PUBLIC HEALTH
Evelyn Toner Registered and Freelance Dietitian Evelyn’s specialist areas include sports nutrition, gastroenterology – especially IBS – health and wellbeing. She enjoys media work and running her social media persona ‘The Active Dietitian’ (on Instagram as @the_active_ dietitian).
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NUTRITION AND WELLBEING IN THE WORKPLACE Unemployment is at its lowest level since 1975, with three quarters of UK adults (32.6 million people) currently in employment - the highest since records began in 1971. 74% are in full-time employment, spending approximately 37 hours/week at work.1 It, therefore, makes sense that health and wellbeing in the workplace is given adequate attention and resources. With this in mind, the UK government has placed a high importance on improving the health of the country’s workforce over recent years, with the development of guidance from NICE2 and the NHS Five Year Forward View.3 The BDA also picked this up and made it a priority for 2015-2017 with the creation of their ‘BDA Work Ready Program’,4 which aims to benefit both employers and employees by providing dietetic support and expertise to help reduce a wide range of preventable ill health conditions, improve resilience and mental wellbeing.4 Now, I’m not suggesting that weight is the only factor affecting health; but, much of the research has found links between being overweight or obese with increasing absenteeism and sick leave from work – often due to preventable ‘obesity-related health conditions’, such as musculoskeletal disorders and chronic diseases.4 Up to 10% of all sick leave has been attributed to lifestyle behaviours and obesity,4 with 25% of the UK working age population having at least one preventable condition, eg, diabetes or heart disease, which acts as a barrier to productive employment.5 This can be a considerable cost for both individual companies and for the economy as a whole, with NICE estimating the cost of lost productivity due to obesity alone in a company of 1000 employees to be £126,000/year.6 Ill health resulting from obesity can also be a precipitating factor in the transition to early retirement, disability pension, social welfare, or unemployment.4 Obesity, musculoskeletal conditions and
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depression have been identified as the top three causes of sick leave, all of which can be improved by optimising the nutritional status of our workforce.4 Therefore, it makes sense to look at the barriers to good nutritional health and consider some changes/practices that may help overcome these. Factors such as working patterns, including shift work, working long hours and lone working, can all affect an employee’s ability to make healthy food choices when at work. They can also lead to increased snacking and disrupt ‘normal’ meal patterns.4 Other disruptive working patterns include short, or a lack of structured breaks with limited time to eat, working in high-pressure environments, having limited access to healthier food choices, regular travel for work and long periods of sitting. EATING HABITS OF THE WORKING POPULATION
Let’s take a closer look at the eating habits of our working population to better understand what choices are being made, and therefore, provide insight on what could be targeted. Research has found that, typically, those working regular daytime hours usually eat breakfast at home. However, over half do ‘sometimes’ have breakfast outside of the home, with the top three choices on these occasions being a ‘hot roll/sandwich’, ‘cooked breakfast’ or a ‘pastry’.4,7 The habitual practice here could be exploited, and having breakfast at home could be encouraged and promoted.4 Certainly, encouraging regular breakfast
PUBLIC HEALTH Table 1: BDA guidance on vending machine food choices17 Max 250kcals per product Single serving sizes (30g) for savoury snacks Smaller bottles and cans of unsweetened and carbonated drinks – sugar free and low calorie drinks should make up 80% of provisions and be displayed prominently. At least 2 snack items with the following nutritional content – price competitively: • Total fat ≤17.5g/100g • Total Sugars ≤15g/100g • Saturated fat ≤5g/100g • Salt/Sodium ≤1.5g/0.6g/100g Unsalted nuts and seeds may exceed 17.5g fat/100g but the packet must still contain ≤250kcals/pack.
consumption is a key point, whether at home or at work, as one study of nurses found lower stress levels, fewer cognitive mistakes and fewer minor accidents amongst breakfast eaters.8 A survey of lunchtime habits found that almost 40% of workers brought in a homemade lunch between two to five times a week, with a third of people saying that they checked the nutritional content when purchasing lunchtime meals.4,9 This is positive and should be encouraged to increase the frequency with which people bring in their own lunch. The increasing awareness of nutritional labelling should be utilised by food establishments, including work canteens, to provide information for informed choices. The fact that at least 60% of workers are buying their lunch outside the home every day is interesting and could suggest a high reliance on work canteens, thus giving the employer a golden opportunity to effect change. However, a poll by the BDA found that 62% of employees sometimes, or always, skipped their lunch break,4 identifying a culture that employers could target for change. The Mintel snacking survey found that 97% of adults tend to snack between meals,10 a habit which is often prevalent at work, therefore providing an excellent opportunity for employers to offer healthy options, to educate employees and increase awareness of what a ‘healthy snack’ might be. A good example here would be the provision of readily available and attractive fruit and vegetable options – a recent 2019 study has found that increasing fruit and vegetable intake, even by one portion/ day improves mental health and wellbeing.11 Having access to more fruit and vegetables at work, therefore, would benefit not only the physical health of a workforce, but the mental health too.11 THE IMPORTANCE OF HYDRATION
We cannot discuss nutritional wellbeing without mentioning the importance of hydration. It
is well established that adequate hydration is important to maintain focus, concentration and safety and that dehydration can impact on both physical and mental performance,12 having a similar effect on brain structures as mild cognitive impairment13 and contributing to fatigue, headaches and impaired reaction times. One study of vehicle drivers found that those who were dehydrated made a similar number of errors when driving as a drunk driver.14 Hydration is an important consideration for employers as the work environment can contribute to the risk of dehydration, for example, working in a warm environment, needing to wear protective clothing, a lack of breaks to obtain fluids, or even a fear of taking toilet breaks as often as may be necessary. One particular workforce group I will quote as an example of this, are hospital workers. They are at increased risk of dehydration due to their environment – air conditioning, warm temperatures, long busy shifts, limited breaks and a ban on consuming drinks when face-to-face with patients or relatives.4 A 2016 study found that 45% of doctors and nurses were dehydrated by the end of their shift – this significantly impaired their cognition and shortterm memory.15 In the development of their program, the BDA’s evidence review found that targeting the individual alone is not effective and the surrounding environment is a big influencer on health and nutrition choices, with one study of 9000 workers concluding that obesity levels were higher in those who frequently ate in the staff canteen.16 Therefore, it’s important to provide not only individual education directed at behaviour change – either by one-to-one consultations, or in a group setting – but also to address the surroundings and food availability by targeting canteens, vending machines (see Table 1), www.NHDmag.com April 2019 - Issue 143
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PUBLIC HEALTH Table 2: Practical measures for change in the workplace • Plan the launch period of any new intervention strategically so it doesn’t clash with an especially busy or stressful time in the industry, to help increase buy-in and commitment. • Involve employees in the planning and implementation of any intervention; consider gender and culture. • Provide educational materials on nutrition and health, eg, leaflets, posters, workshops, workplace ‘champions’. Have nutritional information available for canteen meals and displaying this at the point of choice and purchase. • Combine an element of physical activity promotion alongside dietary interventions. • Provide adequate and functioning water taps or ‘hydration stations’ in convenient locations, consisting of a variety of hot and cold options to suit all tastes. Tea, coffee, milk and low calories drinks all count towards the recommended daily fluid intake. • Provide clean and hygienic areas for food preparation and storage, and include cupboard space, a fridge, cutlery, kettle, microwave and washing-up facilities, to facilitate meals brought in from home. • Provide products that are lower in saturated fat and salt, eg, soups, meat options, spreads, oils used in food prep and as dressings. • Provide higher fibre starchy carbohydrates, eg, breakfast cereals and breads and meal deals that include a starchy carbohydrate, vegetables and a portion of fruit. • Sell fruit cheaper than processed desserts. • Provide structured and regular breaks, with cover for lone workers. Break any historical culture that encourages working through breaks. • Secure appropriate contracts with vendors that support changes to healthier food provision and incentivisation.
snack provision, hydration facilities and effect organisational policy changes.4 A study by Warwick Medical School,18 commissioned by Public Health England, showed that using ‘nudge’ theory encourages healthy eating in hospital canteens. The researchers found that reducing the effort required to select healthy options, or increasing the effort required to select unhealthy options, improved diets. Increasing the availability of healthy options also drove healthier diets. See Table 2 for some practical measures that employers can take to promote healthier choices amongst their workforce. Cost is always going to be an important factor for any company considering a new intervention or programme to increase awareness of, or provide, healthier eating opportunities in the workplace. It can be difficult to quantify or monetise the benefits of such programmes. Nevertheless, employers should be reassured by the BDA findings that such interventions can increase productivity by 1-2%, and by the strong association between obesity and increased sick leave.4 Therefore, by promoting healthy weight maintenance amongst employees, absenteeism will reduce. Merseyrail reduced their staff sickness leave from 155 days to 35 days in one year, reducing their cost of sickness by £11,000 in the first year alone.4 An airline company achieved a 5% weight loss in men who attended an intervention, which was maintained at a two30
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and-a-half-year follow-up.4 So, with strategic implementation of a nutritional care program, the benefits can outweigh and cover the costs. Studies have suggested that companies who invest in the health and wellbeing of their workforce have a more positive corporate image, loyal employees and a higher standard of customer service.4 In the long term, organisations need to implement strategies to reinforce and sustain initial behaviour changes, provide regular update sessions and policy reviews.4 An example of this could be to provide an annual ‘health awareness day’ where employees could have a health +/weight check, access to a dietitian and obtain information on healthy eating. CONCLUSION
Employment levels in the UK are currently at the highest they’ve been in over 40 years. Nevertheless, sickness and absenteeism is a considerable cost for employers. Obesity is one of the top causes of sick leave, most likely due to its associated conditions. Optimising nutrition in the workplace, therefore, needs to be a priority in order to preserve our workforce. In order to succeed, any intervention in the workplace must involve both the individual and the surrounding environment, and employers need to take practical steps to make healthier food choices easier and more attractive to employees.