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Healthy meals at worksite canteens - Social shaping as a framework for understanding

sustainable interventions

Thorsen, Anne Vibeke; Jørgensen, Michael Søgaard; Mikkelsen, Bent Egberg

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Thorsen, A. V., Jørgensen, M. S., & Mikkelsen, B. E. (2010). Healthy meals at worksite canteens - Social shaping as a framework for understanding sustainable interventions. Kgs. Lyngby: DTU Management. (PhD thesis; No. 3.2010).

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Healthy meals at worksite canteens:

Social shaping as a framework for understanding sustainable interventions PhD thesis 3.2010 DTU Management Engineering Anne Vibeke Thorsen April 2010 Healthy meals at worksite canteens

- social shaping as a framework for understanding sustainable interventions Anne Vibeke Thorsen Ph.D. thesis Technical University of Denmark, Department of Management Engineering, 2010 Healthy meals at worksite canteens Supervisors Associate professor, Ph.D. Michael Søgaard Jørgensen, Dept. of Management Engineering, Section of Innovation and Sustainability, Technical University of Denmark Professor, Ph.D. Bent Egberg Mikkelsen, Nutrition & Public Food Systems, Aalborg University, Denmark (former Department of Nutrition, National Food Institute, Technical University of Denmark.

Evaluation committee Associate professor Christian Clausen, Dept. of Management Engineering, Section of Innovation and Sustainability, Technical University of Denmark Professor, Maria Lennernäs, Kristianstad University College, Sweden Project Coordinator Gitte Laub Hansen, the Cancer Society, Denmark Title: Healthy meals at worksite canteens - social shaping as a framework for understanding sustainable interventions Type: Ph.D. thesis Anne Vibeke Thorsen, 2010 ISBN nr: 978-87-90855-74-1 Dept. of Management Engineering, Section of Innovation and Sustainability. Building 424, DK-2800 Lyngby, Technical University of Denmark, Print: Schultz Grafisk A/S

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Table of contents Table of contents





1. Introduction

1.1 Background

1.2 Research focus and research questions

1.3 Outline of the thesis

2. Healthy eating at worksites

2.1 International perspective

2.2 Danish perspective

3. Theoretical frame

3.1 Sustainability of an intervention

3.2 Method applied at the original ‘6 a day’s intervention study

3.3 Social shaping approach to healthy eating

4. Methodology

4.1 Case study methodology

4.2 Questionnaire survey (Paper 1)

4.3 Record to monitor the F&V consumption (Paper 2)

4.4 The qualitative research interview (Paper 3)

5. Results

6. Discussion

6.1 Reflection on the quantitative and qualitative methods 6.1.1 The self-administered questionnaire (Paper 1) 6.1.2 The record to monitor the F&V consumption (Paper 2)

–  –  –

6.1.3 The case study design and qualitative research interview (Paper 3) 6.1.4 Combining the quantitative and the qualitative method

6.2 Discussion of the findings 6.2.1 Paper 1 – Healthiness of canteens 6.2.2 Paper 2 - Sustainability 6.2.3 Paper 3 – Social shaping

7. Conclusion and recommendations

7.1 The conclusions of the thesis

7.2 The perspective of the thesis

7.3 Some recommendations for future interventions Reference List

List of papers


Paper 1: Healthiness of canteens Paper 2: Sustainability Paper 3: Social shaping Appendices

Appendix A

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Preface The aim of this Ph.D. thesis is to make a contribution to the promotion of healthy eating in the worksite setting. The thesis is completed in co-operation with the Department of Management Engineering (MAN), Section of Innovation and Sustainability and the Department of Nutrition (FOOD), National Food Institute, Technical University of Denmark.

The foundation of this thesis is nutrition, since my educational background is in food science.

Furthermore I have an interest in social psychology, sociology and food sociology that I studied in US at the Culinary Institute of America and at Dutchess County Community College in Poughkeepsie, NY.

Through the years I have been working with interventions aiming at promoting healthy eating at worksite canteens and I have noticed that the availability of healthy food is of great importance to health promotion. I have also noticed that the meals available in worksite canteens are not always healthy compared to the nutritional recommendations. I found that the canteen managers and staff at the canteens are experts, not only in preparing the meals but also in knowing the social context of the canteen in relation to the worksite. They are important stakeholders in any health promotion intervention regarding the canteen and in order to sustain the intervention the canteen manager‟s commitment to change is crucial.

It is my impression that the sustainability of an intervention is often talked about but not often studied. As I previously (from 2000-2002) worked with the promotion of healthy meals in Danish worksite canteens, it made sense for me to return to these canteens to study the mechanisms of sustainability. The idea was to study the 5 year sustainability of a 6 month fruit and vegetables (F&V) intervention in five Danish worksite canteens in order to build up more scientific evidence about planning and embedding of healthier worksite eating. The current thesis presents the outcome of this work.

It is my idea and hope that the combination and presentation of my research will provide the reader with the best possible understanding of the diverse aspects of the sustainability of an intervention.

–  –  –

Acknowledgements I am so grateful to many people for supporting me through this Ph.D. study.

I would especially like to thank my main supervisor Michael Søgaard Jørgensen (MAN, DTU) for being very supportive and enthusiastic about the study. From him I learned always to be modest in my research and towards the people with whom I work. I also want to thank my other advisor Bent Egberg Mikkelsen (Nutrition and Public Food Systems, Aalborg University, former FOOD, DTU) for his support. Their competences lie at the interdisciplinary research combining several areas from food science and environmental science to action research, user innovation and participatory approach The staff and the canteens managers at the five worksite canteens are sincerely thanked for being cooperative and patient towards the project and my research through the last 10 years since the „„6 a day‟ -project started in 2000.

My colleges at MAN are thanked for having me around and a special thank to the head of MAN, professor Per Langaa Jensen for having confidence in me. Mette Weinreich Hansen is thanked for good discussions and for reviewing Paper 3 and Mirjam Godskesen (MAN) is thanked for coaching me through changing times. Also the MEAL element group (FOOD, MAN) is thanked for numerous and inspiring meetings during the years.

From FOOD my very good colleague Anne Dahl Lassen is thanked for her never ending support in my research. She has a great knowledge in this area and has been of great inspiration.

The head of the FOOD department Inge Tetens has been very supportive and my colleges Anja Biltoft-Jensen, Anne Marie Bech, Camilla Hoppe, Ellen Trolle, Margit Groth, Sisse Fagt from FOOD all did contribute to my research and kept me on track. A special thank to Annelise Christensen who helped me set up the thesis and to Volodja Epremian for keeping track on the references.

I would also thank Jens S Andersen and Ole Hels both from FOOD that performed the statistical analysis in Paper 1 and Paper 2.

I have enjoyed many good discussions about the project during the writing of my thesis with Eva Høy Engelund and Ida Husby. Also a special thank to Liselotte Schäfer Elinder and Vibeke Bagger for reviewing my thesis.

My very good friend Elizabeth Shieh has been a very patient reader editing my three papers and this thesis and also kept my spirit high and encouraged me to finish my Ph.D.

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At last I would like to thank my family, friends and my three children, Christian, Oscar and Victoria for being supportive and around me during this tough period of my life. Finally Thomas is thanked for his support and love.

Holte, April 2010 Anne Vibeke Thorsen This Ph.D. thesis has been carried out during my employment at the Department of Nutrition, the Technical University. It is part of the project “Meal elements optimizing the quality of distributed meals” a co-operation between the Department of Management Engineering, the Division of Nutrition, National Food Institute, and the Food Production Engineering (former BioCentrum-DTU), all at Technical University of Denmark. The work was financially supported by The Directorate for Food, Fisheries and Agro-Business and by the Department of Management Engineering and the Division of Nutrition, National Food Institute at Technical University of Denmark.

Healthy meals at worksite canteens

Sammendrag Den ernæringsmæssige udfordring i forhold til arbejdspladser er at forbedre adgangen til sundere måltider – især for grupper med et lavere uddannelsesniveau. Strategier, som for eksempel at øge tilgængeligheden af sund mad og at nedbryde barrierer for at spise sundt, kan hjælpe brugerne af arbejdspladskantiner til at ændre deres kostvaner i en sundere retning.

Det er en central udfordring at fastholde offentlige sundhedsfremme-tiltag, ikke kun i forhold til arbejdspladser, men inden for sundhedsfremme generelt. Der er kun udført relativt få empiriske studier på dette område. Mange sundhedsinterventioner glemmer at betragte de forskellige arenaer som fx. arbejdspladser og skoler som komplekse systemer, der dynamisk interagerer med centrale aktører, med organisationen og det omgivende samfund.

Erfaringerne med interventioner til fremme af sundere kost på arbejdspladser såvel i Danmark som internationalt er udgangspunktet for denne undersøgelse. De langsigtede resultater af sådanne tiltag er indtil nu kun blevet analyseret i et begrænset omfang. Ydermere har sundhedsfremmetiltag på arbejdspladser kun haft et begrænset fokus på analyser af arbejdets og arbejdsmiljøets betydning for effektiviteten af tiltagene.

På denne baggrund er det overordnede formål med denne Ph.d. afhandling at bidrage til at fremme sund kost på arbejdspladser ved at udvikle en dybere forståelse af den langsigtede effekt af tiltag i arbejdspladskantiner. Afhandlingen analyserer den længerevarende effekt af at øge forbruget af frugt og grønt på fem arbejdspladser. Analysen benytter en kombination af social formning og et arbejdspladspolitisk perspektiv som teoretisk grundlag for at forstå formningen og forankringen af sådanne tiltag. Disse casestudier er kombineret med en spørgeskemaundersøgelse blandt ca. 550 arbejdspladskantiner om blandt andet sundheden i deres udbud af mad.

Målet med denne afhandling var at:

1. Undersøge om måltider i arbejdspladskantiner er sunde og nemt tilgængelige, og hvad indikatorerne er for at arbejdspladskantiner tilbyder sunde måltider.

2. Måle og analysere den langvarige effekt af en intervention med henblik på at øge forbruget af frugt og grønt på arbejdspladskantiner.

3. Identificere og vurdere succesfaktorer for langsigtet effekt af interventioner, der søger at øge forbruget af frugt og grønt på arbejdspladser med kantiner.

–  –  –

Hovedresultaterne af undersøgelsen er:

Kun 12 % af kantinerne blev vurderet til at være overordnet sunde, dvs. de tilbyder sunde valg inden for såvel varmt måltid som smørrebrød og salat. Specielt arbejdspladser med mere end 75 % kvinder tilbød ofte sunde menuer. Størrelsen af arbejdspladsen korrelerer positivt med sandsynligheden for et sundere måltidudbud. Denne undersøgelse antyder ydermere en positiv sammenhæng mellem finansiel støtte til kantinen fra den pågældende arbejdsplads og tilgængelighed af sunde måltidudbud.

Fire ud af fem arbejdspladskantiner var i stand til enten at fastholde deres resultater i form af et øget forbrug af frugt og grønt - eller endda at øge forbruget fra baseline til 5 års opfølgningen med et gennemsnitligt forøget forbrug på 95 g per kunde/måltid/dag. Én af de fem kantiner kunne ikke opretholde tiltaget og gik næsten tilbage til dens udgangspunkt (baseline). I gennemsnit havde de fem kantiner ved 5 års opfølgningen et frugt og grønt-forbrug på 208 g per kunde/måltid/dag.

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