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Sweden

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 Sweden is taking part.

Partners

Edenred

https://www.edenred.se

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.

Karolinska Institutet

http://ki.se/start

The Karolinska Institutet is one of Europe’s largest medical universities. It is also Sweden´s largest centre for medical training and research. Through research, education and information, the Karolinska Institutet contributes to improving human health. Each year, the Nobel Assembly at Karolinska Institutet awards the Nobel Prize in Physiology or Medicine. The department of Biosciences and Nutrition performs research and education in areas of medical science and offers an international working environment. Most research projects it conducts are in the context of national and international networks.

The Karolinska Institutet was a FOOD member during the project phase.

Keyhole Restaurant Association

The Keyhole Restaurant Association is a non-profit organisation with the Swedish National Food Administration and the Swedish National Institute of Public Health as members. The Keyhole branding was introduced in Sweden in 1989 aiming to make it easier for consumers to identify healthier alternatives in order to reduce the risk of cardiovascular conditions.
The keyhole is a voluntary label. Food producers are themselves responsible for ensuring that foods with the keyhole symbol conform to National Food Administration’s regulations. Keyhole labelling in restaurants is also voluntary, but the restaurants need to go through a certification process to use the symbol. The National Food Administration has established a new certification body aimed at assuring the quality of the meals served at restaurants. The Keyhole Restaurant Association was established in January 2009.

Methodology

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.

In Sweden, the Keyhole certification programme for restaurants was the only programme reviewed as it is considered the main programme of its kind and importance in Sweden. The Swedish National Food Administration launched the certification scheme for restaurants in 2009. The objectives of the programme were to create a network of restaurants offering healthy food across Sweden. This was achieved by creating a certification scheme with yearly follow-up and evaluations.
The scheme benefited from the backing on the National Food Administration who owns the Keyhole label making it easily recognisable and being the main incentive for big restaurant chains to join the programme. Initially the programme was financed by the Swedish agricultural department but as the certification is offered at a cost to the restaurants the aim was to make it self-financing.
This Swedish scheme aims to achieve the same targets as the FOOD project. The Keyhole certification of the restaurants however is more specific in terms of the nutritional specifications of the food labelled is a ‘Keyhole’ dish, than is demanded by the FOOD project. Making use of the widely accepted ‘Keyhole’ label the programme is both attractive to participate in and well received by the public.

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 weren’t 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

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 weren’t 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 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 Institut 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.

Employees

412 Swedish employees responded to the questionnaire. From this initial investigation, some important results emerged that helped to shape the first set of tools and messages.

Figure 1: Breakdown of employee reported weight

This first graph analyses the overall weight of employees. Sweden is the country with the highest reported overweight ratio out of the six countries (Belgium, the Czech Republic, France, Italy, Spain, Sweden) with fewer than 50% of the respondents being of a normal weight.

Figure 2: Percentage of employees having lunch daily:

The percentage of employees who have a lunch break during the working day is shown in the following graph. 87.6% of employees, the highest of the six countries, have a lunch break every working day. Only a small minority never have a lunch break clearly making the majority a suitable target group.

Figure 3: Breakdown of lunch places frequented by Swedish employees:

More than half of Swedish employees eat lunch in a restaurant (45.3%):
When in the restaurant, the majority of employees reported choosing their meal based on what they want to eat at that time (54%). Only 23% of respondents reported choosing the balanced dish. This finding should be passed on the restaurants to encourage them to make the balanced dish the tastiest to get it chosen more often.
Another issue emerged from the survey regarding the need to educate employees about the benefits of balanced meals as only about a third reported choosing the restaurant based on the nutritional quality of the food on offer.
Positively, the survey concluded that the Swedish employees are relatively health conscious having the right attitude for such interventions. 51% of respondents have fruit as a snack, drink water at lunchtime and have rather healthy breakfast.
The majority of employees (26.9%) chose the Keyhole symbol as the best to indicate the healthy balanced dish. This cooperation with the scheme has led to a number of country specific tools to be developed building on the programme’s existing initiatives (see tray model and information holders in chapter 8).
The decision on type of messages to be designed was to have them short, simple and playful.

Restaurants

80 restaurants responded to the first questionnaire. The majority of restaurant owners expressed the wish to receive information and training on balanced food including staff training as well as cooking and serving instruction. More than 50% claimed not to have sufficient skills for preparing balanced meals yet the percentage of those who claiming to have knowledge (45%) was the biggest out of the six countries.

Figure 4: Restaurant owners’ knowledge about balanced food

92.5% of respondents (the highest out of the six countries) do not see any obstacles to promoting balanced nutrition in their restaurants.

It clearly appears that in Sweden, both employees and restaurant owners are open to learning more about healthy food and lifestyle.

The Keyhole label was accepted by both sectors making it a potentially good scheme to partner with. Through collaboration with the Keyhole scheme the FOOD project was to benefit from increased visibility and acceptability.

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 common European recommendations to employees and one to the restaurants.

Recommendations to the employees

The employee recommendations in Sweden were borrowed from the Swedish National Food Administration’s nutrition recommendations. The recommendations are for the entire day and are based on a four-week menu. Specifically regarding lunch in a restaurant, there are five main principles added to the six common European recommendations:

  • Taste the food before adding salt and/or try other condiments.
  • Lower the use of fat and preferably use vegetal oils.
  • Eat at least 5 portions of fruit/vegetables per 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, roast, grill, etc.).
  • Choose water to accompany your lunch.
  • Choose the keyhole meal.
  • Use the tray model for composing your balanced meal.
  • Use the salad bar for topping up your lunch meal with vegetables/fruit/cooked pulses.
  • Eat high fibre bread/whole wheat bread.

Recommendations to the restaurants

Thirteen recommendations in total were agreed on in Sweden. On top of the common recommendation, the following twelve recommendations are country specific and are adapted from the ‘Keyhole restaurant certification’ criterion:

  • Favour cooking methods such as steam, oven, or grill.
  • Offer dishes in 2 sizes.
  • Use the keyhole symbol to identify balanced meals on the menu.
  • Provide at least one Keyhole dish at the top of the menu (dish of the day).
  • Calculate meal composition and portion size (Näringsvärdesberäkning på måltiderna) Dietist/Keyhole.
  • Offer fish dishes at least once a week as one of the Keyhole dishes (consider lactose and gluten).
  • Use the ”tray model” (an upgraded ”platemodel”) as information about balanced meals.
  • Enable the customer to eat more vegetables - by for example leaving space for salad on the plate, serving salad first, or serving more salad on the plate.
  • Divide the salad bar into categories - for instance into "unlimited amount" and "limited amount" sections. (The Limited amount should contain salads that are pre-mixed with dressings etc.)
  • Use a salad bar with at least 8 different choices of vegetables, fruit, cooked pulses.
  • Always have tap water available.
  • Always have high fibre bread available (e.g. Knäckebröd)(Keyhole marked bread).
  • Always have low fat dressing and oil based dressing available - no (max 2%) trans fatty acids.

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 Sweden, restaurants have to apply all the 13 recommendations.

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.

After Paris and Brussels, the FOOD bus stopped in Stockholm on October 12th, 2009.
Despite the cold weather, the public came and enjoyed the different activities. The chef Paul Svensson, who works in one of Sweden’s most famous restaurants (F12), prepared healthy sandwiches and foods that fit the tray model for the event.
In addition, the nutritionist Christel Lynch presented a questionnaire designed by the Karolinska Institutet, one of the partners. The answers provided the base for a deeper analysis of nutritional habits through the help of a computer programme that can analyse diets.

Communication tools

Along the project and programme phase, several communication tools targeting both target groups were created:

See the Communication tools for employees

See the Communication tools for restaurants

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

697 employees participated in the second questionnaire compared with 412 in the first round of 2009. 63% of them claimed to be eating rather healthily, displaying a similar attitude to the 2009 respondents.
Around a quarter of respondents claimed to be aware of a programme promoting healthy food, yet the majority (60%) were unaware of such programmes with 37% out of those interested to learn about them.
Out of the respondents that were aware of the FOOD project (14%) most of them knew what the project was about. Despite the low awareness of the project (with only French employees scoring lower), these finding indicate that for those familiar with the content, the FOOD project message was clear and that it has been positively associated with the Keyhole symbol.
A large majority of respondents have a lunch break every day, or almost daily (89%). Out of these 55% have lunch in a restaurant once a week or more frequently. The two main reasons for the employees not to have restaurant food were: preferring to bring food from home and lack of time.
Restaurant choice was based mainly on: the restaurant offering a pleasant environment, varied meals and fast service. This indicates a slight change from the 2009 results in which proximity to the workplace was the second determinant in the restaurant choice, now only ranking fourth in degree of importance.
Positively, customers reported that vegetables were being served with all meal options often or always (75%), tap water was being served on demand free of charge (75%), fish was on the menu often or always (68%) and poultry or white meat also being on the menu often or always (55%).
However, some of the recommendations were less adhered to. Foods that have been oven baked, steamed or grilled were reported by 60% of the respondents to be on the menu rarely, seldom or never. Wholemeal bread was rarely, sometimes or never on offer (40%). Staff was rarely, sometimes or never willing to provide help with the balanced meal choice (86%) or equally was rarely knowledgeable about it (72%). Optional portion sizes were rarely, sometimes or never offered for the main meal (60%).
These findings indicate that further work with the restaurants is needed to increase the offer of balanced meals and improve their adherence to the FOOD project recommendations. Employee attitude should also receive further attention as less than a third of the respondents would often or always choose a balanced meal if it was on offer.

Restaurant questionnaire results

60 restaurants participated in the second questionnaire (down from 80 in the first round).
45% of the respondents claimed to be aware of a programme promoting healthy or balanced food. The 45% who did not, would have liked to learn more about the subject.
A quarter of the respondents claimed to have seen the FOOD logo and material yet only 3 restaurants were fully aware of the project. The very short time frame between the launch of communication tools and the evaluation might mostly explain it. This sample size is too small to draw meaningful conclusions from.
A third of respondents had either made some or considerable changes to their food based on nutritional recommendations in the past 12 months or were considering making some. However, 41% of respondents reported not having thought about the need for making such changes. Most frequently mentioned reasons for not making changes were the perception that these changes were not necessary as the restaurant already served healthy food or that customers do not demand this (most of the respondents had not noticed any change in demand for balanced meals by their customers).

Due to the fact that neither of the surveys aimed at assessing the nutritional quality of the food on offer nor establishing a change in intake, it is of course not possible to determine whether there was a change in behaviour. Nevertheless, the objective of the project to promote healthy eating and to provide the target groups with clear and practical information seems to be achieved.
The positive results from the surveys relate to the fact that a large number of restaurants had either made changes to the food they offer, based on nutritional recommendations in the past 12 months or were considering doing so. This was evident by fact that customers noticed certain recommendations being implemented in the restaurants.
Respondents had positively associated the project with Keyhole scheme, which added synergy to the partnership in Sweden.

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.
Sweden participated in 2012.

Click here to consult the results for Sweden

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.