy J, Herman CP. Mental health and eating behaviours: A bi-directional relation. Can J Public Health 2005 Jul-Aug;96 Suppl 3:S43-6, S49-53. 53. Sela A, Berger J, Liu W. Variety, vice, and virtue: How assortment size influences option choice. Journal of Consumer Research 2009;35(6):941-951. 54. Herman CP, Roth DA, Polivy J. Effects of the presence of others on food intake: A normative interpretation. Psychol Bull 2003;129(6):873-886. 55. Heinen L, Darling H. Addressing obesity in the workplace: The role of employers. The Milbank Quarterly 2009;87(1):101-122. 56. Hull HR, Radley D, Dinger MK, Fields DA. The effect of the Thanksgiving holiday on weight gain. Nutr J 2006 Nov 21;5:29.

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Common Psychological Biases That Influence Health Behaviours The human mind is extremely complex and influences food choices without conscious awareness. These psychological biases can prevent people from making consistent healthy food choices.

Cognitive Bias A cognitive bias occurs when the brain allows judgments and decisions to be made based on personal experience, likes, dislikes and cultural experiences without supporting evidence. Several cognitive biases exist that apply to how people think about health. Optimistic Bias From a nutrition perspective, optimistic bias causes people to underestimate the consequences of their food intakes. People usually rate their nutrition-related risk to be lower compared to others.1,2 As a result of this bias, people accept the messages in health promotion campaigns but believe them to be more applicable to others than to themselves.

Because of this bias, people do not realize that their diet requires improvement. As a result, they fail to take action. Tailored feedback from health professionals seems to be the most appropriate method to address this bias. However, research shows that some people receiving negative tailored feedback are even less likely than others to take action on a health issue.2

Optimistic bias was evident in the report: Recommendations of the Sodium Working Group. “Public opinion research has shown that Canadians are aware of sodium as a health issue, but perceive it as everybody else’s problem. Very few understand what a healthy amount of sodium is, and most continue to have high dietary intakes.”3

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Status Quo Bias “When in doubt, do nothing!” People seem to prefer having things stay the same.4 Part of the status quo bias is a tendency to feel worse about poor outcomes of changes they made compared to poor outcomes that resulted from not making a change.5 Brand loyalty is an example of status quo bias. Once people are relatively happy with a product, they will not seek out alternatives, even if superior products become available.4 The status quo bias might help to explain why it is so hard to make changes as an individual. It also might help to explain why people tend to resist imposed changes.

Restraint Bias “I’ll buy this bag of cookies and just have one…” There is a tendency to overestimate one’s ability to resist impulsive behaviours, which causes people to expose themselves to temptation.6 The assumption that individuals “should be able to” control themselves could explain acceptance of food temptations in the workplace environment. Unfortunately, people are tempted and eventually succumb to behaviours that result in poor health outcomes. A common example is bringing in high-calorie “treats” to share with for coworkers, ultimately contributing to poor diet quality.

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Hyperbolic Discounting “The time to begin most things is ten years ago." ~Mignon McLaughlin People seem to be aware of the risks related to eating less healthy food and beverages but seem to “forget” about long-term health goals when they make food decisions.7 Hyperbolic discounting is the preference for immediate payoffs compared to future gains. For example, eating a tasty brownie now verses enjoying good health in the future. This bias is also evident in the form of other human traits such as procrastination, overspending and failure to save for retirement.8

Third Person Bias “…that might fool someone else, but it won’t fool me…” The third person bias is the tendency to believe that others are more influenced by media messages than oneself.9 However, simply seeing a logo or watching a food commercial might create a desire to eat!10 The billions of dollars that are spent advertising food products should suggest that they are an effective way to increase sales. Especially since the pattern of nutritional imbalance found in the common American diet mimics the pattern of imbalance in advertised foods.11

‘Sin taxes’ such as those placed on tobacco or alcohol products have been used in the past to decrease this bias, as there is an immediate negative consequence to making a decision that may result in poor health outcomes.7

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The “Halo” Effect “These chips have no trans fat, so I can eat as many as I want…” How a particular food is marketed can influence whether or not one chooses to eat it and how much of it is consumed. A halo effect occurs when one judges a food be ‘healthy’ because one component of it is perceived as healthy. People tend to underestimate the caloric content of foods served at restaurants that market themselves as ‘healthy’. As a result, they often order higher calorie side dishes, which contributes to higher overall caloric intakes.12 Similarly, when snack foods are marketed as ‘healthy’ many people assume that these products either taste bad or can be consumed in limitless amounts.13-15 Just mentioning certain ingredients or attributes can create positive or negative biases about the perceived taste of food. In one study, the mere mention of soy made people evaluate a product as “grainy” and “tasteless” compared to those who tasted the same product with no mention of soy. Suggesting that the product contained soy made people believe that they tasted it, even though the product did not contain any soy.13 Food product names also have a huge effect on whether people choose to eat them. Descriptive names tend to increase taste ratings and overall sales. They also make

people think that they contain more calories and are more satisfying than menu items with plain names.12 For example, “Traditional Cajun Red Beans with Rice” verses “Red Beans with Rice”. 13

Implications for Workplaces The psychological factors that influence food related behaviours occur outside the conscious awareness of individuals. Educating people about these psychological influences does little to change the individual perception of health and lifestyle behaviours, as people continue to believe that the messages are more applicable to others than themselves. It is important for health promoters to be aware of these psychological influences and accept them as part of the human condition, rather than having an expectation that people ‘should’ behave differently. The most important strategy to counter these psychological biases is to ensure that the workplace food environment is structured in such a way that healthy eating is ‘just another part’ of the average workday. For strategies to implement supportive healthy eating environments in workplaces, please to the section ‘Part III - Making the Shift: Comprehensive Strategies to Promote Healthy Eating’. This resource is available for download at: http://www.projecthealth.ca under ‘Toolkits’.

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Psychological Bias References 1. Shepherd R, Shepherd R. Resistance to changes in diet. Proc Nutr Soc. 2002;61:267-272. 2. Raats MM, Sparks P. Unrealistic optimism about diet-related risks: Implications for interventions. Proc Nutr Soc. 1995;54:737-745. 3. Sodium Working Group. Sodium reduction strategy for Canada, recommendations of the Sodium Working Group. 2010. 4. Samuelson W, Zeckhauser R. Status quo bias in decision making. Journal of Risk and Uncertainty. 1988;1:7-59. 5. Fleming SM, Thomas CL, Dolan RJ. Overcoming status quo bias in the human brain. Proc Natl Acad Sci U S A. 2010;107:6005-6009. 6. Nordgren LF, van Harreveld F, van der Pligt J. The restraint bias: How the illusion of self-restraint promotes impulsive behavior. Psychol Sci. 2009;20:1523-1528. 7. Scharff RL. Obesity and hyperbolic discounting: Evidence and implications. J Consum Policy. 2009;32:3-21. 8. Angeletos G, Laibson D, Repetto A, Tobacman J, Weinberg S. The hyperbolic consumption model: Calibration, simulation, and empirical evaluation. Journal of Economic Perspectives. 2001;15:47-68.

9. Sun Y, Pan Z, Shen L. Understanding the thirdperson perception: Evidence from a meta-analysis. Journal of Communication.;58:280-300. 10. Harris JL, Bargh JA, Brownell KD. Priming effects of television food advertising on eating behavior. Health Psychol. 2009;28:404-413. 11. Mink M, Evans A, Moore CG, Calderon KS, Deger S. Nutritional imbalance endorsed by televised food advertisements. J Am Diet Assoc. 2010;110:904-910. 12. Chandon P, Wansink B. The biasing health halos of fast-food restaurant health claims: Lower calorie estimates and higher side-dish consumption intentions. Journal of Consumer Research. 2007;34:301-314. 13. Wansink B, van Ittersum K, Painter JE. How descriptive food names bias sensory perceptions in restaurants. Food Quality and Preference. 2005;16:393400. 14. Wansink B, Huckabee M. De-marketing obesity. California Management Review. 2005;47:1-13. 15. Howlett E, Burton AS, Bates K, Huggins K. Coming to a restaurant near you? Potential customer responses to nutrition information disclosure on menus. Journal of Consumer Research. 2009;36:494-503.

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Physiological Barriers to Healthy Eating Will Power, Self-Control and Personal Responsibility Self-control is required help people follow a healthy diet. But what is will power? The Self-Control Theory Researchers have been investigating the ability of subjects to use self-control under different conditions. There are a wide variety of behaviours that are expected of employees during any given workday that require the use of self-control (e.g., paying attention during meetings).3 There is some evidence that suggests that self-control is a limited energy source.3 How Will Power Works Researchers believe that will power is controlled by the brain. Even though the brain only makes up two per cent of body mass, it uses 20 per cent of the body’s energy.3 Each time participants in studies use self-control, there is a small but measurable drop in blood glucose.4,5 It appears that exerting self-control causes the

brain to use up just enough blood glucose to make it difficult to complete a secondary act requiring self-control.3 Implications for Workplaces 1. Employees will likely perform better when they are well nourished (i.e., skipping meals will lead to a drop in blood glucose that may impair one’s ability to concentrate). 2. Tempting employees with less healthy food and beverages when self-control is at its lowest (e.g., right before lunch), or when employees are trying to concentrate (e.g., during a meeting) can make it difficult for them to consistently eat a healthy diet.6 The self control theory may also help to explain some other food related phenomenon such as the “What the Hell”,7,8 and “Token Salad” effects9 as well as other justification type behaviours described on the following page.10

Food for Thought: SELF-CONTROL INFLUENCES HEALTH BEHAVIOURS Even if employees resist temptation initially, research shows that individuals who are trying to maintain a healthy diet usually have a breakdown in self-control later in the day.3,4 One study even showed that smokers were more likely to smoke after being required to resist eating cookies.11 The bottom line: Being exposed to tempting food may have an influence on other health behaviours.11

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“What The Hell?”7,8 “I’ve already blown my diet; I might as well keep going” The “What The Hell” effect is a reaction that dieters have, often causing them to abandon their diets especially in situations where dieters have less control over food choices or feel deprived. Once dieters give in and break their diet, they feel that the day is lost. This results in giving into further temptation and eating more of whatever food is available.7,8

The self-control theory may explain why people seek out nutrition education, request healthy eating programs, demand healthy food on menus and then do not select the healthier options. The very thing that people need to exercise self-control when faced with eating decisions is depleted when they are hungry (i.e., blood glucose), causing them to make more indulgent ‘choices’ when they are available.

Justification “It was a tough day at the office, we should go out tonight…”

The Token Salad “I’ll have the burger and fries” The majority of consumers are health conscious, however, the food industry reports that consumers say they want more salads offered, but when they are added to the menu, salad sales do not increase.9,13 In fact, when healthy items are added to the menu, some food providers notice an increase in the sale of the least healthy menu items.9,13

People working towards a goal that requires high-personal effort, (e.g., completing a major presentation at work) feel that they can indulge after meeting that goal.9,10,12

Food For Thought: INDULGENT DISTRACTIONS A group of participants had to resist eating a plate of cookies while completing a challenging mental task. They gave up after only 8 minutes. The group that was allowed to eat the cookies lasted 19 minutes, while another group that did not have any food provided to them lasted 21 minutes.6 The bottom line: The availability of tempting foods when employees are trying to work can be mentally distracting and counterproductive.3,13,14

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Physiological Barriers References 1. Krebs-Smith SM, Reedy J, Bosire C. Healthfulness of the U.S. food supply: Little improvement despite decades of dietary guidance. Am J Prev Med. 2010;38:472-477. 2. Hill JO. Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition Institute of Food Technologists, and International Food Information Council. Am J Clin Nutr. 2009;89:477-484. 3. Gailliot MT, Baumeister RF. The physiology of willpower: Linking blood glucose to self-control. Pers Soc Psychol Rev. 2007;11:303-327. 4. Gailliot MT, Baumeister RF, DeWall CN, et al. Selfcontrol relies on glucose as a limited energy source: Willpower is more than a metaphor. J Pers Soc Psychol. 2007;92:325-336. 5. Miller HC, Pattison KF, DeWall CN, RayburnReeves R, Zentall TR. Self-control without a "self"?: Common self-control processes in humans and dogs. Psychol Sci. 2010;21:534-538. 6. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis. 2008;5:A23. 7. Canadian Obesity Network. False hopes and overwhelming urges. Conduit. 2009;Winter.

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8. Polivy J, Herman CP, Deo R. Getting a bigger slice of the pie. Effects on eating and emotion in restrained and unrestrained eaters. Appetite. 2010;55:426-430. 9. Wilcox K, Vallen B, Block L, Fitzsimons GJ. Vicarious goal fulfillment: When the mere presence of a healthy option leads to an ironically indulgent decision. Journal of Consumer Research. 2009;36:380393. 10. Sela A, Berger J, Liu W. Variety, vice, and virtue: How assortment size influences option choice. Journal of Consumer Research. 2009;35:941-951. 11. Shmueli D, Prochaska JJ. Resisting tempting foods and smoking behavior: Implications from a self-control theory perspective. Health Psychol. 2009;28:300-306. 12. Chandon P, Wansink B. The biasing health halos of fast-food restaurant health claims: Lower calorie estimates and higher side-dish consumption intentions. Journal of Consumer Research. 2007;34:301-314. 13. Keohane J. Fat profits: On the services of fast food chains. Portfolio.com. 2008 Accessed 3/10/2009. 14. Muraven M, Baumeister RF. Self-regulation and depletion of limited resources: Does self-control resemble a muscle? Psychol Bull. 2000;126:247-259.

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Is Eating an Addiction? “A loss of control over food intake” fits the description of classic substance abuse disorders.1 As with drug abuse, people continue to ‘use’ despite knowing about the negative effects on their bodies, feeling the negative physical consequences of use, (e.g., pain or chronic disease), and experiencing feelings of isolation due to the stigma of being overweight or obese.1

Poor Diet Quality and Addiction Just as poppies and coca beans are relatively harmless in their natural form, once components are extracted, refined and concentrated, they become potent drugs such as opium and cocaine. Sugars and fats are also found in nature in small concentrations and like drugs, are not addictive, until processed.1

“I just need something sweet.” The involvement of the dopamine reward system may explain the desire to eat something (e.g., dessert), even when no longer hungry (e.g., after a big meal). The addiction process is likely a key reason that the majority of individuals have not been able to control their intake of refined grains, fats and sugars. However, unlike other addictive substances, food and beverages containing refined grains, fat and sugar are heavily advertised, inexpensive and difficult to avoid.

Researchers have found that eating refined grains (i.e., white flour), sugars, and fats commonly found in processed food, stimulate the dopamine system in the brain similar to the reward pathway for drugs such as cocaine.1-5 Eating food and beverages that contain refined grains, fats and sugars causes the loss of dopamine receptors.6 The result of having fewer dopamine receptors is that more substance (i.e., food) is required to feel satisfied.2 This promotes overeating and a preference for processed, high-fat, highsugar foods, which increases the risk of developing nutrition related chronic conditions.

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Is Eating is an Addiction References 1. Ifland JR, Preuss HG, Marcus MT, et al. Refined food addiction: A classic substance use disorder. Med Hypotheses. 2009;72:518-526.

4. Avena NM, Rada P, Hoebel BG. Sugar and fat bingeing have notable differences in addictive-like behavior. J Nutr. 2009;139:623-628.

2. Mahapatra A. Overeating, obesity and dopamine receptors. ACS Chemical Neuroscience. 2010;1:396397.

5. Zheng H, Lenard NR, Shin AC, Berthoud HR. Appetite control and energy balance regulation in the modern world: Reward-driven brain overrides repletion signals. Int J Obes (Lond). 2009;33 Suppl 2:S8-13.

3. Lutter M, Nestler EJ. Homeostatic and hedonic signals interact in the regulation of food intake. J Nutr. 2009;139:629-632.

6. Stice E, Yokum S, Blum K, Bohon C. Weight gain is associated with reduced striatal response to palatable food. J Neurosci. 2010;30:13105-13109.

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Conclusion The current food environment offers multiple opportunities for employees to consume food and beverages with minimal nutritional value. The onus is on employees to resist tempting food and beverages if they want to maintain good health. The common belief that individuals are responsible for their own eating behaviour is challenged by the evidence that individuals are highly influenced by portion size, pricing, marketing and convenience. People can only resist the food environment for so long before giving into temptation. Humans may not psychologically be able to identify that a poor quality diet poses a risk to their own personal health and may not be physiologically equipped to manage multiple requirements for self-control. Finally, the brain possesses a reward pathway that creates a strong desire to eat less healthy food and beverages that contain high amounts of fat, sugar and refined flour, which has nothing to do with a need for calories.

It is not realistic to offer less healthy choices and expect employees to consistently follow a healthy diet. Individuals must make choices for themselves, but the environment significantly influences the content of the choices people make.1 Ensure that the environment in your workplace makes healthier choices the easiest choices and minimizes the burden on employees to resist tempting food and beverages with minimal nutritional value. There are many initiatives and strategies that workplaces can implement to create a supportive healthy eating environment. Refer to the section ‘Part III - Making the Shift: Comprehensive Strategies to Promote Healthy Eating’ for strategies to improve the food environment in your workplace. This resource is available for download at: http://www.projecthealth.ca under ‘Toolkits’.

Conclusion References 1. Brownell,KD, Kersh,R, Ludwig,RC, Post,RC, Puhl,RM, Schwartz,MB, Willet,W. Personal responsibility and obesity: a constructive approach to a controversial issue. Health Affairs. 2010;29(3):378-386.

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PART III

MAKING THE SHIFT Comprehensive Strategies to Promote Healthy Eating

INTRODUCTION

6.0

7.0

CURRENT EVIDENCE

49

OVERVIEW OF COMPREHENSIVE WORKPLACE HEALTH PROMOTION

52

GETTING STARTED: PLANNING A COMPREHENSIVE HEALTHY EATING STRATEGY FOR WORKPLACES 55 STEP 1 – OBTAIN MANAGEMENT SUPPORT

57

STEP 2 – ESTABLISH A WELLNESS COMMITTEE

58

STEP 3A – ASSESS WORKPLACE HEALTH NEEDS

62

STEP 3B – ASSEMBLE A HEALTHY EATING SUBCOMMITTEE

65

STEP 4 – DEVELOP AN ACTION PLAN

66

STEP 5 – DEVELOP THE EVALUATION PLAN

71

STEP 6 – CHECK-IN WITH MANAGEMENT

73

STEP 7 – IMPLEMENT THE PLAN

74

STEP 8 –EVALUATE AND UPDATE THE STRATEGY

76

STRATEGIES TO PROMOTE HEALTHY EATING IN THE WORKPLACE

79

7.1

AWARENESS RAISING

83

BULLETIN BOARDS AND POSTERS

84

DISPLAYS AND HEALTH FAIRS

84

EATRIGHT ONTARIO

84

EMAILS, NEWSLETTERS AND OTHER EMPLOYEE COMMUNICATIONS

85

EVENTS

86

HEALTH SCREENING AND HEALTH RISK ASSESSMENTS

86

LUNCH AND LEARNS

87

MOBILE HEALTH TECHNOLOGY

87

PAMPHLETS

88

POINT-OF-DECISION NUTRITION INFORMATION

89

PROMOTING LOCAL FOOD OPPORTUNITIES

90

VIDEOS

90

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Table of Contents

PART III

7.2

7.3

7.4

SKILL BUILDING

93

LUNCH AND LEARNS

94

HEALTH FAIRS

94

SMART PHONE APPLICATIONS

94

KNOWLEDGE SKILLS

94

PLANNING SKILLS

95

MEAL PREPARATION AND COOKING SKILLS

96

GARDENING SKILLS

97

CHALLENGES AND CONTESTS

98

HEALTH PROMOTION PROGRAMS

99

SUPPORTIVE ENVIRONMENTS

103

ACCESS TO REGISTERED DIETITIANS

105

CAFETERIAS

107

CELEBRATIONS

121

COMMON AREAS

125

FACILITIES

129

MEETINGS AND EVENTS

131

ORGANIZATIONAL CULTURE

139

PEER SUPPORT GROUPS

145

PROMOTING LOCAL FOOD

149

VENDING MACHINES

159

WORKPLACE GARDENS

165

POLICY DEVELOPMENT

171

8.0

SPECIAL CONSIDERATIONS

181

9.0

COMMUNITY INVOLVEMENT

199

10.0

APPENDIX A: NUTRITION CRITERIA

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PART III – ‘MAKING THE SHIFT: COMPREHENSIVE STRATEGIES TO PROMOTE HEALTHY EATING’ This is the third part of a toolkit designed to give employers and health intermediaries the tools to create a comprehensive healthy eating strategy in their workplace. Current eating habits place employees at risk for developing nutrition-related chronic diseases. Despite efforts and campaigns aimed at helping people to make healthy choices, eating habits have been getting worse over the years.1 This is most likely due to changes in the food environment, including increased portion sizes as well as widespread availability and promotion of less healthy foods described as “Foods to Limit” by Canada’s Food Guide (e.g., cakes, pastries, candies, chocolate, cookies, granola bars, ice cream, doughnuts, muffins, french fries, potato chips, salty snacks and sweetened hot and cold beverages).1-12

The presence of chronic diseases has substantial negative financial implications for workplaces. For more background information on the business case for promoting healthy eating in the workplace visit the Project Health website http://www.projecthealth.ca to download a copy of: PART I – ‘THE COST OF DOING NOTHING: THE BUSINESS CASE’. The food environment influences the eating habits of employees. Most healthy eating interventions are focused on changing individual eating habits without making improvements to the food environment. For more background information on the limitations of current healthy eating promotion strategies visit the Project Health website http://www.projecthealth.ca to download a copy of: PART II – ‘EXAMINING THE EVIDENCE: ADDRESSING THE LIMITATIONS OF CURRENT INTERVENTIONS’

Many people struggle to make healthy choices when offered tempting foods.3,13-16 Consequently, the types and amounts of food available to people in their work environments should be carefully considered. A supportive healthy eating environment can be created in the workplace by promoting healthy food and by improving the nutritional quality of foods available to employees in cafeterias, vending machines, meetings, events and food left in common areas (e.g., candy bowls on desks and leftover food placed in the work area). Workplaces should also think about, celebrating, fundraising and rewarding employees without using food. Workplaces have multiple opportunities to improve employee eating habits, ranging from interventions that improve individual knowledge about healthy eating, to changing the food environment by implementing supportive environments and policies that ensure that employees are offered and sold healthy food and beverages in the workplace. Project Health - Comprehensive Strategies to Promote Healthy Eating

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This guide will provide steps to implement a comprehensive healthy eating strategy in workplaces. To begin the process of planning a healthy eating strategy, it is important that all key stakeholders in the organization support the concept. Key stakeholders may include: senior management, unions and employee associations, employees, occupational health, health and safety representatives, human resources and benefits, communications and food service providers.

Current Evidence The current literature suggests that environmental interventions are helpful when encouraging healthier eating habits among employees.17-20 However, the majority of research on the promotion of healthy eating in workplaces consists of healthy eating education and environmental supports such as point-of-decision information (e.g., stickers identifying healthier choices and nutrition information such fat content, calories, etc.), promotional materials, preferential pricing for healthier choices, increased availability of healthier choices and targeted food placement (e.g., food items placed at eye-level or at the cash register).21,22 These studies show a small impact from these types of environmental strategies.21,22 It is possible that the limited impact that these strategies have is due to the fact that individuals still have to make the healthier choice, while less healthy choices remain widely available. Canada’s Food Guide recommends that people limit foods and beverages high in calories, fat, sugar or salt. (e.g., cakes, pastries, candies, chocolate, cookies, granola bars, ice cream, doughnuts, muffins,

french fries, potato chips, salty snacks, and sweetened hot and cold beverages).2 The literature is limited in terms of the effectiveness of decreasing exposure of “Foods to Limit”. However, we do know that the food environment has changed drastically in the past few decades. This has increased the number of calories available per person in the food supply, mostly from “Foods to Limit”.1,8-12,23 Studies of neighbourhoods show that poor quality food environments are associated with low quality diets.24-26 It has also been established that any cues associated with food or eating (e.g., watching others eat, watching food commercials, having food available in close proximity, etc.) has the potential to motivate individuals to eat.4,27-29 Food cues encourage people to eat without being aware, making it difficult for individuals to resist eating when food cues are present.4,27 From a harm reduction standpoint, it makes sense to limit food cues in the workplace, especially for “Foods to Limit”, as they have the potential to cause harm by promoting the development of nutrition-related chronic disease.27,28,30

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Introduction

Introduction

Overview of Comprehensive Workplace Health Promotion There are three critical areas in organizations that influence employee health and health behaviours. Occupational Health & Safety

Voluntary Health Practices

Organizational Culture/Change

Occupational Health and Safety The first area, traditional health and safety initiatives, protect employees from physical harm or exposure to harmful substances with the goal of reducing work related injury, illness and disability.

Voluntary Health Practices The second area is voluntary health practices (e.g., promotion of smoke-free living, physical activity, healthy eating, etc.). Workplace health promotion strategies often focus on changing voluntary health practices of individuals by raising awareness and offering opportunities to build skills. The initiatives are often targeted at individual behaviour; however, they are less likely to be effective compared to strategies that also target organizational factors that have an effect on personal health practices. For example, individuals may use food to cope with job stress, which then contributes to the development of nutrition-related health problems.16,31-37

Organizational Health When planning workplace health promotion efforts it is important to make improvements in the organizational culture either before or in conjunction with voluntary health promotion activities. A supportive organizational culture means the workplace promotes physical and mental health and well-being. There are many areas that workplaces can target to improve the health outcomes of employees such as enhancing social support, ensuring a job effort-reward balance and improving job control, work structure, communication strategies, organizational change processes and management style.38 In a supportive workplace culture, employees have adequate job training, a sense of fairness and respect on the job, work-life balance, some control over how their work is completed and are rewarded adequately for their efforts. In an ideal workplace, efforts are made to manage and prevent workplace conflict and help is available to assist employees in times of distress.38 A negative organizational culture can limit the effectiveness of workplace health promotion efforts. Address any issues related to organizational culture that affect employee health to enhance the effectiveness of your comprehensive healthy eating strategy. See the Organizational Culture section on page 137 for suggestions on improving organizational culture to support your wellness efforts.

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Making the Shift References 1. Slater J, Green CG, Sevenhuysen G, Edginton B, O'Neil J, Heasman M. The growing Canadian energy gap: More the can than the couch? Public Health Nutr 2009 Nov;12(11):2216-2224.

17. Verweij LM, Coffeng J, van Mechelen W, Proper KL. Meta-analysis of workplace physical activity and dietary behaviour interventions on weight outcomes. Obesity Reviews 2011;12(6):406-429.

2. Health Canada. Eating Well with Canada's Food Guide: A resource for educators and communicators. Ottawa: Health Canada; 2007.

18. DeJoy DM, Parker KM, Padilla HM, Wilson MG, Roemer EC, Goetzel RZ. Combining environmental and individual weight management interventions in a work setting: Results from the Dow Chemical Study. J Occup Environ Med 2011 Mar;53(3):245-252.

3. Zimmerman FJ. Using marketing muscle to sell fat: The rise of obesity in the modern economy. Annu Rev Public Health 2011 Apr 21;32:285-306. 4. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis 2008 Jan;5(1):A23.

19. Heinen L, Darling H. Addressing obesity in the workplace: The role of employers. The Milbank Quarterly 2009;87(1):101-122.

5. Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annu Rev Nutr 2004;24:455-479.

20. Quintiliani L, Poulsen S, Sorensen G. Healthy eating strategies in the workplace. International Journal of Workplace Health Management 2010;3(3):182-196.

6. Kelly B, Halford JC, Boyland EJ, Chapman K, Bautista-Castano I, Berg C, et al. Television food advertising to children: A global perspective. Am J Public Health 2010 Sep;100(9):1730-1736.

21. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health 2008;29:253-272.

7. Bleich S, Pollack K. The publics' understanding of daily caloric recommendations and their perceptions of calorie posting in chain restaurants. BMC Public Health 2010;10(1):121.

22. Mhurchu CN, Aston LM, Jebb SA. Effects of worksite health promotion interventions on employee diets: A systematic review. BMC Public Health 2010;10:62.

8. Woodward-Lopez G, Kao J, Ritchie L. To what extent have sweetened beverages contributed to the obesity epidemic? Public Health Nutr 2010 Sep 23:111.

23. Bleich S, Cutler D, Murray C, Adams A. Why is the developed world obese? Annu Rev Public Health 2008;29:273-295.

9. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011 Jun 23;364(25):2392-2404. 10. Malik VS, Schulze MB, Hu FB. Intake of sugarsweetened beverages and weight gain: A systematic review. Am J Clin Nutr 2006 Aug;84(2):274-288. 11. Walker KZ, Woods JL, Rickard CA, Wong CK. Product variety in Australian snacks and drinks: How can the consumer make a healthy choice? Public Health Nutr 2008 Oct;11(10):1046-1053. 12. Brownell KD, Farley T, Willett WC, Popkin BM, Chaloupka FJ, Thompson JW, et al. The public health and economic benefits of taxing sugar-sweetened beverages. N Engl J Med 2009 Oct 15;361(16):15991605. 13. Wilcox K, Vallen B, Block L, Fitzsimons GJ. Vicarious goal fulfillment: When the mere presence of a healthy option leads to an ironically indulgent decision. Journal of Consumer Research 2009;36:380393. 14. Weijzen PL, de Graaf C, Dijksterhuis GB. Discrepancy between snack choice intentions and behavior. J Nutr Educ Behav 2008 Sep-Oct;40(5):311316. 15. Bryant EJ, King NA, Blundell JE. Disinhibition: Its effects on appetite and weight regulation. Obes Rev 2008 Sep;9(5):409-419. 16. Devine CM, Nelson JA, Chin N, Dozier A, Fernandez ID. "Pizza is cheaper than salad": Assessing workers' views for an environmental food intervention. Obesity (Silver Spring) 2007 Nov;15 Suppl 1:57S-68S.

24. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR,Jr. Associations of the local food environment with diet quality--a comparison of assessments based on surveys and geographic information systems: The multi-ethnic study of atherosclerosis. Am J Epidemiol 2008 Apr 15;167(8):917-924. 25. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR, Franco M. Fast-food consumption, diet quality, and neighborhood exposure to fast food: The multiethnic study of atherosclerosis. Am J Epidemiol 2009 Jul 1;170(1):29-36. 26. Boone-Heinonen J, Gordon-Larsen P, Kiefe CI, Shikany JM, Lewis CE, Popkin BM. Fast food restaurants and food stores: Longitudinal associations with diet in young to middle-aged adults: The CARDIA study. Arch Intern Med 2011 Jul 11;171(13):11621170. 27. Cohen DA. Neurophysiological pathways to obesity: Below awareness and beyond individual control. Diabetes 2008 Jul;57(7):1768-1773. 28. Rothman AJ, Sheeran P, Wood W. Reflective and automatic processes in the initiation and maintenance of dietary change. Annals of Behavioral Medicine 2009;38(Suppl. 1):S4-S17. 29. Levitsky DA, Pacanowski CR. Free will and the obesity epidemic. Public Health Nutr 2011 Sep 19:1-16. 30. Brownell KD, Kersh R, Ludwig DS, Post RC, Puhl RM, Schwartz MB, et al. Personal responsibility and obesity: A constructive approach to a controversial issue. Health Aff (Millwood) 2010 Mar-Apr;29(3):379387. 31. Shain M, Kramer DM. Health promotion in the workplace: framing the concept; reviewing the evidence. Occup Environ Med 2004 Jul;61(7):643-8, 585.

Project Health - Comprehensive Strategies to Promote Healthy Eating

32. Schulte PA, Wagner GR, Ostry A, Blancforti LA, Cutlip RG, Krajnak KM, et al. Work, obesity, and occupational safety and health. Am J Public Health 2007;97(3):428-436. 33. Raulio S, Roos E, Mukala K, Prattala R. Can working conditions explain differences in eating patterns during working hours? Public Health Nutr 2008 Mar;11(3):258-270. 34. Nishitani N, Sakakibara H, Akiyama I. Eating behaviour related to obesity and job stress in male Japanese workers. Nutrition 2009;25(1):45-50. 35. Fernandez ID, Su H, Winters PC, Liang H. Association of workplace chronic and acute stressors with employee weight status: Data from worksites in turmoil. J Occup Environ Med 2010 Jan;52 Suppl 1:S34-41.

36. Kouvonen A, Kivimaki M, Virtanen M, Heponiemi T, Elovainio M, Pentti J, et al. Effort-reward imbalance at work and the co-occurrence of lifestyle risk factors: cross-sectional survey in a sample of 36,127 public sector employees. BMC Public Health 2006 Feb 7;6:24. 37. Berset M, Semmer NK, Elfering A, Jacobshagen N, Meier LL. Does stress at work make you gain weight? A two-year longitudinal study. Scand J Work Environ Health 2011 Jan;37(1):45-53. 38. Canadian Mental Health Association. Comprehensive Workplace Health Promotion – Affecting Mental Health in Workplace. 2010; Available at: http://wmhp.cmhaontario.ca/comprehensiveworkplace-health-promotion-affecting-mental-healthin-the-workplace. Accessed November 8, 2013.

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GETTING STARTED Planning a Comprehensive Healthy Eating Strategy for Workplaces

This section has been adapted from The Health Communication Unit publication, “The Eight Steps to Developing a Health Promotion Policy” available from: http://www.thcu.ca/resource_db/pubs/489887946.pdf

Elements of an Effective Comprehensive Healthy Eating Strategy There is no single correct approach to implement a comprehensive workplace healthy eating strategy. The workplace health promotion literature suggests that there are eight elements that help to make workplace health promotion strategies successful. This section outlines these elements, which in practice may not always occur in the order presented.

Step 1 – Obtain Management Support To create a healthy workplace, it is important that everyone in the organization is working towards a common goal. The most important part of any organizational change is management support.39,40 Obtaining senior management support is essential to generate resources such as employee time and financial support required to initiate and maintain successful wellness programs.41 Additionally, senior managers must be prepared to see the process through to the end.40 Without this commitment, the chances of success are significantly reduced. All levels of the organization need to be engaged in the wellness approach to make

the strategy a success.42 If some members of the organization are not supportive of a healthy eating strategy, you may need to do some work to create buy-in. Creating Buy-in Decision-makers will need to know why a healthy eating strategy is important.43 Put together a business case for your organization and align the business case with current organization priorities, mission and values.42 Include any relevant information from previous employee interest surveys that indicates healthy eating is a priority for employees.

The Role of Management in Increasing Employee Acceptance It is possible that employees may be somewhat resistant to some aspects of your healthy eating strategy. When senior management’s commitment and involvement is visible, employees are more likely to commit to and participate in creating a healthy workplace. Managers play a critical role in organizational change; therefore, the approach of management representatives is important.

An effective manager is sensitive to employee needs, trustworthy, walks the talk, treats others with respect and communicates well with employees.40,44 It will be important for management representatives to talk to those who are most resistant to changes. Listening to concerns and being compassionate about others’ feelings, opinions and fears can help to increase employee acceptance of changes.39,40

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Step 2 – Establish a Wellness Committee A committee approach is helpful to exchange ideas between employees, service providers, wellness staff and management.41 Successful workplace health initiatives often indicate that program acceptance was achieved using a committee approach.21,45-48 Involve all relevant stakeholders, so that committee decisions will consider different perspectives. A wellness committee is responsible for conducting health needs assessments, organizing awareness raising and skill building activities, planning supportive environment interventions, drafting policies for management approval and evaluating outcomes.

Engaging Employees There are a number of ways to involve employees in the decision-making process ranging from consultation to direct involvement in decision-making.40,44 For example, employees can be consulted about services they would like through surveys, suggestion boxes and focus groups.

Employees should have a greater role in the decision-making process if it is felt that there may be some resistance to changes.39 Individuals who are most likely to be resistant to changes should be involved in the process, so that concerns can be heard and addressed. This also gives employees time to prepare for the changes.42 Ensure that employee involvement happens early and often in the process.40,42,49 It is important to outline to employee stakeholders what decisions they will be able to influence. For example, management may have already made the decision that there will be changes (e.g., “we will be making changes to the workplace food environment to make sure that there is an emphasis on healthy food, whenever food is offered or sold to employees"). In this case, the wellness committee might be asked to make a decision such as: the types of changes that will be made, how the changes are made, where to start the process and how long the process should take.

Project Health - Comprehensive Strategies to Promote Healthy Eating

Organizing the Committee Develop a Terms of Reference for the wellness committee. A Terms of Reference is a document that defines what the wellness committee is responsible for and what types of decisions it can make. It should specify the roles and responsibilities of committee members and outline how decisions are made.

Figure 1 - Sample Terms of Reference

(Committee name) Terms of Reference Purpose of the (Committee Name) The purpose of the (committee name) is to develop, implement, evaluate and sustain a comprehensive health promotion strategy in the workplace. The intent is to make the healthy choices the easy choices and ensure that workplace practices are consistent with the healthy living messages promoted in the workplace. The (committee name) will be responsible for leading the process to create a comprehensive health promotion strategy in our workplace. For example, the committee will:        

Develop the terms of reference Complete a healthy eating needs assessment Set priorities for action Develop a plan to address identified areas of concern Carry out the duties outlined in the plan Manage resources (time, budget) Evaluate initiatives Communicate with workplace employees and managers about the committee activities

Membership The Committee will consist of (number of members) members and will include representatives from: (e.g., management, unions/employee associations, employees, health and safety staff, etc.) Roles and Responsibilities Chair The Chair of the (committee name) will be determined by (e.g., rotating through all members, designated chair each year, etc.). The Chair will be responsible for: calling for agenda items and drafting the agenda for meetings; ensuring quorum is achieved; and guiding committee members to work toward a common goal.

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Recorder The recorder will take minutes of each meeting and give to the chair for distribution within (number of days) days of the meeting. (Decide how the recorder will be chosen e.g., volunteer at each meeting, rotating recorder, designated recorder, etc.). Members Members of the (committee name) will:   

Attend meetings Conduct discussions in a professional manner (e.g., constructively dealing with conflict) Complete tasks as assigned

Decision-making When making decisions, the (committee name) will strive for consensus. If consensus cannot be achieved after a reasonable length of time, decisions will be made by (decision mechanism): (e.g., majority vote, designated decision-maker such as a senior manager, etc.). Meetings Meetings will be held on the (designated day) of each month or at the call of the Chair. There will be a minimum of (number) meetings per year. A quorum of fifty percent plus one must be met in order to proceed with the meeting.

Workplace Examples: WELLNESS COMMITTEE TERMS OF REFERENCE Provincial Health Services Authority http://www.phsa.ca/NR/rdonlyres/3DDA4DE0-6725-4842-AAF0BD88CB61CFF7/0/FoodPolicyAL_300November2010.pdf (page 7)

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Agenda and Minutes Have an agenda for each meeting using a standard format, to guide everyone on what will be accomplished in the meetings. Keep minutes to record the committee discussions and post the minutes, so that all employees can see what the committee is discussing and planning.

Figure 2 – Minutes Template Committee name: ______________________________________ Meeting date: ____________________________________________ Participants: _____________________________________________ Regrets: _________________________________________________ Chair: _____________________ Recorder: ____________________ Agenda Item

Discussion Points

Decisions

Action (who will complete the action and when will it occur)

1.0 Welcome and Introductions 2.0 Review and Additions to Agenda 3.0 Review of Minutes of Previous Meeting 4.0 Business Arising from the Minutes 5.0 New Business

Date, time and location of next meeting: _____________________

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Step 3A – Assess Workplace Health Needs Understanding the needs of employees is an essential part of developing a comprehensive workplace health program. Before proceeding with a healthy eating initiative, conduct a general health needs assessment to determine the health priorities of your employees and managers. The results of the health needs assessment are critical to determine readiness for change and will guide decisions in subsequent phases of the workplace wellness program. Methods for assessing employee needs include having informal discussions, suggestion boxes, focus groups and surveys. Examine other sources of information such as absenteeism, productivity, disability claims and benefit costs to identify if healthy eating is an issue for your workplace. It is possible that your employees have health concerns that are not related to healthy eating or that the timing is not right for a healthy eating initiative in your workplace. Sometimes workplaces are ready to make changes in one area (e.g., tobacco cessation) without being equally ready to make changes in other areas, such as changing the workplace food environment.50 If this is the case, you may want to focus your wellness efforts on other health promotion areas and revisit healthy eating as a priority later on.

What are employees interested in? This information can be helpful in planning awareness raising and skill building activities and may also help to create buy-in for supportive environment and policy development initiatives.

Are there barriers to healthy eating in the workplace? Often people have good knowledge about healthy eating but find it difficult to follow through. Identify factors in your workplace that act as promoters or barriers to healthy eating.

Asking the right questions The answers your employees will give depend on how the questions are asked. For example, employees may indicate that they would like healthy eating lunch and learns because that is they type of health promotion activity that is most familiar to them. However, if you were to ask why employees wanted education, you may find that employees are having difficulty managing a chronic health condition, an issue that requires a comprehensive strategy, rather than a simple education approach. To avoid frustration, think about how you will use the information before adding questions to surveys and only ask employees if they want services that you will be able to provide.

Tools: CONDUCTING HEALTH NEEDS ASSESSMENTS To conduct a comprehensive general health needs assessment. Visit http://www.projecthealth.ca

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Needs Assessment Questions for Healthy Eating Review these sample questions and use them as a guide when you develop needs assessment questions for your workplace. Please note that this is not an exhaustive list of questions but a sample to get you started.

Figure 3 – Needs Assessment Questions Identifying Barriers to Healthy Eating  What challenges do you face in following a healthy diet? (Open-ended)

Workplace Related Barriers to Healthy Eating  Not enough time during the work day to eat / too busy to take a break  Not enough healthy options at work  Healthy options are too expensive  Healthy options are not tasty  Healthy options are not appealing  Healthy options are not convenient  Not sure which options are healthy  Work related stress makes it hard for me to follow a healthy diet  Food being offered/shared in common areas is not healthy  Fundraisers conducted in the workplace offer tempting food  Options in workplace vending machines are not healthy  Food that is served during meetings/events is not healthy  My job requires me to entertain clients which makes it hard to follow a healthy diet  What changes can we make to the workplace to help you eat healthier? (Open-ended)

Barriers to Healthy Eating at Home  Healthy food is too expensive  Stress related to home/personal issues makes it hard for me to follow a healthy diet  Have trouble resisting tempting food at home  Lack of support from family members  Lack of support from friends  Not enough time to shop for groceries  Not enough time to cook/prepare healthy meals  I am not sure how to prepare healthy meals  I am not sure how to follow a healthy diet  I find nutrition/food labels difficult to understand

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Employee Interest Questions I am interested in:  Learning how to choose healthier food options  Improving my cooking skills  Participating in a workplace garden  Learning about gardening at home  Buying produce from a cooperative agriculture program  Attending a farmers market  Having an on-site farmers market  Learning more about (open-ended)  Having these activities at work (open-ended)

Interest in Health Risk Assessments (HRAs) I would like to have a health screening for the following:  Cholesterol  Triglycerides  Blood pressure  Blood glucose (blood sugar)  Body Mass Index  Waist Circumference

Tools: PROJECT HEALTH CAN HELP! Project Health staff are available to help you build your business case, create buy-in among staff and decision-makers, participate in events, offer educational materials, develop action plans and assist in implementing and evaluating initiatives. Visit http://www.projecthealth.ca or call 519-575-4400 (TTY 519-575-4608). Project Health - Comprehensive Strategies to Promote Healthy Eating

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Step 3B – Assemble a Healthy Eating Subcommittee Once you establish that healthy eating is a priority area for your workplace through your health needs assessment (step 3A), consider creating a healthy eating subcommittee. This ensures that the wellness committee has representatives from all perspectives involved in promoting healthy eating in the workplace. Develop a terms of reference for the healthy eating sub-committee and follow the same process for setting meeting agendas and minutes. Ensure that enough time is allotted for everyone to participate (e.g., four hours per month to attend meetings and participate in activities). If a workplace has food service providers (e.g., cafeterias, cafes, etc.) it is important that they be involved in committee discussions regarding potential food service changes.

Who to involve Consider involving representatives from: 

Management/supervisors



Health and safety committee members



Wellness committee members



Human resources



Employees



Unions and employee associations



Food services personnel



Purchasing department



Fundraising committee



Social committee



Training and development staff



Marketing and communications staff



Benefits staff



Health champions



Other relevant workplace stakeholders

Once the priorities for action have been established, the food service provider will be responsible for the implementation of the changes.

Tip: HEALTHY EATING CHAMPIONS Invite ‘healthy eating champions’ to be a part of your committee. A healthy eating champion is an employee that is passionate and dedicated to healthy eating who can communicate information to co-workers, listen effectively and seek feedback from their peers.49 Having champions on your committee will help to create excitement and buy-in among staff about healthy eating initiatives.

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Step 4 – Develop an Action Plan The committee responsible for developing the healthy eating strategy should review the information collected during the needs assessment, then prioritize areas to work on and put together a high level plan. The plan should: 

Make program recommendations



Clarify the high level goals of the program



Identify required resources



Establish a timeline for implementation

Plans should address, or at least acknowledge, issues related to how occupational health and safety, voluntary health practices and organizational culture are influencing the priority areas for your comprehensive healthy eating strategy. When developing the plan, use the information collected from the needs assessment to prioritize the workplace actions to address areas of concern.

When prioritizing action areas consider: 

The ease of implementing solutions, such as quick wins that may motivate and encourage continued progress



The possibility of making a difference, (e.g., existence of effective solutions), employer readiness to change, likelihood of success and other issues related to workplace policies or politics



The costs that will be incurred if no action is taken



The subjective opinions and preferences of workplace stakeholders, including managers, employees and their representatives51



You may want to target some activities to certain groups of employees or include spouses to reinforce healthy behaviours at home as well as work52

Workplace Example: CAPITAL HEALTH - HEALTHY EATING STRATEGY In 2011, Capital Health developed a healthy eating strategy to work toward a goal of providing 100% healthy choices in their restaurants, vending, retail and catering operations. This logic model shows the corporate healthy eating goals, objectives, areas of intervention, communication plan and awareness raising, skill building, environmental supports and policy components of the strategy. http://www.cdha.nshealth.ca/system/files/sites/92/documents/capital-health-healthyeating-strategy.pdf

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Putting Your Healthy Eating Plan Together Using a Comprehensive Approach A comprehensive approach to wellness programming includes all four key health promotion approaches.

Awareness Raising

Supportive Environment

Awareness raising activities provide information to employees about the benefits of making healthy eating choices. Examples of awareness raising activities include: providing information about healthy eating in pamphlets, company newsletters, articles on the company intranet and healthy eating information posted on bulletin boards.

A supportive environment means that the workplace contains sustainable ongoing activities that make it easier for employees to make healthy eating choices. This includes reducing barriers in the workplace environment that make it difficult for employees to follow a healthy diet.

Skill Building

Workplace policies provide clear definitions of expected employee behaviour and mandate the roles and responsibilities of employees and managers to ensure supports are in place to help individuals make healthy choices. For example, a workplace may choose to have a policy that vegetable and fruit options must be provided whenever food is served in workplace meetings.

Skill building activities give employees an opportunity to learn skills that will help them to change healthy eating behaviours. Examples include education sessions where employees learn food skills such as vegetable, fruit and herb gardening, healthy cooking techniques, nutrition label reading and menu planning.

Policy Development

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Creating Goals and Objectives By setting out goals and objectives you can track the process of your strategy to determine if you have been successful in your efforts. Goals are statements of broad, long-term accomplishments expected from the program. Each goal should have one or more objectives to accomplish the goal. An objective is a statement that describes what the project is trying to achieve.

An objective should be written in a way that allows it to be evaluated. Use SMART objectives that are: Specific Measurable Attainable Realistic Timely

Tip: EXAMPLE GOALS AND OBJECTIVES FOR FOOD SERVED IN MEETINGS

Goal: To create a workplace environment that supports healthy eating. Objectives: Specific: What do you want to do? Example: Create a policy that ensures healthy food is served. Measurable: How much and how often will it be done? Example: In every meeting where food is served. Attainable: How will it be done? Example: Employees will order food using set nutrition criteria. Realistic: Will employees be able to follow the policy? Example: Employees will use a standard catering form. Timely: When will it be done? Example: The policy will take effect July 1, 2015. Objective Summary: Our workplace will create a policy that ensures healthy food is served whenever food is offered in meetings. Employees will order food using a standard catering form, which will be based on a set nutrition criteria. The policy will take effect July 1, 2015.

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Establish a Timeline Prioritize your action items. Start small and work towards bigger initiatives.43 Establish a timeline for each part of the strategy. Plan out what needs to be done and when it needs to be completed. Ensure your timeline is realistic and gives a reasonable time for activities to be completed.43 If you anticipate a great deal of resistance, proceed slowly with changes.44

Program Timing Determine the best time of the year to offer programs. Some initiatives may need to be scheduled monthly or quarterly, while others less often.52 Activities should be scheduled at times that are convenient for participants.52 For example, offering activities before and after work to meet the needs of shift workers.52 Participation in events may be increased if employees are able to attend during work time.

Examine how existing policies and procedures influence eating habits. For example a performance management system that rewards high output, regardless of how the results are achieved, may encourage unhealthy behaviours to get the work done.51

Promotion and Communication Create a communication plan to inform employees about planned activities.44 If your workplace contains different types of employees (e.g., office workers and drivers), identify the most effective way to communicate with each group. Plan to give employees clear and consistent details about the healthy eating strategy. Employees will need information on how, when and where changes will occur. They will also need to know who will be doing the work.

Establish a Budget

Consider developing a logo or branding your health initiatives to make it easily recognizable to employees.

Consider the resources that will be needed to complete the plan such as staff time and financial resources for incentives, printed, materials, food costs, etc.

When making changes to foods offered and sold to employees, ensure employees know that they always have the option to bring their own food to work with them.

Integration

Education

Ensure that planned initiatives are integrated into the overall organization’s goals and priorities so that it is an everyday part of the organization, rather than an extra responsibility.42,51 Try to incorporate a ‘health and wellness lens’ into decision-making processes so that any new workplace decisions are assessed for their impact on employee health.51

Plan an educational component to your strategy. Employees will require education on the environmental, genetic and social influences on eating habits as well as the limitations of current dietary interventions. Without education, employees may feel that healthy eating is solely a personal responsibility and resist changes to the workplace food environment.53-55

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Figure 4 – Workplace Healthy Eating Action Plan Worksheet After completing your workplace nutrition needs assessment, reflect on the areas that were identified and make a plan to address each area. Highlight three areas where your workplace is doing well with regard to implementing healthy eating practices and policies: 1. __________________________________________________________________________________________________________________ 2. __________________________________________________________________________________________________________________ 3. __________________________________________________________________________________________________________________

List three priority areas where workplace healthy eating practices need improvement: 1. __________________________________________________________________________________________________________________ 2. __________________________________________________________________________________________________________________ 3. __________________________________________________________________________________________________________________

Once your priority areas have been determined, create a plan to improve each area. Start small, even tackling one area will make a difference. Make sure you include activities from all four comprehensive health promotion areas: awareness raising, skill building, supportive environments and policy. Goal: ________________________________________________________________________________________________ Objective

Strategies Target Evaluation Person Resources Timeline Awareness Skill Supportive Policy Audience Method Responsible Needed Raising Building Environment Development

Step 5 – Develop the Evaluation Plan Monitoring and evaluating your workplace wellness initiatives is a very important step in your wellness programming cycle. This information will help you identify your successes and enable you to modify your future wellness strategies.52 Programs and initiatives should be evaluated on the goals and objectives set during the planning process.52 In addition to evaluating each initiative, it is important to evaluate the healthy workplace program’s overall success after three to five years or after a significant change such as new management.51

Consider tracking process indicators as well as short-term outcome measures that will indicate if your program has been successful. Long-term successes in the promotion of healthy eating can be somewhat challenging to measure and problems related to poor diet quality may take decades to appear. When evaluating health promotion activities there are several types of success indicators that are commonly used: formative, process, short-term and long-term outcome indicators.

Figure 5 – Types of Success Indicators Formative Indicators

Process Indicators

(These indicators identify if interventions will meet the needs of employees)42

(These indicators identify what works and does not work in your workplace)





Appeal of incentives – Do employees like the incentives offered? Do the incentives motivate staff to participate?



Ensure that the committee had representation from all stakeholder groups



Determine how the programs and initiatives were implemented (e.g., designated people were able to carry out their assigned activities)



Track participation rates, uptake of health risk assessments and use of employee assistance programs (EAP)



Ask employees how satisfied they are with initiatives



Track costs to determine if programs and initiatives were accomplished according to the budget

Usability of information or interventions – Is the information targeted, relevant and easily understood by employees?

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Outcome Indicators (These example indicators show whether the program met its objectives)

Short-Term Indicators 





Uptake of current healthy food and beverage options in the cafeteria, catering or vending operations Group statistics of employee physical assessments including BMI, waist circumference, blood pressure and blood glucose screening Intentions of behaviour change and personal goal setting among employees37 knowledge52



Increased



Self-reported behaviour change52



Positive changes in workplace culture52



Positive sustained environmental changes and/or healthy eating policy implementation



Cafeteria and/or vending sales

Long-term Outcome Indicators41,52 

Absenteeism rates



Presenteeism rates (productivity losses)



Self-reported job satisfaction and employee morale



Employee turnover



Disability claims



WSIB claims



Prescription drug benefits costs



Changes in risk factors (aggregate HRA data such as blood pressure, cholesterol etc.)

Tip: EVALUATION EXAMPLE If the previous policy example were evaluated (food policy for meetings), tracking these indicators can help to determine if the goal and objectives were met:  Do employees understand how to complete the new catering form? Formative  Was policy implemented on the target date? Process  Were employees and managers who order food trained by the target date? Process  Have managers had to remind employees to follow the policy? Process  Are the employees who order food following the policy? Process  If the policy is not being followed, what is the reason? Process  Does data show that catering orders show that healthier food is being ordered? Outcome  How satisfied are employees with the food offered in meetings? Process  Have there been any changes to food expenditures/budget? Outcome

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Step 6 – Check-in with Management Ongoing communication with management is important throughout the entire process. This step is essential to guarantee support and approval for funding or human resources. It’s also needed for a commitment to their role in the communication of the plan, role modelling and to ensure leadership presence.

Once the plan has been drafted, organize a final check-in with management before proceeding. Present the drafted plan to managers and any organized labour groups for approval. Include goals, objectives and planned activities, as well as plans for communication and evaluation.

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Step 7 – Implement the Plan Now that your plan has been approved, it is time to implement your strategies. Don’t forget to incorporate the evaluation process into each activity. Here are some other tips to help make your strategy a success!

Launch your initiative! Once your healthy eating strategy is ready to implement, it is important that management representatives (e.g., CEO, President, Director, union leader, etc.) communicate with employees.52

Incentives Incentives can build motivation by offering rewards for healthy behaviours. Incentives also create interest in participating in wellness activities. When you provide incentives, the company sends the message that it is committed to employee health.52

Other Considerations52 

Ask employees what types of rewards motivate them



Make sure every participant who achieves a goal receives some recognition



Use internal communication strategies such as email, posters, pay-stub attachments, internal websites and word-of-mouth to spread the word!

Use incentives to promote your worksite wellness program through logos and branding



Avoid rewards for biometric changes (e.g., cholesterol improvements)

Launch the event with activities such as:



Avoid offering incentives for the “best” or the “most.” This tends to discourage participation by those who are likely to get the most benefit from joining



Avoid incentives that are not in keeping with health messaging. For example, gift certificates for tanning are not consistent with sun safety recommendations; gift certificates for restaurants are not consistent with healthy eating messages

Communication may need to occur several times in order to ensure that everyone who is affected is informed of when changes will occur and how changes will affect them.



Giveaways



Contests and competitions



Free health assessments with personalized feedback



Loyalty cards as an incentive for selecting healthier options



Food tasting table



Information on what employees can do at home (e.g., packing lunches, family meals)56



Vouchers for “Maximum Nutritional Value” food and beverages in the cafeteria (See Appendix A for the Nutrition Standards for Workplaces©)

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Ideas for Incentives 

Merchandise that promotes your company (e.g., cups, pens, day timers, etc.)



Apparel or reusable grocery bags that promote your wellness messaging or your wellness branding



Pedometers (higher end) – walking or bicycle



Gift cards for local farmers markets, movie tickets, local attractions, travel, books, malls, downloadable music or books, drug stores, hardware stores, etc.



Booklet of passes to recreational facilities (e.g., swim passes, gym passes, skating, bowling, etc.)



Useful household items such as magazine subscriptions, beach towels, cooler bags or backpacks, gardening tools, etc.



Eco-friendly items such as solarpowered cell chargers, crank flashlight/radios, rain barrels or biodegradable bags



Event tickets for music or sport events



Paid time off (e.g., Friday afternoon)



A draw for one big item (e.g., active gaming console, electronic devices such as e-readers, MP3 players, mobile devices, cameras, DVDs with a physical activity focus, trips and vacations, spa packages, etc.)

For more information on healthy incentive ideas, visit: http://www.projecthealth.ca and click on the ‘Toolkits’ tab.

Step 8 – Evaluate and Update the Strategy Once your program has been implemented, start collecting the data from your evaluations. Review the information that you collected during the evaluation and use it to plan next steps. Complete another needs assessment to determine if needs are met or if new needs have arisen.

The committee should present the report to management and other key stakeholders along with suggested recommendations.51 This can help to gain further commitment from your workplace decision-makers.

The healthy eating committee should use this information to create a report that identifies: if goals and objectives were met, indicator results, implications of results, any issues that hindered the process and most importantly, recommendations for program improvements. This will help you decide what changes or improvements need to be made and will help you determine what activities should continue and expand upon.

Don’t forget to celebrate your successes!

Celebrate Your Successes!

Even if things didn’t work out as you expected them to, your wellness committee has gained insight into what worked and what didn’t which will help you move forward in future programming! Share your successes with all employees in your workplace to create energy, enthusiasm and momentum for your strategy.

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Getting Started References 1. Slater J, Green CG, Sevenhuysen G, Edginton B, O'Neil J, Heasman M. The growing Canadian energy gap: More the can than the couch? Public Health Nutr. 2009;12:2216-2224. 2. Health Canada. Eating Well with Canada's Food Guide: A Resource for Educators and Communicators. Ottawa: Health Canada; 2007. 3. Zimmerman FJ. Using marketing muscle to sell fat: The rise of obesity in the modern economy. Annu Rev Public Health. 2011;32:285-306. 4. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis. 2008;5:A23. 5. Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annu Rev Nutr. 2004;24:455-479. 6. Kelly B, Halford JC, Boyland EJ, et al. Television food advertising to children: A global perspective. Am J Public Health. 2010;100:1730-1736. 7. Bleich S, Pollack K. The publics' understanding of daily caloric recommendations and their perceptions of calorie posting in chain restaurants. BMC Public Health. 2010;10:121. 8. Woodward-Lopez G, Kao J, Ritchie L. To what extent have sweetened beverages contributed to the obesity epidemic? Public Health Nutr. 2010:1-11. 9. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med. 2011;364:2392-2404. 10. Malik VS, Schulze MB, Hu FB. Intake of sugarsweetened beverages and weight gain: A systematic review. Am J Clin Nutr. 2006;84:274-288. 11. Walker KZ, Woods JL, Rickard CA, Wong CK. Product variety in Australian snacks and drinks: How can the consumer make a healthy choice? Public Health Nutr. 2008;11:1046-1053. 12. Brownell KD, Farley T, Willett WC, et al. The public health and economic benefits of taxing sugarsweetened beverages. N Engl J Med. 2009;361:15991605. 13. Wilcox K, Vallen B, Block L, fitzsimons GJ. Vicarious goal fulfillment: When the mere presence of a healthy option leads to an ironically indulgent decision. Journal of Consumer Research. 2009;36:380393. 14. Weijzen PL, de Graaf C, Dijksterhuis GB. Discrepancy between snack choice intentions and behavior. J Nutr Educ Behav. 2008;40:311-316.

18. DeJoy DM, Parker KM, Padilla HM, Wilson MG, Roemer EC, Goetzel RZ. Combining environmental and individual weight management interventions in a work setting: Results from the Dow Chemical Study. J Occup Environ Med. 2011;53:245-252. 19. Heinen L, Darling H. Addressing obesity in the workplace: The role of employers. The Milbank Quarterly. 2009;87:101-122. 20. Quintiliani L, Poulsen S, Sorensen G. Healthy eating strategies in the workplace. International Journal of Workplace Health Management. 2010;3:182-196. 21. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health. 2008;29:253-272. 22. Mhurchu CN, Aston LM, Jebb SA. Effects of worksite health promotion interventions on employee diets: A systematic review. BMC Public Health. 2010;10:62. 23. Bleich S, Cutler D, Murray C, Adams A. Why is the developed world obese? Annu Rev Public Health. 2008;29:273-295. 24. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR,Jr. Associations of the local food environment with diet quality--a comparison of assessments based on surveys and geographic information systems: The multi-ethnic study of atherosclerosis. Am J Epidemiol. 2008;167:917-924. 25. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR, Franco M. Fast-food consumption, diet quality and neighborhood exposure to fast food: The multi-ethnic study of atherosclerosis. Am J Epidemiol. 2009;170:2936. 26. Boone-Heinonen J, Gordon-Larsen P, Kiefe CI, Shikany JM, Lewis CE, Popkin BM. Fast food restaurants and food stores: Longitudinal associations with diet in young to middle-aged adults: The CARDIA study. Arch Intern Med. 2011;171:1162-1170. 27. Cohen DA. Neurophysiological pathways to obesity: Below awareness and beyond individual control. Diabetes. 2008;57:1768-1773. 28. Rothman AJ, Sheeran P, Wood W. Reflective and automatic processes in the initiation and maintenance of dietary change. Annals of Behavioral Medicine. 2009;38:S4-S17. 29. Levitsky DA, Pacanowski CR. Free will and the obesity epidemic. Public Health Nutr. 2011:1-16.

15. Bryant EJ, King NA, Blundell JE. Disinhibition: Its effects on appetite and weight regulation. Obes Rev. 2008;9:409-419.

30. Brownell KD, Kersh R, Ludwig DS, et al. Personal responsibility and obesity: A constructive approach to a controversial issue. Health Aff (Millwood). 2010;29:379-387.

16. Devine CM, Nelson JA, Chin N, Dozier A, Fernandez ID. "Pizza is cheaper than salad": Assessing workers' views for an environmental food intervention. Obesity (Silver Spring). 2007;15 Suppl 1:57S-68S.

31. Shain M, Kramer DM. Health promotion in the workplace: Framing the concept; reviewing the evidence. Occup Environ Med. 2004;61:643-8, 585.

17. Verweij LM, Coffeng J, van Mechelen W, Proper KL. Meta-analysis of workplace physical activity and dietary behaviour interventions on weight outcomes. Obesity Reviews. 2011;12:406-429.

32. Schulte PA, Wagner GR, Ostry A, et al. Work, obesity and occupational safety and health. Am J Public Health. 2007;97:428-436. 33. Raulio S, Roos E, Mukala K, Prattala R. Can working conditions explain differences in eating patterns during working hours? Public Health Nutr. 2008;11:258-270.

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34. Nishitani N, Sakakibara H, Akiyama I. Eating behaviour related to obesity and job stress in male Japanese workers. Nutrition. 2009;25:45-50. 35. Fernandez ID, Su H, Winters PC, Liang H. Association of workplace chronic and acute stressors with employee weight status: Data from worksites in turmoil. J Occup Environ Med. 2010;52 Suppl 1:S3441. 36. Kouvonen A, Kivimaki M, Virtanen M, et al. Effort-reward imbalance at work and the co-occurrence of lifestyle risk factors: Cross-sectional survey in a sample of 36,127 public sector employees. BMC Public Health. 2006;6:24. 37. Berset M, Semmer NK, Elfering A, Jacobshagen N, Meier LL. Does stress at work make you gain weight? A two-year longitudinal study. Scand J Work Environ Health. 2011;37:45-53. 38. Canadian Mental Health Association. Comprehensive Workplace Health Promotion – Affecting Mental Health in Workplace. Available at: http://wmhp.cmhaontario.ca/comprehensive-workplacehealth-promotion-affecting-mental-health-in-theworkplace. 39. Kerber K, Buono AF. Rethinking organizational change: Reframing the challenge of change management. Organizational Development Journal. 2005;23:23-38.

46. Cousineau T, Houle B, Bromberg J, Fernandez KC, Kling WC. A pilot study of an online workplace nutrition program: The value of participant input in program development. J Nutr Educ Behav. 2008;40:160-167. 47. Hersey J, Williams-Piehota P, Sparling PB, et al. Promising practices in promotion of healthy weight at small and medium sized U.S. worksites. Prev Chronic Dis. 2008;5:1-11. 48. Kruger J, Yore MM, Bauer DR, Kohl HW. Selected barriers and incentives for worksite health promotion services and policies. . Am J Health Promot. 2007;21:439-447. 49. Vales E. Employees CAN make a difference! involving employees in change at Allstate Insurance. Organizational Development Journal. 2007;25:27-31. 50. Weiner BJ, Lewis MA, Linnan LA. Using organization theory to understand the determinants of effective implementation of worksite health promotion programs. Health Educ Res. 2009;24:292-305. 51. World Health Organization. Healthy workplaces: A model for action for employers, workers, policy-makers and practitioners. 2010. 52. Utah Department of Health. Building a healthy worksite: A guide to lower health care costs and more productive employees. 2010.

40. Bruckman JC. Overcoming resistance to change: Causal factors, interventions and critical values. Psychologist-Manager Journal. 2008;11:211-219.

53. O'Brien KS, Puhl RM, Latner JD, Mir AS, Hunter JA. Reducing anti-fat prejudice in preservice health students: A randomized trial. Obesity (Silver Spring). 2010;18:2138-2144.

41. World Health Organization, World Economic Forum. Preventing noncommunicable diseases in the workplace through diet and physical activity: WHO/World economic forum report of a joint event. 2008.

54. Barry CL, Brescoll VL, Brownell KD, Schlesinger M. Obesity metaphors: How beliefs about the causes of obesity affect support for public policy. Milbank Q. 2009;87:7-47.

42. Berry LL, Mirabito AM, Baun WB. What’s the hard return on employee wellness programs? the ROI data will surprise you and the softer evidence may inspire you. Harvard Business Review. 2010:104-112. 43. Wright S. Dealing with resistance. Nursing Standard. 2010;24:18-20.

55. Alvaro C, Jackson LA, Kirk S, et al. Moving governmental policies beyond a focus on individual lifestyle: Some insights from complexity and critical theories. Health Promot Int. 2010 56. Business in the Community. Healthy eating toolkit: Healthy people = healthy profits. 2009.

44. Kotter JP, Schlesinger LA. Choosing strategies for change. Harvard Business Review. 2008;86:130-139. 45. Lassen A, Bruselius-Jensen M, Sommer HM, Thorsen AV, Trolle E. Factors influencing participation rates and employees' attitudes toward promoting healthy eating at blue-collar worksites. Health Educ Res. 2007;22:727-736.

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Strategies

STRATEGIES To Promote Healthy Eating in the Workplace

Awareness raising Skill building

Policy development

Supportive environment

Healthy Eating Strategies at a Glance Definitions of Success Each section contains definitions of success that represent the gold standard of what a workplace would achieve in each topic area to be successful. Initially, workplaces may choose their own goals and strive towards achieving the definitions of success. In order to make the greatest impact on the wellness of your employees and company, all four of the following health promotion strategies need to be considered in your wellness planning efforts.

Awareness Raising Awareness raising activities provide information to employees about the benefits of making healthy choices.

           

Bulletin Boards and Posters Displays and Health Fairs* EatRight Ontario Emails, Newsletters and Other Employee Communications Events* Health Screening and Health Risk Assessments* Lunch and Learns* Mobile Health Technology* Pamphlets Point-of-Decision Nutrition Information Promoting Local Food Videos

*These activities may be considered skill building if a hands-on learning component is added (e.g., label reading, menu planning, cooking skills, self-monitoring, etc.)

Skill Building Skill building activities help to educate employees and develop the necessary skills to support a healthy choice.

        

Lunch and Learns Health Fairs Smart Phone Applications Knowledge Skills Planning Skills Meal Preparation and Cooking Skills Gardening Skills Challenges and Contests Health Promotion Programs

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Supportive Environment Supportive environments strengthen and enhance employees’ healthy practices. These activities make it easier for employees to make healthy choices.

          

Access to Registered Dietitians Cafeterias Celebrations Common Areas Facilities Meetings and Events Organizational Culture Peer Support Groups Promoting Local Food Vending Machines Workplace Gardens

Policy Development Policies enhance and sustain healthy practices by clarifying roles and expectations between employers and employees. Policies can be implemented to strengthen workplace support for healthy eating in any of the areas that have been covered in this toolkit including:  Awareness Raising  Skill Building  Supportive Environments  Organizational Culture

Special Considerations This section addresses considerations for some specific employee populations that are hard to reach with traditional health promotion strategies or that have specific needs related to healthy eating.

Community Involvement Workplaces often work with other organizations to benefit the community. This section offers suggestions on how to incorporate community involvement into your comprehensive healthy eating strategy.

Did You Know: WATERLOO REGION’S HEALTHY WORKPLACE AWARDS The Waterloo Region Healthy Workplace Awards program recognizes and celebrates workplaces in Waterloo Region who demonstrate a strong commitment to improved health for their employees. Workplaces that implement a healthy eating strategy that includes all four health promotion strategies may be eligible for a Waterloo Region Healthy Workplace Award. For more information on the health workplace awards see: http://www.projecthealth.ca/awards-program

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Awareness raising activities increase employees' general knowledge about a health topic to help them make healthy food choices. It is the first step in supporting employees to improve their eating habits. When used as part of a comprehensive workplace strategy, awareness raising can help employees understand what changes will need to be made and why changes are needed. As part of awareness raising, be sure to include information about how the environment affects individual health behaviours. There are many ways to create awareness about healthy eating. These activities do not need to be expensive or time consuming. Try adding recipes, humour, statistics, trivia, weekly health tips, quotes and simple messages into healthy eating education activities.1

Definition of Success  Nutrition information and/or educational opportunities are provided to employees on an ongoing basis, using a variety of activities.

Awareness Raising

Awareness Raising

Bulletin Boards and Posters Create a bulletin board in a high traffic area where you can post information and posters on various nutrition topics. 

For a listing of posters available for loan, visit: http://www.projecthealth.ca/project-healthtopics/healthy-eating

Displays and Health Fairs Displays Similar to bulletin boards, displays can create interest around healthy eating, especially when they include interactive components. 

Healthy eating displays are available for loan. To view the displays, visit: http://www.projecthealth.ca/project-health-topics/healthy-eating

Health Fairs Invite Project Health staff to attend your workplace health fair to give employees an opportunity to ask questions and learn about healthy eating. Health fairs that offer education, information and pamphlets are considered to be awareness raising opportunities. 

For more information on planning a health fair see the Project Health Toolkit “Planning a Health Fair” at: http://www.projecthealth.ca under ‘Toolkits’



For more information or to book a health fair, contact Project Health at: http://www.projecthealth.ca or 519-575-4400 (TTY 519-575-4608)

*Skill building can also be incorporated into health fair displays (e.g., label reading, self-monitoring, etc.)

EatRight Ontario Many people have questions about nutrition and health. EatRight Ontario provides a free Registered Dietitian consultation service to all Ontario residents. 

EatRight Ontario can be accessed by visiting http://www.eatrightontario.ca or by calling toll free 1-877-510-5102. Telephone services are available Monday through Friday between 9:00 am to 5:00 pm. Over 100 languages are available



Order EatRight Ontario promotional materials from the Service Ontario website https://www.publications.serviceontario.ca/ecom and search for “EatRight” in the “Quick Publications Search” box at the top

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Emails, Newsletters and Other Employee Communications Emails Email messages have the potential to reach large numbers of people and can provide immediate feedback to participants.2,3 They are suitable for employees who have easy access to the internet with their own personal email address.3 Emails may help increase the effectiveness of other strategies (e.g., directing employees to new articles on healthy eating on a website, etc.).3,4 However, the effect sizes are usually small, so emails should be used as part of a comprehensive healthy eating strategy, rather than a standalone technique.2-5 Tips: 

Keep an archive of previous email messages so employees can go back to relevant topics3



Consider increasing the frequency of email messages to intensify impact (e.g. one per week)5



Track the number of emails viewed (e.g., request read receipts), or number of hits on the website2,3



Keep emails in a user-friendly format and accessible to individuals with limited computer skills3



Include thought provoking messages (e.g., examples of how to improve eating habits)5,6



Determine topics of interest of employees and tailor health messages accordingly3,6,7



Invite employee’s family members to subscribe to email and newsletters, as the individual who is most responsible for household food shopping and preparation may be a family member of the employee6

Newsletters (print or electronic) Newsletter articles and inserts can serve many purposes (e.g., enhance support among workers, provide information/education, promote activities or special events and help support a corporate culture that encourages healthy eating). 

EatRight Ontario offers a newsletter service. Employees and health promoters can sign up at: http://www.eatrightontario.ca/en/NewsletterSignUp.aspx



Use information provided by EatRight Ontario for newsletter content in newsletters. (Ensure that you acknowledge EatRight Ontario as the source). http://www.eatrightontario.ca



Identify any employees who will not be reached by a newsletter and explore other options to reach them

Other Employee Communications Other ways to communicate information with staff include: 

Simple messages on pay cheque stubs or pay cheque inserts



“Pop-up” messaging when employees use the company intranet

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Events Plan a workplace event to celebrate health promotion occasions such as Nutrition Month® in March or Healthy Workplace Month in October. Be sure to plan events well in advance to make sure that you have enough time to organize activities and promote the event to staff members. Include posters, handouts, promotional cafeteria specials or free samples of healthy items, quizzes, contests or lunch and learns to celebrate your event. 

Visit http://www.dietitians.ca for more information on Nutrition Month® and http://www.healthyworkplacemonth.ca for Healthy Workplace Month

Health Screening and Health Risk Assessments Many employees appreciate the opportunity to be screened for health conditions while at work. This can be especially important for populations that do not have regular contact with a physician. Health Risk Assessments (HRAs) are a recommended strategy for workplaces when they include a health education component.8 When HRAs provide information only, they are considered to be awareness raising only. However, skill building activities can also be incorporated into HRAs (e.g., setting goals, creating action plans, etc.). 

Conduct on-site blood glucose, blood pressure, waist circumference and cholesterol screening



Ensure that feedback is given in a confidential manner



Refer individuals to see other medical professionals for follow-up when appropriate

Tools: PLANNING FOR HEALTH SCREENING WELCOA See the resource “Choosing the Health Risk Assessment That's Right For You” for information on hiring a health screening provider. http://www.absoluteadvantage.org/uploads/files/Choosing_HRA.pdf Centers for Disease Control and Prevention Checklist for Planning Employee Health Risk Appraisal Implementation http://www.cdc.gov/nccdphp/dnpao/hwi/downloads/HRA_checklist.pdf

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Lunch and Learns Educate your employees about healthy eating over the lunch hour. 

See the Project Health website for Lunch and Learn updates (minimum 10 employees in attendance, call 519-575-4400 (TTY 519-575-4608) for booking): http://www.projecthealth.ca/menu-services/lunch-and-learn

*When lunch and learns provide information only, they are considered to be awareness raising activities, however, skill building can also be incorporated into lunch and learn sessions (e.g., label reading, setting goals, self-monitoring, etc.)

Mobile Health Technology Mobile Health (mHealth) involves the use of mobile phone technology to promote health, prevent disease and provide health care. Such technology includes, but is not limited to text messaging and smartphone applications.9 Text Messages Text messaging is the least advanced, but most widely adopted and least expensive of mHealth technologies.9 According to the Canadian Wireless Telecommunication Association, Canadians send 199 million text messages per day.10 However, the use of text messaging varies by age, culture and other demographic factors. The use of text messaging for preventive health behaviour change is relatively new. There is established research evidence of the effectiveness of text messaging in clinical management of existing health conditions; however the research on its use in healthy individuals is still in its first generation. However, early evidence is showing that, at least in the short term, this type of messaging may have a positive effect on sustaining positive health behaviours.9,11,12 Effectiveness of text messaging may be enhanced by tailoring messages to individuals. Tailoring could involve:11,12 

including employee name or nickname in the message



incorporating individual goals into messages



allowing participants to write the messages they will receive



allowing participants to specify days and times when they would like to receive the messages



basing messages on a health behaviour change theory (e.g., stages of change) that takes into the account an individual’s current state of readiness for making changes to eating habits

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Smart Phone Applications Hundreds of smartphone apps (applications) are available to help individuals monitor physical activity and food intake.13 Some smartphone apps also offer information about the food allergen content of food items. Although users give smartphone apps high ratings for satisfaction the effectiveness of these applications to help individuals improve their dietary intake has yet to be established.13 In addition, there are some concerns about the accuracy of the information provided by smartphone apps.13 Smartphone apps that can be used to set goals or build skills such as keeping a food journal are considered to be skill building activities. 

Typically the calorie and allergen information provided by these apps is derived from the United States Department of Agriculture, Nutrient Database of Foods and is more indicative of foods offered the United States.13 Therefore, if seeking out food related smartphone apps use apps that are based on the Canadian Nutrient File database to be more reflective of foods available in Canada



Smartphone apps should not be used in place of advice from health professionals

Pamphlets Make educational materials available to employees in an accessible area. 

Several healthy eating pamphlets are available from Project Health at: http://webapps.regionofwaterloo.ca/phrcpamphletordering. Additional nutrition pamphlets can be found at: http://www.region.waterloo.on.ca/nutrition



Dietitians of Canada produces several educational nutrition pamphlets available at: http://www.dietitians.ca/Your-Health/Nutrition-A-Z.aspx

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Point-of-Decision Nutrition Information Point-of-decision nutrition information means that nutrition information is available to individuals at the moment that they are making a food decision. There are three general types of point-of purchase information strategies:

1. Nutrition Labels The Nutrition Facts Panel available on packaged food in Canada. These labels describe the nutritional content of food items. Sometimes this type of nutrition information is also made available to consumers in other formats such as websites, pamphlets, tray liners and posters.

2. Point-of-Purchase Messaging Point-of-purchase messaging includes prompts or tips to encourage people to make healthier choices (e.g., “grab a salad!”). Point-of-purchase messaging can be attached to walls, shelves, refrigerators and serving areas in the form of posters, glass clings, floor clings, table tents and displays.

3. Nutrition Symbols Nutrition symbols are sometimes used to identify healthier choices that meet a specified nutrition criterion. Many food companies have designed their own nutrition symbols (e.g., President’s Choice® Blue Menu, etc.) and some workplaces design their own stickers or logos to show items that meet nutritional criteria selected by the workplace.

Effectiveness of Point-of-Decision Nutrition Information Consumers report using nutrition information when making food decisions and studies show that consumers who use nutrition labelling tend to reduce their caloric intake.14-21 However, providing point-of-decision nutrition information may not always be effective at motivating people to make healthier choices. Research shows mixed results on the effectiveness of point-ofdecision nutrition information. Several studies indicate that providing nutrition information at the point-of-decision had a positive effect on food purchases,14,18-20,22 while others report little or no effect.23-26

The Bottom Line Point-of-decision nutrition information may have a small effect when used as part of a comprehensive healthy eating program, involving education and environmental changes. However, point-of purchase nutrition information is not likely to be effective as a stand-alone intervention.26

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Using Point-of-Decision Making Nutrition Information 

Nutrition information must be made available at the moment that food decisions are being made in order to be effective. Put nutrition information directly on products or on menu boards rather than in pamphlets or on websites14



Provide skill building opportunities to help employees learn how to use and interpret nutrition information. For example, labelling caloric content is only useful if employees understand how many calories they need each day23,27,28



When using nutrition symbols ensure that the nutritional parameters consider the overall nutritional quality of food items rather than just a few nutrients. For example, some nutrition symbols may be liberal (allowing high amounts of some nutrients that should be limited such as sodium) or based on only a few nutritional parameters (such as low-fat or high fiber), while failing to address other nutrients that may negatively impact health (such as sodium or added sugar)



Use information in conjunction with positive changes to the nutritional content of foods offered. Otherwise, using point-of-decision information strategies without improving the nutritional quality of the food can leave employees feeling as though it is much too difficult to actually consume a healthy diet29

Promoting Local Food Opportunities Make educational materials about local foods available to employees. 

Place Buy-Local Buy-Fresh maps in an accessible area: http://www.foodlink.ca/index.php?p=blbf_map_locations



Place a link to the Foodlink Waterloo Region website on your intranet: http://www.foodlink.ca



Post opportunities for employees to participate in local food related events: http://www.wrfoodsystem.ca/events

Videos Videos can be used by health promoters to educate others about healthy eating.



For a listing of healthy eating videos available from Project Health, visit: http://tinyurl.com/6pdnoml

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Awareness Raising References 1. Gates D, Brehm B, Hutton S, Singler M, Poeppelman A. Changing the work environment to promote wellness: A focus group study. AAOHN J. 2006;54:515-520.

17. Kimathi AN, Gregoire MB, Dowling RA, Stone MK. A healthful options food station can improve satisfaction and generate gross profit in a worksite cafeteria. J Am Diet Assoc. 2009;109:914-917.

2. Norman GJ, Zabinski MF, Adams MA, Rosenberg DE, Yaroch AL, Atienza AA. A review of eHealth interventions for physical activity and dietary behavior change. Am J Prev Med. 2007;33:336-345.

18. Post RE, Mainous AG,3rd, Diaz VA, Matheson EM, Everett CJ. Use of the nutrition facts label in chronic disease management: Results from the national health and nutrition examination survey. J Am Diet Assoc. 2010;110:628-632.

3. Plotnikoff RC, McCargar LJ, Wilson PM, Loucaides CA. Efficacy of an E-mail intervention for the promotion of physical activity and nutrition behavior in the workplace context. Am J Health Promot. 2005;19:422-429.

19. Roberto CA, Larsen PD, Agnew H, Baik J, Brownell KD. Evaluating the impact of menu labeling on food choices and intake. Am J Public Health. 2010;100:312-318.

4. Woodall WG, Buller DB, Saba L, et al. Effect of emailed messages on return use of a nutrition education website and subsequent changes in dietary behavior. J Med Internet Res. 2007;9:e27.

20. Temple JL, Johnson K, Recupero K, Suders H. Nutrition labels decrease energy intake in adults consuming lunch in the laboratory. J Am Diet Assoc. 2010;110:1094-1097.

5. Plotnikoff RC, Pickering MA, McCargar LJ, Loucaides CA, Hugo K. Six-month follow-up and participant use and satisfaction of an electronic mail intervention promoting physical activity and nutrition. Am J Health Promot. 2010;24:255-259.

21. Howlett E, Burton AS, Bates K, Huggins K. Coming to a restaurant near you? potential customer responses to nutrition information disclosure on menus. Journal of Consumer Research. 2009;36:494-503.

6. Block G, Block T, Wakimoto P, Block CH. Demonstration of an E-mailed worksite nutrition intervention program. Prev Chronic Dis. 2004;1:A06. 7. Cousineau T, Houle B, Bromberg J, Fernandez KC, Kling WC. A pilot study of an online workplace nutrition program: The value of participant input in program development. J Nutr Educ Behav. 2008;40:160-167. 8. Task Force on Community Preventive Services. A recommendation to improve employee weight status through worksite health promotion programs targeting nutrition, physical activity, or both. Am J Prev Med. 2009;37:358-359. 9. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev. 2010;32:56-69. 10. Canadian Wireless Telecommunications Association. Facts & figures. 2011;2012. 11. Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service. Am J Prev Med. 2009;36:165173. 12. Gerber BS, Stolley MR, Thompson AL, Sharp LK, Fitzgibbon ML. Mobile phone text messaging to promote healthy behaviors and weight loss maintenance: A feasibility study. Health Informatics J. 2009;15:17-25. 13. Gan KO, Allman-Farinelli M. A scientific audit of smartphone applications for the management of obesity. Aust N Z J Public Health. 2011;35:293-294. 14. Bassett MT, Dumanovsky T, Huang C, et al. Purchasing behavior and calorie information at fastfood chains in New York City, 2007. Am J Public Health. 2008;98:1457-1459.

22. Ellis S, Glanville NT. Trans fat information on food labels: Consumer use and interpretation. Can J Diet Pract Res. 2010;71:6-10. 23. Harnack LJ, French SA, Oakes JM, Story MT, Jeffery RW, Rydell SA. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trial. Int J Behav Nutr Phys Act. 2008;5:63. 24. Vyth EL, Steenhuis IH, Heymans MW, Roodenburg AJ, Brug J, Seidell JC. Influence of placement of a nutrition logo on cafeteria menu items on lunchtime food choices at Dutch work sites. J Am Diet Assoc. 2011;111:131-136. 25. Elbel B, Kersh R, Brescoll VL, Dixon LB. Calorie labeling and food choices: A first look at the effects on low-income people in New York City. Health Aff (Millwood). 2009;28:w1110-21. 26. Swartz JJ, Brxton D, Viera AJ. Calorie menu labeling on quick-service restaurant menus: An updated systematic review of the literature. International Journal of Behavioral Nutrition and Physical Activity. 2011;8 27. Piron J, Smith LV, Simon P, Cummings PL, Kuo T. Knowledge, attitudes and potential response to menu labelling in an urban public health clinic population. Public Health Nutr. 2010;13:550-555. 28. Krukowski RA, Harvey-Berino J, Kolodinsky J, Narsana RT, Desisto TP. Consumers may not use or understand calorie labeling in restaurants. J Am Diet Assoc. 2006;106:917-920. 29. Engbers LH, van Poppel MN, Chin A Paw M, van Mechelen W. The effects of a controlled worksite environmental intervention on determinants of dietary behavior and self-reported fruit, vegetable and fat intake. BMC Public Health. 2006;6:253.

15. French SA. Pricing effects on food choices. J Nutr. 2003;133:841S-843S. 16. Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: The potential health benefits of providing nutrition information in restaurants. Am J Public Health. 2006;96:1669-1675.

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Food skills are all the skills individuals need to provide good food for their household, make healthy choices and prepare meals that are safe, nutritious and culturally acceptable.1 Skill building activities give employees a chance to master skills that will help them to choose and prepare healthy food.

Definition of Success  Skill building opportunities are provided to employees on a regular basis. Skill building refers to activities that include a hands-on component such as workplace challenges, meal planning, label reading, shopping, budgeting, meal preparation and gardening. Some skill building activities can occur in the workplace; however, it may be easier in some instances to locate an agency that can provide skill building education for your employees (e.g., community college, community centre, local market, private company, etc.).

Skill Building

Skill Building

Lunch and Learns When lunch and learns contain a skill building component such as label reading, goal setting or self-monitoring, they can be counted as skill building activities. 

See the Project Health website for Lunch and Learn updates. Be sure to request a skill building component when booking your lunch and learn (minimum 10 employees in attendance). Call 519-575-4400 (TTY 519-575-4608) or visit: http://www.projecthealth.ca/menu-services/lunch-and-learn

Health Fairs When health fair displays contain skill building components (e.g., label reading, self-monitoring, etc.) they can be counted as skill building opportunities 

For more information on planning a health fair see the Toolkit “Planning a Health Fair” under the ‘Toolkits’ section of the Project Health website: http://www.projecthealth.ca



For more information or to book a health fair contact Project Health: http://www.projecthealth.ca/menu-services/health-fairs

Smart Phone Applications (Apps) Smartphone apps that can be used to set goals or build skills such as keeping a food journal are considered to be skill building activities. See the smartphone apps section on page 86 for more information.

Knowledge Skills Knowledge skills include utilizing nutrition information, reading food labels, practicing food safety and incorporating or substituting ingredients.

Reading Nutrition Labels 

Introduce short interventions held at workstations that teach employees one basic healthy eating skill, such as learning how to find sodium or sugar on nutrition labels



Include a label reading education session into healthy eating lunch and learns

Planning Skills Planning skills include: planning meals for the week, creating shopping lists, food budgeting and coordinating food preparation.

Meal Planning 

The Canada’s Food Guide website offers educational tools that describe appropriate portion sizes, allow individuals to create personal Food Guides, as well as providing tips for planning meals, shopping, reading food labels, snacking and eating out http://www.hcsc.gc.ca/fn-an/food-guide-aliment/index-eng.php



EatRight Ontario offers a menu planner, recipes and other food skill resources http://www.eatrightontario.ca

Healthy Eating on a Budget 

EatRight Ontario offers a Healthy Eating on a Budget resource http://www.eatrightontario.ca/en/Budget.aspx

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Meal Preparation and Cooking Skills These skills include thinking creatively about using leftovers and adjusting recipes, mechanical techniques such as chopping, mixing and cooking and using senses such as sight, taste, smell, texture and temperature to make food visually appealing, appetizing and enjoyable. Individuals with cooking skills are more likely to make healthy food choices. Men and individuals living alone generally report less skill with food and cooking and rely more on ready-made meals and convenience foods, which may be less nutritious.2 

Offer employees opportunities to develop their interest and confidence in cooking. Look for courses offered in colleges, community centres, farmers’ markets or other local venues



Provide workers with healthy recipes. Many reputable websites offer free recipes including EatRight Ontario http://www.eatrightontario.ca and Dietitians of Canada http://www.dietitians.ca



Offer healthy cookbooks (such as the titles offered through Dietitians of Canada) to workers, to borrow, purchase or for use as rewards or incentives http://www.dietitians.ca



Recipe Analyzer is a tool available from Dietitians of Canada that analyzes recipes for nutrition content. Individuals may find this tool helpful to assess their favorite recipes: http://www.dietitians.ca/Your-Health/Assess-Yourself/Recipe-Analyzer.aspx



Educate employees about food safety techniques. This can include food safety techniques for packing a lunch, cooking on the barbeque, picnics, general food safety in the kitchen and more. Health Canada offers an interactive website on safe food handling: http://www.hcsc.gc.ca/fn-an/securit/kitchen-cuisine/index-eng.php or The Partnership for Consumer Food Safety Education http://www.fightbac.org

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Gardening Skills People who garden at home consume vegetables and fruit more often, leading to higher quality diets.3 Gardening also has other benefits such as providing opportunities to be physically active, reducing the effects of stress and lowering the risk of developing cardiovascular disease and depression.4 

Offer employees and their families opportunities to learn gardening skills. Look for courses offered in colleges, community centres, farmers markets or other local venues or sponsor a course in your workplace



Use vegetable and fruit plants, flowers, herbs, bulbs and gardening supplies as prizes during challenges and competitions



Distribute resources about vegetable and fruit freezing, which are available from Project Health: http://projecthealth.ca/project-health-topics/healthy-eating



Offer workshops on food preservation techniques such as freezing and canning to help individuals learn how to extend the local, seasonal harvest

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Challenges and Contests Challenges and contests can be a great way to encourage behaviour change by allowing employees to try a new behaviour. Here are some considerations to make before implementing a healthy eating challenge in your workplace.

Try This! 

Hold contests and challenges for at least two months to encourage employees to form new habits5



Instead of weight loss, promote positive behaviour changes, such as eating more vegetables, fruit and whole grains, or eating less sodium or sugar



Educate employees about healthy living and offer skill building sessions as part of the challenge or contest (e.g., cooking challenges)



Give healthy living incentives (e.g., pedometers, Frisbees, gardening tools, sunscreen, hats, reusable water bottles, reusable shopping bags, grocery lists, cooking utensils, healthy cookbooks, etc.) either as one grand prize or in increments (e.g., passport system that includes attending education sessions and participating in challenges). An incremental award system may help to motivate people to participate in all of the challenge activities



Launch the challenge with an activity or event



Have FUN!

Are there any concerns? 

The popularity of television shows such as The Biggest Loser® have inspired similar weight loss challenges in workplaces. The television show contestants have medical supervision, personal trainers and nutrition consultants. These individuals are able to focus on weight loss without the distractions and stresses of daily life. Employees do not have these supports during workplace weight challenges and therefore, the weight loss achieved on these shows is somewhat unrealistic for employees



A weight loss challenge may have unintended side effects on employees attempting to lose weight, such as using unhealthy practices like fasting, skipping meals, using weight loss supplements or following unbalanced nutrition plans



Weight challenges may result in lower self-esteem for some individuals, especially if the focus is on superficial results such as weight and appearance rather than positive health outcomes and the adoption of healthy behaviours

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Health Promotion Programs Health promotion programs promote knowledge and skills that help participants follow a healthy diet. Health promotion programs are typically time limited (e.g., 14 week program). Health promotion programs in general, have been successful at promoting short-term positive changes in dietary intake.6 If health promotion programs are offered on an ongoing basis (e.g., weekly), they are considered to be supportive environment similar to peer support programs. See page 143 for more details.

Essential Elements for Health Promotion Programs If your workplace decides to implement a healthy eating promotion program, look for programs that contain these elements. This will increase the chances that your program will be effective.

1. Paid Time Offering paid time to attend health promotion programs can significantly increase employee participation rates.7

2. Structured Programs Use programs that incorporate foods skills such as meal planning, food preparation techniques, label reading and budgeting. Structured programs with scheduled sessions that include skills development have better results than self-directed or education-only programs.8

3. Tailored Programs Ensure the program is tailored for the needs of your employee group.9,10

4. Integration Link the health promotion program with other related programs (e.g., health screening and health risk assessments, occupational health and safety initiatives, etc.).9

5. Goal Setting Have employees set personal goals that are SMART (Specific, Measurable, Attainable, Realistic and Timely) (e.g., “I will bring a healthy lunch to work at least three days per week”).6,11-14

6. Self-monitoring Encourage employees to monitor their food intake using paper or electronic tools (e.g., food diaries).13,15-17

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7. Rewards and Incentives Offer rewards or competitions to motivate employees to stick to their goals.7,18 Even reverse financial rewards have been shown to help motivate people (i.e., contracts where people deposit their own money and get it back when they meet their personal goal).18,19 However, incentives are only useful for as long as they are in effect.6,19 For a listing of incentive ideas see page 74 or visit http://www.projecthealth.ca and select ‘Toolkits’ to see the Incentives that Support Wellness Programming factsheet.

8. Program Intensity Plan for several personal contacts. Programs tend to have more success with a higher number of contacts over a longer period of time (i.e., at least two months).5,13,16,18,20

9. Individual versus Group Approach Use individual or group approaches as both formats have proven effective.13

10. Communication Strategy Determine the most effective way to communicate with your employees (e.g., face-to-face, telephone, print materials, email or internet). Research suggests that programs that incorporate face-to-face contact at least once per month are most effective.18 Some web-based applications can be used for conducting assessments, providing information and tracking progress.21 However, individuals that are familiar with technology are more inclined to use it to keep records.22,23 Incorporate tailored feedback, as it is more effective than general information.9,13,18,20 Ensure feedback is timely and is provided in a confidential manner.9

11. Social Support Include family members to increase program effectiveness.6,24 This may be especially important in the case of healthy eating, as the employee may not be responsible for the majority of household food shopping and preparation. People who are supported by friends, family and colleagues are more successful at behaviour change than those who try to do it alone.9,13,25,26

12. Program Leaders Both health professionals or lay leaders can be effective program leaders, as long as the program has been developed by a health professional.13,27

13. Multi-Component Interventions Incorporate several health behaviours into your program (e.g., healthy eating and physical activity) as these tend to be more effective.13

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Skill Building References 1. Vanderkooy P. Food skills of Waterloo Region adults. Region of Waterloo Public Health; 2010. 2. van der Horst K, Brunner TA, Siegrist M. Readymeal consumption: Associations with weight status and cooking skills. Public Health Nutr. 2011;14:239-245. 3. Nanney MS, Johnson S, Elliott M, Haire-Joshu D. Frequency of eating homegrown produce is associated with higher intake among parents and their preschoolaged children in rural Missouri. J Am Diet Assoc. 2007;107:577-584.

15. Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: A systematic review of the literature. J Am Diet Assoc. 2011;111:92-102. 16. Burke LE, Steenkiste A, Music E, Styn MA. A descriptive study of past experiences with weight-loss treatment. JADA. 2008;108:640-647. 17. Wing RR, Crane MM, Thomas JG, Kumar R, Weinberg B. Improving weight loss outcomes of community interventions by incorporating behavioral strategies. Am J Public Health. 2010;100:2513-2519.

4. Van Den Berg AE, Custers MHG. Gardening promotes neuroendocrine and affective restoration from stress. Journal of health Psychology. 2011;16:3-11.

18. Benedict MA, Arterburn D. Worksite-based weight loss programs: A systematic review of recent literature. Am J Health Promot. 2008;22:408-416.

5. Lally P, Van Jaarsveld CHM, Potts HWW, Wardle J. How habits are formed: Modelling habit formation in the real world. Eur J Soc Psychol. 2010;40:998-1009.

19. Levy RL, Finch EA, Crowell MD, Talley NJ, Jeffery RW. Behavioral intervention for the treatment of obesity: Strategies and effectiveness data. Am J Gastroenterol. 2007;102:2314-2321.

6. Archer WR, Batan MC, Buchanan LR, et al. Promising practices for the prevention and control of obesity in the worksite. Am J Health Promot. 2011;25:e12-26. 7. Linnan LA, Sorensen G, Colditz G, Klar DN, Emmons KM. Using theory to understand the multiple determinants of low participation in worksite health promotion programs. Health Educ Behav. 2001;28:591607. 8. Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: A randomized trial. JAMA. 2003;289:1792-1798. 9. Sparling PB. Worksite health promotion: Principles, resources, and challenges. Prev Chronic Dis. 2010;7:A25. 10. Janer G, Sala M, Kogevinas M. Health promotion trials at worksites and risk factors for cancer. Scand J Work Environ Health. 2002;28:141-157. 11. World Health Organization. Healthy workplaces: A model for action for employers, workers, policy-makers and practitioners. 2010. 12. Steyn NP, Parker W, Lambert EV, Mchiza Z. Nutrition interventions in the workplace: Evidence of best practice. South African Journal of Clinical Nutrition. 2009;22:111-117. 13. Greaves CJ, Sheppard KE, Abraham C, et al. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health. 2011;11:119. 14. World Health Organization, World Economic Forum. Preventing noncommunicable diseases in the workplace through diet and physical activity: WHO/World Economic Forum Report of a Joint Event. 2008.

20. Eakin EG, Lawler SP, Vandelanotte C, Owen N. Telephone interventions for physical activity and dietary behavior change: A systematic review. Am J Prev Med. 2007;32:419-434. 21. Norman GJ, Zabinski MF, Adams MA, Rosenberg DE, Yaroch AL, Atienza AA. A review of eHealth interventions for physical activity and dietary behavior change. Am J Prev Med. 2007;33:336-345. 22. Maruyama C, Kimura M, Okumura H, Hayashi K, Arao T. Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: A randomized controlled trial. Prev Med. 2010;51:11-17. 23. Morgan PJ, Collins CE, Plotnikoff RC, et al. Efficacy of a workplace-based weight loss program for overweight male shift workers: The workplace POWER (preventing obesity without eating like a rabbit) randomized controlled trial. Prev Med. 2011;52:317325. 24. Quintiliani L, Poulsen S, Sorensen G. Healthy eating strategies in the workplace. International Journal of Workplace Health Management. 2010;3:182-196. 25. Rigsby A, Gropper DM, Gropper SS. Success of women in a worksite weight loss program: Does being part of a group help? Eat Behav. 2009;10:128-130. 26. Shay LE. A concept analysis: Adherence and weight loss. Nurs Forum. 2008;43:42-52. 27. Boyko J, McRae L, Robeson P. Worksite nutrition and physical activity interventions for controlling employee overweight and obesity: Evidence and implications for public health Hamilton, ON: McMaster University.: health-evidence.ca; 2010.

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A supportive environment includes ongoing, sustainable activities that make it easier to make healthy choices and participate in healthy behaviours. In a supportive environment, employees do not have to actively resist an environment full of less healthy choices in order to follow a healthy lifestyle.

Definition of Success  See each individual section under supportive environment for a list of applicable success indicators

Supportive Environments

Supportive Environments

Environmental interventions place less responsibility on individuals and do not require employees to self-select into programs – a major barrier in reaching many employees. Workplaces can improve the environmental factors that influence eating behaviours in the workplace. This section outlines the steps to creating a supportive healthy eating environment in your workplace. Example strategies include: 

Improving the nutritional quality of food offered during meetings and celebrations and sold in cafeterias, cafes, vending machines and workplaces stores



Encouraging managers and employees to avoid using food as a reward or for fundraising purposes



Creating on-site farmers’ market or workplace garden



Offering nutrition counseling benefits or services for employees who have nutrition-related health conditions



Sourcing food from local and sustainable food producers



Ensuring that food offered to employees has been handled in a safe manner



Providing adequate time and space to eat and facilities to allow employees to store and prepare their own food



Fostering a supportive workplace culture to minimize stress and encourage positive employee interactions

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Workplaces can offer several services that can help individuals eat healthier. These include services provided by a Registered Dietitian through health benefits, on-site services or through an employee assistance program (EAP)

Definition of Success  High-risk employees have access to the services of a Registered Dietitian through health benefits, on-site services or through EAP

Registered Dietitian Services Dietitians offer services such as nutrition assessments, diet modification and counselling to help individuals achieve nutrition goals.1 Currently, there is good evidence that intensive dietitian counselling for adults with certain conditions can improve nutrition related risks, especially when combined with physical activity.1,2 However, nutrition counselling is not as effective at promoting healthy eating among healthy adults without identified nutrition risks.1 Nutrition therapy provided by Registered Dietitians has been proven to improve health risks for the following conditions:1 

high cholesterol (i.e., LDL, total cholesterol)



high blood pressure



diabetes management



pre-diabetes (high blood glucose)



kidney disease



weight management

Counselling services provided by Registered Dietitians in Canada are not covered by all employee health benefit packages and employee assistance programs. Workplaces may want to consider the addition of dietitian consulting services to workplace health benefits for high-risk employees. Current evidence suggests that dietitian interventions may improve health outcomes and be delivered at a reasonable cost. Many studies do not cover cost-effectiveness and therefore there is limited evidence for long-term economic benefits.1

Tools: REGISTERED DIETITIANS Registered Dietitians are regulated health professionals uniquely trained to counsel individuals on diet, food and nutrition.1 For a list of Registered Dietitians in Waterloo Region see: http://chd.region.waterloo.on.ca/en/healthyLivingHealthProtection/resources/Register edDietitians.pdf

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Access to Registered Dietitians

Access to Registered Dietitians

Access to Registered Dietitian References 1. Royall D. A systematic review of the effectiveness of nutrition counselling interventions by dietitians in outpatient and in workplace settings. Dietitians of Canada; 2009.

2. Anderson LM, Quinn TA, Glanz K, et al. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: A systematic review. Am J Prev Med. 2009;37:340-357.

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Many working adults find it difficult to make time for healthy eating. The workplace cafeteria is an excellent place to promote healthy eating habits by providing employees with healthy food and beverages. There are several environmental factors that influence employee food choices such as the availability of healthy and less healthy choices, the taste and price of available food and beverages, portion sizes, convenience and marketing. Often attempts to promote healthier items are unsuccessful because only one aspect is addressed such as making healthier options available without considering placement, pricing, promotion, convenience or taste. Ideally, all of these aspects will be addressed to promote healthy eating in your workplace.

Definition of Success  At least 80 per cent of food and beverages meet the criteria for the

“Maximum Nutritional Value” or “Sell/Offer Most” categories*  Ideally, food and beverages that meet the criteria for the “Sell/Offer Less”

category are limited to 20 per cent or less*  Ideally, food and beverages that meet the criteria for the “Not

Recommended” category are not offered*  Meals include three of the four food groups from Canada’s Food Guide**  Price, placement and promotion are used to market healthier food and

beverages  Food and beverages offered are culturally acceptable  Local and/or organic food is used whenever possible  Food service employees have food safety training  Food service operations are as energy efficient as possible *See the Nutrition Standards for Workplaces© in Appendix A for a description of food categories. **Please visit http://healthcanada.gc.ca/foodguide for a copy of Canada’s Food Guide

Cafeterias

Cafeterias

1.0 Needs Assessment A cafeteria needs assessment can take many forms, including surveys or focus groups with employees to identify their needs. The assessment should also include information from cafeteria managers and employees about the operations of the cafeteria and suggestions they have for improvements. Assess the current cafeteria operations and identify both positive and negative aspects of the service in terms of promoting healthy eating. Identify training needs, as skills vary widely among food service personnel (e.g., training on food preparation techniques, food presentation, marketing and customer service). For more information on assessing needs in your workplace see page 62 in the ‘Getting Started’ section.

2.0 Evaluation Indicators Tracking indicators will help to determine if there have been positive changes in the promotion of healthy food and beverages in the cafeteria. Identify relevant indicators in your cafeteria and monitor them before, during and after your interventions. Some possible indicators include: 

The current percentage of food and beverages that are available for sale from the “Maximum Nutritional Value”, “Sell/Offer Most”, “Sell/Offer Less” and “Not Recommended” categories based on the criteria in the Nutrition Standards for Workplaces©



Cafeteria sales (e.g., sales of healthy meal specials, salads etc. at the point of purchase through cash register sales or number of portions sold.)



Meals include three of the four food groups from Canada’s Food Guide



Healthier food and beverages are promoted, priced competitively and placed in convenient locations



Food and beverages offered are acceptable to various cultures in the workplace



The number of food service employees that have food safety training



Food safety reports from Public Health Inspectors



The percentage of local and/or organic food that is purchased for the cafeteria



The environmental impact of food service operations (e.g., waste reduction, energy use)



Employee satisfaction with cafeteria food services (e.g., taste, price, quality, convenience)



Note barriers, challenges and successes in the implementation process



Any other relevant indicators

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3.0 Creating a Healthy Cafeteria 3.1 Improve the Nutritional Content of Available Food and Beverages Ensure meals meet Canada’s Food Guide recommendations Most meals do not follow current Canada’s Food Guide recommendations. In order to promote healthy eating habits, the food offered in the cafeteria should meet Canada’s Food Guide recommendations. This can be achieved using the Nutrition Standards for Workplaces© in Appendix A. Using the nutrition standards ensures that food and beverages offered in the cafeteria are: part of Canada’s Food Guide, are higher in nutrients such as vitamins, minerals and fibre and contain lower amounts of added fat, sugar or salt. Workplaces should aim to serve the majority of food and beverages that meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most” (e.g., 80 per cent of food and beverages offered should come from these categories), with an emphasis on items that meet the criteria for “Maximum Nutritional Value”. Food and beverages from the “Sell/Offer Less” category should be limited (e.g., to 20 per cent or less). Additionally, workplaces should avoid offering food and beverages from the “Not Recommended” category. Assess the food and beverages available in the cafeteria using the Nutrition Standards for Workplaces© in Appendix A (use this information as your baseline data). Then, work with your food service provider to make changes to the nutritional content of food and beverages offered to employees. The changes can be implemented all at once or phased in over time.

Success Stories: IMPROVING NUTRITIONAL QUALITY “Chevron’s food service vendor has a “stealth health” philosophy: it uses quality ingredients and few highly processed options to offer menu items that delight rather than require sacrifice. Instead of seeing a daily “healthy entrée” employees choose from an array of appetizing healthful options, such as meatloaf made with whole grains and low sodium soups made from scratch.”1 An intervention at a truck stop had positive effects on driver’s food habits by providing training for food service workers on healthy food preparation techniques.2 As an added bonus, the food service operator actually saved money using lower-fat cooking methods.2

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Ways to help employees meet Canada’s Food Guide recommendations 

Plan cafeteria meals so they contain three of the four food groups from Canada’s Food Guide. Ensure that half of the plate is from the Vegetables and Fruit food group, one quarter of the plate is from the Grain Products food group and one quarter of the plate is from the Meat and Alternatives food group



Add more vegetables (chopped or pureed) to casseroles, pasta dishes, mixed recipes and sandwich fillings.3 Serve all specials or meals with salads, raw or cooked vegetables or whole or canned unsweetened fruit as sides.4 Add vegetable or fruit garnishes to sandwiches such as grated carrots or slices of fresh fruit3



Reformulate existing food products (i.e., reduce the amount of added fat, salt or sugar used or add more vegetables to the recipe)5-7 Reduce or remove energy dense ingredients used in recipes such as cheese, cream, butter, margarine, oils, mayonnaise, salad dressings, higher fat meats and sugar. Substitute some high fat ingredients such as beef with low energy-density ingredients such as mushrooms (e.g., casseroles, stews, chilli, pizza, etc.)3,7,8 Mix onion, celery, oats and other vegetables in ground meat dishes (e.g., meatballs, meatloaf, etc.)3



Use low fat cooking methods such as grilling, baking, stir-frying, microwaving, steaming, roasting, sautéing, toasting and barbequing



Look for the healthiest ingredients. For example, use low-fat mayonnaise in recipes or low-salt canned products, sauces, breads, etc.



Serve sauces, dressings and gravies in small portions, on the side



Offer smaller servings of grain products such as thin crust on pizzas, small pitas, tortillas, wraps and breads



Remove less healthy drinks, desserts and sides and replace them with healthier tasty options (e.g., fruit salads for dessert instead of cake or baked goods)



Sell sliced fruit or vegetables such as slices of melon or carrot sticks in convenient snack sizes (e.g. 100 g)3



Serve vegetarian meals more often (e.g., once or twice a week). Get inspiration from ethnic cuisine (e.g., Asian dishes) that typically focus on vegetables3

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3.2 Taste Taste can be highly subjective and in some cases, labeling a food as ‘healthy’ causes assumptions of poor taste (e.g., low-fat, light or items that mention they contain ‘healthy’ ingredients such as soy).5,9-12 

When working with populations that are less health oriented, focus on other positive and enjoyable features of healthy options such as “freshness” or “locally grown”



Use appealing descriptive terms in food names, for example, “rich”, “spicy”, “home made”, “chunky” or “traditional”11



The more often a food is tasted the more it is liked.9 If at first the employees do not like the new food items, keep trying, as they may eventually be accepted, especially if they are coupled with well-liked food items



Try offering free samples when introducing new options in the cafeteria

3.3 Price Consumers tend to purchase items that they consider to be reasonably priced. Therefore, healthy food and beverages must be priced competitively (i.e. the same or less than other options).5,9,12-21 

Consider increasing the price of less healthy items (if they are available), to subsidize the price of healthier items such as vegetables and fruit

Success stories: WORKPLACE CAFETERIA PRICING STRATEGIES Between 7-10% of corporate cafeterias run by food service company Sodexho, use pricing strategies to encourage healthy eating. These include increasing the price of less healthy options and using the extra money to subsidize the cost of healthy sandwiches, cut fruit and salads.22 L.L Bean increased the price of burgers and lowered the price for salads. As a result, fruit and salad sales doubled while french fry and burger sales fell by half.22 Humana Inc. subsidizes the sale of healthy items so they can be offered at a discount to employees. When the subsidy was introduced, sales increased by 19 per cent, completely offsetting the cost of the subsidy.23

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3.3 Promotion Marketing can be used to influence employee food choices by offering incentives to eat healthier food and beverages or by using visual prompts that can nudge employees towards making healthier choices. 

Avoid promoting less healthy items, (e.g., “Sell/Offer Less” or “Not Recommended”) such as “buy 10, get one free muffin”. Instead, use this type of promotion to encourage the consumption of healthier items



Remove advertisements for food and beverages that meet the criteria for the “Sell/Offer Less” or “Not Recommended” categories



Use point-of-decision prompts such as logos, nutrition labels and messaging (e.g., posters, glass-clings, tent cards, etc.) to highlight healthier choices in the cafeteria. See page 87 for more information on point-of-decision prompts

3.4 Placement Healthy food and beverages must be as convenient as other choices to encourage consumption.5,13,21,24 

Examine the traffic flow of the cafeteria, to ensure that healthy items are the most convenient to purchase and that they do not take more time and effort to purchase



Typically less healthy options such as food from the “Not Recommended” category are placed at the register, which is considered to be an influential location. Replace these with healthier options. Sales of healthier items can also be increased by placing them at eye level25



Most consumers will make selections that are visible on the menu, rather than asking for alternatives.26 Ensure that the healthiest options are highly visible on the menu. Consider not offering other options on the menu board



Consider making the healthier versions the default options for food, especially if consumers have the option of asking for a variation if they desire. For example, make premade sandwiches on whole grain bread instead of white bread. Employees always have the option of making a special request for white bread instead



Offer employees a salad or steamed vegetables with their entrée and avoid prompting to make less healthy choices

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Healthy Dinner Program Many working adults find it difficult to manage time constraints related to work making convenient access to healthy options especially important.27 Forty-one percent of Canadians feel that their life is so hectic that they find it hard to include healthy food options on a daily basis.28 As a result of time constraints, many people rely on convenience food (e.g., pre-packaged and frozen meals) and food purchased away from home (e.g., fast food, take-out and restaurant meals) instead of preparing meals for themselves.27 Other factors such as lack of food skills and living in a single person household also increase the use of convenience food and food eaten away from home.28-30 Eating food prepared outside the home has been shown to be lower in nutritional quality compared to food prepared at home.31-33 This can lead to a higher prevalence of nutrition related chronic conditions.33 Therefore, some employees may benefit from a healthy meal take-away dinner program.30 A healthy dinner program allows employees to pre-order dinner from the cafeteria for pick up on their way home. Meals should meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most.” One study examined the effects of a workplace hot meal take-away program and showed that vegetable and fruit intakes were higher on days that workers ate meals prepared by this service.34 A meal take-away program can also provide extra revenue for your food service operator.

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3.5 Portion Size Food is being consumed away from home more often, which is associated with increased portion sizes, leading to an increase in total energy intake.6,9,35-40 People served larger portions eat more food, as the amount served is an indicator that it is an appropriate amount to consume.25,37,38,41 Food service establishments can positively influence consumer health by serving appropriate portion sizes.38,42-44

Strategies to Reduce Portion Sizes 

Align portion sizes to those recommended in Canada’s Food Guide



If food and beverages categorized as “Sell/Offer Less” or “Not Recommended” are available in your cafeteria, ensure that the portion sizes are as small as possible



Allow individuals to purchase half-portion sizes on request and price these accordingly (i.e., it should cost half as much)



Consumers tend to avoid extremes (i.e., if small, medium and large are offered, most people choose the medium size).41 Avoid removing the smallest size if it does not sell well (i.e., 250 ml or 8 oz) otherwise it may prompt people to choose even larger portion sizes



Assess the size of serving dishes, glasses and take out containers used in the cafeteria, as people tend to use these items as consumption guidelines.25 Use smaller dishes and containers in the cafeteria to reduce portion sizes (i.e., rather than giving smaller portions in large containers, which may result in customers feeling deprived). For example, serving plates should be no larger than 23 cm (nine inches) in diameter

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3.6 Culturally Appropriate Food and Beverages Waterloo Region is culturally diverse with almost 25 per cent of the population coming from other countries.45 Individuals may have special dietary needs related to cultural practices. Workplaces should be considerate of the diverse needs of the workplace population and make sure that employees have access to food and beverages that align with traditional eating patterns. 

Add extra choices when food is offered to employees (e.g., offering soy milk in addition to cow’s milk or offering vegetarian options). Workplaces may also wish to serve some ethnic cuisines to increase the variety of food offered in the cafeteria



Make ingredient lists available upon request



Assess if employees have any special dietary needs during the needs assessment process. For more information see page 60 of the ‘Getting Started’ section

3.7 Purchasing Local and Organic Food 

Locally produced food is not necessarily farmed using organic farming methods. You may want to use both local and organic criteria for food purchasing at your facility



Explore with your food service providers if it is possible to supply a specified percentage of locally sourced and/or organic food for use in cafeterias, caterings and events



You may not be able to replace all of your current food purchases with local or organic options. However, you can replace some of the items that you currently purchase with local and/or organic products



Consider the capacity of current food services staff to use fresh food. For example, if potatoes currently come peeled and chopped, extra staff time will be needed to use fresh unprocessed potatoes



Buy fresh local produce when in season. This may also require some careful menu planning to ensure that ingredients correspond to seasonal availability. Other items such as meat, eggs and milk may be purchased locally year round

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3.9 Preventing Foodborne illness Foodborne illnesses are caused by ingesting bacteria, viruses or other parasitic organisms in contaminated food or water. It is estimated that there are between 11 million and 13 million cases of food related illness in Canada every year.46 Employers should ensure that food and beverages offered to employees is handled appropriately to reduce the incidence of foodborne illness.

Ways to Reduce the Incidence of Foodborne Illness in Cafeterias Hand Washing 

Educate all food service workers on proper hand washing techniques



Make sure that food service employees have access to proper hand washing facilities and that sinks are in a convenient location to encourage use



Put up hand washing signs in food service areas to prompt employees to wash their hands

Food Safety Training 

Provide food safety training for food service staff. Food service operators with at least one fulltime staff completing food safety training, tend to have better food safety inspection scores compared to operators with no certified staff members.47 Food safety training is offered at Conestoga College: http://www.conestogac.on.ca

Management Responsibilities 

Monitor employees to make sure they are washing their hands appropriately and are using safe food handling techniques



Encourage employees to stay home when they are sick to prevent the transmission of illness to customers and other employees. Individuals with symptoms such as vomiting, diarrhea, fever or sore throat should not have contact with any food or food preparation areas, as they may spread illnesses48



Set up a daily schedule for cleaning equipment, appliances and surfaces and regularly checking equipment such as refrigerators, freezers and dishwashers to make sure they are functioning properly

Tools: FOOD SAFETY For more information on food safety visit: http://www.regionofwaterloo.ca/en/safehealthycommunity/foodsafety.asp

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3.10 Environmentally Friendly Approaches to Food Services Any reduction in energy use or food waste is a positive step to becoming environmentally friendly. Here are some suggestions to help your cafeteria to “go green”: Equipment and Facilities     

Whenever possible purchase Energy Star® appliances.49 These will also give off less heat which may also reduce air conditioning costs49 Use energy efficient light bulbs where applicable and turn off lights when they are not needed49 Turn off equipment when it is not in use49 Use full loads in oven and dishwashers whenever possible49 Ensure equipment is routinely maintained to keep it running properly49

Waste Management     

Look for concentrated products that require less packaging49 Use reusable plates, cups, glasses and cutlery instead of disposables Divide waste into organics, recyclables and waste Request that suppliers offer products that have less packaging49 Buy in bulk when possible to reduce packaging or use reusable bins to transport items (e.g., milk crates)49

Non-food Products  

Use less toxic cleaners and soaps when available. Look for products that are biodegradable49 Reduce the amount of paper used by reducing printing or using double sided printing49 If this is not possible use recycled paper products49

Food Products   



Purchase products that are grown locally to reduce transportation and grown sustainably or organically to reduce pesticide use and to protect the environment49 Use seasonal menus to incorporate produce that is available locally49 Reduce the frequency of offering animal-based protein food and offer smaller portion sizes. This is not only advantageous from a nutritional perspective, but reduces greenhouse gas emissions.49 For example, it requires 40 kcal of fossil fuel based energy to produce one kcal of beef, 14 kcal to produce one kcal of pork and 10 kcal to produce one kcal of poultry.49 However, it only requires 2.2 kcal of energy to produce one kcal of plant proteins.49 Offer more vegetarian, poultry, pork and fish choices and reduce beef choices overall to reduce carbon emissions49 Use fish products that are environmentally sustainable.49 For more information see the resource: A Guide to Eating Fish for Women, Children and Families: http://chd.region.waterloo.on.ca/en/healthyLivingHealthProtection/resources/FishBooklet.pdf

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Cafeteria References 1. Berry LL, Mirabito AM, Baun WB. What’s the hard return on employee wellness programs? The ROI data will surprise you, and the softer evidence may inspire you. Harvard Business Review 2010(12):104-112.

17. French SA, Hannan PJ, Harnack LJ, Mitchell NR, Toomey TL, Gerlach A. Pricing and availability intervention in vending machines at four bus garages. J Occup Environ Med 2010 Jan;52 Suppl 1:S29-33.

2. Gill PE, Wijk K. Case study of a healthy eating intervention for Swedish lorry drivers. Health Educ Res 2004 Jun;19(3):306-315.

18. French SA, Jeffery RW, Story M, Breitlow KK, Baxter JS, Hannan P, et al. Pricing and promotion effects on low-fat vending snack purchases: The CHIPS Study. Am J Public Health 2001 Jan;91(1):112-117.

3. Lassen A, Thorsen AV, Trolle E, Elsig M, Ovesen L. Successful strategies to increase the consumption of fruits and vegetables: Results from the Danish '6 a day' Work-site Canteen Model Study. Public Health Nutr 2004 Apr;7(2):263-270. 4. Rolls BJ. The relationship between dietary energy density and energy intake. Physiol Behav 2009 Jul 14;97(5):609-615. 5. Wansink B, Huckabee M. De-marketing obesity. California Management Review 2005 Summer 2005;47(4):1-13. 6. Krukowski RA, Harvey-Berino J, Kolodinsky J, Narsana RT, Desisto TP. Consumers may not use or understand calorie labeling in restaurants. J Am Diet Assoc 2006 Jun;106(6):917-920. 7. Cheskin LJ, Davis LM, Lipsky LM, Mitola AH, Lycan T, Mitchell V, et al. Lack of energy compensation over 4 days when white button mushrooms are substituted for beef. Appetite 2008;51(1):50-57. 8. Blatt AD, Roe LS, Rolls BJ. Hidden vegetables: An effective strategy to reduce energy intake and increase vegetable intake in adults. Am J Clin Nutr 2011 Feb 2. 9. Eertmans A, Baeyens F, & Van den Bergh, O. Food likes and their relative importance in human eating behavior: Review and preliminary suggestions for health promotion. Health Education Research 2001;16(4):443-456. 10. Chandon P, Wansink B. The biasing health halos of fast-food restaurant health claims: Lower calorie estimates and higher side-dish consumption intentions. Journal of Consumer Research 2007 October 2007;34:301-314. 11. Gal D, Wilkie J. Real men don’t eat quiche. Social Psychological and Personality Science 2010;1(4):291301. 12. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point-of-purchase behavior in adults: A review. Prev Med 2004 Sep;39 Suppl 2:S108-36. 13. French SA. Pricing effects on food choices. J Nutr 2003 Mar;133(3):841S-843S. 14. Andreyeva T, Long MW, Brownell KD. The impact of food prices on consumption: A systematic review of research on the price elasticity of demand for food. Am J Public Health 2010 Feb;100(2):216-222. 15. Block JP, Chandra A, McManus KD, Willett WC. Point-of-purchase price and education intervention to reduce consumption of sugary soft drinks. Am J Public Health 2010 Aug;100(8):1427-1433. 16. Duffey KJ, Gordon-Larsen P, Shikany JM, Guilkey D, Jacobs DR,Jr, Popkin BM. Food price and diet and health outcomes: 20 years of the CARDIA Study. Arch Intern Med 2010 Mar 8;170(5):420-426.

19. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health 2008;29:253-272. 20. Devine CM, Nelson JA, Chin N, Dozier A, Fernandez ID. "Pizza is cheaper than salad": Assessing workers' views for an environmental food intervention. Obesity (Silver Spring) 2007 Nov;15 Suppl 1:57S-68S. 21. Kimathi AN, Gregoire MB, Dowling RA, Stone MK. A healthful options food station can improve satisfaction and generate gross profit in a worksite cafeteria. J Am Diet Assoc 2009;109:914-917. 22. Associated Press. Bosses push staff to eat right, exercise. 2006;. Accessed 05/24, 2011. 23. Houghton J, Neck C, Cooper K. Nutritious food intake: A new competitive advantage for organizations? International Journal of Workplace Health Management 2009;2(2):161-179. 24. Harnack LJ, French SA, Oakes JM, Story MT, Jeffery RW, Rydell SA. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trial. Int J Behav Nutr Phys Act 2008 Dec 5;5:63. 25. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis 2008 Jan;5(1):A23. 26. Downs S, Loewenstein G, Wisdom J. The psychology of food consumption: Strategies for promoting healthier food choices. American Economic Review: Papers & Proceedings 2009;99(2):1-10. 27. Blanck HM, Yaroch AL, Atienza AA, Yi SL, Zhang J, Masse LC. Factors influencing lunchtime food choices among working Americans. Health Educ Behav 2009 Apr;36(2):289-301. 28. Dietitians of Canada. 2006 Nutrition Month Campaign, "Make Wise Food Choices Wherever You Go!" Backgrounder. 2006. 29. Roos E, Sarlio-Lahteenkorva S, Lallukka T. Having lunch at a staff canteen is associated with recommended food habits. Public Health Nutr 2004 Feb;7(1):53-61. 30. Jørgensen MS, Arsky GH, Brandhøj M, Nyberg M, Roos E, Mikkelsen BE. Eating at worksites in Nordic countries: National experiences and policy initiatives. International Journal of Workplace Health Management 2010;3(3):197-210. 31. Devine CM, Farrell TJ, Blake CE, Jastran M, Wethington E, Bisogni CA. Work conditions and the food choice coping strategies of employed parents. J Nutr Educ Behav 2009 Sep-Oct;41(5):365-370. 32. Todd JE, Mancino L, Lin B. The impact of food away from home on adult diet quality. EER-90, U.S. Department of Agriculture, Econ. Res. Serv., February 2010. Adv Nutr 2011;2:442-443.

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33. Fulkerson JA, Farbakhsh K, Lytle L, Hearst MO, Dengel DR, Pasch KE, et al. Away-from-home family dinner sources and associations with weight status, body composition, and related biomarkers of chronic disease among adolescents and their parents. J Am Diet Assoc 2011 Dec;111(12):1892-1897.

42. Wolf AM, Woodworth KA. Obesity prevention: recommended strategies and challenges. Am J Med 2009;122:S19-S23.

34. Quintiliani L, Poulsen S, Sorensen G. Healthy eating strategies in the workplace. International Journal of Workplace Health Management 2010;3(3):182-196.

44. Hill JO. Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition Institute of Food Technologists, and International Food Information Council. Am J Clin Nutr 2009;89:477-484.

35. Steenhuis IH, Vermeer WM. Portion size: Review and framework for interventions. Int J Behav Nutr Phys Act 2009 Aug 21;6:58. 36. Wansink B, van Ittersum K. Portion size me: downsizing our consumption norms. J Am Diet Assoc 2007 Jul;107(7):1103-1106. 37. Geier AB, Rozin P, Doros G. Unit bias. A new heuristic that helps explain the effect of portion size on food intake. Psychol Sci 2006 Jun;17(6):521-525. 38. Rolls BJ, Roe LS, Meengs JS. Larger portion sizes lead to a sustained increase in energy intake over 2 days. J Am Diet Assoc 2006 Apr;106(4):543-549. 39. Rozin P, Kabnick K, Pete E, Fischler C, Shields C. The ecology of eating: Smaller portion sizes in France than in the United States help explain the French paradox. Psychol Sci 2003 Sep;14(5):450-454. 40. Popkin BM, Duffey K, Gordon-Larsen P. Environmental influences on food choice, physical activity and energy balance. Physiol Behav 2005 Dec 15;86(5):603-613.

43. Hill JO, Peters JC, Wyatt HR. Using the energy gap to address obesity: A commentary. J Am Diet Assoc 2009 Nov;109(11):1848-1853.

45. Region of Waterloo Public Health. Immigrants in Waterloo Region - Fact sheet. 2009; . Accessed 01/06, 2012. 46. Canadian Partnership for Consumer Food Safety Education. Be food safe Canada. 2011; Available at: http://www.befoodsafe.ca/en-home.asp. 47. Noble S, Griffiths M, Thompson S, Maclaurin T. Frequency and type of food safety infractions in food establishments with and without certified food handlers. Food Protection Trends 2009;29(12):840-848. 48. Widdowson MA, Sulka A, Bulens SN, Beard RS, Chaves SS, Hammond R, et al. Norovirus and foodborne disease, United States, 1991-2000. Emerg Infect Dis 2005 Jan;11(1):95-102. 49. Wilson ED, Garcia AC. 'Going green' in food services: Can health care adopt environmentally friendly practices? Can J Diet Pract Res 2011 Spring;72(1):43-47.

41. Sharpe K, Staelin R, Huber J. Using extremeness aversion to fight obesity: policy implications of context dependent demand. Journal of Consumer Research 2008 October 2008;35:406-422.

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Often celebrations are a time to share food with friends, family and colleagues. Celebrations can be an important part acknowledging workplace successes and important life milestones. In this section you will find some suggestions to incorporate healthy eating into workplace celebrations.

Definition of Success  Workplace celebrations emphasize foods from the “Maximum Nutritional Value” and “Sell/Offer Most” categories*  Food and beverages that meet the criteria for the “Not Recommended” category are limited or excluded from celebrations. Celebrations that include food and beverages from the “Not Recommended” category are limited to a few occasions throughout the year (e.g., once per month)*  Celebrations incorporate non-food activities *See the Nutrition Standards for Workplaces© in Appendix A for a description of food categories.

Celebrations

Celebrations

1.0 Needs Assessment Take a look at current workplace celebration activities. Note how often they occur and what types of food and beverages are being served during celebrations. Determine if celebrations support your healthy eating strategy and consider improvements to current activities. Ask employees if they are willing to make changes to current celebration events to make them healthier. This will help you determine employee needs. It will also help to create employee and management support for changes the wellness committee may recommend.

2.0 Evaluation Indicators Possible indicators include tracking:      

How frequently do workplace celebrations occur? What types of celebrations involve food? How often do celebrations/events occur without food? If food is served, are healthy options available? Are less healthy options available? How much food is served? What do employees expect during celebrations?

3.0 Creating Healthier Celebrations Food Served During Celebrations Emphasize food and beverages that meet the criteria for the “Maximum Nutritional Value” or “Sell/Offer Most” categories during celebrations. Try to limit the number of occasions food and beverages that fall into the “Not Recommended” category are offered (e.g., once per month). Consider the amount of food that is typically offered during celebrations. If portion sizes are large, serve smaller amounts. Also try to scale down the number of items offered to one or two items if celebrations occur outside of traditional meal times (i.e., they are snacks).

Frequency of Celebrations If workplace celebrations occur frequently, and food and beverages that meet the criteria for the “Not Recommended” category are commonly offered, this practice may begin to compromise diet quality. Consider reducing the frequency of celebrations. For example: 

Instead of celebrating each individual staff members’ birthday, you may wish to have quarterly celebrations (e.g., Spring birthday celebrations that occur from April to June)



Ask staff if it is important to them to celebrate birthdays at work, or if they feel that personal celebrations will suffice

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Celebrating Without Food Employees may appreciate non-food related celebrations; ask if there are other types of rewards or celebratory activities that could take place to mark occasions without food. 

Have a staff bulletin board where notices and pictures can be attached



Acknowledge milestones with non-food items such as cards, flowers, group gifts, etc.



Have fun theme days incorporating costumes or fun activities (e.g., golf putting contest, karaoke etc.), physical activity events (e.g., an afternoon of beach volley-ball or golf)



Take a group break together to enjoy a walk, afternoon tea, etc.



Organize an afternoon retreat (e.g., bowling, attending a movie, volunteering for a community cause during the holidays, etc.)

The Bottom Line There are many ways for workplaces to celebrate. Be creative and engage staff in finding alternative options to food based celebrations.

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In many workplaces, employees bring in ‘treats’ for co-workers to share. Leftover food from meetings and events is often placed in common areas for people to consume. Additionally, fundraisers based on selling “Foods to Limit” (e.g., cakes, pastries, candies, chocolate, cookies, granola bars, ice cream, doughnuts, muffins, french fries, potato chips, salty snacks and sweetened hot and cold beverages) are typically placed in common areas for people to purchase.1 Candy dishes on desks are also an example of food offered in common areas. “Corporate break rooms need not become repositories for unused Halloween candy and holiday leftovers”.2

Definition of Success  Common areas in workspaces are free from food  Employees have been educated on the influence of food in the environment and have accepted the decision to reduce and/or eliminate food in common areas

Common Areas

Common Areas

1.0 Needs Assessment To determine if this is a priority area for your workplace, ask employees about their personal barriers to healthy eating. If employees indicate that they have difficulty resisting tempting food when present, it may be worthwhile to address this issue.

2.0 Evaluation Indicators You will know if efforts have been effective if there is less food left in common areas. This can be periodically monitored throughout the year to see if behaviour changes have been maintained.

3.0 Addressing Food in Common Areas Having the occasional less-than-healthy snack is not going to make or break the health of an employee. However, the calorie margin for ‘treats’ is very small (e.g., 100 kcal per day)3 This is roughly the equivalent of one cookie, 250 ml of soda, 10 jellybeans or 5 chocolate covered almonds.4 Daily consumption of these types of food and beverages is enough to cause employees to develop chronic health problems over time. Employees may enjoy having access to food in common areas or dread the thought of having to avoid eating when tempting foods are available. However, it is possible that employees may resent being told that they are not permitted to bring ‘treats’ to work. Many people believe that each individual’s self-restraint is strong enough to resist temptation (i.e., “the people who do not want to eat it can simply make that ‘choice’”).5 However, the food that surrounds individuals predicts what they will consume. Evidence suggests that people who live in homes with many high-fat and high-sugar foods eat more of these foods.9 Foods high in fat, sugar or white flour act in the brain a similar way to addictive drugs such as cocaine, which makes them very tempting and difficult for people to resist.6-13

Food for Thought: OUT OF SIGHT In one experiment, office workers ate 3.1 more chocolates when they were placed in transparent jars on their desks compared to when the chocolates were in opaque jars.14 The bottom line: Seeing food causes eating.

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The presence of less healthy food and beverages can be extremely distracting for workers. There is evidence that individuals have difficulty doing more than one task requiring self-control at a time.15-18 This creates a scenario where people exposed to tempting food in their work areas will either eat the ‘treat’ and get on with their work (potentially increasing diet related health risks) or try to resist to maintain their health, resulting in distracted and less productive employees. One experiment showed that people trying to do a math quiz while having to resist cookies were less than half as productive as people who did not have to resist cookies.14 Additionally, there is evidence to suggest that people who resist initially, eventually have a breakdown in self-control at a later point in the day, so employees may feel deprived from resisting ‘treats’ at work and give-in later in the day when they get home.15 Having regular access to food in the work area may also create a habit of rewarding oneself to cope with boredom or stress in the workplace.19,20 Bringing in food to share with others may be a profoundly personal issue for some employees and addressing this issue requires a ‘cultural shift’ within the workplace. Be considerate of employee’s feelings and beliefs when addressing this particular concern. To decrease resistance to the suggestion of minimizing or eliminating food in common areas, have a discussion with employees to gauge their readiness to make changes. If employees are resistant to the idea, they may benefit from education on how the food environment impacts individual food choices.21-23 If employees are agreeable to the idea of minimizing or eliminating food in common areas, it may be enough to have an understanding among employees. In this case, there is no responsibility for ensuring that employees stick to the agreement, however, it may be the most acceptable solution among the employees.

Policy If the workplace feels strongly that the practice of offering food in common areas is unacceptable, a policy could be considered. For more information, see the section on policy development. Example policies are available on page 178.

Common Areas References 1. Health Canada. Eating Well with Canada's Food Guide: A resource for educators and communicators. Ottawa: Health Canada; 2007. 2. Heinen L, Darling H. Addressing obesity in the workplace: The role of employers. The Milbank Quarterly 2009;87(1):101-122. 3. Garriguet D. Diet quality in Canada. Health Rep 2009 Sep;20(3):41-52. 4. Health Canada. Nutrient value of some common foods. Published by authority of the Minister of Health. Ottawa, Ontario. 2008. 5. Nordgren LF, van Harreveld F, van der Pligt J. The restraint bias: How the illusion of self-restraint promotes impulsive behavior. Psychol Sci 2009 Dec 1;20(12):1523-1528. 6. Stice E, Spoor S, Ng J, Zald DH. Relation of obesity to consummatory and anticipatory food reward. Physiol Behav 2009 Jul 14;97(5):551-560. 7. Stice E, Yokum S, Blum K, Bohon C. Weight gain is associated with reduced striatal response to palatable food. J Neurosci 2010 Sep 29;30(39):13105-13109. 8. Liu Y, von Deneen KM, Kobeissy FH, Gold MS. Food addiction and obesity: Evidence from bench to bedside. J Psychoactive Drugs 2010 Jun;42(2):133-145. 9. Mahapatra A. Overeating, obesity and dopamine receptors. ACS Chemical Neuroscience 2010;1:396397. 10. Avena NM, Rada P, Hoebel BG. Sugar and fat bingeing have notable differences in addictive-like behavior. J Nutr 2009 Mar;139(3):623-628. 11. Ifland JR, Preuss HG, Marcus MT, Rourke KM, Taylor WC, Burau K, et al. Refined food addiction: A classic substance use disorder. Med Hypotheses 2009 May;72(5):518-526. 12. Lutter M, Nestler EJ. Homeostatic and hedonic signals interact in the regulation of food intake. J Nutr 2009 Mar;139(3):629-632.

14. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis 2008 Jan;5(1):A23. 15. Shmueli D, Prochaska JJ. Resisting tempting foods and smoking behavior: Implications from a self-control theory perspective. Health Psychol 2009 May;28(3):300-306. 16. Gailliot MT, Baumeister RF, DeWall CN, Maner JK, Plant EA, Tice DM, et al. Self-control relies on glucose as a limited energy source: Willpower is more than a metaphor. J Pers Soc Psychol 2007 Feb;92(2):325-336. 17. Gailliot MT, Baumeister RF. The physiology of willpower: Linking blood glucose to self-control. Pers Soc Psychol Rev 2007;11(4):303-327. 18. Muraven M, Baumeister RF. Self-regulation and depletion of limited resources: Does self-control resemble a muscle? Psychol Bull 2000 Mar;126(2):247259. 19. Devine CM, Nelson JA, Chin N, Dozier A, Fernandez ID. "Pizza is cheaper than salad": Assessing workers' views for an environmental food intervention. Obesity (Silver Spring) 2007 Nov;15 Suppl 1:57S-68S. 20. Macht M. How emotions affect eating: A five-way model. Appetite 2008;50(1):1-11. 21. O'Brien KS, Puhl RM, Latner JD, Mir AS, Hunter JA. Reducing anti-fat prejudice in preservice health students: A randomized trial. Obesity (Silver Spring) 2010 Nov;18(11):2138-2144. 22. Alvaro C, Jackson LA, Kirk S, McHugh TL, Hughes J, Chircop A, et al. Moving governmental policies beyond a focus on individual lifestyle: Some insights from complexity and critical theories. Health Promot Int 2010 Aug 13. 23. Barry CL, Brescoll VL, Brownell KD, Schlesinger M. Obesity metaphors: How beliefs about the causes of obesity affect support for public policy. Milbank Q 2009 Mar;87(1):7-47.

13. Volkow ND, Wise RA. How can drug addiction help us understand obesity? Nat Neurosci 2005 May;8(5):555-560.

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The physical set up of your workplace can influence employee eating habits. Employees who bring their own meals tend to eat healthier diets than individuals who purchase food away from home.1

Definition of Success  Employees have access to a clean, attractive eating area  There is enough space for employees to sit and enjoy their lunch  Employees have access to a kitchenette where they can store and heat food

1.0 Needs Assessment During your needs assessment, determine if there are any barriers to healthy eating that occur as a result of the physical set-up of the workplace. For example, do employees need a refrigerator to store lunches? Does the building electrical system prevent the use of toasters, kettles, etc.? Do employees have a clean, attractive area to eat that is away from their desks?

2.0 Evaluation Indicators Some possible indicators include: 

Ask employees what they like and don’t like about current workplace facilities



Record process indicators about what worked, what didn’t and lessons learned

3.0 Creating Supportive Workplace Facilities Kitchenette Provide a kitchenette that includes a sink so employees can rinse food and wash containers, plates, glasses, etc. The kitchenette may also include a refrigerator to store snacks, lunches and beverages. A microwave or toaster oven is also essential to facilitate employees preparing their own lunches. Consider adding a cold water dispenser, water fountain or a water and ice dispenser to promote water consumption. Adding a hot water dispenser can also provide a way for employees to make their own coffee or tea, without the use of a kettle. Implement a regular cleaning schedule for the kitchenette, microwave and refrigerator.

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Facilities

Facilities

Eating Area An attractive eating area encourages employees to take a break from work and enjoy their meals. To create an attractive eating area: 

Provide a clean, quiet, bright space that is away from the work space



Ensure there is adequate seating and a surface to place food in the eating area to allow for comfortable dining



Avoid conducting business meetings and events in this area during meal times to allow employees to relax during their lunch break



Provide enough waste, recycle and organic bins, which should be emptied daily or more often if required

Outdoor Facilities 

Consider adding an outdoor eating facility such as picnic tables for use during warmer months. Ensure the outdoor eating area has shade



Ensure there are adequate bins for garbage, food waste and recyclables. These should be emptied regularly and should be pest proof

Facilities References 1.

McGuire M. (2011). Todd J.E., Mancino L., Lin B-H. The Impact of Food Away from Home on Adult Diet Quality. ERR-90, U.S. Department of Agriculture, Econ. Res. Serv., February 2010. Adv Nutr;2:442-443. DOCS# 1180226

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Workplace meetings and events offer a great opportunity to demonstrate your commitment to employee health and well-being by incorporating healthy eating and active living into workplace events.

Definition of Success  Food is not served during meetings when not required  When offered, emphasize food and beverages that meet the criteria for “Maximum Nutritional Value”  Food and beverages that meet the criteria for “Not Recommended” are not offered to employees during meetings*  Special dietary needs have been accommodated  Locally produced food is offered whenever possible  Safe food handling techniques are used when offering food and beverages  Employees have facilities to wash their hands before food is served *See the Nutrition Standards for Workplaces© in Appendix A for a description of the nutrition categories

Meetings and Events

Meetings and Events

1.0 Needs Assessment Conduct an environmental scan to determine when and how food is ordered for meetings. Determine what types of food and beverages are served during meetings (i.e., what percentage of food and beverages offered to employees meets the criteria for “Maximum Nutritional Value”?). Are portion sizes consistent with recommendations in Canada’s Food Guide? Are food and beverages acceptable to various cultures in the workplace? You may also want to determine the percentage of locally produced food that is currently served and determine if you can increase the amount of locally produced food that you purchase for meetings and events. Conduct focus groups with individuals who are responsible for purchasing and ordering food and beverages for meetings and events, to find out how it is done and if any changes can be made using a similar process (e.g., if changes are too difficult they will not be sustained).

2.0 Evaluation Indicators Tracking indicators before, during and after your interventions will help to determine if positive changes have been made. Identify relevant indicators for your workplace, some possible indicators include: 

Improvements in the nutritional quality of foods served during meetings and events



Decreases in the number of occasions food is offered



The percentage of food served that is locally produced



Changes in the amount of money spent on foods for meetings and events



Ensuring that special dietary needs are being accommodated whenever possible



Doing spot checks to ensure that food is handled in a safe manner (e.g., perishable food is not left sitting out for more than two hours, tongs are available for serving, hand washing facilities are available, etc.)



Any barriers, challenges and successes in the implementation process



Any other relevant indicators

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3.0 Creating Healthier Meetings 3.1

Determining When Meetings or Events Require Food

The first question to ask before planning for food at workplace events is: does this meeting or event require food? Often we offer food because we want people to attend or participate in workplace functions; however, if food is offered to employees above and beyond what they normally consume in a workday, it may contribute to the development of nutrition-related chronic conditions.1,2 Food presented during a meeting may also make it more difficult for employees to concentrate on work related tasks.3 It may also be difficult for employees to follow a healthy diet if they are being offered less healthy choices during work functions. Consider not offering food if a meeting is occurring mid-morning or mid-afternoon. However, you may want to serve tap water or other beverages such as coffee and tea during meetings.

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3.2

Food and Beverages to Serve

If food is appropriate to serve food at your meeting, carefully consider the nutritional quality and safety of the food that is served. Ideally, at least 80 percent of the food and beverages offered during meetings and events meet the criteria for the “Maximum Nutritional Value” or “Sell/Offer Most” categories. Items that meet the criteria for the “Sell/Offer Less” category are limited to 20 per cent or less. Avoid serving foods from the “Not Recommended” category. (See Appendix A for the Nutrition Standards for Workplaces©) Meals should contain three of the four food groups from Canada’s Food Guide, while snacks should contain two of the four food groups. Always offer a vegetable or fruit choice when food is served. Also, order a vegetarian option when ordering entrees. For ideas on what to serve during meetings and events, see the Healthier Food and Beverages for Catered Meetings and Events pamphlet available on the Project Health website: http://www.projecthealth.ca under ‘Toolkits’.

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3.3

Special Dietary Needs

Give attendees at events an opportunity to specify if they have special dietary needs when they are registering for events (e.g., medical, allergies, religious, cultural) so that their needs can be accommodated. The most common food allergies include: peanuts, tree nuts (almonds, Brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pine nuts, pistachio nuts, and walnuts), sesame seeds, milk, eggs, fish (including shellfish and crustaceans), soy, wheat and sulphites.4 The reaction to food allergies can be serious and even fatal. If you have a staff member or attendee with a serious food allergy, ensure that you do not serve food that contains the allergen and that food served has not come in contact with the allergen. For more information on food allergies see Health Canada: http://www.hc-sc.gc.ca/fn-an/securit/allerg/index-eng.php.

3.4

Food Safety

Prevent foodborne illness at your event by: 

Ensuring your food service provider has a good history of compliance with food handling requirements. Check the record of food service providers in Waterloo Region: http://checkit.regionofwaterloo.ca/portal



Making sure food does not sit out at room temperature for longer than two hours. Prevent foodborne illness in high risk foods such as meats, fish, poultry and eggs, salads containing mayonnaise or meats, fish, poultry or eggs, milk and milk products, sandwich meats, soups, chili and stews by keeping these foods at the appropriate temperature. Hot foods should be kept at a minimum temperature of 60˚C (140˚F) (e.g., by using a chafing dish) and cold foods should be kept at 4˚C (40˚C) (e.g., by keeping items on ice)



Handling food with utensils and providing enough utensils for each food item



Planning appropriate disposal for leftover food, plates, cutlery etc.; including garbage, recycling and organics bins



Providing food handlers and attendees with adequate hand washing facilities



Not allowing any employees with communicable illnesses (e.g., with symptoms such as sore throat, diarrhea or vomiting) to prepare or serve food

For more information see the Food Safety webpage from the Region of Waterloo: http://chd.region.waterloo.on.ca/en/index.asp

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3.5

Workplace Barbeques

Here are some healthy eating ideas for the barbeque:5 

Veggie Kabobs – Assemble cherry tomatoes, diced orange and green peppers, mushrooms and red onions on a skewer. If using wooden skewers, soak them in cold water first for about 30 minutes to prevent them from burning. Grill these veggie kabobs for four to five minutes on medium heat



Corn on the cob – Peel away the husks. Place the corn directly on the grill on high heat for about 10 minutes, frequently rotating the cobs to prevent them from charring. Grill until the corn is slightly browned and tender



Grilled fruit – Try fresh, ripe peaches, mangos, pears, nectarines and plantains. Lightly baste fruit slices with a non-stick vegetable spray. Place large pieces directly on the grill and smaller pieces on skewers or a grill pan. Grill just until the fruit gets tender and the grill marks show



Fish – Firm fleshed fish such as salmon, tilapia or halibut are great on the grill. Sprinkle some herbs over a fish fillet and then wrap them loosely in foil paper to create a packet or tent. Place them directly on the grill for about ten minutes. The steam trapped in the foil packet essentially cooks the fish and the flavour locks in. If you prefer barbequing fish directly on the grill, place it skin-side up. The skin helps to hold the fish together



Stir-grilled veggies – This is a cross between stir-frying and grilling. Stir-fry veggies in a grilling basket on the BBQ. Try stir-grilling shrimp and scallops too



Tofu – Buy extra firm tofu and soak it in your favourite marinade overnight. Cook on a lightly greased grill for about four or five minutes a side or until browned or threaded on your veggie kabobs



Grilled Panini sandwiches – Cut Panini buns in half lengthwise and place them face down on the grill until toasted. Stuff the bun with grilled zucchini, eggplant, red pepper and provolone cheese. For a meat-lovers’ version, add grilled chicken breast

Healthy barbeque information provided by EatRight Ontario http://www.eatrightontario.ca/.

Beverages 

Serve water, sparkling water and small servings of 100% fruit juice (i.e. 125 to 250 ml)

Food Safety for Barbequing Ensure that you follow safe food handling techniques while barbequing to prevent foodborne illness. http://chd.region.waterloo.on.ca/en/healthyLivingHealthProtection/resources/BBQFoodSafetyHome .pdf Project Health – Comprehensive Strategies to Promote Healthy Eating

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3.6

Green meetings

Workplace meetings and events can generate a large amount of waste or use unnecessary resources. Take steps to make your meeting more eco-friendly: 

Have attendees RVSP so that you know how much food to order. This will eliminate food waste



Plan meals using portion size recommendation in Canada’s Food Guide. Ensure that meals have at least three of the four food groups. Half the plate should consist of vegetables, one quarter Grain Products and one quarter Meat or Meat Alternative. Consider offering a fruit based dessert



Request that the caterer offer seasonal food that is locally produced. (Locally produced organic or sustainably produced food is even more environmentally friendly)



Serve water, juice and coffee in jugs. Provide reusable mugs or glasses or ask attendees to bring their own mugs. If you are using a caterer, make a request for reusable dishes, trays, glasses, mugs and linens. If this is not an option, ask for items that are recyclable or compostable such as paper plates, napkins or corn based utensils



Ensure you have adequate bins for organics and recyclables. Mark the bins clearly so attendees know what items go in each bin



Use bulk condiments such as salad dressing, spreads etc., instead of individual packages



Collect plastic name tags at the end of the event and reuse at other events



Minimize paper use by offering electronic versions of documents, posting the agenda in one location for everyone to view and by conducting event registration by telephone or email

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Meetings and Event References 1. Hill JO, Peters JC, Wyatt HR. Using the energy gap to address obesity: A commentary. J Am Diet Assoc. 2009;109:1848-1853.

3. Cohen D, Farley TA. Eating as an automatic behavior. Prev Chronic Dis. 2008;5:A23.

2. Hill JO. Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. Am J Clin Nutr. 2009;89:477-484.

4. Health Canada. It's your health - food allergies. 2009. 5. EatRight Ontario. Over the Grill. Available at: http://www.eatrightontario.ca/en/ViewDocument.aspx?id=188.

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A supportive workplace culture means the workplace promotes physical and mental health. There are many areas that organizations can target to improve the health outcomes of employees such as social support, workplace culture, job control, effortreward balance, work structure, communication, organizational change processes and management style. High levels of workplace related stress can negatively affect personal health practices and organizational culture. A comprehensive workplace health promotion strategy can be used to create a healthy organization. In a supportive workplace culture employees have adequate job training, a sense of fairness and respect on the job, work-life balance, some control over how their work is completed and are rewarded adequately for their efforts. In an ideal workplace, efforts are made to manage and prevent workplace conflict and help is available to assist employees in times of distress.1 By addressing organizational culture issues that affect employee health, efforts to promote workplace health will be more effective.

Definition of Success  Negative organizational factors are identified and plans are in place to make improvements  Employees and management have opportunities to learn skills in communication, leadership and conflict prevention/resolution  During organizational changes employees are kept well informed and efforts are made to minimize employee stress  Management staff use positive practices that promote work-life balance and ensure reasonable workloads  Management role model healthy behaviours  Employees are encouraged to leave their desks/work area to eat lunch  Employee work efforts are rewarded with non-food rewards

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Organizational Culture

Organizational Culture

1.0 Needs Assessment 

Identify negative organizational cultural factors in your workplace using surveys or interviews. 2 Once problems with organizational culture are identified, take steps to address priority areas

2.0 Evaluation Indicators 

Monitor employee satisfaction with training, communication and overall job satisfaction



Monitor other workplace indicators that can reflect employee satisfaction such as turnover, sick time, complaints, staff negativity and labour grievances

3.0 Creating a Supportive Workplace Culture Skill Building Opportunities 

Teach managers how to identify and support people who are struggling with work/life balance, heightened work demands or problems with mental health.1 Reallocate work when necessary to reduce workload2



Provide skill building sessions for managers, supervisors and employees in communication, leadership and conflict prevention and resolution.2 Staff development and training courses aimed at developing interpersonal skills in the workplace may have additional benefits for employees when they are outside work3

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Supportive Management Practices 

Improve management practices by consulting employees about their work, negotiating workload with employees, using two-way communication and offering constructive feedback to employees2,3



Keep demands on employee time and energy reasonable and provide adequate recognition for work well done3,4



Ensure that working conditions and job demands do not negatively influence employees’ personal relationships3



Corporations could consider ways in which they can make a positive contribution to the community in which they are located, for example, through corporate community involvement3



Management should encourage employees to take their breaks and leave their work areas to enjoy lunch



Management should role model healthy behaviours and support healthy eating strategies in the workplace (e.g., take their lunch breaks, follow policies that support healthy eating)



Ensure managers provide clear and consistent information when organizational change occurs3



During periods of job insecurity, resolve matters quickly to minimize the health consequences of exposing workers to a chronic stressor. Workers should be kept well informed of any changes to reduce rumour and anxiety and maintain job satisfaction3

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Rewarding Employees Employees are motivated in their work when they know that they have made a difference in the organization. Sometimes, small gestures such as a verbal acknowledgement or a hand-written note of thanks can go a long way to show employees that their efforts are appreciated. Occasionally, employees may also desire other forms of rewards such as a party or a tangible reward to celebrate their achievements. Ask employees what types of rewards motivate them. Here are some ideas for rewarding employees for a job well done: 

Give written recognition from supervisor, manager or human resources (e.g., letter of recognition, hand-written notes, certificates of achievement, etc.)



Give verbal recognition from supervisor or manager (e.g., positive feedback, making an announcement in team meetings, etc.)



Ask employees nominate other co-workers for awards or honourable mentions



Give special privileges (e.g., an afternoon off or flexible hours)



Provide a healthy staff lunch or dinner (e.g., chili with a whole wheat bun and a salad, healthy pizza with salad or fruit dessert) or other perks such as “Fresh Fruit Fridays”



Provide employees with requested equipment when group targets are met



Provide opportunities to learn new skills (e.g., internal job shadow, educational activities, or other opportunities for individual growth)



Give gift cards for malls, local stores, entertainment, sporting events, a spa day, a massage, bookstores, downloadable music, etc.



Have employees draw from an assortment of random prizes



Have management complete a task for employees, such as cooking a healthy meal, serving in the cafeteria, car wash etc.



Have an office event during a special holiday or occasion with awards given out for the best team decoration

Make considerations about when rewards are given and make sure that there is a fair and consistent process for rewarding employees. Give individual and team rewards when they are warranted. Also keep in mind that rewards that are given often may eventually be expected by employees, which begin to feel like more entitlements rather than rewards – in this case be spontaneous and creative in your employee rewards!

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Organizational Culture References 1. Canadian Mental Health Association. Comprehensive

Workplace Health Promotion – Affecting Mental Health in Workplace. Available at: http://wmhp.cmhaontario.ca/comprehensive-workplacehealth-promotion-affecting-mental-health-in-theworkplace. 2. World Health Organization. Healthy workplaces: A model for action for employers, workers, policy-makers and practitioners. 2010. 3. Work stress and health: The Whitehall II study. London, England: Published by Public and Commercial Services Union on behalf of Council of Civil Service Unions/Cabinet Office; 2004. 4. Shain M, Kramer DM. Health promotion in the workplace: Framing the concept; reviewing the evidence. Occup Environ Med. 2004;61:643-8, 585.

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Peer support allows individuals to share similar lived experiences and provide advice and encouragement to one another.1-5 Attending an ongoing peer support group may help motivate employees to meet their personal healthy eating goals.2,3,5 “Peer support interventions may contribute to a workplace culture where people care for each other and support each other”5

Definition of Success  Employees are able to participate in an ongoing peer support group that encourages healthy eating

Peer Support Groups

Peer Support Groups

Peer Support Groups as Part of a Comprehensive Approach Educating employees about changing personal healthy eating behaviours may be frustrating if tempting food and beverages are available in the workplace.6 Ideally, interventions that promote healthy eating in the workplace should be implemented along with positive changes to the workplace food environment (i.e., food sold in cafés, cafeterias, vending machines and tuck shops, as well as food offered during meetings, celebrations and workplace events).

1.0 Needs Assessment Ask employees about their needs in a peer support group. Refer to page 60 in the ‘Getting Started’ section for sample survey questions. During your needs assessment, identify employees who may face barriers in linking to social supports (e.g., shift workers, employees who work at alternate locations, etc.).

2.0 Evaluation Indicators Evaluation indicators will help you to determine if the peer support group has resulted in positive changes. Possible evaluation indicators include: 

Formative indicators such as: o





Relevance of nutrition information to employees participating in the group

Process indicators such as: o

Attendance at activities

o

Employee satisfaction with the group

o

Suggestions for changes to the group

Short-term outcome indicators such as: o

Health behaviour changes (e.g., cooking more often, eating more vegetables and fruit, eating fewer “Foods to Limit”, etc.)

o

Increased knowledge or skills (e.g., label reading, gardening, etc.)

o

Increased feelings of social support in the workplace

o

Percentage of employees who have met personal health goals

Refer to page 69 in the ‘Getting Started’ section for more information about evaluation indicators.

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3.0 Implementing Social Support Groups in the Workplace Workplaces are encouraged to offer peer support groups that are relevant for all employees. A peer based group should help individuals succeed in maintaining healthy behaviour changes by: 

Tailoring the group to the needs and interest of the employees



Promoting healthy eating habits such as eating more vegetables and fruit, whole grains, legumes, eating fewer “Foods to Limit”, etc.



Providing opportunities for skill building such as healthy cooking, gardening, label reading, self-monitoring and goal setting



Ensuring the nutrition information shared in the group is from a credible source (i.e., it has been written by a Registered Dietitian)

Some employees may also benefit from a group that provides an opportunity to share experiences living with a health condition (e.g., diabetes, heart disease, etc.).4,5 Promote the group(s) Consider: 

Having wellness champions personally invite employees to join the group



Posting flyers and other promotional materials in high traffic areas (e.g., washrooms, employee entrances, kitchens/cafeterias, etc.)



Advertising the group in employee newsletters, on web portals, etc.



Inviting participants to bring a friend



Having a kick-off event

Taking the Focus Off Weight A “Health at Every Size” (HAES) approach is recommended, which includes the promotion of healthy eating, physical activity, self-acceptance and overall well-being.7-9 This approach targets a larger group of employees compared to weight loss promotion, which may only appeal to a small number of employees.3,10-12 Focusing on weight loss does not guarantee that employees will be healthier, as many individuals who are attempting to lose weight do not follow healthy eating recommendations.9 The HAES approach also reduces the risk of unintended problems that can occur as a result of promoting of weight loss, such as increased stigma,5,13-15 focus on appearance, poor mental health outcomes9,1618 or resorting to unhealthy weight loss practices such as skipping meals. The effectiveness of promoting weight loss is also questionable as weight loss is difficult to achieve and most people who lose weight, gain it back within one year.3,10,19 A study on workplace weight loss programs found that weight loss tends to be very modest (i.e., 3.2 lbs). Therefore, the risks of promoting weight loss in the workplace likely outweigh the benefits compared to a HAES approach.

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Peer Support Groups References 1. Levy RL, Finch EA, Crowell MD, Talley NJ, Jeffery RW. Behavioral intervention for the treatment of obesity: Strategies and effectiveness data. Am J Gastroenterol 2007 Oct;102(10):2314-2321. 2. Rigsby A, Gropper DM, Gropper SS. Success of women in a worksite weight loss program: Does being part of a group help? Eat Behav 2009 Apr;10(2):128130. 3. Shay LE. A concept analysis: Adherence and weight loss. Nurs Forum 2008 Jan-Mar;43(1):42-52. 4. Dale JR, Williams SM, Bowyer V. What is the effect of peer support on diabetes outcomes in adults? A systematic review. Diabet Med 2012 Nov;29(11):13611377. 5. Linnan L, Fisher EB, Hood S. The power and potential of peer support in workplace interventions. Am J Health Promot 2013 Sep-Oct;28(1):TAHP2-10. 6. Kwak L, Kremers SP, Visscher TL, van Baak MA, Brug J. Behavioral and cognitive effects of a worksitebased weight gain prevention program: The NHF-NRG in balance-project. J Occup Environ Med 2009 Dec;51(12):1437-1446. 7. Rothblum ED. Why a journal on fat studies? Fat Studies 2012;1:3-5. 8. Provencher V, Bégin C, Tremblay A, Mongeau L, Boivin S, Lemieux S. Short-term effects of a "health-atevery-size" approach on eating behaviors and appetite ratings. Obesity (Silver Spring) 2007;15(4):957-966. 9. Bacon L, Aphramor L. Weight science: Evaluating the evidence for a paradigm shift. Nutr J 2011 Jan 24;10:9. 10. Burke LE, Steenkiste A, Music E, Styn MA. A descriptive study of past experiences with weight-loss treatment. JADA 2008;108(4):640-647.

11. Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: A systematic review of the literature. J Am Diet Assoc 2011 Jan;111(1):92-102. 12. Wing RR, Crane MM, Thomas JG, Kumar R, Weinberg B. Improving weight loss outcomes of community interventions by incorporating behavioral strategies. Am J Public Health 2010 Dec;100(12):25132519. 13. Yoo JH. No clear winner: Effects of The Biggest Loser on the stigmatization of obese persons. Health Commun 2012 Jun 28. 14. Domoff SE, Hinman NG, Koball AM, Storfer-Isser A, Carhart VL, Baik KD, et al. The effects of reality television on weight bias: An examination of The Biggest Loser. Obesity (Silver Spring) 2012 Jan 12. 15. Puhl RM, Heuer CA. Obesity stigma: Important considerations for public health. Am J Public Health 2010 Jun;100(6):1019-1028. 16. Urquhart CS, Mihalynuk TV. Disordered eating in women: Implications for the obesity pandemic. Can J Diet Pract Res 2011 Spring;72(1):50. 17. Puhl RM, Heuer CA. Public opinion about laws to prohibit weight discrimination in the United States. Obesity (Silver Spring) 2011 Jan;19(1):74-82. 18. Gagnon-Girouard MP, Begin C, Provencher V, Tremblay A, Mongeau L, Boivin S, et al. Psychological impact of a "Health-at-Every-Size" intervention on weight-preoccupied overweight/obese women. J Obes 2010;2010:10.1155/2010/928097. Epub 2010 Jun 29. 19. Curioni CC, Lourenco PM. Long-term weight loss after diet and exercise: A systematic review. Int J Obes (Lond) 2005 Oct;29(10):1168-1174.

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Workplaces can encourage vegetable and fruit consumption by making fresh produce available at the worksite. This can be achieved by organizing a local food project such as a farmers’ market, offering the worksite as a community shared agriculture (CSA) program drop-off site or facilitating the sale of produce directly from farmers to employees. Some research shows that having the opportunity to sample and purchase local food at work increases the chance that employees will continue to purchase local food outside the workplace as well.1 Buying local food supports local farmers, food processors and retailers, which helps to strengthen the local economy. Buying local also helps to protect the environment by reducing carbon emissions that result from packaging and transporting food from distant locations.2

Definitions of Success 

Employees have increased access to vegetables and fruit at work through the promotion of local food (e.g., farmers’ markets, CSA programs and direct purchasing from farmers)



Local food promotion project (e.g., farmers’ market, CSA program) is profitable for the farmers



Employees enjoy participating in the local food project

Promoting Local Food

Promoting Local Food

Is Local Food Organic? Often the terms local and organic are confused. Local food refers to the geographic area where food is produced, while organic refers to the farming method used to produce food. Food is considered to be locally grown if it is produced in Waterloo Region or in the Province of Ontario.

Organic Food The Canadian national standards control: which substances can be used on organic food, how the soil is managed, when and how processing facilities are cleaned, as well as how organic products are separated from non-organic foods while being shipped and sold.

Organic Food and Health Often individuals indicate that they consume organic products because they believe them to be better for their personal health.3,4 Organic food is not necessarily nutritionally superior to food grown using conventional farming methods in terms of vitamin and mineral content.5,6 An independent study showed that on average, organic produce contains higher amounts of antioxidants.7 However, the nutritional differences between organic and conventionally grown produce are unlikely to produce any significant difference in health outcomes.5 Eating organically produced food may be one way to reduce exposure to pesticides.4 However; all food is susceptible to contamination from pollution in the environment. Therefore all vegetables and fruit should be washed thoroughly to remove pesticides and other environmental pollutants.4 People often choose to eat organic food due to concerns of the effects conventional farming methods have on the environment and animal welfare.3 Others choose organic food to avoid eating genetically modified (GM) food.3 GM ingredients can be found in any food product, so they are difficult to avoid unless a product is certified as organic.8

What is Genetically Modified Food? A GMO is a generically modified organism, (e.g., a seed), that has had its genes (DNA) altered to act in a way that does not happen naturally or contains genes from another organism.8 GMOs were developed to have certain benefits. For example, GM foods may grow well even when sprayed with pesticides, have less disease caused by insects or viruses, resist damage due to weather, like frost or draught, ripen slower and last longer during shipping, bruise less easily or have more of a certain nutrient.8 GM foods have been grown and sold in Canada since 1994 and are regulated by Health Canada.8

Information: GENETICALLY MODIFIED FOODS For more information on genetically modified foods visit EatRight Ontario: http://www.eatrightontario.ca/

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1.0 Needs Assessment Are employees interested in having increased access to vegetables and fruit at the worksite? Ensure that employees are interested in having a local food project by asking: 

If employees prefer a farmers’ market, CSA program or direct purchasing from a local farmer



Preferred days and times to have a market or have food dropped off at the worksite9



Effective methods of communication to promote the project among employees (e.g., posters, email, intranet, word-of-mouth, etc.)9

2.0 Evaluation 

Track the number of employees that participate in the local food project



Use sales data to determine if the project is profitable for the farmer(s)



Use surveys to seek feedback from participants



Check-in with vendors throughout the process to determine if any improvements are needed

3.0 Planning a Local Food Project The results of your needs assessment should help you determine if employees are interested in having access to local food at the worksite. It should also indicate what format employees prefer. For more information on planning a farmers’ market see page 150. For more information on planning a CSA program see page 154. If employees would rather purchase food directly from the farmer see page 155 for a listing of resources that can help you locate local farms.

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Farmers’ Markets Workplaces can organize on-site farmers’ markets or make arrangements to attend an existing local farmers’ market at a nearby location. As an added bonus, people who use farmers’ markets enjoy the experience of interacting with farmers and other market patrons and often report an increased sense of community.4,10

Farmers’ Markets at Large Workplaces It may be feasible for large workplaces with several hundred employees to hold an onsite farmers’ market.11 Farmers’ markets are usually held once weekly from late spring until the early fall (due to local produce availability).Typically 300 attendees are required to make the market financially worthwhile for the organizers and vendors.11

Small and Medium Sized Workplaces Smaller workplaces may not have enough employees to host a farmers’ market. In this case, workplaces may choose to make a farmers’ market into a community event or partner with another worksite (to increase sales). Workplaces can make arrangements to attend markets that are already operating close to their worksite. Several farmers’ markets and neighbourhood markets operate within the Region of Waterloo. Workplaces can arrange an ‘employee walk’ or other forms of transportation to visit local farmers’ markets.12 Alternatively, workplaces can make arrangements with local farmers to pre-order produce. For example, circulating an order sheet to purchase specific items when they are available for harvest and having the farmer drop them off at the worksite a few days later.

Tools: FARMERS’ MARKETS IN WATERLOO REGION Foodlink Waterloo Region Foodlink Waterloo Region may be a helpful resource to find local food vendors for your own farmers’ market. Alternatively, this website can locate an existing market that is operating within walking distance of your workplace. http://www.foodlink.ca Neighbourhood Markets Visit the Neighbourhood Markets webpage on the Region of Waterloo website to see locations and operating hours of neighbourhood markets within Waterloo Region. http://chd.region.waterloo.on.ca/en/clinicsClassesFairs/neighbourhoodmarkets.asp

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3.1 Planning the Farmers’ Market Planning Committee Considerations Municipal Zoning and By-laws 

Ensure that your market location complies with local zoning and by-laws. Each municipality in Waterloo Region has different provisions for farmers’ markets. Check with your municipality to determine if your workplace is eligible to have an on-site farmers market. Your workplace may be required to obtain a vendors permit to run an outdoor farmers’ market. If an outdoor market is not possible, workplaces with cafeteria facilities may be able to hold an indoor market.

Market Location 

Pick a location for the market close to your worksite. Ideally the market should occur in a highly visible location such as a main entrance. Try to avoid locations that may be dusty, such as gravel parking lots



Vendors should have enough room to unload their trucks9,11



If you invite members of the community, encourage walking and cycling. Also ensure adequate parking is available.11 Make sure the market is accessible for people of all abilities11

Financial Considerations 

Establish a budget for your market including financial resources for tents, chairs, tables, hand washing facilities, staff time and promotional materials (flyers, posters, etc.)

Staff or Volunteer Resources 

Staff or volunteer time will be required to plan, develop and implement aspects of the farmers’ market. On market days, staff will be needed to assist with the market

Success Story: UNIVERITY OF WATERLOO FARMERS’ MARKET University of Waterloo has been operating a Farm Market since 2006, which features 100% local produce, baked goods, honeys and preserves. The onsite market allows students, staff and faculty and community members to purchase fresh nutritious food without leaving campus, reducing their ecological foot print. Student volunteers operate the not-for-profit market while UW Food Services purchases and transports the shipment to campus, sourced mainly from the Elmira Produce Auction Cooperative. In addition, the market also promotes a "Bring Your Own Bag" program for the market. http://www.foodservices.uwaterloo.ca/uwfarm_market/

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Vendor Selection Process 

Complete a vendor selection process. Determine how many vendors you will need. Ensure that vendor selection process complies with company policies and regulations for vendor selection.9 Also ensure that the vendor selection process is transparent and accessible for all local food producers (e.g., some producers may have difficulty with paperwork or require assistance completing this aspect of the process). Make a decision about whether your market will have the farmer(s) on site or whether food resellers (i.e., food retailers who have not grown the food themselves) are invited to apply.



Decide whether you want to feature local food at your farmers’ market or whether you are willing to accept produce from all over (i.e., imports)



Design a contractual agreement with the vendor.9 Ensure you have a plan as part of the contract for what to do with produce that is not sold at the market (e.g., unsold produce will be used in the cafeteria or donated to a local food bank or homeless shelter). The food producer should not be expected to remove food that was not sold as part of the market1

Legal considerations 

Make sure your insurance policy covers an onsite market. Alternatively, market insurance can be supplied by the vendor. The vendor contract should include details about who is supplying the insurance (i.e., the workplace or the vendor)



Check to make sure your liability insurance covers any volunteer working for the market

Nutrition Considerations 

Ensure that all items that are offered for sale comply with healthy eating standards (i.e., emphasize food and beverages that meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most” in the Nutrition Standards for Workplaces©. Limit food and beverages that meet the criteria for “Sell/Offer Less” to 20 per cent (or less). Avoid offering food and beverages that meet the criteria for “Not Recommended”). See Appendix A for the Nutrition Standards for Workplaces©

Facilities 

Plan ahead to make sure you have enough trash receptacles, recycling and organics bins for vendors and attendees. Decide ahead of time if your workplace or the vendors are responsible for clean-up after the market



If markets are recurring, designate a place to store equipment and supplies for the market11

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Communications 

Communications personnel will be needed to develop promotional items and to create and implement a marketing plan for the market (e.g., intranet, flyers, posters, emails).11 If the farmers’ market is ongoing throughout the season, information on the farmers’ market should be sent to employees on a weekly basis



If you would like to invite members of the community, also consider strategies to inform them (e.g., newspaper, local event bulletin boards, online event calendars, local community associations, etc.)11

Implementation 

Display the name and price of each item clearly9



Invite participants to submit recipes that can be made with items sold at the farmers’ market11



Add excitement to your market by offering a door prize or by holding a contest or challenge. Provide food demonstrations and sampling opportunities



Consider a “bring your own bag” policy



If funds are available, purchase market vouchers and provide them to employees at various recognition events or use as incentives. You may also want to hand out vouchers to entice employees to the grand opening of your farmers’ market

Tools: FARMERS’ MARKET EXAMPLES Kaiser Permanente Thriving Markets Initiative http://www.pps.org/projects/kaiser-permanente-thriving-markets-initiative/ Kaiser Permanente Farmers’ Market Resource Guide http://www.eatbettermovemore.org/sa/enact/healthcare/documents/healthcare.farme rs.tools.KPFarmersMarketResource4.pdf Duke Farmers’ Market http://www.hr.duke.edu/benefits/wellness/farmers/index.php Project Health – Comprehensive Strategies to Promote Healthy Eating

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Community Shared Agriculture Programs (CSAs) 3.2 Planning a CSA Program CSA programs allow consumers to directly share in the local harvest. People purchase a ‘share’ in the crops at the beginning of the season and then receive regular deliveries of farm products, most often produce, throughout the harvest season. The cost, delivery schedule, delivery locations and available crops are unique to each individual CSA program. Contact CSA programs in Waterloo Region to see if you can arrange for your employees to buy shares in a CSA at the beginning of the season and become a drop-off location.

Tools: CSA PROGRAMS IN WATERLOO REGION Foodlink Waterloo Region Use the “Find Local Food” search to find CSA programs in Waterloo Region http://www.foodlink.ca

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Purchasing Directly from Farmers 3.3 Planning a Direct Purchase Program Start by contacting local farmers to determine if they are able to offer delivery to the worksite. Inquire about available crops as well as pricing. Once a farmer is selected, decide on a communication strategy to let employees know what is available. Also determine the best way to place an order. For example, workplaces could circulate a list of available produce among their employees and designate one staff member to put in a collective order for the next week.

Tools: LOCAL FOOD RESOURCE Foodlink Waterloo Region Foodlink connects consumers to local foods in Waterloo Region. The website contains recipes, information on seasonal availability, local food and organic products as well as a map to help you find local food sources. http://www.foodlink.ca/

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Promoting Local Food References 1. Ross NJ, Anderson MD, Goldberg JP, Rogers BL. Increasing purchases of locally grown produce through worksite sales: An ecological model. Journal of Nutrition Education. 2000;32:304-312. 2. Foodlink Waterloo Region. Foodlink Waterloo Region. Available at: http://www.foodlink.ca. Accessed 03/09/, 2011. 3. Padel S, Foster C. Exploring the gap between attitudes and behaviour: Understanding why consumers buy or do not buy organic food. British Food Journal. 2005;107:606-625. 4. Cohen M. Environmental toxins and health--the health impact of pesticides. Aust Fam Physician. 2007;36:1002-1004. 5. Dangour AD, Dodhia SK, Hayter A, Allen E, Lock K, Uauy R. Nutritional quality of organic foods: A systematic review. Am J Clin Nutr. 2009;90:680-685. 6. Dietitians of Canada. Are organic foods better for my health? 2010.

7. Benbrook C, Zhao,X., Yáñez,J., Davies N, Andrews P. New evidence confirms the nutritional superiority of plant-based organic foods. The Organics Centre; 2008. 8. EatRight Ontario. Understanding Genetically Modified Foods. Available at: http://www.eatrightontario.ca/en/Articles/Foodtechnology/Biotechnology/Novel-foods/UnderstandingGenetically-Modified-Foods.aspx. Accessed 01/06, 2012. 9. Centers for Disease Control and Prevention. CDC garden market example. Atlanta: Centers for Disease Control and Prevention; 2010. 10. McCormack LA, Laska MN, Larson NI, Story M. Review of the nutritional implications of farmers' markets and community gardens: A call for evaluation and research efforts. J Am Diet Assoc. 2010;110:399 11. Network for a Healthy California - Worksite Program. Establishing a worksite farmers' market. California Department of Public Health; 2008. 12. Centre for Health Improvement. Worksite wellness program keeps employees healthy. 2008.

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Vending machines stocked with inexpensive, less healthy food options have the potential to harm the health of employees over time. The most important factors in making food choices are taste and price.1-5 Products offered in vending machines tend to be the least nutritious foods and beverages sold and are the most convenient to purchase.6,7 By offering less healthy food choices at a low price, you may be unintentionally encouraging employees to eat less healthy food and beverages in place of meals or healthy snacks.4,8

Definition of Success  If vending machines are present, there is an emphasis on food and beverages that meet the criteria for the “Maximum Nutritional Value” or “Sell/Offer Most” (e.g., aim for 80 per cent of the vending machine contents from these categories).  Food and beverages from the “Sell/Offer Less” category are limited (e.g., stock 20 per cent or fewer products from this category).  Avoid offering food and beverages from the “Not Recommended” category in vending machines. *See Appendix A for a copy of the Nutrition Standards for Workplaces©.

Vending Machines

Vending Machines

1.0 Needs Assessment Assess the purpose of the vending machines in your workplace. Are they meant for employees who work shifts or who do not have access to a workplace cafeteria? Are vending machines there for snacking purposes? Are vending machines a source of revenue for fundraising purposes? If the vending machine is present for financial purposes, assess the actual profits from the machine and determine if these funds could be raised in another manner.

2.0 Evaluation Indicators 

Assess current vending machine offerings using the Nutrition Standards for Workplaces© in Appendix A



Set targets for increasing the amount of food and beverages that meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most”



Audit the machine regularly to ensure that healthy options are present as requested and that food safety protocols are being followed



Check to make sure that the price, placement and promotion of foods in vending machines encourages the healthier options



Monitor vending sales before and after the implementation of healthier food choices



Note barriers, challenges and successes in the process of implementing healthier choices



Track any other relevant indicators

3.0 Creating Healthy Vending Machines 3.1 Determining Employee Food Access Needs Ask employees if they use the vending machine, how often they use it and the time of day that they typically use the machines. (One study found vending machine use to be low, with 85 per cent of employees reporting that they infrequently or never used them.6) Consider whether your workplace requires a snack vending machine or if staff needs can be better met through other food service options or by providing a kitchenette with a sink, fridge, microwave, toaster, hot water dispenser, etc. Also determine whether your workplace requires a beverage vending machine or if staff needs can be met by providing hot and cold water dispensers, water fountains or water and ice machines.

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3.2 Implementation Considerations Using Nutrition Standards Emphasize products that meet the criteria for the “Maximum Nutritional Value” or “Sell/Offer Most” categories in the Nutrition Standards for Workplaces©. Limit items from the “Sell/Offer Less” category (e.g., stock 20 per cent or fewer products from this category) and avoid items from the “Not Recommended” category. See Appendix A for a copy of the Nutrition Standards for Workplaces©. Refer to the Non-Perishable Brand Name Food List for food and beverages that meet the criteria for “Maximum Nutritional Value” that can be stocked in vending machines http://chd.region.waterloo.on.ca/en/healthyLivingHealthProtection/resources/BrandName_FoodList _NonPerishables.pdf The Nutrition Standards for Workplaces© can be phased in over time. This strategy may be helpful if there is resistance to removing less healthy options from vending machines, as it provides some time for employees to get used to the changes. For example, start with a target of 50 per cent of items from the “Maximum Nutritional Value” or “Sell/Offer Most” categories and work towards 80 per cent. At the same time, work on phasing out items that meet the criteria for “Not Recommended”. Consider Employee ‘Choice’ It is often argued that individuals need to have both healthy and less healthy ‘choices’. However, people may consume food products simply because they are in the workplace environment, so installing a vending machine may tempt employees to consume food and beverages they might not otherwise choose.6,8,9 The presence of a vending machine is a cue that can influence people to eat less healthy food and beverages.10-13 In studies, the presence of vending machines was directly correlated with the consumption of food and beverages high in fat and sugar.8,11,14 Employers should not feel obligated to offer less than healthy snacks to their employees. Employees always have the option of bringing their preferred snacks to work with them and therefore, always have the right to choose what they want to eat.15 If you are making changes to existing vending machine services you may want to conduct a survey or a taste test event (to allow employees to sample products) to help determine what products should be stocked in the vending machine.

Price Strategically price food and beverages that meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most” categories so they are at least $0.50 less expensive than options from the “Sell/Offer Less” category.

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Placement Ensure the healthier items are placed in the machine so that employees notice them first (e.g., placed at eye level, etc.).

Food Safety Have a plan in place to ensure your machines are checked at regular intervals to remove any expired products. Ensure that vending machines containing perishable foods are kept at safe temperatures.

Working with an External Vendor If an external vendor stocks your vending machines you will need to have a meeting with your vendor to discuss the food products that you would like to have in your machines as well as the price, placement and promotion strategy for healthier items.16 You may include terms your written agreement with a vending company to ensure the vendor is filling the machines according to your specifications. A written agreement with your vending company would be considered a healthy eating policy. For more information on healthy eating policies see page 171.

Success Story: WATERLOO WELLINGTON COMMUNITY CARE ACCESS CENTRE The Waterloo Wellington CCAC made changes to their snack vending machine by changing options to healthier choices. After a period of time, it was determined that the vending machine was not well used and it was subsequently removed from the workplace. Initially, a few employees were dissatisfied by the removal of the machine; however, there have been no further complaints since the machine was removed.

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Vending Machine References 1. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point-of-purchase behavior in adults: A review. Prev Med. 2004;39 Suppl 2:S108-36. 2. Eertmans A, Baeyens F, & Van den Bergh, O. Food likes and their relative importance in human eating behavior: Review and preliminary suggestions for health promotion. . Health Education Research. 2001;16:443-456. 3. Elinder LS, Jansson M. Obesogenic environments – aspects on measurement and indicators. Public Health Nutr. 2008;12:307-315. 4. French SA. Pricing effects on food choices. J Nutr. 2003;133:841S-843S. 5. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health. 2008;29:253-272. 6. Gorton D, Carter J, Cvjetan B, Ni Mhurchu C. Healthier vending machines in workplaces: Both possible and effective. N Z Med J. 2010;123:43-52. 7. Ashe M, Feldstein LM, Graff S, Kline R, Pinkas D, Zellers L. Local venues for change: Legal strategies for healthy environments. The Journal of Law, Medicine & Ethics. 2007;35:138-147. 8. Lawrence S, Boyle M, Craypo L, Samuels S. The food and beverage vending environment in health care facilities participating in the healthy eating, active communities program. Pediatrics. 2009;123 Suppl 5:S287-92.

9. Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annu Rev Nutr. 2004;24:455-479. 10. Stice E, Spoor S, Ng J, Zald DH. Relation of obesity to consummatory and anticipatory food reward. Physiol Behav. 2009;97:551-560. 11. Koordeman R, Anschutz DJ, van Baaren RB, Engels RC. Exposure to soda commercials affects sugar-sweetened soda consumption in young women. An observational experimental study. Appetite. 2010;54:619-622. 12. Mink M, Evans A, Moore CG, Calderon KS, Deger S. Nutritional imbalance endorsed by televised food advertisements. J Am Diet Assoc. 2010;110:904-910. 13. Harris JL, Bargh JA, Brownell KD. Priming effects of television food advertising on eating behavior. Health Psychol. 2009;28:404-413. 14. Fox MK. Improving food environments in schools: Tracking progress. J Am Diet Assoc. 2010;110:10101013. 15. Brownell KD, Kersh R, Ludwig DS, et al. Personal responsibility and obesity: A constructive approach to a controversial issue. Health Aff (Millwood). 2010;29:379-387. 16. Gillis B, Mobley C, Stadler DD, et al. Rationale, design and methods of the HEALTHY study nutrition intervention component. Int J Obes (Lond). 2009;33 Suppl 4:S29-36.

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Workplace gardens create many benefits for workplaces and their employees. A workplace garden is a common meeting place where employees can socialize while working together to grow herbs, vegetables and fruit. A workplace garden can provide an environmentally friendly source of healthy local produce for your employees, your food service operations and can even be donated to members of the community who experience food insecurity. Gardeners often report eating more vegetables and fruit compared to non-gardeners.1 Working in a garden has also been shown to decrease stress levels in individuals and also provides employees with an opportunity to be physically active at work.1,2 Additionally, employees learn food skills related to growing produce.

Definition of Success  Staff participate in workplace gardening  Education is provided to employees regarding safe and sustainable gardening methods  Employees express enjoyment in their workplace gardening experience  Employees were able to consume (or donate) vegetables and fruit from the workplace garden

Adapted from: Community Garden Council of Waterloo Region. Starting a Community Garden in Waterloo Region 2007

Workplace Gardens

Workplace Gardens

1.0 Needs Assessment Ask employees if they are interested in having a workplace garden. If so, get a group of gardening enthusiasts together, promote the garden concept and recruit volunteers.

2.0 Evaluation Indicators After the first year, use participant feedback to start planning for the following year. Ask participants about their workplace garden experiences including: what worked, what needs improvement, budget concerns, etc. Keep track of what was produced and how it was used.

3.0 Implementing a Workplace Garden Planning Process 

Winter is a good time to begin planning the garden



If you do not have a gardening expert at your workplace, consider hiring someone from the community that can get your garden started



Form a planning group and create a garden plan. A committee should be in place to organize the garden and conduct meetings. Decide on the best way to communicate with one another



Make a list of what your ideal garden will look like, who it will involve and what you will need to get started. The plan should include: budget, location of the garden, equipment and storage needs

Tools: LOCAL INFORMATION ON STARTING A GARDEN Community Garden Council meetings: http://www.together4health.ca/workgroups/community-gardens/upcoming-events Community Gardens of Waterloo Region website: http://www.together4health.ca/workgroups/waterloo-region-community-gardencouncil Vegetable garden tips: http://www.together4health.ca/workgroups/community-gardens-waterlooregion/planting-and-caring-basic-vegetable-garden

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Staff 

Staff time may be required to plan, develop and implement aspects of the workplace garden



Remind staff working in the garden to use sun protection gear such as sunscreen and hats

Facilities, Legal and Health and Safety Stakeholders 

Check to make sure your workplace insurance policy covers the land use for gardening



Pick a garden site. Ensure the garden site has full or partial sun for four to eight hours per day. Make sure road salt from snow removal will not contaminate the site. The space should be accessible for individuals of all abilities



Determine if your proposed site is appropriate for a garden. Check the site for indications of illegal dumping or burning of garbage. Turn the soil and check for dark patches or odours (e.g., from chemicals or gasoline). Contact your municipality for information on the site history. Soil testing should be considered for sites that have a questionable history or that are next to a busy highway, rail corridor or gas station. Soil testing can be done through the University of Guelph. In some cases, container gardening, raised bed gardening or rooftop gardening may be more appropriate



Call before you dig! Check with representatives from hydro, phone, cable, gas, water and sewer to avoid cutting into lines



Find a water source, water barrels are an eco-friendly way to provide water for your garden



If possible, provide a source of shade nearby



Gates and fencing, such as: wood, plastic, chain link, post and wire or snow fence may be required



4x4 and 6x6 timbers or other material for constructing raised beds or containers for container gardening may be required



Consider adding a composter for lawn cuttings, leaves and some kitchen leftovers to the workplace garden

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Materials Once the site has been determined and a water source secured, you will need to obtain: 

Seeds, seedlings, bulbs, bedding plants or cover crop seeds



Topsoil, compost, manure, mulching materials such as shredded leaves, hay, shredded bark or wood chips



Garden hose, spray nozzles, hose reel, rain barrel or water tank and watering cans



Insecticidal soaps and hand-held sprayers. Involve the Health and Safety committee (e.g., for MSDS sheets)



A wheelbarrow and garden cart, tool and storage shed, locks, benches and picnic tables



Compost bins or materials to build your own composter

Sustainability 

Book garden work days to dig the garden, lay out the plots and walk paths and prepare the soil



Keep a schedule of tasks that need to be performed. Divide the work evenly. Involve gardeners in tasks like planting flowers around the garden site, clean up and harvest

Success Stories: ADDITIONAL WORKPLACE GARDEN EXAMPLES: Gardens at Work: 2010 Report http://www.employergardens.com/haberman-garden/gardens-work-2010-report Employee Gardens! (Great for keeping the workplace healthy and happy!) http://jaticus.com/?p=37 Out of the Office http://www.organicgardening.com/living/out-office Grow in Your Job. 4 tips to help you start at community garden at work http://www.organicgardening.com/learn-and-grow/grow-your-job Vegetable Patches at Work are a Nice Perk http://www.treehugger.com/files/2010/07/more-companies-providing-vegetablepatches.php

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Workplace Garden References 1. McCormack LA, Laska MN, Larson NI, Story M. Review of the nutritional implications of farmers' markets and community gardens: A call for evaluation and research efforts. J Am Diet Assoc. 2010;110:399-408. doi:10.1016/j.jada.2009.11.023. 2. Van Den Berg AE, Custers MHG. Gardening promotes neuroendocrine and affective restoration from stress. Journal of Health Psychology. 2011;16:3-11.

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One way to influence health behaviour is through workplace health policies. A policy is a formal written statement that helps clarify roles and expectations of management and employees. Well written policies define acceptable and unacceptable behaviour and clearly state the implications of not following the policy. A written food and nutrition policy is a way to support other elements of a healthy workplace nutrition environment (i.e., awareness raising, skill building and supportive environment initiatives). A well written policy is consistent with the values of the organization, ensures consistency in decision-making, fosters sustainability and clarifies functions and responsibilities.1 A policy typically includes an objective, definitions and expectations of management and employee behaviour. In addition, a policy is generally: required, equitable, sustainable, incentive-based (punitive or positive) and enforceable (where there is meaningful consequences for unsafe, unhealthy or prohibited behaviour). Policies should be made available to all employees and managers and adherence to the policy should be monitored.

Definition of Success  Written policies are developed, communicated, monitored and enforced for all applicable areas in the workplace that influence healthy eating. This includes policies that support healthy eating initiatives such as awareness raising and skill building activities and supportive environment strategies including strategies that address organizational culture. Use the previous sections in the toolkit to formulate the focus of your policy

Policy Development

Policy Development

1.0 Needs Assessment Before commencing with a policy, conduct a needs assessment. Determine priority areas and focus on a policy that will have a significant impact on health behaviours. 

Gather information about your organization such as anonymous group health data from the benefits provider and employee assistance program. Conduct an audit of the workplace to determine factors that support or discourage healthy eating



Conduct an employee needs assessment. The results will help you determine if your workplace is ready for change and what changes employees are willing to accept. Consulting employees before proceeding with policy development will help to increase employee and management support for the policy



Review current policies and procedures to determine if there is an existing healthy eating policy



Review current policies and procedures to determine if any are having a negative effect on eating behaviours



Ensure key stakeholders (e.g., members of the healthy eating committee, management, labour groups, food service providers, etc.) are part of the policy development process. Your policy should represent the needs of both the employers and employees



Assess workplace capacity to support the logistics of evaluating, enforcing and evaluating the policy. A policy will only be effective if it is monitored and enforced. The workplace should also have the ability to follow through with an implementation strategy to ensure management and employees are aware of their role in following the policy



Think about the future, will anything be happening in the organization that may affect the policy?

2.0 Evaluation Indictors1 

Use the previous sections in this toolkit to help you determine your evaluation indicators for your policy. For example, if you are writing a healthy meetings policy, you would use the evaluation indicators from the Meetings and Events section under Supportive Environments

Seek employee feedback after the implementation of the policy to: 

Determine if the policy is being applied



Identify barriers to policy compliance. (Whenever possible address employee concerns in a timely manner)

3.0 Healthy Eating Policy Development 3.1 Writing a Healthy Eating Policy Introductory Statement A statement that introduces the concept of the policy. Example: (Employer name) is committed to promoting a healthy lifestyle by utilizing safe food handling practices and supporting accessibility of healthy food and beverage choices in the workplace. Rationale/Objective/Purpose Concrete examples about why your workplace is implementing the policy (i.e., what is the goal of the policy.) Example: To ensure that healthy food choices are offered and safe food handling procedures are followed at all workplace functions where food and beverages are served. Scope The definition of where your policy is applicable. Example: The policy applies to all workplace departments and events. Definition The definition of what is considered “healthy” food; so that people know what types of food and beverages they can offer. Example: Foods offered will meet nutrition criteria for “Maximum Nutritional Value” or “Sell/Offer Most”. Principles/Procedures/Requirements How the policy will be accomplished. Select appropriate policies for your workplace that addresses your workplace needs assessment. Example: At least 80 per cent of foods offered or sold to employees will meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most”. Foods categorized as “Not Recommended” will not be offered or sold to employees in the workplace. Guidelines/Nutrition Criteria See the Nutrition Standards for Workplaces© in Appendix A

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Responsibilities Management: Example: Management is responsible for being familiar with their responsibilities under the Policy. Example: Ensuring that the Policy is posted in the workplace in a visible and accessible spot. Example: Investigating and dealing with incidents of non-compliance with the Policy. Responsibilities Employees: Example: Being familiar and following through with their responsibilities under the Policy. Training and Information How managers and employees will learn about the policy and where they can go for reference materials to assist in following the policy. Example: All employees will be provided with appropriate information and instruction on the contents of the Policy. Evaluating and Accountability How the organization will monitor compliance and what will happen if the policy is not followed? Example: Departments must periodically evaluate the implementation of this Policy and be able to demonstrate compliance. Example: Food items that do not meet the nutrition criteria specified in this Policy, will not be purchased with company funds. Other Sections

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3.2 Policy Considerations to Support Healthy Eating Facilities 

Employees have access to an clean and attractive eating area that is away from their workspace

Cafeterias, Cafés, Meetings and Events, Vending Machines 

Employees have access to healthy, reasonably priced and culturally appropriate food choices



Healthy food options (i.e., food and beverages that meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most”) will be provided whenever food is offered or sold in the workplace



Healthy options (i.e., food and beverages categorized as “Maximum Nutritional Value” or “Sell/Offer Most”) will be priced the same or lower than other choices in the workplace



Food from local sources will be provided whenever possible



Staff will follow safe food handling recommendations when high risk food is served in meetings, events, cafeterias, celebration events, fundraisers and vending machines



Tap water is available to all staff during meetings, events and celebrations



The cafeteria provider will have at least one full-time staff member with Safe Food Handler certification



The promotion of foods categorized as “Sell/Offer Less” or “Not Recommended” is prohibited, (e.g., advertisements, decals on vending machine, specials, posters, email notifications, etc.)



Waste will be minimized by reducing the amount of packaging and disposable dishes used, recycling and by diverting food waste to an organics program

Fundraising 

Fundraising does not include the sale of food and beverages categorized as “Not Recommended” (i.e., bake sales, cookies, chocolate bars, muffins, etc.)

Organizational Culture 

Create a positive workplace culture where all employees are treated in a fair manner with a focus on respect and acceptance.2 Enforce a zero tolerance policy for workplace harassment, discrimination or other anti-social behaviours3,4



Create flexible work policies to allow employees to enhance work-life balance (e.g., offer flexible work hours, work from home options, child or elder care time, subsidies or spaces, etc.)3-5



Provide adequate time for employees to eat on their lunch break



Provide work time to allow employees to attend awareness raising and skill building activities

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3.3 Build support for the policy6 It is important that stakeholders and decision-makers understand the need to proceed with the policy. In communications, focus messages on the links between the policy and eating a healthy diet. Use simple descriptions of solutions and emphasize that change is warranted and desired. Prepare to counter arguments such as: the policy will be too costly, it is not the workplace’s responsibility to restrict individual freedoms and that there is a non-policy solution to the problem. For more information on making the case for policy, see Part I “The Cost of Doing Nothing the Business Case” and Part II “Examining the Evidence: Addressing the Limitations of Current Interventions”. 3.4 Implement the policy6 Ensure the following conditions are met before embarking on policy implementation: 

The policy meets stated goals and objectives



The policy objectives are measurable and an evaluation plan is in place



Decision-makers and stakeholders have approved the policy



An accurate estimate of the resources needed to implement your policy has been developed



The timeline is realistic and appropriate



The policy specifies who is responsible for what will be done and when it will be done



Make the policy accessible to all employees. Ensure the policy has been explained to all staff through information sessions, training sessions, at staff meetings and during orientation for new staff



Ensure that the policy implementation plan includes a communication plan so that all individuals affected by the policy are aware of policy specifics and expected behaviour

3.5 Evaluating and Enforcement 

Make plans for evaluating and enforcement of the policy

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SAMPLE POLICIES Healthy Eating Policy (Government of Nova Scotia ) http://www.gov.ns.ca/psc/v2/pdf/employeeCentre/healthyWorkplace/healthyEating/02 _SupportiveEnvironment.pdf#Page=19 Eat Smart Meet Smart Healthy Meetings Policy (Western and Northern Collaborative for Healthy Living) http://www.health.gov.bc.ca/healthyeating/pdf/eat-smart-meet-smart.pdf Nutrition Policy (Union River Healthy Communities) http://healthycom.org/cms/files/sample-workplace-nutrition-policy-inc-vending.pdf Food Donated by Employees Policy (Mecklenburg County, NC Healthy Weight Task Force) (http://www.fitcitychallenge.org/Content/m1/Worksite/PDF/PolicyFoodDonatedByEmp loyees.pdf Green Meetings (National Recycling Coalition) http://www.fs.fed.us/sustainableoperations/greenteamtoolkit/documents/NationalRecyclingCollolitionGreenMeetingsReference.pdf Healthy Meetings Policy (University of Windsor) http://www1.uwindsor.ca/hr/system/files/Healthy%20Meeting%20Policy.pdf *This is not a comprehensive list but a sample of existing policies

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Frequently Asked Questions Are guidelines the same as policies? Sometimes guidelines are confused with policies. For example, a guideline exists when employees are provided with information that they may choose to use to help them make healthier lifestyle choices, such as guidelines for “what to serve during meetings”, yet there is no explicit expectation that the employee will follow the guidelines, or consequence if they do not follow the guidelines. A policy is different than a guideline in that the behaviour outlined in the policy is expected or required of all employees, and that it is not up to the employees’ discretion as to whether or not they will follow the policy.

Is a commitment statement the same as a policy? A commitment statement shows that your workplace cares about employee health. For example, “our organization is committed to offering healthy and nutritious food choices”. Although a commitment statement shows a positive intent, it is difficult for employees to decipher how this statement should impact their behaviour. For example, when can employees expect to have healthy choices and what is the definition of a healthy choice? As a result of a formalized policy, employees who order food know that they are expected to provide healthy options. A policy provides defines what a healthy choices is, it also defines when healthy choices will be offered. For example, “a healthy choice is a food item that meets the criteria for “Maximum Nutritional Value” or “Sell/Offer Most” (See Appendix A). Healthy food will be available whenever food is offered or sold in the workplace.

Is having a policy the same as creating a supportive environment? Supportive environments create an environment that fosters good health. Within a supportive environment, employees feel that the organization provides them with encouragement, opportunities and rewards for developing or maintaining a healthy lifestyle. Sometimes supportive environments are created in the absence of policy.

Example: Supportive environment in absence of a workplace policy A workplace cafeteria provider decides that it will offer a healthy entrée option every day. Although this is a positive health promotion activity, there is no formal expectation that it will continue. In this case, the cafeteria may decide that if the healthy entrée does not sell well, they will discontinue the item. Similarly, the cafeteria may consider a food item to be a healthy choice; however, the workplace may disagree on the definition of a ‘healthy choice’. When a workplace has a cafeteria policy, there is a clear definition of ‘healthy food choices’ (e.g., “Maximum Nutritional Value” or “Sell/Offer Most”). Similarly, it would not be up to the discretion of the cafeteria to decide whether or not to continue to offer a healthy entrée, regardless of sales performance.

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Policy References 1. NSW Department of Commerce Office of Industrial Relations. Workplace policies and procedures. 2011. 2. Berset M, Semmer NK, Elfering A, Jacobshagen N, Meier LL. Does stress at work make you gain weight? A two-year longitudinal study. Scand J Work Environ Health. 2011;37:45-53.

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3. World Health Organization. Healthy workplaces: A model for action for employers, workers, policy-makers and practitioners. 2010.

4. Work stress and health: The Whitehall II study. London, England: Published by Public and Commercial Services Union on behalf of Council of Civil Service Unions/Cabinet Office; 2004. 5. Shain M, Kramer DM. Health promotion in the workplace: Framing the concept; reviewing the evidence. Occup Environ Med. 2004;61:643-8, 585. 6. The Health Communication Unit. The eight steps to developing a health promotion policy.

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Certain workplace populations may be at higher risk of developing chronic health conditions or may be difficult to reach with traditional health promotion strategies. This section will address some common workplace issues that pose challenges in supporting healthy eating. Topics include strategies for promoting healthy eating among shift workers, drivers, targeting male populations, working families, smokers and individuals working in hot conditions.

Definition of Success  Comprehensive workplace health promotion interventions are tailored to meet the needs of unique workplace populations

Special Considerations

Special Considerations

Shift Workers It is estimated that approximately 25 per cent of workers in Canada work rotating shifts.1 Many employees enjoy shift work, while others feel it is “just part of the job.” No matter which category shift workers fall into, it can be difficult for these workers to find a work-life balance. As a result, some shift workers may have reduced access to meals, time constraints for food preparation and disrupted family mealtime activities, which can cause a reliance on fast food or vending machines.1,2

Shift Work and Health Shift workers have higher risks for experiencing problems related to insomnia, chronic fatigue, anxiety, depression and fertility problems. They also have higher risks of developing chronic conditions such as cardiovascular disease, hypertension, diabetes and high cholesterol.1,3-6 Shift work is also related to weight gain.1,3,7,8

Up to 75 per cent of shift workers experience appetite disturbances and gastrointestinal symptoms such as constipation and heart burn.1 The negative associations between shift work and health could occur because shift work interferes with the metabolic and hormonal changes that occur as part of the circadian rhythm.4,5 Additionally, shift workers may not participate in health promoting behaviours such as cooking healthy meals, eating at home and leisuretime physical activity if they feel the need to catch up on sleep.1 Although many studies have not shown any differences between the nutritional intakes of regular day workers compared to shift workers, some studies show that sleep deprived individuals consume more calories per day, partially due to a reliance on snacks and sugary food products.1-4,7,9

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Interventions for Shift Workers  Workers who bring meals from home

consume healthier diets.3 Provide refrigerators and microwaves and ensure employees have enough time to eat  If food services are offered, provide

smaller portions of foods, as eating large quantities may cause fatigue  Provide workers with competitively priced

healthier options in vending machines and cafeterias. Consider decreasing or removing items that meet the criteria for “Not Recommended” in the Nutrition Standards for Workplaces©.

 To reduce gastrointestinal discomfort,

make low-fat, high-fiber snacks available and avoid providing spicy, high-fat and fried foods  Encourage workers to drink tap water

throughout their shift  Avoid encouraging excessive caffeine

intakes (i.e., more than 2 to 3 cups of coffee per day) as this can interfere with sleep once the shift is completed  Optimize scheduling practices so that

employees have enough time between shifts to receive adequate sleep

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Professional Drivers Fatigue and Collisions Estimates suggest that up to 20 per cent of all road collisions are related to fatigue.16-19 This is concerning given the high prevalence of fatigue and sleep apnea among professional drivers. Approximately 25 per cent of professional drivers have sleep apnea.9,10 Individuals with sleep apnea are two to three times more likely to be involved in a collision.18

Professional Drivers and Health Personal health behaviours are commonly influenced by occupation.9-13 Professional drivers are often subject to a stressful work environment due to long work hours, irregular shifts, low job control, social isolation and anxiety over deadlines, traffic and weather conditions.9-13 Drivers are less likely to be physically active during leisure time and less likely to eat a healthy diet due to the limited availability of healthy food.11,13 Many drivers are at an increased risk of developing health problems due to job related factors including, weight gain, hypertension, high cholesterol, diabetes and sleep apnea.9-15

Unfortunately, drivers may be unaware of this risk, since their perceptions of daytime sleepiness are not a reliable indicator of their actual level of fatigue.20 In one study of drivers, 76 per cent had sleep apnea but none reported any symptoms.20 When tested, almost half of these drivers (47 per cent) showed symptoms of excessive daytime sleepiness, putting them at high risk for being involved in a collision.20 This has important safety implications for professional truck drivers. In 2008, collisions involving heavy trucks accounted for only seven to eight per cent of all collisions but approximately 20 per cent of all road fatalities in Canada.21

The Bottom Line Due to the nature of the occupation, drivers can be difficult to reach through traditional health promotion strategies.11 However many drivers can be reached through locations where they regularly stop such as truck stops and depots. .

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Interventions for Drivers:  Drivers may benefit from regular health

screening for blood pressure, diabetes and cholesterol. Consider implementing these programs where drivers congregate  Encourage drivers to bring meals from

home. This is associated with higher vegetable and fruit intakes12

 Competitions for drivers have also been

successful in promoting healthy eating and physical activity. The team competition format can increase social interactions between drivers and appeals to individuals with a competitive nature11

 Offer fresh fruit, healthy snacks or healthy

take away meals to drivers at stops and depots  Ensure drivers have high levels of

supervisor support and reduced job strain, factors associated with a greater likelihood that drivers will have healthier eating habits12  Provide realistic schedules that include

time for traffic congestion, allow drivers to adhere to speed limits and provide time for physical activity and adequate sleep.12 Drivers should be involved in scheduling processes

Success Story: A HEALTHY EATING INTERVENTION FOR DRIVERS One intervention provided truck drivers with educational materials and personal health assessments at a frequented truck stop. The menu was altered to offer healthier foods. The cooks at the truck stop were educated on healthy food preparation and wait staff served as health promoters by offering healthier choices to drivers. Interviews with drivers and staff showed that drivers were more inclined to choose healthier alternatives as a result of the intervention.14 As an unplanned bonus, the healthier cooking methods actually saved the truck stop money!

Tools: ROAD SAFETY For information on implementing road safety initiatives for your workplace, visit the Project Health website http://www.projecthealth.ca or call 519-575-4400 (TTY 519-5754608)

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Targeting Male Populations

Encouraging men to use health services is considered to be one way to improve men’s health, since there tend to be differences in the way that men and women address health concerns.22 Despite the fact that men are more at risk of developing cardiovascular disease and diabetes, they can be difficult to engage in health strategies.23-25 “I’ll just wait to see if it fixes itself” Men have been referred to as poor patients who only seek medical help when their problems become difficult to treat.22,26-30 In fact, men tend to avoid seeking out health services as long as they can continue in their regular daily activities.23 Often, men avoid seeking medical services as they do not want to waste medical services or appear foolish, fussy or weak to their peers.23,26,29-31 Instead, men tend to ‘wait and see’ and give problems a chance to heal themselves.23,29,30

Some men commented that fussing about health and nutrition too much is considered to be vain, narcissistic and feminine, while having a disregard for their body is considered to be ‘macho’.32 This traditional ‘macho’ stereotype of being tough, independent and self-reliant, may prevent some men from seeking help, participating in health promoting behaviours and eating healthy food.26,29-31,33 However, current role models for men are more physically fit compared to older generations, which may allow younger men to adopt healthier lifestyles without feeling less masculine.32 The concept of lifestyle ‘balance’ can be misinterpreted as engaging in both ‘good’ and ‘bad’ behaviours (e.g., healthy eating today to balance heavy drinking tomorrow).32,34 This ‘balance’ approach allows men to think they can address health without giving up the appearance of being masculine.32

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Men and Eating Behaviours Men and women seem to have very different behaviours when it comes to health and nutrition. While women tend to be concerned about outward appearance and healthy living, some men feel that health campaigns are intrusive and resent interference from others because they believe that food selection is a personal choice.24,26,35-38

which may make it less likely that they pick options that have healthy sounding names such as “nature salad” that tend to be associated with feminine characteristics.41 Food options named using words like “hearty”, “chunky” or “western” may make it more likely that men will choose them.41

Although men are aware of nutritional guidelines, they often show skepticism and resistance to education.37-39 In focus groups, many male interviewees explained that they “feel healthy,” so they have no reason to change current dietary habits.37,40 Quite often, men describe healthy eating as being bland and insufficient (e.g., “rabbit food”), and think that eating healthy food deviates from social norms and conventional patterns of their way of life.24,26,31,33,37 Large portion sizes, hearty satisfying foods, red meat and alcohol are typically related to masculinity, while vegetables, fruit and yogurts are considered to be feminine.37,38,41 It appears that men tend to make food choices that express their gender identity,

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Interventions for Male Populations Traditional health promotion strategies may not impact men’s eating habits. To engage male employees, develop a comprehensive, targeted workplace-based healthy eating strategy! 28,42

Raising Awareness with Health Assessments  Men respond to gentle wake-up calls and will

make long-term health changes when they can see the practical benefits of change. Creating too much fear will cause men to avoid dealing with symptoms or looking after their health27  Have a health professional complete

assessments during work hours as men may not attend programs held outside of work hours25,43  Ensure that workplace health screenings are

“one stop shops” held in an area that is appealing to men and where they tend to congregate27  Health is perceived to be a ‘female’ word,

use more functional terms such as “check” or “measure” to describe the assessment.27 One successful program in Australia used the name “PitStop program”44

 Include measurements of weight, height,

Body Mass Index, waist circumference, blood pressure, cholesterol, blood glucose and carbon monoxide levels. Consider adding dietary intake, alcohol intake and physical activity assessments25,45  Ask lifestyle questions first to put men at

ease before conducting medical tests.27 Weight and height measurements should be done at the end, as this is the least favourite part of the assessment27  Use practical information such as a red,

yellow and green grading system to show how close they are to recommended parameters.27 Privacy is important, so results should be covered with a top sheet27  Having same-day results motivates men to

participate and reduces the anxiety involved with waiting for results27

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Educating Men (Awareness Raising and Skill Building)  Offer health information that is both

accessible and meaningful to men as they like to have access to health information prior to seeking help23  Men prefer clear, written instructions6  Present advice in a caring and non-

judgemental way.27 Health information should not place all the blame on the individual27  On-going support and advice is important

to help men who would like to achieve a healthy lifestyle25  Approach health topics with humour and a

positive tone, as this is part of the male experience24,25,27

 Discuss alcohol as part of healthy eating

and weight management education25  Plan activities where they can participate

with other male colleagues.24,25,33,42 Workplace support is important for men to maintain a healthy lifestyle  Provide health information from health

professionals directly, with an emphasis on reliable information.27 Be sure to include nutrition information sessions, healthy food samples and food models  Teach food skills in a way that appeals to

men. These experiences need to be fun; have a practical application and an element of competition. In a study of single men, there was interest in learning how to cook, as it supports the masculine identity of being able to “fend for oneself,” but was also viewed as a way to impress prospective dates24,25  Include female partners and other family

members who can help male workers seek out health advice and provide encouragement to participate in health initiatives38

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Supportive Environment and Policy  Address stress in the workplace to help

moderate eating behaviours and other risk factors such as smoking, drinking and substance misuse.25,26,31,34,35 The workplace is a place where men find their self-esteem either enhanced or diminished.27,30 Long commute times, job insecurity, lack of job control and a lack of feeling valued are all stressors for men.7,46-48 Men are unlikely to discuss stress or mental health issues, which may lead them to engage in unhealthy coping behaviours49  Involve men in needs assessments and

 Create an environment that encourages

healthy eating. This is more acceptable than interventions that single out individuals, rely solely on educational strategies or that focus on weight loss.24,30 This means that the healthy choice is the default choice  Men are highly influenced by food cues,

meaning that they eat when food is present or when food is advertised, making a supportive food environment especially important for men58  Offer free samples and pair ‘new’ healthy

choices with well-liked options. Also, new food options may not be popular right away, so repeated exposure to new healthier foods may increase taste preference for these items7,43,58-60

program planning to see what types of programs in which they would enjoy and participate30,49  Bring services to men in an informal

environment where they feel comfortable33,50-56

 Highlight the pleasurable effects of eating

healthy food when marketing to men (e.g., focus on taste or freshness rather than on health claims)61

 Competition can be an important

motivator for men to participate in health promotion activities. Pay careful attention to avoid causing lower self-esteem.25 Iron Chef® anyone?

 Try “nutrition stealth”. In workplaces

 Focus on how healthy eating will improve

work performance.24,25 This is important to a man’s identity and sense of masculinity.57 Taking charge of one’s health and seeking help in a timely fashion are perceived as being in line with other masculine attributes such as productivity, vitality and strength24,30

Project Health - Healthy Eating Toolkit for Workplaces

where men are typically resistant to healthy eating (i.e., they assume that any food that is healthier must taste terrible). This involves improving the nutritional quality of foods that are already provided. Modify existing products by increasing vegetable content and adding less salt, fat and sugar. One study found that subjects could not tell the difference when some of the beef in a recipe was replaced with mushrooms35

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Employees with Families Workplaces can create healthy eating strategies that will benefit employees throughout the continuum of raising a family, from pregnancy through parenting teenagers.

Mothers

Interventions for Pregnancy

Women make up almost half of the workforce and over 75 per cent of these women are in their childbearing years.62 Eight out of ten women will become pregnant during their working years. Most of these women will continue to work during pregnancy and plan to work after their baby is born.63

Proper nutrition plays an essential role in a healthy pregnancy; however, eating well before pregnancy is also important. Workplaces can provide supports for pregnant employees by:

As it is recommended that children be breastfed to 24 months of age and beyond, some women may continue to breastfeed after they return to work. Supporting mothers who continue to breastfeed demonstrates a commitment to the health and well-being of employees and their families. It also provides benefits for your workplace such as lower absenteeism and health care costs, higher productivity, loyalty and improved public relations.

 Accommodating frequent breaks (e.g., for

frequent small meals) and allowing flexible work schedules (e.g., for attending medical appointments or for those who experience nausea and vomiting)  Posting signs in eating areas that highlight

important nutrients for pregnant women (e.g., folate rich foods) and that caution women about foods to avoid during pregnancy  Offering pregnancy related

awareness raising materials and opportunities for skill building

Interventions for New Mothers 

Create a mother-friendly workplace strategy in your workplace

Tools: SUPPORTING NEW MOTHERS IN YOUR WORKPLACE For more information on supporting a healthy pregnancy or creating a mother-friendly workplace strategy, visit Project Health at: http://www.projecthealth.ca or call 519-575-4400 (TTY 519-575-4608).

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Employees with Children Parents are the most important influence on children’s eating habits and often express concerns about their children’s diets.64 Common concerns include eating too much ‘junk food’, not eating enough and ‘picky eating’.64 Due to an increase in dual-income families, many parents experience tensions between work and family life. In 2001, 62 per cent of couples with children were also in dualincome families.65 The time pressures related to daily life can make it difficult for individuals to incorporate positive lifestyle behaviours into their everyday lives, such as healthy eating.62 Encouraging and supporting employees to adopt healthy habits will benefit the health of individual employees and their families, which can have a positive effect on absenteeism, productivity and health benefit costs.66

Interventions for Employees with Children Employers can assist employees and their families to improve eating habits by: 

Providing skill-building sessions on buying and preparing healthy food



Offering a healthy dinner take-home program if your workplace has a cafeteria. Eating meals away from home is associated with developing health problems (e.g., take out, restaurants, fast-food).67 This is a way to improve cafeteria sales as well as the health of your employees and their families



Offering flex-time makes it easier for employees to put healthy behaviours into practice. This may result in increased home food preparation, family meals and opportunities for physical activity. These factors have a positive emotional effect on children and employees alike and have the added bonus of reducing absenteeism rates66,68



Making an effort to decrease workrelated stress may also have a favourable impact on healthy living behaviours both at work and at home69

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Employees Working in Hot Conditions Outdoor workers and factory workers may encounter hot conditions while on the job. Under normal working conditions, men need approximately 2.5 litres of water per day (for sedentary workers) to 3.2 litres per day (for moderately-active men). Women require 1.5 to 2.5 litres of water per day, for sedentary and moderately-active women respectively.70 However, in a hot environment water needs can increase to over six litres of water per day, due to sweating!70 As a general rule, manual labourers should drink between 600 ml to 1000 ml per hour in hot weather, while sedentary workers should consume 400 ml.71,72

Caffeine and Hydration There is no evidence that caffeine causes dehydration or electrolyte imbalance.73,74 Health Canada recommends that caffeine should be limited to 400 mg per day for the general population and 300 mg per day for women of childbearing age (about 500 ml of coffee per day).75 High intakes of caffeine can have undesirable side effects such as insomnia, anxiety and headaches. There are also links between high caffeine consumption and health problems such as high blood pressure, osteoporosis and negative effects on reproduction.75

Interventions for Hot Conditions:

Beverages provide about 80 per cent of water needs while food provides the remaining 20 per cent.70 Fluid needs can be met with plain water, while regular food consumption can replenish electrolytes and maintain energy. However, if sweating is excessive or employees are not eating regularly, workers may benefit from an electrolyte replacement drink (e.g., Gatorade®, Powerade®, etc.).72 Improving ventilation and providing shade may help workers maintain hydration.72 Providing shade will also protect outdoor workers from harmful UV rays.



Inform workers of hydration guidelines



Ensure cold water is available to employees at all times



Provide workers with reusable drinking containers



Ensure employees have adequate time for meals and snacks



Provide shade and/or adequate ventilation for employees who work in hot conditions



Offer drinks containing electrolytes for employees who experience excessive perspiration

Tools: OUTDOOR WORKERS AND SHADE For more information on sun safety and shade in the workplace visit the ‘Sun Protection’ section of the Project Health website http://www.projecthealth.ca or call 519-575-4400 (TTY 519-575-4608).

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Employees Who Smoke It is important that employees who are trying to quit smoking are supported in the workplace. Part of this supportive environment includes reducing exposure to less healthy food and beverages. It is likely too difficult for people to try to resist multiple temptations at one time. It appears that self-control will eventually break down if there are too many temptations in the environment.76

Interventions for Smokers 

The U.S. Clinical Practice Guidelines for smoking cessation recommend that individuals focus on changing smoking behaviour alone rather than incorporating calorie restriction, at least until they are confident that they will not have a smoking relapse76,77



A supportive smoke-free environment can help individuals who are trying to quit avoid triggers for smoking behaviour



Additionally, a supportive healthy eating environment can help these employees focus on living smoke-free!

Food for Thought: MULTIPLE TEMPTATIONS One study showed that smokers who had to resist eating cookies were more likely to smoke than those who had to resist vegetables.2 This even happened to individuals who were not trying to quit.2 The bottom line: A supportive, healthy eating environment can help employees to maintain other health behaviours such as smoke-free living.

Tools: SMOKING CESSATION IN THE WORKPLACE Contact Project Health for assistance in supporting your smoke-free environment: http://www.projecthealth.ca or 519-575-4400 (TTY 519-575-4608).

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Special Considerations References 1. Atkinson G, Fullick S, Grindey C, MacLaren D. Exercise, energy balance and the shift worker. Sports Medicine 2008;38(3):671-685.

17. Anund A, Kecklund G, Peters B, Akerstedt T. Driver sleepiness and individual differences in preferences for countermeasures. J Sleep Res 2008 Mar;17(1):16-22.

2. The PLoS Medicine Editors. Poor diet in shift workers: A new occupational health hazard? PLos Med 2011;8(12):e1001152.

18. Ellen RL, Marshall SC, Palayew M, Molnar FJ, Wilson KG, Man-Son-Hing M. Systematic review of motor vehicle crash risk in persons with sleep apnea. J Clin Sleep Med 2006 Apr 15;2(2):193-200.

3. Morikawa Y, Miura K, Sasaki S, Yoshita K, Yoneyama S, Sakurai M, et al. Evaluation of the effects of shift work on nutrient intake: A cross-sectional study. J Occ Health 2008;50(3):270-278. 4. Ohlmann KK, O'Sullivan MI. The costs of short sleep. AAOHN J 2009 Sep;57(9):381-385. 5. Suwazono Y, Dochi M, Oishi M, Tanaka K, Kobayashi E, Sakata K. Shiftwork and impaired glucose metabolism: A 14-year cohort study on 7104 male workers. Chronobiology International 2009;26(5):926941. 6. Wolk R, Somers WK. Sleep and the metabolic syndrome. Experimental Physiology 2007;92(1):67-78. 7. Schulte PA, Wagner GR, Ostry A, Blancforti LA, Cutlip RG, Krajnak KM, et al. Work, obesity, and occupational safety and health. Am J Public Health 2007;97(3):428-436. 8. J. Park. Obesity on the job. 2009. 9. Moreno CR, Louzada FM, Teixeira LR, Borges F, Lorenzi-Filho G. Short sleep is associated with obesity among truck drivers. Chronobiol Int 2006;23(6):12951303. 10. Wiegand DM, Hanowski RJ, McDonald SE. Commercial drivers' health: A naturalistic study of body mass index, fatigue, and involvement in safety-critical events. Traffic Inj Prev 2009 Dec;10(6):573-579. 11. Olson R, Anger WK, Elliot DL, Wipfli B, Gray M. A new health promotion model for lone workers: Results of the Safety & Health Involvement For Truckers (SHIFT) pilot study. J Occup Environ Med 2009 Nov;51(11):1233-1246. 12. Buxton OM, Quintiliani LM, Yang MH, Ebbeling CB, Stoddard AM, Pereira LK, et al. Association of sleep adequacy with more healthful food choices and positive workplace experiences among motor freight workers. Am J Public Health 2009 Nov;99 Suppl 3:S636-43. 13. Yamada Y, Ishizaki M, Tsuritani I. Prevention of weight gain and obesity in occupational populations: A new target of health promotion services at worksites. J.Occ.Health 2002;44:373-384. 14. Gill PE, Wijk K. Case study of a healthy eating intervention for Swedish lorry drivers. Health Educ Res 2004 Jun;19(3):306-315. 15. Martin BC, Church TS, Bonnell R, Ben-Joseph R, Borgstadt T. The impact of overweight and obesity on the direct medical costs of truck drivers. J Occup Environ Med 2009 Feb;51(2):180-184. 16. Stevenson M, Sharwood LN, Wong K, Elkington J, Meuleners L, Ivers RQ, et al. The heavy vehicle study: A case-control study investigating risk factors for crash in long distance heavy vehicle drivers in Australia. BMC Public Health 2010 Mar 26;10(1):162.

19. George CF. Sleep apnea, alertness, and motor vehicle crashes. Am J Respir Crit Care Med 2007 Nov 15;176(10):954-956. 20. Dagan Y, Doljansky JT, Green A, Weiner A. Body Mass Index (BMI) as a first-line screening criterion for detection of excessive daytime sleepiness among professional drivers. Traffic Inj Prev 2006 Mar;7(1):4448. 21. Minister of Public Works and Government Services. Transportation in Canada 2008, an overview. 2008. 22. Robertson LM, Douglas F, Ludbrook A, Reid G, van Teijlingen E. What works with men? A systematic review of health promoting interventions targeting men. BMC Health Serv Res 2008 Jul 3;8:141. 23. Smith JA, Braunack-Mayer A, Wittert G, Warin M. "It's sort of like being a detective": Understanding how Australian men self-monitor their health prior to seeking help. BMC Health Serv Res 2008 Mar 14;8:56. 24. Sabinsky MS, Toft U, Raben A, Holm L. Overweight men’s motivations and perceived barriers towards weight loss. European Journal of Clinical Nutrition 2007;61(4):526-531. 25. Harrison A. Health of men – weight management partnership. Community Practitioner 2007;80(9):31-34. 26. Courtenay WH. Constructions of masculinity and their influence on men's well-being: a theory of gender and health. Soc Sci Med 2000 May;50(10):1385-1401. 27. Linnell S, James S. Involving men in targeted primary health care: Men's health MOTs. Community Pract 2010 May;83(5):31-34. 28. Davis C. Men behaving badly. Nursing Standard 2007;21(21):18-20. 29. Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: Literature review. J Adv Nurs 2005 Mar;49(6):616-623. 30. O'Brien R, Hunt K, Hart G. 'It's caveman stuff, but that is to a certain extent how guys still operate': Men's accounts of masculinity and help seeking. Soc Sci Med 2005 Aug;61(3):503-516. 31. Emslie C, Hunt K. The weaker sex? Exploring lay understandings of gender differences in life expectancy: a qualitative study. Soc Sci Med 2008 Sep;67(5):808816. 32. O'Brien R, Hunt K, Hart G. 'The average Scottish man has a cigarette hanging out of his mouth, lying there with a portion of chips': Prospects for change in Scottish men's constructions of masculinity and their healthrelated beliefs and behaviours. Crit Public Health 2009 Sep;19(3-4):363-381. 33. Lassen A, Bruselius-Jensen M, Sommer HM, Thorsen AV, Trolle E. Factors influencing participation rates and employees' attitudes toward promoting healthy eating at blue-collar worksites. Health Educ Res 2007 Oct;22(5):727-736.

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34. Robertson S. 'Not living life in too much of an excess': Lay men understanding health and well-being. Health (London) 2006 Apr;10(2):175-189. 35. Eertmans A, Baeyens F, & Van den Bergh, O. Food likes and their relative importance in human eating behavior: Review and preliminary suggestions for health promotion. Health Education Research 2001;16(4):443456. 36. Krukowski RA, Harvey-Berino J, Kolodinsky J, Narsana RT, Desisto TP. Consumers may not use or understand calorie labeling in restaurants. J Am Diet Assoc 2006 Jun;106(6):917-920. 37. Gough B, Conner MT. Barriers to healthy eating amongst men: A qualitative analysis. Soc Sci Med 2006;62(2):387-395. 38. Sellaeg K, Chapman GE. Masculinity and food ideals of men who live alone. Appetite 2008;51(1):120128. 39. Weaver NF, Hayes L, Unwin NC, Murtagh MJ. “Obesity” and “clinical obesity” Men’s understandings of obesity and its relation to the risk of diabetes: A qualitative study. BMC Public Health 2008;8:311-318. 40. Gregory CO, Blanck HM, Gillespie C, Maynard LM, Serdula MK. Perceived health risks of excess body weight among overweight and obese men and women: differences by sex. Prev Med 2008;47(1):46-52.

50. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health 2008;29:253-272. 51. Cousineau T, Houle B, Bromberg J, Fernandez KC, Kling WC. A pilot study of an online workplace nutrition program: The value of participant input in program development. J Nutr Educ Behav 2008;40(3):160-167. 52. Crimmins TJ, Halberg J. Measuring success in creating a "culture of health". J Occup Environ Med 2009 Mar;51(3):351-355. 53. Hersey J, Williams-Piehota P, Sparling PB, Alexander J, Hill MD, Isenberg KB, et al. Promising practices in promotion of healthy weight at small and medium sized U.S. worksites. Prev Chronic Dis 2008;5(4):1-11. 54. Kruger J, Yore MM, Bauer DR, Kohl HW. Selected barriers and incentives for worksite health promotion services and policies. Am J Health Promot 2007;21(5):439-447. 55. Ryan M, Chapman LS, Rink MJ. Planning worksite health promotion programs: Models, methods, and design implications. Am J Health Promot 2008 JulAug;22(6):suppl 1-12, iii following p. 452.

41. Gal D, Wilkie J. Real men don’t eat quiche. Social Psychological and Personality Science 2010;1(4):291301.

56. Gates D, Brehm B, Hutton S, Singler M, Poeppelman A. Changing the work environment to promote wellness: A focus group study. AAOHN J 2006 Dec;54(12):515-520.

42. Lemon SC, Zapka J, Li W, Estabrook B, Magner R, Rosal MC. Perceptions of worksite support and employee obesity, activity and diet. American Journal of Health Behaviours 2009;33(3):299-308.

57. Smith JA, Bollen C. A focus on health promotion and prevention through the development of the national men's health policy. Health Promot J Austr 2009 Aug;20(2):98-101.

43. Devine CM, Nelson JA, Chin N, Dozier A, Fernandez ID. "Pizza is cheaper than salad": Assessing workers' views for an environmental food intervention. Obesity (Silver Spring) 2007 Nov;15 Suppl 1:57S-68S.

58. Saunders M, Peerson A. Australia's national men's health policy: Masculinity matters. Health Promot J Austr 2009 Aug;20(2):92-97.

44. Government of Western Australia Department of Health, WA County Health Service. Pit Stop. 2006; Available at: http://www.wacountry.health.wa.gov.au/index.php?id=6 20. Accessed December 22, 2010. 45. Racette SB, Deusinger SS, Inman CL, Burlis TL, Highstein GR, Buskirk TD, et al. Worksite Opportunities for Wellness (WOW): Effects on cardiovascular disease risk factors after 1 year. Prev Med 2009 Aug-Sep;49(2-3):108-114. 46. Raulio S, Roos E, Mukala K, Prattala R. Can working conditions explain differences in eating patterns during working hours? Public Health Nutr 2008 Mar;11(3):258-270. 47. Nishitani N, Sakakibara H, Akiyama I. Eating behaviour related to obesity and job stress in male Japanese workers. Nutrition 2009;25(1):45-50. 48. Giskes K, Kamphuis CB, van Lenthe FJ, Kremers S, Droomers M, Brug J. A systematic review of associations between environmental factors, energy and fat intakes among adults: Is there evidence for environments that encourage obesogenic dietary intakes? Public Health Nutr 2007 Oct;10(10):1005-1017. 49. Macdonald JJ. Shifting paradigms: A socialdeterminants approach to solving problems in men's health policy and practice. Med J Aust 2006 Oct 16;185(8):456-458.

59. Goetzel RZ, Baker KM, Short ME, Pei X, Ozminkowski RJ, Wang S, et al. First-year results of an obesity prevention program at the Dow Chemical Company. J Occup Environ Med 2009;51(2):125-138. 60. Elinder LS, Jansson M. Obesogenic environments – aspects on measurement and indicators. Public Health Nutr 2008;12(3):307-315. 61. Harris JL, Bargh JA, Brownell KD. Priming effects of television food advertising on eating behavior. Health Psychol 2009 Jul;28(4):404-413. 62. Almey M. Women in Canada: work chapter updates [online]. 2006; Available at: http://www.statcan.gc.ca/pub/89f0133x/89f0133x20060 00-eng.htm. Accessed 08/10, 2010. 63. Best Start. Workplace reproductive health - research & strategies. 2001. 64. Slater A, Bowen J, Corsini N, Gardner C, Golley R, Noakes M. Understanding parent concerns about children's diet, activity and weight status: An important step towards effective obesity prevention interventions. Public Health Nutr 2010 Aug;13(8):1221-1228. 65. Statistics Canada. Income of individuals, families and households. 2001. 66. Sepulveda MJ, Tait F, Zimmerman E, Edington D. Impact of childhood obesity on employers. Health Aff (Millwood) 2010 Mar-Apr;29(3):513-521.

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67. Fulkerson JA, Farbakhsh K, Lytle L, Hearst MO, Dengel DR, Pasch KE, et al. Away-from-home family dinner sources and associations with weight status, body composition, and related biomarkers of chronic disease among adolescents and their parents. J Am Diet Assoc 2011 Dec;111(12):1892-1897. 68. Devine CM, Farrell TJ, Blake CE, Jastran M, Wethington E, Bisogni CA. Work conditions and the food choice coping strategies of employed parents. J Nutr Educ Behav 2009 Sep-Oct;41(5):365-370. 69. Offer A, Pechey R, Ulijaszek S. Obesity under affluence varies by welfare regimes: The effect of fast food, insecurity, and inequality. Econ Hum Biol 2010 Dec;8(3):297-308. 70. Sawka MN, Cheuvront SN, Carter R,3rd. Human water needs. Nutr Rev 2005 Jun;63(6 Pt 2):S30-9. 71. Miller VS, Bates GP. Hydration, hydration, hydration. Ann Occup Hyg 2010 Mar;54(2):134-136.

73. Ganio MS, Casa DJ, Armstrong LE, Maresh CM. Evidence-based approach to lingering hydration questions. Clin Sports Med 2007 Jan;26(1):1-16. 74. Armstrong LE, Casa DJ, Maresh CM, Ganio MS. Caffeine, fluid-electrolyte balance, temperature regulation, and exercise-heat tolerance. Exerc Sport Sci Rev 2007 Jul;35(3):135-140. 75. Health Canada. It's your health - caffeine. 2006. 76. Shmueli D, Prochaska JJ. Resisting tempting foods and smoking behavior: Implications from a self-control theory perspective. Health Psychol 2009 May;28(3):300-306. 77. M. C. Fiore, W. C. Bailey, S. J. Cohen, S. F. Dorfman, M. G. Goldman and G. R. et al Gritz. Treating tobacco use and dependence. Clinical practice guideline. U.S. Department of Health and Human Services. Public Health Service. Rockville, MD. 2000.

72. Miller V, Bates G. Hydration of outdoor workers in north-west Australia. J Occup Health Safety - Aust NZ 2007;23(1):79-87.

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DOCS# 1180238

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Organizations have an impact on the community where they operate. Often workplaces will make efforts to improve the well-being of the surrounding community. For example, workplaces often participate in fundraisers and food drives that support local organizations and charities. Participating in community causes gives employees a sense of pride and accomplishment.

Definition of Success  Fundraising involves events or non-food items  Healthy food is donated to local food banks and other charity organizations  If food is sold for fundraising purposes, only food and beverages that meet the criteria for “Maximum Nutritional Value” or “Sell/Offer Most” are used* *See the Nutrition Standards for Workplaces© in Appendix A for a description of food categories

Community Involvement

Community Involvement

Fundraising Strategies Fundraisers often rely on the sale of less healthy food options. However, there are plenty of healthy alternatives for a successful fundraiser: 

Raffle or 50/50 tickets can be sold for prize draws (e.g., money, event ticket, day off, etc.). Ensure prizes support healthy living messages (e.g., avoid alcohol and candy prizes)



Sell common household items such as garbage bags, gift paper, greeting cards reusable lunch bags, tote bags, t-shirts, hats, first aid kits, emergency preparedness kits, mugs, water bottles, pens, stationary or calendars with your workplace logo



Sell gardening products such as flowers, bulbs, vegetable, fruit or herb plants



Have employees donate time and items for a company garage sale or silent auction



Create a healthy eating cookbook



Hold a charity car wash or golf event



Offer employees the option of having a payroll deduction for a charity (one-time or ongoing)



Have employees find sponsors for physical activity based events such as walk or run events, rowing or dragon boat events, biking or triathlon events (swim, bike and run)



Allow employees to make a small donation to participate in dress-down days, theme days or costume days (e.g., Halloween). Offer tax receipts for larger financial donations



Sell tickets for a workplace talent show (e.g., music, skits, acting, dancing, art, etc.)



Have employees donate requested items for selected charities (e.g., mittens and hats)



Visit http://www.shopandsupport.ca for more fundraising options

For more information on healthy workplace fundraising, visit the ‘Toolkits’ section of the Project Health website: http://www.projecthealth.ca

The Bottom Line When organizing fundraisers ensure that your planned activities are aligned with your wellness promotion messaging (e.g., avoid chocolate and candy, alcohol, tanning, etc.).

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Food-based Fundraising Strategies Whenever possible try not to have food-based fundraisers. However, if you choose food-based events to raise money, ensure that the food served meets the criteria for “Maximum Nutritional Value”. Also, make sure that any food served has been handled according to foods safety requirements. See the Nutrition Standards for Workplaces© in Appendix A for a description of food categories. 

Serve a healthy meal for a charity event. Have a charity barbeque (e.g., shish-ka-bobs with corn), or a charity lunch or dinner (e.g., chilli with whole-grain bread and a salad with vinaigrette dressing)



Healthy pizza day – serve a healthier pizza (i.e. request thin, whole grain crust, less cheese or part-skim cheese with 20% M.F. or less), lean meat such as chicken, vegetable toppings and low sodium pizza sauce. Also order a salad or veggie sticks with low fat dressing on the side to accompany the pizza



Sell vegetable and fruit boxes from local suppliers



Use a fruit basket as a prize



Try to avoid bake sales, as items offered tend to fall into the “Not Recommended” category. If you decide to have a bake sale feature recipes that meet the criteria for “Maximum Nutritional Value”

The Bottom Line Ensure that workplace fundraisers do not undermine healthy eating messaging.

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Food Donations Food banks and other local agencies in Waterloo Region aim to provide a selection of food that is safe, healthy and personally acceptable. Food banks often receive donations of less healthy food items. With an adequate supply of healthy food donations, charitable organizations can offer a selection of healthy, nutritious food to patrons and programs who receive food assistance. Workplaces can encourage employees to bring in healthier food and beverages during food drives. See the Nutrition Standards for Workplaces© in Appendix A for a description of food categories.

Tools: BRAND NAME FOOD LIST The Brand Name Food Lists contain the brand names of perishable and non-perishable food and beverages that are available in grocery stores and other retail settings that meet the criteria for "Maximum Nutritional Value", which follow the recommendations in Canada's Food Guide. The lists are available on the Project Health website http://www.projecthealth.ca

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Vegetable and Fruit Donations Some food banks and other charitable organizations accept donations of fresh fruit and vegetables. Your workplace can contribute by: 

Creating a workplace garden and donating vegetables and fruit to local agencies



Donating a plot of land to community agencies to create a community garden



Making financial or equipment donations to support existing community gardens



Your employees can also donate vegetables and fruit from their own gardens at home

COMMUNITY GARDENS IN WATERLOO REGION For more information on community gardens in Waterloo Region, visit Community Gardens of Waterloo Region: http://together4health.ca/workgroups/waterloo-region-community-garden-council

Success Story: TOYOTA MOTOR MANUFACTURING CANADA (TMMC) TMMC in Cambridge is promoting healthy eating through the creation of a Charity Vegetable Garden. Toyota's workplace garden uses a ‘natural gardening’ approach by using only natural soils, collecting seeds for future years and sharing gardening tips, which are passed along through the generations. Twenty volunteers from all over the organization nurture the garden. All of the produce is donated to a local charity. DOCS# 1180199

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