The European FOOD -Fighting Obesity through Offer and Demand- programme was created as a project in 2009 thanks to the co-funding of the European Commission (DG SANTE).
Edenred, as lead partner and coordinator, proposed to representatives of Public Health Authorities, Nutritionists, Research centres and Universities in six countries (Belgium, the Czech Republic, France, Italy, Spain, and Sweden) to form a Consortium of partners.
Despite the end of the EU funding in April 2011, the partners decided to take advantage of the actions and results and continued under a long-term programme, to which Italy is taking part.
Edenred designs and develops voucher programmes for companies and public authorities. Its flagship product is the meal voucher (or Ticket Restaurant®) which has been in practice worldwide for more than 50 years and is used by more than 43 million people every day in 42 countries.
Meal vouchers can act as a launch pad for effecting a change of employee food and lifestyle habits. Furthermore, the FOOD project – which became a long-term programme - is in perfect harmony with Edenred’s stated corporate social responsibility goals, of which access to balanced nutrition is a key priority. Edenred is responsible for the coordination of the programme and for the dissemination of the information and results.
University of Perugia
The University of Perugia is one of the most accredited national universities and holds a prestigious place within the European context. The university has three Centres of Excellence of international importance as well as a number of national research centres. Moreover, the University has collaborative scientific relationships with other European, American, Japanese, Chinese and Indian universities. The university is a member of the International Association for Health Promotion and Education and since 1996 is also a partner of the European Network for Workplace Health Promotion (ENWHP). In particular, Dr Giuseppe Masanotti has been consulate for ENWHP of the National Institute for Health Protection at Work. The institute is also a consulate of the Umbria Region and the Ministry of Health for public health policies – in particular on the subjects of training on health promotion.
Città Sane (WHO Europe)
The Healthy Cities Project is supported by the World Health Organization (WHO), the United Nations specialized agency for health, which is operating since 1948 with the objective of ensuring the highest level of health for the world’s population.
The WHO works directly with local governments, through its Center for Urban Health and a network of cities (Città Sane), to support countries in promoting the conception and awareness of public health, developing local policies for health and health programs, preventing and overcoming threats and health risks, anticipating future health challenges.
The Città Sane Project was created to help cities concretely pursue these objectives. The key words are: comprehensive health, individual well-being as well-being of the community and the role of cities as health promoters.
Istituto Superiore di Sanità
The Istituto Superiore di Sanità (ISS) is the leading technical and scientific body of the Italian National Health Service. Its activities include research, clinical trials, control, and training. The ISS promotes scientific research in a wide variety of fields of special relevance for public health, and in particular basic, translational and clinical research in major disease areas, including cancer, neurological, infectious and rare diseases. ISS is a scientific institute where regulatory sciences go together with experimental sciences, in particular for the field of advanced therapies. For more than 20 years ISS scientists have served as experts to the Italian competent authority AIFA (Italian Medicine Agency) for authorizing clinical studies in Italy, as well as experts participating in EMA (European Medicine Agency) working groups, which generated guidelines for gene therapy and biotechnology.
Step 1 : Research and knowledge
Inventory of existing results
During the project phase (2009-2011) and before the creation of the tools and the launch of communication campaigns, the Consortium took several actions to understand what had been done so far in health promotion at the workplace and to determine the needs of both target groups, employees and restaurants.
A detailed inventory of existing programmes related to nutritional interventions was first conducted. This review of existing programmes was carried out in order to understand the initiatives already carried on in the various countries regarding interventions to promote healthy eating through a work setting. The core of the review focused on initiatives targeting balanced food in restaurants and those targeting employees in a company setting.
70 programmes matched the review criteria in the 6 countries and were entered into the study.
It was launched jointly by CCM (the national centre for diseases prevention and control) and Formez (a survey and training centre) in 2007. The targets of the programme were to encourage local authorities to identify and promote best practices on correct and balanced diet, physical activity, prevention of smoking and alcohol habits. This national programme coordinated many local initiatives yet had a long hierarchy of organisations involved and due to little feedback on the projects, was hard to assess.
The programme was launched in 2007 by DoRS. DoRS was founded in 1988 in the Piedmont Region to facilitate health change for individuals and organisations. The programme promoted a good nutritional culture among employees using a computer-based system created by dieticians, doctors and computer scientists. The programme used a variety of tools most of them computer based for the purpose of health promotion and was free to use.
It was launched by the National Institute for Research of Food and Nutrition (INRAN) in 1986 for an undefined period of time. The programme aimed to provide families, schools, companies and institutions with valid advice on eating in a balanced way according to Italian culinary traditions. Around 30 experts provided technical and scientific expertise to consumers aiming to improve their eating habits. The programme was widespread yet evaluated only twice since its launch.
It was launched by the National Institute for Research of Food and Nutrition (INRAN) in 2006 for 2/5 years and was free to use. The programme aimed to inform and educate consumers, companies, institutions and schools on food and nutrition subjects, promoting healthy behaviours and lifestyles. The programme was well communicated through events and advertising campaigns yet ended in mid-2008, earlier than planned for unpublished reasons.
It was launched in 2005 by the Health Ministry and the Public Education Ministry. The aims of the programme were to encourage consumption of fruit and vegetable based snacks. It targeted school children, teachers, parents and employees promoting nutrition education. The programme encouraged collaboration between education and health bodies, and public and private bodies. Most of the effort was directed at the schools with limited initiatives in the workplace. As part of the project, vending machines were installed offering freshly cut and ready to eat fruit and salad.
This programme was launched by the province of Bologna in 2008 for a nine months period. The target audience was composed of employees of a manufacturing company in Bologna. The objectives of the programme were to promote a healthy lifestyle, interventions on catering, availability of healthy food and physical activities. Positively, the programme brought together several sectors yet due to the short duration and the ambitious targets and lack of evaluation, it is unclear if objectives were met.
This programme was launched in the province of Bolzano in 2006. It targeted at companies and municipalities and aimed to improve the level of awareness on healthy lifestyles. A network of companies and municipalities was formed by the creation of a certification programme and a separate network of cooking and nutrition experts was launched for a three-year period. Many initiatives were carried out bringing together public and private partners yet the only five communities and nine companies ended up participating.
It was launched by SICURF@D in 2001. The SICURF@D website devoted to online information and training on safety at the workplace, targeted companies, industries and trade unions in the district of Prato promoting health at work by adopting a healthy lifestyle and appropriate nutrition. Free access was provided on the internet offering training through the website. However, the concrete advice was limited in quantity and in quality and targeted at a very limited audience geographically.
This annual conference organised by one of the major restaurant and food service companies in Italy, CIR Food, was launched in 2004 and aims to spread information to restaurants about healthy and balanced nutritional habits. Despite the fact that it reached a small target audience this event is currently still gaining recognition and popularity.
In summary, it is clear that issues of nutrition are becoming important as several interventions were identified in Italy with all but one initiated by public bodies. Only one of the interventions was targeted at restaurants. All the programmes were free to use but their impact is hard to assess as only two had evaluation planned into the implementation process. In all but two of the programmes the cost remains unknown. Three programmes had high levels of communication and those also involved scientific knowledge, which was absent from some of the other programmes.
The review of the existing programmes included in the inventory enabled the partners to draw several common conclusions:
- There was a general lack of evaluation of most programmes
- The projects were not well promoted
- Target audiences were mostly passive
- Low presence of professionals
- Unsuitable tools were created as a result of wrong assessment of the target audience’s
- Lack of visibility and clarity of the tools created
Quantitative and qualitative surveys
First questionnaires for employees and restaurants (2009)
Following the review of existing programmes and based on the main findings, a survey was launched, with two questionnaires: one aimed at restaurants and the other at employees. The survey was conducted in each of the participating countries through Edenred’s network, designed by the CIRIHA and the Institute Paul Bocuse and later analysed by the Research Centre of the Institute Paul Bocuse, in France.
At least 52,000 employees and 5,000 restaurants were targeted by the questionnaires in the six participating countries. A total of 4,529 employees and 399 restaurants responded to the questionnaires, a response rate above the 5% that was anticipated.
795 Italian employees responded to the questionnaire. From this initial survey, some important results emerged that helped to shape the first set of tools and messages.
Figure 14: Breakdown of employee reported weight
The previous graph analyses the overall weight of employees. In Italy, the largest number of employees with normal weight (67.4%) was identified out of the six countries and the fewest reported to being obese (5.5%) in line with the OECD results in chapter 1.
More than 10% of respondents never have breakfast with 60.9% of employees (the fewest of the six countries) reporting to having a breakfast every day. This is one of the unhealthy habits of Italian employees that the national partners wish to change as highlighted in the Guidelines for a healthy Italian nutrition available for the employees.
More than 80% of employees reported having a lunch break every single day and only 2% never have one. However as it can be seen in the next graph, similar to the results from Spain and France, employees frequently eat at home or eat food brought from home. 50% of those who eat in a restaurant are the main targets of the communication programmes and tools.
Figure 15: Breakdown of lunch places frequented by Italian employees
Over half of employees claimed to choose the restaurant they have lunch in, based on its proximity to their workplace. Affordable or cheap was the second reason mentioned by 32.5% of respondents. In line with the results from the other six countries, the majority of employees choose what they are going to eat based on what they feel like at that given time. Positively though, the second chosen factor was the ‘what is good for me’.
The meaning of balanced nutrition to 66.8% of respondents is ‘eating pleasant food while at the same time protecting your health’. Only very few of the respondents associated balanced food with being low in calories, fat, salt and sugar. This is an indication that balanced food is not associated with diet but encouragingly has positive connotations.
In terms of nutritional advice in the restaurants, 41.3% of respondents would have liked to see a symbol indicating the balanced dish.
72 restaurants responded to the first survey. More than 50% were independently run and only 1.4% belonging to a chain, which is typical to the Italian restaurant sector and causes an added difficulty in reaching this very segmented sector.
Figure 16: Respondents’ restaurant classification:
In Italy, the fewest respondents out of the six countries, claimed to have knowledge about balanced food. The majority, in line with responses from all other countries apart from Spain, state that they could learn more.
Figure 17: Restaurant owners’ knowledge about balanced food
90.3% of respondents (the second highest after Sweden out of the six countries) do not see any obstacle to promoting balanced nutrition in their restaurants.
The Italian restaurant sector is very fragmented consisting mainly of independently owned restaurants. Only 16.9% respondents claimed to have an overall knowledge of balanced nutrition. Nevertheless, the majority was open to learning more about it with very few who saw any obstacles to doing so. With the majority of employees choosing their lunch restaurant based on proximity to their work place, and choosing to eat what they feel like at the time, it is important to improve the offer in these restaurants thus improving employees’ chances of receiving a healthy meal.
Restaurant qualitative survey
In parallel with the quantitative survey, a qualitative restaurant study has been conducted in 2009. This survey was conducted in twelve countries (Belgium, Brazil, the Czech Republic, France, Germany, Greece, India, Italy, Morocco, Poland, Spain, United Kingdom) and five restaurants were chosen in each country. The aims of the survey were to understand how and why chefs cook the way they do, and what could trigger a change in attitude. The next stage was to try and convince restaurants that cooking healthily has many benefits with no additional costs.
Apart from one pizzeria, all other restaurateurs were aware of a raise in demand for healthy food by the customers. They have noticed a growing preference for quality not quantity. Quality is manifested in using local produce and Italian olive oil. None of the restaurants interviewed were aware of any government initiatives to promoted healthy eating, as currently in Italy none exists. The restaurants serving Italian food were also aware of seasonal food and were changing their menu regularly.
In regard making changes to the way they cook, only three reported having the willingness to make changes and would consider those only following demand from the customers. The restaurateurs were looking for ways that would encourage restaurants to cook healthily suggesting tax incentives as one possible option. Several of the restaurant owners were keen to participate in training that demonstrates healthy cooking in an economical way.
Step 2 : Recommendations
Following a consolidation of the results from the first survey of 2009 and the inventory, experts outlined a set of recommendations targeted at restaurants and employees.
The purpose of these recommendations was to offer tangible and practical advice to help both target groups adopt healthier nutritional habits.
Despite the intention of some partners to have only common European recommendations, each country decided to adapt the recommendations to its local cultural habits. Following further consultation on national level, the partners accepted six recommendations to employees and one to the restaurants.
The National Institute for Research of Food and Nutrition (INRAN) guidelines provided the basis for the national recommendations in Italy. These ten recommendations tackle the relevant priority areas of nutrition.
The partners addressed the cultural and educational differences between the target groups by creating simple and clear recommendations to engage with both the employees and the restaurateurs.
The recommendations have however been updated in 2016.
Recommendations to the employees (2009)
- Taste the food before adding salt.
- Choose water to accompany your lunch.
- Pay attention to the portion you need, it can be larger or smaller.
- Eat at least 5 portions of fruit and vegetables a day.
- As a dessert, choose a fresh fruit based option and sometimes as an alternative, a dairy product.
- Choose types of cooking that do not add too much fat (steaming, roasting, grilling, etc.).
- During breaks, avoid snacks that are fatty or rich in salt or sugar.
- Some days try and do without meat. The combination of legumes and cereals is a good alternative.
Recommendations to the restaurants (2009)
- Offer vegetables as side dish.
- Offer legumes and vegetables.
- Offer wholemeal bread at lunchtime.
- Use little salt in the dishes you offer, using spices preferentially.
- Offer dishes made with poultry or, if possible, white meat.
- Have fish as part of the meals offered.
- Prefer the use of olive oil.
- Offer dairy-based dessert (milk-based ice cream, yoghurt instead of sorbet), or fruit-based dessert.
- Preferentially offer olives and raw vegetables instead of crisps and pretzels.
- Favor steaming, grilling or oven-baking, avoiding excessive condiments.
- Offer natural or sparkling water if possible.
Recommendations to the employees
- Avoid salt, or use it in moderation, since many foods already contain it. In any case, use iodised salt (no more than a pinch or one single sachet)
- Drink water during lunch
- Pay attention to the portion size you need, and moderate consumption of processed and fatty meals
- Eat at least 5 portions of fruit and veg a day
- Have a fruit-based dessert, or alternatively, a yoghurt
- Use cooking methods that don’t require much in fats (oven cooking, steaming or grilling)
- Avoid snacks rich in saturated fats, salt or sugar
- An alternative to meat is a combination of legumes and cereals
- Lead a varied diet, and during the week eat fish and legumes at least three times, alternating the main protein source (meat, fish, eggs and cheeses)
- The balance is reached by maintaining a healthy lifestyle day in day out
Recommendations to the restaurants
- Make imaginative meals, varying the foods and even their colouring
- Offer legumes regularly
- Offer whole bread at the table
- Use little (iodised) salt in meals that also contain spices
- Alternate between animal proteins (red and white meat, dairy products and eggs)
- Offer fish-based meals regularly
- Use extra virgin olive oil
- Offer fruit-based desserts
- Offer raw vegetables and yoghurt rather than potato chips and savoury snacks
- Steam cook, instead of grilling or oven cooking, avoiding the excessive use of condiments
- Offer mineral water
- Increase the supply of seasonal fruit and veg
Criteria to respect in order to be part of the FOOD restaurants’ network
Following the creation of the FOOD recommendations for restaurants, a network of restaurants respecting a certain number of recommendations was created.
In Italy, restaurants have to apply 7 out of the 11 recommendations in order to be part of the FOOD restaurants network.
To see the map of the entire network of FOOD restaurants, click here
Step 3 : Communication strategy
The road show (2009)
The communication campaign officially started in October 2009 with a ‘road show’ in the six participating countries. A double-decker bus customised with the FOOD colours drove through the main city of each of the six countries of the project phase. The journey started in Paris and then continued on to Brussels, Stockholm, Prague, and Milan ending in Madrid. These one-day stops enabled the partners to showcase the first tools created and to explain the project objectives and actions.
The fifth stop of the Road Show FOOD bus was in Milan, on October the 20th, 2009.
Communication tools for Employees and Restaurant owners had been especially prepared for the event: newsletter, meal voucher advertising, leaflet, flyer, website, pedometers and more.
The representative of the Instituto Nazionale di Ricerca per gli Alimenti e la Nutrizione (INRAN) supported the team with a much-appreciated demonstration that included videos describing the guidelines for a balanced nutrition.
Visitors were invited to calculate the number of calories in a dish and in a recipe, etc. Many journalists participated in the FOOD press conference.
On top of that, visitors could meet experts for an individual and personalised session.
Finally, visitors had the opportunity to try a 10kg vest, aiming at demonstrating the impact of excess weight on the body: a lasting experience for those who tried!
image du Roadshow
Along the project and programme phase, several communication tools targeting both target groups were created:
Step 4 : Evaluation
Second questionnaires for employees and restaurants (2010)
A second survey was conducted in 2010 to try and evaluate the first stage of the project and the success of the tools. At this point the project had achieved many of its targets. Nutritional recommendations had been formed in each country for both the restaurants and the employees and communication tools were created in each country and across the whole project. More than 100 communication initiatives were introduced and implemented in the 28 months duration of the project. Especially popular was the website that was visited more than 66,600 times between February 2009 and May 2011.
It was estimated that after 28 months, around four million employees and 195,000 restaurants had been reached by the messages of the project.
The evaluators pointed out to several difficulties encountered regarding the survey questionnaires, in particular the fact that the questionnaires ended up being very long due to need to assess several types of national interventions, possibly resulting in fewer responses.
Outcomes and impacts on a European level were analysed by the Centre of Research of the Institut Paul Bocuse.
The questionnaires have reached a minimum of 52,000 employees. It is hard to say in which way the project had impacted on employees’ choice of balanced food as the general objective was to sensitise and provide this target group with the information needed to help them make healthier choices. Nevertheless, an important result from the 2010 survey was that 59% of employees were in favour of eating healthily at lunchtime meaning that this continues to be an important target group.
From the restaurant perspective, at least 5,000 establishments were reached via the questionnaires. Very positively, after a few months, more than 1,760 restaurants joined the FOOD restaurant network following national recommendations despite the fact that the interventions targeted at the restaurant staff took place quite late in the project. This short time frame could also offer an explanation to the second survey’s pretty low awareness results from restaurants (only 10% of respondents were familiar with the project’s objectives), yet the results indicated that 51% of them saw the value in serving healthy meal.
Therefore, continued support from programmes such as FOOD is needed to further increase the demand for this kind of food/meals by the customers and to increase the number of restaurants offering it.
On top of the many actions and tools created and implemented and the creation of the FOOD restaurant network a further achievement of the project is the creation of a successful partnership between the public and private sectors.
Employee questionnaire results
760 employees responded to the second questionnaire with more people over 50 participating and more of them being women compared with the first survey. The majority of respondents claimed to eat rather healthily (64%).
Unlike the results in 2009, 83,4% of respondents perceived balanced food to mean ‘various food in a moderate amount, in a nice environment’. Low calorie, fat, salt, and sugar were yet again only chosen by a small minority.
A smaller proportion (32%) of respondents were aware of a programme promoting healthy or balanced food in this sample than for the 2009 questionnaire with most of the information coming from the food industry.
15% of respondents have seen the FOOD logo. Out of these, only 3% of respondents (22 people) stated that they knew the content of the programme, with the website being their main source of information. Taking into account the very short time frame in which the actions and communications for this target group were produced, these figures were encouraging and welcomed by the national experts.
A majority (over 65%) of respondents reported having a lunch break every day (or almost every day) during the working week. Similar to the results from 2009, those who do not have lunch in a restaurant eat at home or bring their lunch from home. For those choosing not to eat out, the main reasons given were: preferring homemade food, lack of time and the inferior nutritional quality of the restaurant food.
The top five factors important to respondents in choosing a restaurant were: speed of service, affordability, the nutritional quality of the food, pleasant environment and a varied menu. Proximity to the workplace, which was ranked third when consolidating the results from the six countries, was only the seventh factor chosen by the Italian employees. This is different to the 2009 results where proximity was the main factor in choosing where to have lunch.
Apart from speed of service and affordability, Italian employees continue to place an emphasis on issues concerning healthy eating.
Restaurant questionnaire results
Fewer restaurants participated in the second questionnaire, 52 compared with 72 in 2009. Around 40% of them independently owned. Almost 65% of these restaurants offer a ‘dish of the day’ and over 60% offer a set menu at lunchtime.
75% of respondents showed interest in healthy or balanced food but only a few were aware of any existing nutritional programmes. Over 70% of respondents were interested in learning more about the subject. 23% perceived their knowledge to be sufficient and only 4% were not interested. These results indicate that restaurant owners are willing to learn more about healthy food and that they continue to be a good target group for the project’s interventions.
Lack of time and budget are most frequently chosen as reasons for not offering balanced meals. These results make it clear that working with restaurants to educate them about healthier cooking methods that are not more expensive or time consuming, should be advocated. This is in line with the response that free and short training sessions and leaflets are the most desired material for nutritional information.
In the past 12 months, half of respondents have either made some changes based on nutritional recommendations, were preparing to make changes or were considering making those changes. The restaurants currently have a positive attitude toward the nutritional recommendations. With the exception of an increase in the demand for different portion sizes, restaurant owners have not observed a change in the demand for healthier food by their customers.
Despite the difficulty in comparing the survey from 2009 to the later one, some themes emerge from both. Healthy food continued to be important to both target groups. Employees considered their eating habits to be rather healthy often choosing their lunch place based on nutritional quality of the food on offer, and three quarters of restaurateurs were interested in issues concerning balanced food. Both target groups were also interested in learning more about the subject.
In this second survey, both employees and restaurants were mostly still unaware of national nutritional programmes and with the lack of one; the FOOD project has an important role to play in educating these target groups about food and nutrition.
The FOOD barometers (since 2012)
Questionnaires inspired from the 2009-2010 surveys, called the FOOD barometers, are launched every year since 2012 to monitor the evolution of the habits and opinions of both target groups – employees and restaurants - about balanced food.
Step 5 : Adaptation and dissemination
The data collected during the evaluation allows the partners to adapt the communication strategy to employees and restaurants’ needs and expectations. This is a continuous improvement of the programme, its messages and communication tools.