Food Choice at Worl Study

1. FOOD CHOICE AT WORK STUDY
Sarah Fitzgerald, Post-doctoral Researcher, Food Choice at Work
Lead Investigator: Dr Fiona Geaney
Principal Investigator: Prof Ivan Perry

2. Problem...

3. Potential solution…
• Improving peoples’ dietary behaviours could reduce the prevalence of diet-
related diseases.
• Given the complicated intricacies of dietary behaviour (i.e. individual,
environmental, biological + psychological factors), there is a need to develop
effective complex interventions to promote long-term dietary change.
Where? The workplace
• Most adults spend approximately 2/3 of their waking hours at work.
• Employees are increasingly reliant on their workplaces to provide at least one
of their daily meals.
• Can tolerate interacting intervention components while assessing the impact
in relatively homogenous populations within controlled environments.

4. Gap in the research..........
• Moderate positive effect on fruit + vegetable intakes reported from previous
workplace dietary interventions but studies were of low-intensity with suboptimal
study designs and were poorly reported.
• Interventions focused mainly on information provision and failed to examine other
factors known to have an impact on dietary behavior i.e. environmental ‘nudging’
approaches. Also failed to combine economic cost outcomes with health outcomes.
Therefore, the effectiveness and cost-effectiveness of complex (multi-level)
workplace dietary interventions remained unknown.

5. Food Choice at Work study protocol
Aim: To assess the effectiveness and cost-effectiveness of complex
workplace dietary interventions focused on environmental modification
alone or in combination with nutrition education.

6. Recruitment
IDA website: list of manufacturing workplaces in Cork
Eligible if met the specified selection criteria
Purposively selected and allocated 4 workplaces
Workplace inclusion criteria
- Manufacturing multinational workplace
- Employs >250 employees
- Daily workplace canteen for employees
- Commit to complex intervention for duration of
the study
Employee inclusion criteria
- Any permanent, full-time employee
- Consumes at least one main meal at work daily

7. Control workplace
Education workplace
Environment workplace
Combined workplace
(education + environment)

8. FINDINGS FROM THE FOOD
CHOICE AT WORK STUDY

9. Food Choice at Work trial profile
Baseline
n=850
(aged 18-64
years)
Follow-up at 3-
4 months
n=678 (80%)
Follow-up at
7-9 months
n=541 (64%)
850 recruited
Control
111 employees
84 participated
Education
226 employees
160 participated
Environment
113 employees
96 participated
Combined
400 employees
338 participated
70 participated 113 participated 74 participated 284 participated

10. Demographics of study sample
The majority of participants were:
 male (76%),
 aged 30-44 years (64%)
 married/cohabiting (73%)
 tertiary level education (80%)
 non-managers (76%)
 usually worked during day (65%)
 were overweight/obese (70%)

11. Changes within workplaces from baseline to 7-9 months
27
-157
-111
-242
-250 -200 -150 -100 -50 0 50
Total energy intake (Kcal/day)
Control Education Environment Combined (education + environment)

12. Changes within workplaces from baseline to 7-9 months
1.9
1.8
0.7
9.1
-7.1
-3.2
-0.6
-6.8
-11.4
-8.8
-0.5
-4.6
-14.2
-7
-1.4
-11.1
-15 -10 -5 0 5 10
Total fat (g/day)
Saturated fat (g/day)
Salt (g/day)
Total sugars (g/day)
Control Education Environment Combined (education + environment)

13. Interventions vs. control workplaces
Dietary intakes and nutrition knowledge: Significant reductions in
intakes of saturated fat (p=0.013), salt (p=0.010) and increases in
nutrition knowledge (p=0.034) between baseline + follow-up at 7-9
months in the combined intervention vs. the control workplace.
Health status: Small but significant falls in BMI (-1.2kg/m2 (95%CI
-2.385, -0.018, p=0.047) were observed in the combined
intervention. No significant changes in waist circumference and
blood pressure were observed.
Effects in the education alone and environment alone workplaces
were smaller and generally non-significant.

14. Combining nutrition education and environmental dietary
modification strategies may be an effective approach for
promoting a healthy diet and weight loss at work.
The combined dietary intervention is scalable and wide
scale implementation should be considered in local, national
and international workplaces.
Conclusion

15. Economic evaluation of FCW interventions
Aim:
To conduct an economic evaluation of
nutrition education, environmental
dietary modification and combined
workplace interventions, relative to a
control workplace.

16. Economic Evaluation of FCW interventions
Baseline Cost-Utility
Analysis (QALYs)
Cost-Effectiveness
Analysis (Sensitivity
Analyses)
1. BMI
2.Waist circumference
3.Weight
Cost-BenefitAnalysis
(Net Benefit)
Schema of economic evaluation of FCW interventions

17. Education
Costs (€)
Environ.
Costs (€)
Combined
Costs (€)
Control
Costs (€)
Set-up costs
Nutritionist 600 2,494 3,138 -
Catering costs 41 490 490 -
Mgment stakeholder 42 84 42 -
Printing and materials 1,019 85 1,019 -
Employee time 53 53 53 -
Sub-total 1,755 3,206 4,742 -
Maintaining
costs
Nutritionist 12,509 262 12,245 -
Catering costs 1,573 - 1,573 -
Mgment stakeholders 126 126 126 -
Printing and materials 282 - 282 -
Employee time 8,241 - 8,241 -
Sub-total 22,730 388 22,467 -
Physical
assessment
Nutritionist 7,175 11,003 7,175 11,304
Employee time 5,397 5,930 5,397 6,184
Sub-total 12,572 16,933 12,572 17,488
Total cost
(PSA ranges)
37,058
(30,641 - 45,030)
20,527
(16,193 - 25,938)
39,782
(32,645 - 48,639)
17,488
(13,981 - 21,872)
Cost per employee 71.68 39.70 76.95 33.83
Costs for implementing and delivering the FCW interventions

18. Primary outcome:
Improvement in
QALYs
• Informed the baseline CUA
• EQ-5D questionnaires at baseline and
at 7-9 months follow-up
Secondary
outcomes:
(Clinical)
• Insensitivity of QALYs
• BMI, weight & waist circumference
• One-way sensitivity analysis
Absenteeism
• Net benefit
• IBEC estimate €864/employee [14]
• Daily rate (5.98 days)
• Daily cost: €144.48/employee
Identify, measure and value outcomes

19. Variable Workplace Baseline (mean (SD)) 7-9 months (mean (SD)) Change (baseline to 7-9 months) (SD)
QALYsa
Control 0.93 (0.12) 0.92 (0.13) -0.01 (0.11)
Education 0.92 (0.11) 0.95 (0.10) +0.03 (0.12)
Environment 0.90 (0.12) 0.95 (0.11) +0.05 (0.11)
Combined 0.93 (0.10) 0.94 (0.10) +0.01 (0.09)
BMI (kg/m2)
Control 27.6 (4.1) 27.9 (4.3) +0.36 (1.20)
Education 27.4 (4.5) 26.9 (4.0) -0.44 (1.75)
Environment 32.0 (5.1) 30.3 (5.2) -1.70 (1.10)
Combined 27.2 (3.9) 27.1 (4.0) -0.07 (1.01)
WC (cm)
Control 91.7 (12.1) 93.3 (12.7) +1.51 (6.76)
Education 92.1 (12.5) 91.7 (12.0) -0.42 (4.79)
Environment 92.8 (14.9) 92.3 (10.3) -0.47 (2.82)
Combined 93.6 (10.4) 93.2 (10.7) -0.43 (3.70)
Weight (kg)
Control 80.3 (15.3) 81.2 (15.8) +1.00 (3.4)
Education 83.0 (15.4) 81.8 (14.6) -1.22 (4.8)
Environment 81.6 (17.9) 81.7 (18.3) -0.10 (2.9)
Combined 83.6 (14.2) 83.5 (14.2) -0.18 (2.7)
Absenteeism
(days)
Control 1.3 (3.4) 1.6 (4.9) +0.3 (5.3)
Education 2.6 (5.1) 2.2 (2.7) -0.4 (4.66)
Environment 2.1 (3.1) 1.4 (2.7) -0.7 (3.7)
Combined 2.3 (5.1) 1.5 (2.3) -0.8 (5.4)
Change in outcomes from baseline to 7-9 months within workplaces

20. Sensitivity analysis using clinical measures
 Structural uncertainty around the health outcome parameters.
 One-way sensitivity analysis (CEAs using clinical measures).
 Parameter uncertainty accounted for through the use of Monte Carlo simulation.
Probabilistic sensitivity analysis
 Uncertainty may surround true value of model parameters.
 PSA performed by assigning probability distributions to individual model parameters.
 Monte Carlo simulation propagated uncertainty throughout model (10,000 iterations).
 Probabilistic ICERs plotted onto ICE planes + CEACs summarised decision uncertainty.

21. Summary of results: interventions v’s control
CUA Sensitivity Analyses CBA
BMI WC Weight Absenteeism
Education
ICER Deterministic
€970.55/QALY €45.04/ kg/m2 €19.57/cm €17.31/kg €54.50/day
ICER Probabilistic
€1,075.14/QALY €45.04/ kg/m2 €20.28/cm €17.36/kg €53.98/day
Net benefit:
€61.84/employee
Environment
ICER Deterministic
€97.95/QALY €14.22 /kg/m2 €2.97/cm €6.73/kg €5.60/day
ICER Probabilistic
€92.96/QALY €14.04 /kg/m2 €3.13/cm €6.96/kg €5.27/day
Net benefit:
€145.82/employee
Combined
ICER Deterministic
€2,156.05/QALY €99.77 /kg/m2 €22.23/cm €37.54/kg €38.55/day
ICER Probabilistic
€2,686.61/QALY €98.04 /kg/m2 €22.03/cm €38.78/kg €37.66/day
Net benefit:
€118.70/employee

22. CEACs of interventions v’s control

23.  Appropriateness of the ceiling ratio: Absence of current national threshold and concerns
that most recent threshold is too high for reimbursement decisions regarding
‘low-agency’ public health interventions.
 Suitability of QALYs: Robustness of QALYs tested through the inclusion of intervention
specific outcomes. Results confirmed the baseline CUA.
 Role of CBA: While monetising absenteeism facilitates translation of outcomes into
realisable benefits for employers, net benefit results are dependent on monetary
estimate of absenteeism.
 Perspective matters: Values placed on benefits vary with perspective. Employers likely to
place a high value on reducing absenteeism. When interpreting the CBA, consideration
should be given to the value placed on reducing absenteeism by the employer.
 Future research: Needs to include long-term outcomes.
Discussion

24. FOOD CHOICE AT WORK
Ultimate healthy eating management system for employees,
workplace stakeholders and caterers

25. Food Choice at Work Programme
Healthier Menus
(DASH-Omni Heart Meals,
Lower in FSSS & Portion
Size Guidance)
Ground-Breaking
Solutions for a Healthier
Eating Environment
(choice architecture)
Daily Application
of Our Calorie &
Traffic Light
Coding System
Strategic
Positioning
of Healthier
Alternatives
Monthly Nutrition
Themes: Emails,
Posters & Video
Sessions
Health Check and
Nutrition Clinics

26. Our Team
Management
•Dr Fiona Geaney
•Frank Beechinor
•Clare Kelly
Research and
Development
• Professor Ivan Perry
•Sarah Fitzgerald,
Post-doctorate
•Karen Buckley O’Farrell,
MPH Intern
Workplace
leaders
•Jessica Scotto Di
Marrazzo
•Clodagh Murphy
•Lauri Gilgan
•Louise Welland
 A highly experienced team of research nutritionists and dieticians implement, monitor and
evaluate our programme in each workplace
 Sell directly to the corporate customers and indirectly through catering partners

27. Customers so far… 2017 Customers...

29. Conclusion
• Food Choice at Work represents a potentially viable
model that is effective and feasible to implement in all
public and private workplace settings.
• If adopted by healthcare/ workplace stakeholders +
policy makers may reduce the prevalence + economic
burden of diet-related disease nationally and
internationally.

30. Thank you for your time.
Any questions?