Faculty of Health Sciences Department of Public Health

A community intervention study to test the cost and impact of integrated nutritional intervention in a catering on the change in diet quality and weight of diners

Thesis submitted in fulfillment of the requirement for Master in Public Health degree By: Liron Sabag (Sharon)

Supervised by: 1. Danit R Shahar, Department of Public Health, The S. Daniel Abraham International Center for Health and Nutrition, Faculty of Health Sciences, Ben- Gurion University of the Negev 2. Tzahit Simon-Tuval, Department of Health Systems Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev

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A community intervention study to test the cost and impact of integrated nutritional intervention in a catering on the change in diet quality and weight of diners

Thesis submitted in fulfillment of the requirement for Master in Public Health degree

By: Liron Sabag (sharon)

Supervised by: 1. Danit R Shahar, Department of Public Health, The S. Daniel Abraham International Center for Health and Nutrition, Faculty of Health Sciences, Ben-Gurion University of the Negev 2. Tzahit Simon-Tuval ,Department of Health Systems Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev

Submitted by:______Date:______Approved by supervisor:______Date:______Approved by supervisor:______Date:______Approved by Head of Curriculum Committee:______Date:______

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Abstract Background: There has been an increase in the global obesity epidemic during the past 3–4 decades, associated with high energy dense diet and increased risk of chronic diseases. Following the setting approach, environmental dietary intervention as opposed to an individual-based behavioral intervention holds the advantage of creating enabling environment and improving accessibility, while avoiding unnecessary stressors and conflicts that may be associated with direct interaction with the targeted population. An integrated nutritional intervention was examined in the current study. Gap in knowledge: Few studies have assessed the impact of catering-based dietary intervention programs on diet quality and preferences of the diners. In addition, little is known about the incremental costs associated with nutritional change of the menu from the catering perspective. Main objectives: 1. To estimate the impact of integrated nutritional intervention on the change in diet quality and weight of diners; 2. To evaluate the incremental costs of nutritional change in the meal served by a catering service from the catering perspective. Methods: A clinical trial was designed to analyze an integrated nutritional intervention . The intervention group (n=67(: Kibbutz Magen was exposed to a catering-based intervention that included: menu change, food labeling, and health communication using electronic media during lunchtime, as well as monthly lectures on nutrition and healthy lifestyle. Control group (n=67(: Kibbutz Nir-Yitzhak was exposed solely to monthly lectures. Both groups were compared for eating habits, dietary intake, and weight change. Study measures were collected at baseline and after 3 months. Inclusion criteria: diner aged over 30 years who eats lunch provided by the kibbutz’s catering service at least 3 days a week. Study measures included: general and demographic information questionnaire, nutritional and physical activity knowledge evaluation, lifestyle questionnaire, and food frequency questionnaire, as well as anthropometric measurements. The intervention was developed by Ofira Katz Shufan (as part of her PhD thesis). Nutritional values of chosen dishes were compared to current dietary guidelines. Incremental cost of improving the menu quality referred to the costs associated with replacing ingredients with healthier ones and/or changing the preparation techniques. Results: There was no difference in the nutritional quality of the study participants’ diet according to the Mediterranean Diet Score and the Diet Quality Score. According to the Food Frequency questionnaire )FFQ(, no significant difference was found in the consumption of fruits and vegetables before the intervention, but according to the lifestyle questionnaire after intervention, the daily fruits and vegetables intake of the intervention group increased by 55 grams (p = 0.058), and the fruits intake increased by 32 grams (p = 0.008). No difference was reported by the control group in fruits and vegetables intake (p = 0.975), and fruits intake (p = 0.351). According to the FFQ, there was a III decrease in the consumption of trans fat after the intervention in the intervention group (p = 0.031). A similar trend was also observed in the control group, yet with borderline significance (p = 0.058). In addition, in the intervention group there was a reduction in the percentage of calories from bread and cereals (p = 0.049), and reduction in the percentage of calories from meat at borderline significance (p = 0.058). In contrast, in the control group, no such results were observed, neither in the percentage of calories from bread and cereals (p = 0.235), nor in the percentage of calories from meat (p = 0.562). Multivariable models predicting different measures of diet quality revealed that the intervention group was an independent determinant of improved diet quality only with regard to meat consumption. Specifically, the intervention group was more likely to report reduction in meat intake (OR = 2.99, 95% CI [1.10, 8.09], p = 0.031). There was no significant change in the weight of participants after intervention both in the intervention group (p = 0.654) and in the control group (p = 0.422). Analysis of the incremental costs associated with recipes’ modifications revealed that it ranged between -27.5 NIS and +733.5 NIS. In most of the recipes that were modified (57.7%), the incremental cost increased. However, in 46.8% (n=256) of 547 modified dishes that were purchased during the 3-week period, the incremental cost associated with recipe modifications increased. If the recipe’s modification was based on replacing factory-made sauces with self-made ones, the incremental cost in 89.6% (n=490) of 547 purchased dishes increased. The recipes’ modifications led to a decrease in sodium levels in 84.6% of the recipes, a decrease in the amount of carbohydrates in 80.8% of the recipes, a decrease in the amount of saturated fat in 53.8% of the recipes, and a 76.9% reduction in calories. Finally, we found as the saturated fat and energy decreased due to recipe modifications, the incremental cost of the recipe increased (rs= -0.610, p = 0.001; rs= -0.582, p = 0.002, respectively).

However, a decrease in sodium (rs= -0.049, p = 0.814), and carbohydrate (rs= 0.133, p = 0.518) were not associated with increased incremental costs. Conclusions: A catering-based intervention program was mildly effective in improving diet quality and nutritional habits, and not effective in improving diners’ weight in the short-term. Increase in incremental cost was mainly derived from replacing factory-made sauces with self-made ones. Improved values of saturated fat and energy were associated with higher incremental costs; however, decreases in sodium and carbohydrates were not associated with increased incremental costs. Our study may contribute to the development of catering-level interventions and may serve as a model for similar environmental intervention in catering systems in various settings. Further studies may be designed to examine an intervention that includes both individual-level and environment-level strategies, and should adopt objective and accurate dietary assessment methods. Key Words :Dietary intervention, Catering, Weight, incremental cost IV

Table of Contents

LIST OF TABLES ...... IV LIST OF FIGURES ...... IV LIST OF ABBREVIATION ...... IV 1. BACKGROUND ...... 1 1.1 REVIEW OF LITERATURE ...... 1 1.2. GAP OF KNOWLEDGE ...... 4 1.3. OBJECTIVES ...... 4 1.4. SECONDARY AIMS ...... 4 1.5. RESEARCH HYPOTHESES ...... 5 2. METHODS ...... 6 2.1. STUDY PROCEDURE ...... 6 2.2. STUDY POPULATION ...... 8 2.3. SAMPLE SIZE CALCULATION ...... 9 2.4. INCREMENTAL COST ASSOCIATED WITH NUTRITIONAL CHANGE ...... 11 2.5. STUDY MEASURES FOR THE EFFECT OF THE INTERVENTION: ...... 11 2.6. VARIABLES DESCRIPTION ...... 12 2.7. STATISTICAL ANALYSIS ...... 13 3. RESULTS: ...... 14 3.1. RESULTS OF INTEGRATED NUTRITIONAL INTERVENTION ...... 14 3.1.1. DIETARY INTAKE AND DIET QUALITY ACCORDING TO LIFESTYLE QUESTIONNAIRE14 3.1.2. DIETARY INTAKE AND DIET QUALITY ACCORDING TO THE FFQ ...... 20 3.1.3. THE IMPACT OF INTEGRATED NUTRITIONAL INTERVENTION ON WEIGHT ...... 29 3.1.4. CHANGE IN THE LEVEL OF NUTRITIONAL AND PHYSICAL ACTIVITY KNOWLEDGE ..29 3.2. CHANGING THE INGREDIENTS AND PREPARATION TECHNIQUES OF RECIPES: THE IMPACT ON NUTRITIONAL VALUES AND COSTS ...... 30 3.2.1. INCREMENTAL COSTS ASSOCIATED WITH RECIPES MODIFICATION ...... 30 3.2.2. CHANGE IN NUTRITIONAL VALUES (CALORIES, SATURATED FAT, CARBOHYDRATES, SODIUM) FOLLOWING RECIPES MODIFICATIONS...... 34 4. DISCUSSION AND SUMMARY OF THE RESULTS ...... 37 4.1. SUMMARY OF THE RESULTS ...... 37 4.2. DISCUSSION ...... 38 4.3. STRENGTHS AND LIMITATION ...... 42 5. CONCLUSION ...... 43 REFERENCES ...... 44 APPENDICES: ...... 54 APPENDIX A: THE STUDY TIME-LINE ...... 54 V

APPENDIX B: SAMPLE INFORMED CONSENT FORM...... 55 APPENDIX C: MEASUREMENT UNITS ...... 56 APPENDIX D: GENERAL INFORMATION: FROM A QUESTIONNAIRE ON GENERAL AND DEMOGRAPHIC INFORMATION ...... 57 APPENDIX E: FOOD FREQUENCY QUESTIONNAIRE ...... 60 APPENDIX F: NUTRITIONAL AND PHYSICAL ACTIVITY KNOWLEDGE EVALUATION ...... 65 APPENDIX G: LIFESTYLE QUESTIONNAIRE...... 70 APPENDIX H :NUTRITION QUALITY SCORE ...... 79 APPENDIX I: MEDITERRANEAN DIET SCORE ...... 81 APPENDIX J:EXAMPLES OF RECIPES ...... 82 APPENDIX K: ESTIMATE OF INCREMENTAL COST FOLLOWING THE RECIPES’ CHANGES ...... 83 APPENDIX L: THE CHANGE IN NUTRITIONAL VALUES AFTER APPLICATION OF RECOMMENDATIONS FOR IMPROVEMENT OF RECIPES ...... 88

List of Tables Table 1 : Description of the intervention program...... 7 Table 2: General comparison between kibbutzim...... 9 Table 3: List of study variables...... 12 Table 4: Baseline characteristics of the study participants by study group...... 14 Table 5: Univariate analysis of improved fruits consumption...... 16 Table 6: Multivariate analysis for factors associated with improved consumption of fruits . .. 16 Table 7: Univariate analysis of improved fruit and vegetables consumption...... 17 Table 8: Multivariate analysis for factors associated with improved consumption of fruits and vegetables ...... 18 Table 9: Change in the consumption of fruits and vegetables following the intervention...... 20 Table 10: Changes in daily consumption of macronutrients following the intervention...... 21 Table 11: Changes in daily intake of selected micronutrients following the intervention...... 22 Table 12: Univariate analysis of reduced trans fat consumption...... 23 Table 13: Multivariate analysis for factors associated with reduction in consumption of trans fat...... 24 Table 14: Changes in daily intake of food groups adjusted for energy intake following the intervention...... 25 Table 15: Univariate analysis of reduced bread and cereal consumption...... 26 Table 16: Multivariate analysis for factors associated with reduced consumption of bread and cereal...... 27 Table 17: Univariate analysis on reduced meat consumption...... 27 Table 18: Multivariate analysis for factor associated with Reduction in consumption of meat.28 Table 19: Changes in nutrition scores (MED Diet Score, Diet quality score) following the intervention...... 29 Table 20: Changes in anthropometric measurements following the intervention...... 29 Table 21: Changes in nutritional and physical activity knowledge following the intervention.30 Table 22: The difference between the kibbutzim in improving nutritional and physical activity knowledge ...... 30 Table 23: The cost of ingredients in self-made sauces...... 32 VI

Table 24: Examples for the calculation of incremental cost following the recipes’ modification...... 33 Table 25: Comparing the incremental costs associated with modification of the recipe’s sauce...... 34 Table 26: Examples of change in the nutritional values of the recipes following recipe modification...... 35 Table 27: The change in nutritional values of self-made sauces compared to factory-made sauces after recipe modification...... 36 Table 28: Correlation between change in nutritional values and change in recipe cost...... 36

List of Figures Figure 1: Selection of recipes for modification...... 8 Figure 2: Flowchart of participants over the course of the study...... 10 Figure 3: Change in consumption of fruit and vegetables following the intervention...... 15 Figure 4: Do you think you maintain a healthy lifestyle? ...... 18 Figure 5: The percentage of participants who changed their choice towards fruits as sweet food...... 19 Figure 6: Do you eat a variety of foods? ...... 19 Figure 7: How would you define your daily menu? ...... 19 Figure 8: Do you think you maintain a healthy lifestyle? ...... 20

List of abbreviation FFQ -Food Frequency questionnaire DASH -Dietary Approaches to Stop Hypertension CVD -Cardiovascular disease Med diet score -Mediterranean Nutritional score OR -Odds ratio CI -Confidence interval BMI -Body Mass Index PA -physical activity

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1. BACKGROUND 1.1 REVIEW OF LITERATURE Obesity prevalence is increasing worldwide reaching pandemic proportions 1,2,3. One of the major causes is energy imbalance between energy intake and energy expenditure mainly due to consumption of energy-dense foods and a decrease in physical activity. The obesity pandemic is associated with increased risk for chronic diseases including cardiovascular diseases, diabetes, musculoskeletal disorders, and some cancers (endometrial, breast, and colon) 3. To reduce obesity by 2020 the U.S. Department of Agriculture and the U.S. Health and Human Services published dietary guidelines, focusing on five main areas: 1. Follow a healthy eating pattern across the lifespan; 2. Focus on variety, nutrient density, and amount; 3. Limit calories from added sugars and saturated fats, and reduce sodium intake; 4. Shift to healthier food and beverage choices; and 5. Support healthy eating patterns for all 4. Similar guidelines were also adopted in Israel by the Ministry of Health and in a position paper of the Cardiologists Association and Dieticians in Israel )update published April 2015( 5. The core recommendations are to prefer fresh foods without added sugar, salt, or high-calorie sauces and use different cooking methods for preserving the natural nutrients found in the foods. Additionally, the position paper recommended to include in the daily diet at least five fruits and vegetables and in general to adhere to a healthy dietary pattern such as the Dietary Approaches to Stop Hypertension )DASH( and the Mediterranean Diet 5. In the Scientific Report of 2015, the Dietary Guidelines Advisory Committee considered the workplace as one of the social and environmental factors that influence lifestyle behaviors and therefore may be a target for an intervention program 6. The rate of eating outside the home increased in the last decade; thus, it has a significant impact on the quality and quantity of dietary intake. In many cases, the food served by catering services has lower health qualities, thus creating to some extent an obesogenic environment 7,8,9,10 .Therefore, the workplace may be an efficient target for promotion of a healthy diet. The importance of food at work is reflected in the Millennium Development Goals that set targets for 2015 11. Since 1986 the Ottawa Charter discussed the importance of settings to promote health, as it drew on the principles of health for all with an emphasis on creating positive health. The Ottawa Charter stated that "Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love" 12. On this basis, the settings-based approach was developed. The key strategic point of the settings approach was to move health promotion away from focusing on individual behaviors and communities at risk to developing a strategy that encompasses a total population within a given setting 13. The workplace setting is feasible to implement new health promotion interventions by changing worksite nutrition policies, and thereby might improve labor productivity by 1–2% through reduced absenteeism, reduced attendance at work while sick, and affecting obesity through 2 reducing the average BMI by 5–10% 14. Similar findings were found in a 2010 systematic review by the CDC’s Task Force on Community Preventive Services, revealing that evidence- based wellness programs make positive changes on health, biometric measures, and organizational outcomes, such as health care use and worker productivity 15. On the one hand, individualized interventions where the person is the target, are commonly used to improve dietary intake. but it turns out that this strategy were not sufficient for changing dietary intake 16. On the other hand, It was found that the change in diet quality and the surrounding environment were effective on influencing healthy lifestyle and preventing obesity 16, more than interventions targeted toward individuals.17 Institutional environments (as in catering) are fertile settings for intervention because strategies can use existing structures 16. The catering sector can be a promising environment for enhancing diet quality. It appeals to a wide range of permanent diners, and forms a meeting point between the food, the diner, and the environment. In a systematic review that included six studies conducted in Brazil, the USA, the Netherlands, and Belgium, that examined the effect of different intervention strategies of dietary modifications in the workplace food service (alone or in combination with nutrition ). The intervention uses one or more of the following strategies: 1. Changes in dietary content of available foods/meals as a result of modified food preparation practices (e.g. reduction in salt, sugar or fat content, increase in fruit, vegetables or fibre content). 2. Changes in portion size. 3. Changes in the food choices available to employees by increasing the availability of healthy options (e.g. addition of healthy foods to canteen menus, special cost offers with healthy food choices) or reducing the availability of unhealthy options or simultaneously increasing the availability of healthy options and decreasing the availability of ‘unhealthy’ options. 18 Various methods was used to assess the effects of change in dietary behavior, such as 24-h dietary recall measures, food diaries, weighed food records, food frequency questionnaires (FFQs). The effectiveness of workplace dietary modification interventions on employees' dietary behavior, tested from the clinical health status, self-efficacy, perceived health, determinants of food choice, nutrition knowledge, co-worker support, job satisfaction, economic cost and food-purchasing patterns. The effectiveness of these interventions measured at the individual/employee level and the employer/worksite level 18. In the review they conclude that limited evidence suggests workplace dietary modification interventions alone or in combination with nutrition education, increase fruit and vegetable intakes 18. Interventions with point-of-purchase information show moderate but significant impact on diet quality 19. In some studies nutrition information with calorie labeling on menus appeared to assist consumers in the selection and consumption of fewer calories 20,21.However, In other studies knowing or being able to read and interpret nutritional labeling on food purchased does not necessarily result in consumption of healthier foods, and reducing total calories consumed 22,23. Menu-labeling intervention findings have noted a lack of consistent associations between menu labeling and foods purchased 22. The addition of Fat labeling in worksite cafeterias positively influenced the amount of total fat intake and desserts 24. Interventions that combine changes in the physical food environment, information and dialogue-based initiatives, and organizational changes, showed significant positive nutritional effects, Including a median daily decrease in fat intake, cake, and sweets, and a median increase in intake of dietary fiber and fruit 25. 3 Another study on work site health-promotion programs which focused on the strategies of environmental change that include point-of-purchase labeling, promotional materials, expanded availability of healthy foods, and targeted food placement found that fruits, vegetables, and fat intake were positively influenced following this program 26. It is estimated that changes in diet following wellness programs can be accompanied with medical-cost savings and reduced absenteeism, with estimated returns on investment averaging $3.27 and $2.70 saved over 3 years, respectively, for every $1.00 invested 27. A meta-analysis from 2011 that analyzed the differences in prices of healthier versus less healthy foods or dietary patterns, found that comparing food-based diet patterns, healthier diets cost $1.48/day ($1.01 to $1.95) and $1.54/2000 kcal ($1.15 to $1.94) more. Comparing nutrient-based patterns, price per day was not significantly different (lower vs. upper quantile: $0.04; p = 0.916), whereas the price per 2000 kcal was $1.56 ($0.61 to $2.51) more 28. Other studies confirmed these findings, showing that for the same number of calories, healthy items cost more than less healthy items 29,30. Moreover, over time the prices of healthy vs. unhealthy products are rising faster 30,31. There are a number of key areas in food policies action, including: food environment, food system, and behavior change communication. An efficient strategy for changing the food environment is by offering healthy foods in public institutions 32. In a health promotion study in Australia, barriers for eating healthy in office-based workplaces were “unhealthy food available in office” (30.6%) and “lack of healthy options near office” (28.8%) 33. Another example of the efficiency of health promotion in the workplace is the DIRECT RCT study. In parallel with intervention with three types of diet (low fat, Mediterranean, and low carbohydrate) during 2 years, a modification in the level of the catering was performed, indicating the feasibility of performing change in the workplace as part of a dietary intervention 34. when examining the effect of the three types of diet on participants’ weight, they found that there was better weight control in the low-carbohydrate diet and in the Mediterranean diet, which showed an advantage in diabetes control 35. Following four years, the people on the Mediterranean diet maintained their weight loss along with reduction in their disease biomarkers.36 On the other hand in another randomized trial conducted in Spain, even without weight loss, the risk of participants that were on the Mediterranean diet for cardiovascular events and incidence of type 2 diabetes decreased 37,38. Chronic diseases have economic consequences. For example, in Europe costs associated with cancer reached a level of €126 billion in 2009, while costs of Cardiovascular disease (CVD) was estimated at EU €169 billion annually in 2003, an expense that also includes productivity losses because of early death, informal care cost, and lost working days 39,40. There is evidence that dietary change can lead to economic savings in a variety of diseases such as cancer and cardiovascular disease (CVD), heart attacks and stroke 41,42,43. Health and economic benefits 4 from dietary improvements have been conservatively estimated to be over $70 billion annually in the United States 44. Moreover, a 10% reduction in sodium consumption over 10 years’ intervention across 183 nations was shown to avert approximately 5.8 million Disability Adjusted Life Years per year related to cardiovascular diseases 42. A similar trend of influence can be seen in a national effort to decrease salt consumption by 3 g per day, which would result in saving $10 to $24 billion in healthcare cost on CVD 41. These findings were confirmed in other studies with different levels of savings in health care costs 43,45. The same direction was shown by reducing both saturated fat and salt 46. A kibbutz is a collective community in Israel, and initially adopted socialism and Zionism values, including: equality between people, economic and ideological participation. The kibbutz today is usually a small settlement with several hundred members, and its livelihood, in most cases, is based on agriculture and industry. The kibbutz members eat meals together in a communal dining room, and this place has important role in the kibbutz communal life, 47 and therefore can be a good place for dietary intervention. The present study examines the effect of integrated nutritional intervention, which includes nutritional changes of the recipes, structural change in the dining room, health communication and lectures on healthy diet and exercise, and in addition examines the impact of the change in recipes on incremental cost from the catering perspective.

1.2. Gap of Knowledge Only limited studies have assessed the impact of integrated nutritional intervention on diet quality and preferences of the diners. In addition, little is known about the incremental costs of menu nutritional change from the catering perspective.

1.3. Objectives 1) To estimate the impact integrated nutritional intervention in a catering system on

changes in diet quality and weight of diners. 2) To evaluate the incremental costs of nutritional change in the meal served by a kibbutz catering service.

1.4. Secondary aims 1) To evaluate the impact of integrated nutritional intervention in catering on the level of nutritional and physical activity knowledge. 2) To estimate the impact of the change in the nutritional components and preparation techniques on improving meal quality (calories, saturated fat, carbohydrates, sodium). 5 1.5. Research hypotheses 1) Diet quality of diners in the intervention group will be significantly improved following the intervention compared to that of the control group. 2) Weight loss in the intervention group will be greater compared to that of the control group. 3) Healthier menu according to current nutritional guidelines will cost more due to changes in food items and food preparation techniques.

6 2. Methods The study was performed as a one-phase clustered controlled clinical trial in two large catering systems at kibbutz Magen and kibbutz Nir-Yitzhak. The study work plan in details is described in appendix A.

2.1. Study procedure We identified two catering systems that provide lunch during all weekdays. We chose two kibbutzim that share similar characteristics, Kibbutz Magen (intervention group) and Kibbutz Nir Yitzhak (control group). Participants who agreed to participate in the study and met the inclusion criteria were recruited following their written informed consent (Appendix B) and filled study questionnaires. Sixty-seven participants were recruited from each kibbutz. Upon recruitment and after 3 months, anthropometric measures were elicited from all participants. The Ben-Gurion University Human Subject Research Committee approved the study (#1397-1). The integrated nutritional intervention was developed as part of the PhD thesis of Ofira Katz-Shufan based on a literature review and qualitative data collection and analyses (Table 1). This intervention included the following components: 1. Information on recipes (ingredients and preparation techniques) of lunch menus and the frequency these are served in kibbutz Magen were obtained from the kitchen workers. The portions were calculated according to the measurement units depicted in Appendix C. Based on this information we designed an algorithm for choosing receipts that were modified during the intervention (Figure 1). The difference in nutritional values of recipes before and after modification were calculated using the Tzameret nutritional database (Database of the Ministry of Health, MOH). 2. Structural change in the way the lunch menu is served in the dining room was implemented. 3. Health communication about recommended food choices was provided through various ways, e.g. e-mails, text messages and electronic board. 4. Lectures on nutrition and healthy lifestyle were conducted by registered dietitian and a physical activity specialist at three time points throughout the study. These lectures were the single components that was administered in both groups.

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Table 1 : Description of the intervention program.

Program Description Intervention Control Component MAGEN NIR- YITZHAK 1. Recipes Recipes were chosen for modification based on a + - nutritional predefined algorithm (based mainly on the dietary change recommendation toward Med-diet, a. Lowering: saturated and trans fat, sugar, salt, and processed foods. b. Increasing: fruits, vegetables, and whole grains. 2. Structural Changing the order of the dishes presentation: + - change in a. Healthier dishes presented at noticeable the dining location. room b. Un-healthy items presented at non-central location. c. Nutritional dishes label presented for healthy dishes based on the 2016 MOH recommendations. 3. Health a. An on-going campaign for encouraging + - communicati healthy food choices by: on b. Electronic board in the dinning-room. c. Posters in the dining room. d. Flyers sent in mailboxes. e. E-mail messages. f. Cell-phone text messages. 4. Lectures Three education lectures took place: at baseline, + + after 1 and 3 months. Topics included: a. Nutrition, lifestyle, and health (by a registered dietitian). b. Practice of healthy nutrition at home and out of home (by a registered dietitian). c. Physical activity (by a physical activity specialist). Brochure that summarizes the main issues were handed to participants and sent to those who did not attend the educational meetings.

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Figure 1: Selection of recipes for modification.

2.2. Study population Participants were recruited from two kibbutzim from the Negev area, which share the same characteristics including number of members, age distribution and type of kibbutz in the sense of community management (Table 2). The catering of Kibbutz Magen was chosen for the integrated nutritional intervention while the catering of Kibbutz Nir-Yitzhak was chosen as the control group. Inclusion criteria: The study population consist of diners over the age of 30, who were eating at the kibbutz dining room at least 3 times a week Exclusion criteria: Regular diners at the kibbutz dining room who do not choose their own food.

9 Table 2: General comparison between kibbutzim.

Kibbutz Magen Kibbutz Nir Yitzhak Location Southern District, Southern District, Eshkol Regional Council, Eshkol Regional Council, Israel Israel Date of immigration to Israel 1949, Kibbutz Hashomer 1949, Kibbutz Hashomer Hatzair Hatzair Population 2014 (according to 538 638 Central Bureau of Statistics) Income sources Agriculture, Agriculture, Magen eco-Energy Polycack – Plastic Factory factory. Chemda – Pharmaceutical Chemistry Factory. Number of persons aged 30+ 277 361 Type of grouping Collaborative Renewable The "Collaborative kibbutz" model refers to a kibbutz in which all members are paid equally. In contrast, the "renewed kibbutz" models refers to a kibbutz in which members receive differential wages. In both models, ownership of the means of production of the kibbutz remains common. 2.3. Sample size calculation

Sample size was calculated using Winpepi Software, with 80% power and α=0.05. The sample size calculation was based on the expected change in consumption of fruits and vegetables (in grams), assuming SD=76.7 in the intervention group , and SD=82.5 in the control group 4848 .The recommendations of the World Health Organization is to eat five servings of fruits and vegetables per person per day, equivalent to intake of at least 400 gr per day 4949. To identify a difference of one serving of fruits and vegetables consumption (80 gr) the required sample size is n=17 participants per group, and total of n=34. For difference of half serving (40 gr) the required sample size is n=64 participants per group. In order to consider dropouts and variability in diners age and gender we added another 30% to the larger sample size, resulting in 84 diners in each kibbutz catering.

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Figure 2: Flowchart of participants over the course of the study.

11 2.4. Incremental cost associated with nutritional change

The incremental cost associated with the nutritional improvements refer to the cost of recipe ingredients, labor hours of skilled and unskilled workers, water, gas, and electricity. The costs were calculated from the kibbutz perspective, thus refer to the actual costs paid by the kibbutz including taxes, subsidies, and discounts. Cost estimates and tariffs were obtained from the accounting system of the kibbutz.

2.5. Study measures for the effect of the intervention:

Participants completed the following questionnaires at baseline and after 3 months (questionnaires are included in appendices D, E, F, G): 1. General Information- Socio-demographic characteristics. 2. Food frequency questionnaire (FFQ), a validated measure that includes 126 food items and three portion-size pictures for 17 items 50. Data elicited by this measure was analyzed via computerized dietary intake software from the S. Daniel Abraham International Center for Health and Nutrition at Ben-Gurion University of the Negev 51. 3. Nutritional and physical activity knowledge evaluation. A 27-question questionnaire that was based on Parmenter’s general nutrition knowledge questionnaire for adults 52. The questionnaire contains various questions, including open questions, such as "Write three types of cereals". In addition, there are true / false questions, such as "high intensity exercise is needed to achieve health benefits? true / false" And closed questions with four response options, such as "Recommended duration of exercise per week:150 /60 /45 /90 ". 4. Lifestyle questionnaire that including questions on healthy diet53 and physical activity54. The questionnaire contains questions about eating habits that characterize the type and amount of food drinks consumed, the eating manner and reasons for eating. In addition, it contains questions about the frequency and intensity of performing various types of physical activity. The questionnaire contains closed questions with 3/4/5 answer options (depending on the type of question). Example of a question “When I want something sweet, I usually take: fruit/sweetened yogurt /energy snack/ candy, cookie, cake or chocolate.”

In addition, anthropometric measurements, including weight and abdominal circumference, were measured in light clothing and without shoes by a certified dietitian (the research student). Weight was measured using digital scales with an accuracy of 0.1 kg TANITA type. Height was measured using a folding portable 12 altimeter with accuracy of 0.1 cm SECA type. Waist circumference was measured with a measuring tape, with an accuracy of 0.1 cm.

2.6. Variables description

Variables descriptions are detailed in Table 3.

Table 3: List of study variables.

Variable type Variable Source of information Independent variables Age (years) Reported by participants Gender – Male [n (%)] Number of weekly lunches at the dining room Years of education Status of employment Dependent variables Anthropometric Weight (kg) Measured by dietitian measurement Height (cm) BMI* (kg) BMI = Weight Height (cm)2 Dietary intake Daily fruits and vegetables Calculated from both the Life style consumption (number of questionnaire and from the FFQ. servings and weight) and other food groups, depending on results Diet quality score Calculated using a 13-item questionnaire based on Naimark et al. 55. Data was taken from the FFQ, and the calculation is detailed in Appendix H. Nutritional and physical Nutritional and physical activity activity knowledge knowledge evaluation. A score of 0 to 31 is possible depending on the number of correct answers (Appendix F). Mediterranean Nutritional Calculated based on the FFQ, score (Med diet score) similar to that done by Panagiotakos et al. 56; and the calculation is detailed appendix I. high MED diet score is inversely associated with risk of mortality from all causes, and with lower risk for CVD and cancer in general population 57(Appendix I).

13 2.7. Statistical analysis

The data was encoded into a computerized database. Data was collected at the individual level, but the primary unit of analysis was at the group level (each kibbutz). Data processing was carried out using IBM SPSS statistics software (version 23). Tests were considered significant at p < 0.05 (both sides). The characteristics of the participant was reported as means and standard deviation for continuous variables, and as percentage for categorical variables. To examine the impact of integrated nutritional intervention on between-groups and within-group changes in diet quality and diners’ weight (which were normally distributed) was conducted by independent T-Test and paired T-Test, respectively. To examine these changes. for ordinal variables or non-normally distributed variables (e.g. eating habits or level of nutritional and physical activity knowledge) we used a one-way analysis using Mann-Witnney Test. Within-group analysis these variables (before and after intervention) was done using Wilcoxon Test. For dichotomous variables such as performing physical activity, we analyzed between-groups and within-group differences using 풙ퟐ and McNemar's Test, respectively. Normality of the standardized residuals was assessed using the Shapiro–Wilk test. In order to examine the relative contribution of each variable to the outcome variable, we specified a multivariate logistic regression model to examine determinants of the study outcomes (e.g. those who improved consumption of fruits following the intervention).

To evaluate the incremental costs of nutritional change in the catering’s menu, and the impact of the change in the nutritional components and preparation techniques on improving meal quality, we used Excel software 2013. To test the correlation between the change in dietary values and the cost of the change, we conducted Pearson and spearman correlation.

14 3. Results:

3.1. Results of integrated nutritional intervention

Table 4 presents the characteristics of the study participants at baseline in both study groups. No difference was shown between the two groups at baseline. But it is important to note that the population was relatively older in both kibbutzim, most of them members of the kibbutz, who reported eating nearly 30 years in the kibbutz dining room. The average BMI in both groups is in the overweight range, and nearly half of the population has an academic education.

Table 4: Baseline characteristics of the study participants by study group*.

Intervention group Control group p (Magen) (Nir Yitzhak) value N=67 N=67 Age 55.5±15.8 59.2±15.5 0.172 51(32-83) 57(30-87) Gender – Male, n (%) 35 (52.2) 37 (55.2) 0.729 Kibbutz member, n (%) 56 (84.8) 49 (74.2) 0.131 Number of weekly lunches at the dining room: 0.338 3-4 times a week, n (%) 30 (44.8) 23 (36.5) >5 times a week, n (%) 37 (55.2) 40 (63.5) Number of years eating in this 0.632 dining room 28.9±16.9 30.8±20.5 62(1-63) 64.5(0.5-65) Educational level, n (%) 0.300 Under academic education 31 (46.3) 37 (55.2) Academic education 36 (53.7) 30 (44.8) Height (cm) 166.8±10.3 166.8±9.6 0.993 51(137-188) 43(146-189) Weight (kg) 80.1±15.0 76.8±15.3 0.212 66.0(50.4-116.4) 61.2(46.2-107.4) BMI 28.6±4.8 27.6±4.7 0.214 22.4(20.9-43.3) 20.0(19.2-39.3) Physical activity (minuets/week) 0.568 285.3±379.4 317.9±294.4 2160(0-2160) 1110(0-1110)

* Values are mean±SD, range (minimum-maximum) unless otherwise specified

3.1.1. Dietary intake and diet quality according to lifestyle questionnaire

The first aim of the study was to determine the impact of the intervention on the change in diet quality of diners compared with the control. 15

Fruits and vegetables intake From the lifestyle questionnaire, we chose questions related to dietary intake and lifestyle in general. Changes in fruits and vegetables intake (in gram) following the intervention in both study groups (selected variables) are presented in Figure 3. There was an increase of 32 g in fruits intake in the intervention group (P = 0.008), but not in the control group (P = 0.351). In addition, in the intervention group there was an increase in the combined fruit and vegetable intake of 55 g at a borderline significance (P = 0.058), while no significant difference was observed in the control group (P=0.975). In addition, no significant difference was observed between groups following the intervention in fruits and vegetables intake (P=0.676) (Figure 3).

Figure 3: Change in consumption of fruit and vegetables following the intervention. (Control group N=67, Intervention group N=67)

A univariable analysis of determinants of improved fruits consumption are presented in Table 5. A multivariable logistic model revealed that improved fruits intake is predicted by academic educational level )OR=4.39, 95% CI [1.24,15.50], P = 0.022). The study group was not an independent determinant of improved consumption of fruits )OR=1.28, 95% CI [0.40, 4.08], P = 0.679). (Table 6)

16 Table 5: Univariate analysis of improved fruits consumption. (Control group N=67, Intervention group N=67) OR CI 95% p value Age (years) 1.02 0.99-1.06 0.247 Kibbutz 0.51-4.24 0.481 Intervention group (1) 1.46 control group (0) Gender 0.28-2.35 0.717 Female (1) 0.82 Male (0) Kibbutz Member 0.54-35.48 0.166 Yes (1) 4.39 No (0) No. of years eating in this dining room. 1.02 0.99-1.05 0.158 Educational level: 1.02-9.87 0.046 Academic education (1) 3.18 Under academic education (0) BMI 1.07 0.96-1.19 0.199 Diet Quality Score 0.92 0.81-1.05 0.207 Med Diet Score 1.13 0.83-1.53 0.433 Nutritional and physical activity 1.04 0.93-1.16 0.505 knowledge Do you think you maintain a healthy 0.37-4.60 0.670 lifestyle? Yes (1) 1.13 Otherwise (0) How would you define your daily menu? 0.00-0.00 0.999 Very healthy (1) 0.00 Otherwise (0) When you feel like something sweet you 0.88-2.01 0.278 usually prefer (time 0): Fruit (1) 0.42 Otherwise (0)

Table 6: Multivariate analysis for factors associated with improved consumption of fruits. (Control group N=67, Intervention group N=67)

OR 95% CI p Value Age (years) 1.04 1.00-1.08 0.069

Gender – 0.33-3.15 0.966 Female (1) 1.02 Male (0) Intervention group (1) 1.28 0.40-4.08 0.679 control group (0) Educational level: 1.24-15.50 0.022 Academic education (1) 4.39 Under academic education (0) Area under the ROC curve 0.716 [ 95% CI: 0.59-0.84], P = 0.005 17 A univariable analysis of determinant of improved fruits and vegetables consumption are presented in Table 7. A multivariable logistic model revealed that improved fruits and vegetables intake is predicted by higher BMI )OR=1.10, 95% CI [1.00,1.22], P = 0.054). The study group was not an independent determinant of improved consumption of fruits and vegetables )OR=1.26, 95% CI [0.50,3.22], P = 0.623). (Table 8)

Table 7: Univariate analysis of improved fruit and vegetables consumption. (Control group N=67, Intervention group N=67) OR CI 95% p value Age (years) 1.00 0.97-1.03 0.830 Kibbutz 0.60-3.55 0.405 Intervention group (1) 1.46 control group (0) Gender 0.49-2.87 0.701 Female (1) 1.19 Male (0) Kibbutz Member 0.47-5.32 0.456 Yes (1) 1.58 No (0) No. of years eating in this dining room. 1.01 0.98-1.04 0.394 Educational level: 0.82-4.98 0.124 Academic education (1) 2.02 Under academic education (0) BMI 1.10 1.00-1.20 0.046 Physical activity, 0.30-3.69 0.640 Yes (1) 1.05 No (0) Diet Quality Score 0.91 0.82-1.02 0.108 Med Diet Score 0.97 0.75-1.25 0.972 Nutritional and physical activity 1.07 0.97-1.19 0.157 knowledge Do you think you maintain a healthy 0.38-3.36 0.822 lifestyle? 1.13 Yes (1) Otherwise (0) How would you define your daily menu? 0.05-4.12 0.487 Very healthy (1) 0.46 Otherwise (0) When you feel like something sweet you 0.23-2.21 0.413 usually prefer (time 0): Fruit (1) 0.69 Otherwise (0)

18 Table 8: Multivariate analysis for factors associated with improved consumption of fruits and vegetables. (Control group N=67, Intervention group N=67) OR 95% CI p Value Age (years) 0.99 0.96-3.23 0.640

Gender – 1.08 0.43-2.68 0.874 Female (1) vs. Male (0) Intervention group (1) vs. control group (0) 1.26 0.50-3.22 0.623 BMI 1.10 1.00-1.22 0.054 Area under the ROC curve 0.656 [ 95%CI: 0.54-0.77], P = 0.017

Eating habits When we examined the difference in the sweet food choices, we assumed that following the intervention more participants from the intervention group will choose fruit that represents healthier choice compared to sweets, sweetened yogurt or energy bar that contain sugar supplementation. As expected, a statistically significant increase was found after the intervention in the intervention group (37.2% vs. 25.8%, P = 0.007), but not in the control group (28.6% vs. 23.8%, P = 0.118) (Figures 4). However, as observed in figure 5, when we examined the participants who improved their choice towards fruits as a sweet food after the intervention, no significant difference was found between the intervention and control groups (P = 0.752). No significant differences were found in other eating habits between and within groups following the intervention (Figures 6-8).

Figure 4: Do you think you maintain a healthy lifestyle? (Control group N=67, Intervention group N=67) 19

Figure 5: The percentage of participants who changed their choice towards fruits as sweet food. (Control group N=67, Intervention group N=67)

Figure 6: Do you eat a variety of foods? (Control group N=67, Intervention group N=67)

Figure 7: How would you define your daily menu? (Control group N=67, Intervention group N=67) 20

Figure 8: Do you think you maintain a healthy lifestyle? (Control group N=67, Intervention group N=67)

3.1.2 Dietary intake and diet quality according to the FFQ

General dietary intake

Fruits and vegetables intake There was no significant difference in dietary intake according to the results of the FFQ (Table 9). Table 9: Change in the consumption of fruits and vegetables following the intervention. Intervention p Control p p Time N N (Magen) Valuea (Nir Yitzhak) Valuea Valueb Vegetables Baseline 470.86±470.81 56 429.31±298.04 55 0.580 0.436 0.733 (gr) 3 months 386.57±218.39 48 423.70±335.90 44 0.536 Change -27.61±230.11 -17.91±329.90 0.876 Vegetables Baseline 6.01±6.30 56 5.29±3.80 55 0.474 0.998 0.957 (n) 3 months 4.99±2.66 48 5.53±4.16 44 0.469 Change -0.00±2.48 -0.04±4.22 0.962 Baseline 627.56±893.61 56 543.07±369.96 55 0.518 Fruits (gr) 0.402 0.425 3 months 522.84±386.91 48 594.65±437.14 44 0.406

Change 44.43±344.33 -40.35±316.60 0.247 Fruits (n) Baseline 5.53±8.37 56 4.59±3.40 55 0.440 0.220 0.973 3 months 5.11±3.92 48 5.65±4.18 44 0.529 21 Change 0.66±3.43 0.02±3.49 0.412 Fruits & Baseline 1098.42±1081.09 55 972.38±557.11 54 0.443 0.827 0.511 Vegetables 3 months 909.42±501.72 46 1018.35±687.35 41 0.392 (gr) Change 16.82±501.59 -58.27±555.07 0.519

Fruits & Baseline 11.59±11.43 55 9.92±5.72 54 0.339 0.411 0.915 Vegetables 3 months 10.11±5.30 46 11.36±7.00 41 0.356 (n) Change 0.67±5.18 -0.11±6.37 0.552

n= number of servings N=Population Size Values are mean±SD a Paired T-test b Unpaired T-test

Macronutrients intake

When analyzing the consumption of macronutrients in both groups, we revealed no significant difference within-group and between groups in energy consumption (in Kcal) (Table 10). As opposed to that, we revealed that the percentage of fat intake was significantly higher in the intervention group compared to the control group following the intervention (P = 0.034). However, in both groups there was no significant change in this consumption following the intervention (Table 10). It should be noted that there was no difference between the groups in the consumption of fat in grams (without adjustment for calories) at baseline (P = 0.165), and after the intervention (P = 0.621).

Table 10: Changes in daily consumption of macronutrients following the intervention.

Intervention p Control p p Time N N (Magen) Valuea (Nir Yitzhak) Valuea Valueb Energy Baseline 1739.60±971.20 57 1608 .65±642.48 55 0.405 0.382 0.121 (kcal) 3 months 1463 .70±690.35 49 1512.7 ±761.00 44 0.746 (Mean±SD) Change -107.07±804.28 -187.12±746.35 0.639 Protein Baseline 17.09±4.92 57 16.51±4.19 55 0.559 0.842 0.667 (% of E) 3 months 17.02 ±4.71 49 16.51 ±4.19 44 0.586 (Mean±SD) Change -0.12±4.04 0.27±3.96 0.654 22 Carbohydrate Baseline 48.40±13.11 57 50.67 ±9.2 55 0.296 0.762 0.608 (% of E) 3 months 47.18 ±9.83 49 50.78 ±10.45 44 0.900 (Mean±SD) Change -0.39±8.44 -0.96±11.71 0.797 Baseline 37.64±9.39 57 35.79±6.86 55 0.238 Fat (% of E) 0.529 0.613 3 months 39.02 ±6.71 49 35.85±7.46 44 0.034 (Mean±SD) Change 0.69±7.17 0.71±8.75 0.991 Baseline 26.01±20.60 57 23.81±12.00 55 0.494 Fiber (gr) 0.574 0.106 3 months 21.47±11.77 49 22.87±13.45 44 0.593 (Mean±SD) Change -1.02±11.96 -3.47±13.26 0.377 Total sugar Baseline 128.93±111.67 57 0.822 117.03±56.13 55 0.312 0.481 (mg) 3 months 111.57±82.75 49 117.28±63.32 44 0.712 Mean±SD Change 2.22±64.94 -9.32±57.48 0.393

n= number of servings N=Population Size Values are mean±SD a Paired T-test b Unpaired T-test Micronutrients intake

The analysis of micronutrients revealed that there was a statistically significant decrease in the trans fat consumption in the intervention group (P = 0.031). In the control group there was a decrease in the trans fat consumption, at a borderline significance (P = 0.058), and no difference was observed between groups (Table 11).

In addition, after the intervention, there was a statistically significant decrease in folic acid intake in the control group (P = 0.020). The same trend was shown in the intervention group (P = 0.181). No difference was found between the groups in other micronutrients (Table11).

Table 11: Changes in daily intake of selected micronutrients following the intervention.

Time p p p Intervention N Control N a a b (Magen) Value (Nir Yitzhak) Value Value

Folic acid Baseline 360.48±238.39 57 0.181 330.43±151.11 55 0.020 0.430 (mg) Mean±SD 3 months 280.14±124.91 49 297.17±161.57 44 0.569

Change -36.01±175.55 -65.73±171.79 0.436

Iron, Fe Baseline 10.29±6.50 57 0.210 9.43±4.18 55 0.105 0.409 (mg) 23 Mean±SD 3 months 8.32±3.58 49 8.53±4.69 44 0.814

Change -0.97±5.05 -1.39±5.29 0.713

Trans fatty Baseline 0.55±0.40 57 0.031 0.57±0.43 55 0.058 0.755 acid (mg) Mean±SD 3 months 0.41±0.24 49 0.44±0.36 44 0.715

Change -0.11±0.34 -0.15±0.48 0.711

Cholesterol Baseline 302.71±191.49 57 0.690 261.29±235.11 55 0.175 0.311 (mg) Mean±SD 3 months 270.26±147.25 49 220.77±125.48 44 0.086

Change -9.28±153.12 -59.02±270.49 0.297

Saturated Baseline 22.65±14.29 57 0.458 21.52±10.41 55 0.238 0.636 fat (mg) Mean±SD 3 months 19.66±10.11 49 20.60±10.64 44 0.664

Change -1.30±11.55 -1.77±9.33 0.841

Sodium Baseline 2461.07±1459.4657 0.246 2330.45±990.23 55 0.157 0.583 (mg) Mean±SD 3 months 2061.95±874.1349 2122.43±1232.80 44 0.784

Change -208.74±1178.10 -263.70±1159.93 0.830

n= number of servings N=Population Size Values are mean±SD a Paired T-test b Unpaired T-test

None of the independent variables that were elicited in our study, including the study group predicted the consumption of trans fat (Tables 12, 13).

Table 12: Univariate analysis of reduced trans fat consumption. (Control group N=67, Intervention group N=67) B OR CI 95% p value Age (years) -0.02 0.98 0.95-1.01 0.301 Kibbutz 0.36 1.44 0.57-3.63 0.445 Intervention group (1) control group (0) Gender 0.14 1.15 0.45-2.90 0.770 Male (0) Female (1) Kibbutz Member 0.55 1.73 0.49-6.09 0.390 No (0) 24 Yes (1) No. of years eating in this dining room. 0.10 1.01 0.98-1.04 0.471 Educational level: 0.03 1.03 0.40-2.63 0.946 Under academic education (0) Academic education (1) BMI 0.01 1.01 0.92-1.11 0.783 Physical activity, -0.79 0.45 0.12-1.74 0.249 Yes (1) No (0) Diet Quality Score 0.01 1.01 0.90-1.13 0.850 Med Diet Score 0.23 1.26 0.95-1.65 0.103 Nutritional and physical activity 0.00 1.00 0.93-1.09 0.876 knowledge Do you think you maintain a healthy -0.64 0.53 0.18-1.52 0.236 lifestyle? Yes (1) Otherwise (0) How would you define your daily menu? -0.12 0.89 0.15-5.19 0.889 Very healthy (1) Otherwise (0) When you feel like something sweet you -0.04 0.96 0.32-2.90 0.946 usually prefer (time 0): Fruit (1) Otherwise (0)

Table 13: Multivariate analysis for factors associated with reduction in consumption of trans fat. (Control group N=67, Intervention group N=67) OR 95% CI P Value Age (years) 0.98 0.95-1.02 0.324

Gender – 1.14 0.45-2.93 0.778 Female (1) vs. Male (0) Intervention group (1) vs. 1.36 0.53-3.49 0.523 control group (0) Area under the ROC curve 0.607 [ 95%CI: 0.47-0.74], P = 0.119

Food groups intake adjusted for energy intake After adjusting for calories, there was no difference in fruit and vegetable consumption within and between-groups (Table 14). However, there was a decrease in the bread and cereal intake after the intervention in the intervention group only (P = 0.049), but we need to take into account the fact that this consumption was significantly lower among the intervention group at baseline (P = 0.030). In addition, after adjustment for energy, there was a decrease in the consumption of meats in the intervention group which was at the boundary of statistically significance (P = 0.058), while no significant difference was found in the control group (P = 0.562) (Table 14).

25 Table 14: Changes in daily intake of food groups adjusted for energy intake following the intervention.

Time p p p Intervention N Control N a a b (Magen) Value (Nir Yitzhak) Value Value

Bread & Baseline 66.30±69.38 56 0.049 124.46±181.99 55 0.235 0.030 Cereals 3 months 47.55±48.77 48 84.58±90.00 44 0.018

Change -19.74±63.75 -38.18±200.37 0.581

Dairy & Baseline 344.32±366.15 56 0.390 319.81±215.96 55 0.592 0.669 Eggs 3 months 342.54±383.73 48 313.61±191.39 44 0.653

Change 29.00±219.04 -21.72±253.92 0.332

Fats Baseline 234.82±244.11 56 0.693 165.35±149.10 55 0.974 0.073

3 months 239.49±233.35 48 168.71±187.39 44 0.114

Change 11.69±192.75 1.11±209.85 0.811

Meats Baseline 289.90±267.69 56 0.058 237.49±168.56 55 0.562 0.221

3 months 205.06±14.27 48 210.26±233.22 44 0.897

Change -73.18±246.23 -25.05±270.82 0.399

Fruits Baseline 336.40±485.10 56 0.745 302.88±203.65 55 0.284 0.637

3 months 268.80±209.71 48 323.97±238.82 44 0.241

Change 9.34±186.83 -30.15±175.56 0.325

Vegetables Baseline 169.00±189.75 56 0.255 146.68±103.50 55 0.631 0.444

3 months 136.93±77.84 48 141.64±110.99 44 0.813

Change -15.58±88.52 -9.38±122.47 0.791

Legumes Baseline 17.01±22.79 56 0.355 17.85±21.85 55 0.263 0.843

3 months 22.24±36.31 48 18.10±25.00 44 0.530 26 Change 5.18±36.33 -4.53±25.23 0.164

Unhealthy Baseline 255.56±297.97 56 0.216 264.75±230.52 55 0.108 0.856 foods 3 months 175.17±12.34 48 219.70±217.51 44 0.244

Change -54.45±284.10 -60.82±234.04 0.912

Alcohol Baseline 11.08±23.29 56 0.619 12.62±35.93 55 0.481 0.789

3 months 10.84±21.94 48 18.93±50.11 44 0.328

Change -1.62±21.26 4.45±39.57 0.382

Fats= all (healthy and unhealthy); Meats= including fish; Unhealthy foods= junk food, cakes, soft drinks n= number of servings N=Population Size Values are mean±SD a Paired T-test b Unpaired T-test

None of the independent variables that were elicited in our study, including the study group, predicted the combined consumption of bread and cereal (Tables 15, 16).

Table 15: Univariate analysis of reduced bread and cereal consumption. (Control group N=67, Intervention group N=67)

B OR CI 95% p value Age (years) 0.00 1.00 0.98-1.03 0.762 Kibbutz 0.57 1.77 0.73-4.29 0.204 Intervention group (1) control group (0) Gender -0.87 0.42 0.17-1.03 0.059 Male (0) Female (1) Kibbutz Member -0.02 0.97 0.37-.60 0.960 No (0) Yes (1) No. of years eating in this dining -0.02 0.98 0.95-1.01 0.228 room. Educational level: 0.28 1.32 0.55-2.17 0.532 Under academic education (0) Academic education (1) BMI -0.02 0.98 0.89-1.08 0.689 Physical activity, 0.35 1.42 0.43-4.69 0.564 Yes (1) No (0) Diet Quality Score 0.08 1.08 0.97-1.21 0.164 Med Diet Score 0.08 1.08 0.83-1.41 0.556 27 Nutritional and physical activity 0.35 1.42 0.43-4.69 0.564 knowledge Do you think you maintain a healthy 0.38 1.46 0.46-4.63 0.517 lifestyle? Yes (1) Otherwise (0) How would you define your daily -0.39 0.68 0.06-7.77 0.754 menu? Very healthy (1) Otherwise (0) When you feel like something sweet 0.22 1.25 0.41-3.84 0.697 you usually prefer (time 0): Fruit (1) Otherwise (0)

Table 16: Multivariate analysis for factors associated with reduced consumption of bread and cereal. (Control group N=67, Intervention group N=67)

OR 95% CI P Value Age (years) 1.01 0.98-1.04 0.506 Gender – 0.40 0.16-1.02 0.055 Female (1) vs. Male (0) Intervention group (1) vs. 1.43 0.56-3.61 0.451 control group (0) Area under the ROC curve 0.644 ( 95% CI: 0.52-0.77], P = 0.028

A univariable analysis of determinant of improved meat consumption are presented in Table 17. A multivariable logistic model revealed that being in the intervention group predicted reduced consumption of meat in the presence of age, gender and self-perceived extent of adoption of healthy lifestyle )OR=2.99, 95% CI [1.10,8.09], P = 0.031). (Table 18)

Table 17: Univariate analysis on reduced meat consumption. (Control group N=67, Intervention group N=67)

B OR CI 95% p value Age (years) 0.02 1.02 0.99-1.05 0.237 Kibbutz 0.94 2.55 1.04-6.27 0.041 Intervention group (1) control group (0) Gender -0.36 0.70 0.29-1.70 0.431 Male (0) Female (1) Kibbutz Member 0.67 1.96 0.73-5.25 0.179 No (0) Yes (1) No. of years eating in this dining room. 0.02 1.02 0.99-1.05 0.266 Educational level: -0.17 0.84 0.35-2.03 0.705 Under academic education (0) 28 Academic education (1) BMI -0.06 0.94 0.85-1.04 0.214 Physical activity, 0.13 1.14 0.35-3.65 0.827 Yes (1) No (0) Diet Quality Score 0.07 1.07 0.96-1.20 0.198 Med Diet Score 0.04 1.04 0.80-1.35 0.750 Nutritional and physical activity -0.01 0.99 0.91-1.07 0.747 knowledge Do you think you maintain a healthy 1.65 5.19 1.08-24.94 0.040 lifestyle? Yes (1) Otherwise (0) How would you define your daily menu? 0.34 1.40 0.12-16.13 0.785 Very healthy (1) Otherwise (0) When you feel like something sweet you 0.40 1.49 0.46-4.82 0.508 usually prefer (time 0): Fruit (1) Otherwise (0)

Table 18: Multivariate analysis for factor associated with Reduction in consumption of meat. (Control group N=67, Intervention group N=67)

OR 95% CI p Value Age (years) 1.02 0.99-1.06 0.118

Gender – 0.65 0.24-1.77 0.403 Female (1) vs. Male (0)

Intervention group (1) vs. 2.99 1.10-8.09 0.031 control group (0) Do you think you maintain a 6.82 1.32-35.25 0.022

healthy lifestyle? Yes (1) Otherwise (0)

Area under the ROC curve 0.723 [ 95%CI: 0.61-0.83], P = 0.001

Changes in nutritional quality scores Surprisingly, Diet Quality Score decreased after the intervention in the intervention group with borderline significance (P = 0.083) whereas no change was detected in the control (P = 0.416), and no change between groups was observed at baseline and following the intervention. (Table 19). No significant change in Med Diet Score was shown following the intervention in the intervention group (P = 0.572), compare to a decrease in the control group’s score with borderline significance (P = 0.087) (Table 19). Thus far, study results partially supported hypothesis #1. Our intervention partially improved the dietary intake of dinners.

29 Table 19: Changes in nutrition scores (MED Diet Score, Diet quality score) following the intervention. Time Intervention p Control p p N N (Magen) Valuea (Nir Yitzhak) Valuea Valueb Diet Baseline 23.74±3.88 63 0.083 22.50±3.08 63 0.416 0.236 Quality score* 3 months 22.68±4.36 51 21.88±4.88 49 0.392 Change -1.06±4.24 -0.62±5.28 0.653 Med Baseline 3.96±1.77 57 0.572 4.21±1.88 45 0.087 0.456 Diet score** 3 months 4.30±1.78 49 3.80±1.88 57 0.187 Change 0.18±2.09 -0.63±2.35 0.093

*Calculated from 13-item questionnaire **Calculated from FFQ n= number of servings N=Population Size Values are mean±SD a Paired T-test b Unpaired T-test

3.1.3 The impact of integrated nutritional intervention on weight

Anthropometric measurements: No change was detected in both weight and BMI over the course of the study. (Table 20). Thus, the study results did not support hypothesis #2.

Table 20: Changes in anthropometric measurements following the intervention. Time Intervention p Control p p N N (Magen) Valuea (Nir Yitzhak) Valuea Valueb Weight (kg) Baseline 80.13±15.05 63 0.654 76.76±15.28 64 0.422 0.212 (Mean±SD) 3 months 80.16±14.98 60 76.56±15.47 58 0.202 Change 0.11±2.00 0.21±2.04 0.793 BMI Baseline 28.62±4.76 63 0.538 27.57±4.69 64 0.433 0.214 (Mean±SD) 3 months 28.56±4.65 60 27.50±4.82 58 0.208 Change 0.06±0.72 0.07±0.72 0.905 n= number of servings N=Population Size Values are mean±SD a Paired T-test b Unpaired T-test

30 3.1.4. Change in the level of nutritional and physical activity knowledge

Analysis of the nutritional and physical activity knowledge evaluation revealed a significant increase in the score of the control group after the intervention (P = 0.025) (Table 21). Surprisingly, this result was not observed in the intervention group (P = 0.100). However, although higher percentage of the intervention group improved their nutritional and physical activity knowledge score (54.0% vs. 62.2%) this difference was not significant (P = 0.418) (Table 22). In addition, when we separately analyzed the change in the knowledge score only for questions that received low score at baseline, no significant difference was observed between groups in the percentage of patients whose knowledge score improved (28.3% vs. 35.3%, P = 0.502).

Table 21: Changes in nutritional and physical activity knowledge following the intervention.

Time p p p Intervention N Control N a a b (Magen) Value (Nir Yitzhak) Value Value

Nutritional Baseline 23.09±4.90 62 0.100 21.17±6.50 60 0.025 0.082 & PA 50 45 0.134 knowledge 3 months 24.42±4.39 22.35±6.18 (Mean±SD) Change 0.63±2.83 50 1.48±4.85 45 0.309 n= number of servings N=Population Size Values are mean±SD a Wilkokson test b Mann-Witney test

Table 22: The difference between the kibbutzim in improving nutritional and physical activity knowledge Intervention (Magen) Control (Nir Yitzhak) p value N(%) N(%) Improve knowledge Yes 27(54.0) 28(62.2) 0.418 score No 23(46.0) 17(37.8)

There was no difference between the kibbutzim in the number of participants who attended the lectures, and the number of lectures they attended (P = 0.471). The effect of presence in the lectures on the knowledge score revealed that the proportions of participants in the intervention group who attended the educational program among whose score improved or did not improve were similar (40.7% vs. 43.5%, P = 0.845). 31 However, the proportions of participants in the control group who attended the educational program was significantly higher among those whose score improved compared to those whose score did not improve (46.4% vs. 17.6%, P = 0.017).

3.2. Changing the ingredients and preparation techniques of recipes: The impact on nutritional values and costs 3.2.1. Incremental costs associated with recipes modification

The increase in the costs associated with recipes’ modification were mainly derived from changing the type of meat, adding oat bran instead of breadcrumbs, substituting factory- made sauces with self-made ones (e.g. chili sauce, pad Thai sauce, teriyaki sauce), adding vegetables, and reducing fat of the cheese. A reduce in the costs associated with recipes modifications was mainly derived from a reduction in the number of sodium-rich products such as salt, soup powder, grilled chicken powder; reduced amount of sauces; reduction in the fat of the cooking cream; and reduction in sugar-rich products such as silane. The single change in the preparation technique of the recipes referred to substituting factory- made sauces with self-made sauces (the recipes are presented in Appendix J). Calculation of the total cost of preparing the self-made sauces is detailed in Table 23. The incremental costs associated with recipes modification ranged between -27.5 and +733.5 NIS per recipe (Table 24). The incremental costs associated with all recipe’s modification is detailed in Appendix K. This calculation revealed that the change in recipes led to greater than zero incremental cost in 15 recipes (57.7% of the modified recipes) and in 11 recipes led to lower than zero incremental cost (42.3% of the recipes). However, this effect depends on the frequency of provision of each recipe. Analysis of actual provision frequency during 3 weeks in the intervention period, revealed that if the recipe’s modification was based only on changing recipe’s ingredients (without using self-made sauces instead of factory-made ones), in 46.8% (n=256) of 547 modified dishes that were purchased during this period the incremental cost associated with recipe’s modification was greater than zero. However, if the recipe’s modification was based on changing ingredient and/or using self-made sauces instead of factory-made ones the incremental cost in 89.6% (n=490) of 547 purchased dishes was positive. Thus, out study results partially supported research hypothesis #3.

32 Table 23: The cost of ingredients in self-made sauces. Recipe Actual Food Amou price Price Source of information ingredient nt after discount Sweet Chili Purchase receipts for a Chili 32.40₪ per 1 sauce in dining room at pepper Kg self- 500 g 16.20 Kibbutz Magen preparation Garlic Purchase receipts for a cloves 54₪ per 1 Kg dining room at peeled 9 g 0.48 Kibbutz Magen White 30.40₪ Per 1 wine 750 L vinegar ML 22.80 Shufersal Online Purchase receipts for a ₪3.65 per 1 Sugar dining room at Kg 645 g 2.38 Kibbutz Magen Cost of 45 Reporting of the ₪27 per hour 20.25 personnel Min dining room manager Cost of Ministry of National cooking 40 15 ₪ per hour Infrastructures Energy gas Min 0.02 and Water

0.57 ₪per hour Electricity 5Min 0.10 Ministry of Energy

Total cost ₪ 1.931 62.24 Teriyaki Soy sauce 29.80₪ Per 1 sauce in reduced 200 5.96 Rami Levy food L self- sodium ML shopping center preparation 300 0.0003₪ Per 1 Water 0.00 ML L Israel Water Authority One orange 4.50₪ per 1 Purchase receipts for a 0.67 squeezed Kg dining room at juice 150 g Kibbutz Magen Purchase receipts for a Brown 10.80₪ per 1 1.08 dining room at sugar Kg 100g Kibbutz Magen Fresh ginger root 19.90₪ per 1 Purchase receipts for a 0.04 finely Kg dining room at chopped 2g Kibbutz Magen A finely chopped Purchase receipts for a 54₪ per 1 Kg 0.16 garlic dining room at clove 3g Kibbutz Magen Chili 11.71₪ Per 1 Rami Levy food 0.05 Gross ML 5 L shopping center Purchase receipts for a 13.50₪ per 1 0.81 dining room at Cornflour Kg 60g Kibbutz Magen 33 Cost of 10 Reporting of the ₪27per hour 4.50 personnel Min dining room manager Cost of Ministry of National 0.15 ₪ per cooking 10 Infrastructures Energy hour gas Min 0.02 and Water Total cost ₪ 0.82 13.31 PAD Thai Soy sauce 29.80 ₪ Per 1 sauce in reduced ML , Rami Levy food L self- sodium 600 17.88 shopping center preparation Rice 200 27.80 ₪ Per 1 , Rami Levy food vinegar ML L 5.56 shopping center Purchase receipts for a ₪3.65 per 1 Sugar dining room at Kg 66 g 0.24 Kibbutz Magen 30 Fish sauce 36₪ Per 1 L ML 1.08 Shufersal Online Chili 136.66₪ Per 1 , Rami Levy food sauce 3 ML L 0.41 shopping center Cost of 15 Reporting of the 27 ₪ per hour personnel Min 6.75 dining room manager/ Cost of Ministry of National 0.15 ₪ per cooking 10 Infrastructures Energy hour gas Min 0.02 and Water Total cost₪ 0.896 31.94

Table 24: Examples for the calculation of incremental cost following the recipes’ modification.

Cost of Cost of Total Recipe name Change in components removing adding incremental components components cost

Replace the type of meat to grind from the muscle (chest 450.00 1197.00 or shoulder so there will be less fat) and grind in place. Homemade -Reduce the amount of meatballs / seasoning of grilled chicken in 0.75 0.37 beef patties / half 733.53 beef and - Reduce the amount of soup 16.76 8.38 turkey patties powder in half -Reduce the amount of bread 114.00 57.00 crumbs in half Add oat bran instead of 52.30 reduced bread crumbs - Reduce the amount of soup 20.96 10.48 powder in half Bolognese - Replacement of tomato paste 302.35 to reduce sodium (tomato paste 146.30 390.488 concentrates without sugar and 34 salt, Grand Italy - Rami Levy price) - Add grated vegetables onion 23.20 8 kg Carrots 3 kg 3.45 7 kg Zucchini 42.00

- Reduce half the amount of 5.98 2.99 teriyaki sauce - Reduce the amount of silane 27.80 13.90 Kotelt pork in half -23.57 - Reduce half the amount of 4.97 2.48 soy sauce - Reduce the amount of soup 8.38 4.19 powder in half - Reduce half the amount of 22.44 11.22 teriyaki sauce - Reduce half the amount of 11.82 5.91 chili sauce -Reduction of half the amount 0.33 0.16 Butterfly of salt Chicken - - Reduce half the amount of 4.97 2.48 -27.55 Reducing soy sauce Components Reduce the amount of seasoning of grilled chicken in 5.04 2.52 half

- Reduce the amount of soup 10.48 5.24 powder in half

Analysis of recipes that could be improved by either reduction of factory-made sauce or replacing factory-made sauces with self-made ones, revealed as expected that replacing factory-made sauce with self-made sauce resulted in higher incremental costs compared to reduction in factory-made sauces. This difference ranged from 2.1NIS per recipe to 56.9 NIS (Table 25).

Table 25: Comparing the incremental costs associated with modification of the recipe’s sauce*. Recipe name Incremental cost Incremental cost Difference in associated with associated with incremental costs reduction in factory- replacing factory- made sauces made sauce with self- made sauce Butterfly Chicken -27.55 +29.37 56.92 Turkey wings -17.65 +21.53 39.19 Stir-fried -9.28 +5.30 14.58 Stir-fried tofu -2.81 +10.59 13.40 Chicken skewers -12.83 -8.46 4.37 Turkey breast -9.07 +34.74 43.81 Spicy carrot salad -0.38 +1.67 2.06 * The change in cost calculated per recipe 35 3.2.2. Change in nutritional values (calories, saturated fat, carbohydrates, sodium) following recipes modifications.

Analysis of the nutritional values for 100 grams dish after recipes modification revealed that sodium levels ranged from a decrease of 486.23 mg to an increase of 7.69 mg. The difference in carbohydrate levels ranged from a decrease of 4.18 gr to an increase of 0.10 gr. The difference in Saturated fat ranged from a decrease of 4.22 gr to an increase of 0.50 gr. The difference in calorie levels ranged from a decrease of 215.55 Kcal to an increase of 16.43 Kcal (Table 26). There was a decrease in dietary values of sodium in 84.6% of the recipes that were modified, carbohydrate in 80.8% of the recipes, saturated fat in 53.8% of the recipes and calorie in 76.9% of the recipes that were modified (Appendix L). Analysis of the change in nutritional values of self-made sauces compared to factory-made sauces after recipes modification revealed that the main difference was a decrease in sodium levels ,which reached up to 122 mg (Table 27). Naturally, the extent of this effect depends on the frequency of provision of the recipes. The change in nutritional values for all the recipes are reported in Appendix L. A correlation between the change in nutritional values of the modified recipes and the incremental costs associated with this change, revealed that as the saturated fat associated with the recipe’s modification decreased, the incremental cost associated with this modification increased (rs= -0.610, P = 0.001). A similar finding was found with regard to the energy value of the recipes. Namely, as the energy value decreased due to recipe’s modification, the incremental cost increased (rs= -0.582, P = 0.002) However, decrease in sodium (rs= -0.049, P = 0.814), and carbohydrate (rs= 0.133, P = 0.518), were not associated with increased incremental costs (Table 28).

Table 26: Examples of change in the nutritional values of the recipes following recipe modification. Saturated Energy fat Carbohydrate Sodium Bolognese -29.96 -0.66 -2.11 -486.23 Cheesecake -23.86 -1.82 0.01 7.69 Stuffed zucchini -60.66 -4.22 0.08 7.47 Chicken cutlets -32.15 -0.35 -4.18 -264.44 Veal cutlet -215.55 -3.78 -1.82 -30.45 Kotelt pork 16.43 0.50 -3.45 -169.69 Cannelloni -55.43 -3.88 0.10 4.00 Butterfly Chicken -6.38 -0.02 -1.39 -346.01 * Nutritional values are shown for 100 grams of product.

36 Table 27: The change in nutritional values of self-made sauces compared to factory- made sauces after recipe modification. Energy Saturated fat Carbohydrate Sodium Stir-fried tofu 0.10 -0.00 0.18 -12.96 Butterfly Chicken -6.47 -0.04 0.04 -122.59 Turkey wings -5.57 -0.07 0.02 -82.42 Stir-fry with chicken 5.83 0.08 -0.25 -37.91 Chicken skewers -1.68 -0.01 -0.23 -34.52 Turkey breast -5.07 -0.04 0.03 -86.32 Spicy carrot salad 0.46 -0.01 0.40 -25.49

Table 28: Correlation between change in nutritional values and change in recipe cost.

Spearman p value rho Change in sodium (mg) -0.049 0.814 Change in saturated fat (mg) -0.610 0.001 Carbohydrate change (gr) 0.133 0.518 Change in energy (Kcal) -0.582 0.002

37 4. Discussion and summary of the results

4.1. Summary of the results

The impact of the intervention on diet quality The diet quality in our study was measured by several diet quality measurements according to the Ministry of Health recommendations. Measurements include: fruits and vegetables intake, diet quality score, and eating habits, as derived from the lifestyle questionnaire. In addition, it was measured by the macronutrients, micronutrients, and Med Diet score calculated from the FFQ. Based on the lifestyle questionnaire we showed an increase in fruits intake, and a borderline significant increase in combined intake of fruits and vegetables following the intervention only in the intervention group. However, when examining the consumption of fruits and vegetables as derived from the FFQ questionnaire, no significant change was observed. In addition, a multivariate analysis revealed that study group was not a significant determinant of improved intake of combined fruits and vegetables or fruits alone. These consumptions were predicted by higher BMI and academic education, respectively. Following the intervention there was a decrease in the consumption of bread and cereals and meat in the intervention group. After adjusting for calories there was a significant decrease following the intervention in the consumption of bread and cereal, and a borderline significant reduction of meat consumption, only in the intervention group. Yet, a multivariate analysis revealed that intervention group was a significant determinant of reduced meat consumption, but not bread and cereal consumption. In addition, we found a decrease in the consumption of trans fat following the intervention in both groups, which was significant in the intervention group and with only a borderline significance in the control group. However, in a multivariate analysis the intervention group was not a significant determinant of reduced trans fat consumption. Finally, there was no significant change in the Diet Quality Score or the Med Diet Score following the intervention in both groups, and there was no significant change in the diners’ weight and BMI following the intervention. The impact of the intervention on the level of nutritional and physical activity knowledge When comparing the level of nutritional and physical activity knowledge, we found a significance increase in the score of the control group after the intervention. This was not observed in the intervention group.

38 The incremental costs associated with nutritional change of recipes The incremental costs associated with recipes modification ranged between negative and positive values, yet, most of the recipes that were modified resulted with increase in the incremental cost. However, analysis of actual provision frequency revealed that if the recipe’s modification was based only on changing the recipe’s ingredients (without using self-made sauces instead of factory-made ones) in less than half of the number of modified dishes that were actually purchased, the incremental cost associated with recipe modification increased. If the recipe’s modification was based on changing ingredients and/or using self-made sauces instead of factory-made ones the incremental cost in most of the purchased dishes was greater than zero. Finally, replacing factory-made sauce with self-made sauce resulted in higher incremental costs compared to recipe modification that was based on reduction of factory-made sauces. The impact of recipes modification on the nutritional value Our study found that changing the ingredients and preparation techniques of recipes led to modifications that ranged between negative and positive values. In fifty percent or more of the recipes that were modified, we observed a decrease in dietary values of sodium, carbohydrate, saturated fat, and calories. In addition, our results revealed that decrease in energy (in Kcal) and saturated fat (in mg) due to recipe modifications were associated with increase in the incremental costs of this modification. However, decrease in sodium and carbohydrate were not associated with increased incremental costs. 4.2. Discussion In this study, we tested the impact of integrated nutritional intervention on improvement in dietary quality. Increasing intake of fruits and vegetables was one of the main goals of our intervention and it is the target of nutritional education and policies around the world. Fruits and vegetables represent nutritious food, containing significant amounts of nutrients with relatively low energy, more so in vegetables 61. Both the Israel Ministry of Health and the World Health Organization as well as Canada, the United Kingdom, and the United States, recommend improving the consumption of fruits and vegetables5,61,62,63. Fruits and vegetables are part of a healthy diet that was shown in many studies to lower the risk for weight gain as well as non-communicable diseases 5,61,62,63. The increased intake of fruit and vegetables and fruit alone in our study is in accord with other intervention studies in the workplaces.18,60,64,65 One study that was performed in workplace cafeterias in Sao Paulo, Brazil, over 6 months, showed a 49 g increase in availability of fruits and vegetables among companies in the intervention group 39 compared with the control group 64. In a systematic review that included six studies conducted in Brazil, the USA, the Netherlands, and Belgium, that examined the effect of dietary intervention in the workplace alone or in combination with nutrition education, found an increase in fruits and vegetables intake 18. Moreover, adding meal labelling improved the dietary intake of fruits and vegetables by 47% (increase in consumption from 31 g to 46 g/100 g of product) 65. The ‘Food at Work’ intervention study, which was performed in eight blue-collar worksites in Denmark, examined the impact of a 6-month intervention study on employees’ dietary habits and on changes in the canteen nutrition environment, found an increase in the consumption of 55 grams of fruit alone and an increase of 95 grams in the combined consumption of fruits and vegetables 60, which is similar to our results. In our study, we found in the intervention group a trend of reducing meat consumption (p = 0.058), as opposed to previous worksite intervention, which included a 16-week Group Lifestyle Balance intervention, where the reduction in red meat consumption was statistically significant 66. Another finding in our study was a reduction in consumption of bread and cereals only in the intervention group. A nutritional intervention program that was performed at the worksite canteens food company in Italy found that after the intervention, there was a significantly higher choice of dishes based on wholegrain cereals, and a lower choice of dishes based on refined cereals 59. Another study that examined the effect of labeled information on food items on buying patterns of college students, found that following the intervention, there were increased sales of tagged items in the cereal and cracker categories, while sales of bread decreased 67. It is recommended that further research will discern between the different cereal types. It is possible that in our study the decrease in calories from cereals and bread is due to dietary recommendations, or a misleading conception of a low carbohydrate diet. Therefore, further research is recommended to explore this finding by collecting medical data as well as knowledge and attitudes toward low carb diets. Interestingly, we did not show a change in the consumption of high-fat foods in both groups. This finding is in contrast to previous intervention studies that showed a decrease in fat intake in the diet 60,68,69. The difference may stem from the fact that, for example, in the ‘Food at Work’ intervention study, they repeatedly encouraged initiating nutrition-related activities addressing both individual and environment levels 60. In addition, as opposed to our study, in the GEICO multicenter trial the participants were asked specifically to be on a low-fat and vegetarian diet 68. Finally, in the study that was carried out in worksite cafeterias, the intervention program included provision 40 of food labeling with specific nutritional information (e.g., calories and macronutrients), and this may better raise awareness of nutritional values and improve nutritional intake 69. Contrary to the results of our study, which showed no change in sugar intake according to the FFQ questionnaire, a previous study that examined the effectiveness and long- term impact of a nutritional intervention program at a worksite canteen showed a reduction in the consumption of sugars 59. This may imply that the effects may be observed in a long-term follow-up. In our study, we did not show a decrease in energy intake. This finding is in contrast to a previous study where food labeling resulted in decreased in caloric intake after the intervention 62. A similar decrease was observed in an intervention study targeting energy and nutrient intake in a worksite cafeterias over 3 months, and based on the objective cafeteria registered data measures of energy intake of purchased foods; however this trend was not observed when analyzing self-report measures of intake with 24 h food recalls 59. Our study revealed a decrease in trans fat consumption, as shown in previous intervention studies 59,68. Unlike other studies, no change was detected in saturated fat intake 59,68. In our study, there was no significant effect of the intervention on the nutrition scores for the Med diet and Diet quality. As opposed to another study that found that an intervention program performed in a dining facility improved soldiers’ diet quality 70. Different methods of calculation of dietary quality estimates may lead to different results of the intervention's impact on nutritional quality. In addition, our intervention program mainly focused on proving enabling environment during lunch, and was not individually-tailored intervention and did not accompany participant during all day. Thus, it did not affect participants’ nutrition score. Finally, some of the questions in the lifestyle questionnaire that were utilized in our study examined eating habits, and this may have affected the score as well. In the current study, we found that the FFQ was not adequately representative of the specific changes in dietary intake following the intervention. One disadvantage of the FFQ is relying on memory rather than information recorded in real time. This may affect the accuracy of the results. Additionally, due to the cognitive load involved in filling out a large number of questionnaires, participants may have been less careful in addressing every item of the FFQ in detail. Another explanation is that the FFQs lack detailed information on the food preparation techniques and there are only predefined portion sizes. All participants filled the FFQ in a self-reported manner and not by an 41 interviewer. We feel that this self-administered method was not appropriate to capture an accurate measure of intake in our population. Therefore, the results of the FFQ were inconsistent and hard to explain. For future studies assessing the impact of an intervention program on diet, a shorter clear and less detailed approach (e.g., using a photograph of the chosen meal) should be used. In addition, it would be important to pretest the dietary assessment method in a targeted study population. It is also necessary to examine objective measures of dietary consumption, and not rely only on self-reported questionnaires. It is recommended to make a focused assessment of a targeted meal, as was conducted in previous studies 59. Finally, quality criteria for the accuracy of the data collected need to be considered 71. The purpose of our intervention program and short-term follow-up was to promote changes in eating habits and dietary intake and not particularly to affect weight. In addition, the participants were not recruited by weight criteria. Indeed, we did not capture any within and between-groups difference in weight loss. The PREDIMED study suggested that healthy diet even without weight change, improved health indicators 72. In our case, the nutritional and physical activity knowledge score was higher in both groups at baseline and after 3 months. However, the score did not increase after the intervention as opposed to the results of previous studies that showed significant improvement in knowledge following intervention with nutrition application 73. In accordance to our expectations, changing the ingredient and preparation techniques of selected recipes in order to improve their nutritional values increased their cost 28,29,30,31. The cost of the change depends on the quality of the product (such as the type of meat), and suppliers’ discounts. We found that the incremental costs that were associated with self-made sauces were higher compared to reduction in the quantities of problematic components of the factory-made sauce; yet, this modification improved the nutritional value of the recipe. We saw that the change in price was found in the correlation with trans fat levels and calories, and thus may affect public health 41,42,45,46. We found that when more ingredients of a recipe are prepared from raw materials and fewer processed ingredients such as sauces, we achieve greater decrease in unhealthy nutrients, such as sodium and saturated fat levels. It should be noted that the change in recipes was carried out theoretically; therefore the level of participants’ response to the change was not examined. We recommend that further studies will examine the food choices and the amount of dietary intake after the nutritional modification of the menu.

42 4.3. Strengths and limitation

The Strengths of this study

Many workplaces in Israel offer their employees lunch in a catered system. Lunch is the main and largest meal of the day for most of the workers. Therefore, these meals have a significant impact on their dietary intake and diet quality. The catering system of a kibbutz that was analyzed in the current study is a model for a workplace catering system, since most residents of the kibbutz work in the kibbutz. Furthermore, a catering menu can have a great effect on the overall daily dietary intake since eating in the workplace can be an educational benchmark for the adoption of a healthy diet and affect the workers’ health outcomes. The study’s uniqueness is derived from the fact that it evaluated the effect of integrated nutritional intervention, on diet quality using several measures, thus enriched and extended knowledge and provided comprehensive evidence. Second, the current study provided an actual estimate of the incremental costs associated with recipes’ modifications towards nutritional improvement. This analysis is unique in Israel, and may provide the basis for future cost effectiveness analysis of similar strategies. The study design and results could contribute to development of catering-level interventions and may serve as a model for similar environmental intervention in catering systems in various settings.

The limitations of this study

1) During the study, we encountered difficulties due to the change in the management of the catering in both kibbutzim. Kibbutz Nir Yitzhak (the control group) changed the caterer employed by the kibbutz during the intervention. This change influenced the type of dishes served and thus could affect the results of the study. 2) The follow-up period was relatively short. A higher effect may have been accumulated if the follow-up was longer. 3) There was no randomization of assignment to the study groups. 4) The study sample is not representative of the population of diners in other catering systems. 5) The sample size was calculated on the basis of the effect size fruits and vegetables consumption, although other outcomes were examined in this study. 6) There may be inaccuracies in reported recipe preparation (portions and ingredients) due to changes in availability of products. 7) The data on the number of dishes that is obtained from each recipe was not available; thus, we could not calculate the total actual weighted incremental costs associated with all recipes’ modifications. 43 8) The diet quality was estimated based on self-reported measures that may be subject to recall bias and social desirability bias; however, this limitation does not weaken the study results, since our focus was to analyze the relative changes following the intervention, rather than the absolute values. 9) The outcome variable was elicited using questionnaires that referred to a weekly dietary intake, while our intervention program was focused on the diners’ lunch. Further research should incorporate objective measures that will elicit the actual dietary intake during lunch as derived, for example, from the dining room’s cash register.

5. Conclusion

According to our study results, a catering-level intervention program only mildly affect the nutritional habits and food choices. It seems that a combined intervention that includes both individually-tailored strategies and environmental strategies will have more influence on dietary changes. In addition, we recommend that future studies will adopt objective and accurate dietary assessment methods such as photographs of the purchased meal. An increase in incremental cost was mainly derived from replacing factory-made sauces with self-made ones. Improved values of saturated fat and energy were associated with higher incremental costs; however, decreases in sodium and carbohydrates were not associated with increased incremental costs. The fact that the incremental costs of the nutritional change towards healthy dishes were greater than zero from the kibbutz perspectives may be offset by the potential savings resulting from the expected improvement in health, yet this analysis is based on the societal perspective. Our study may contribute to the development of catering-level interventions and may serve as a model for similar environmental intervention in catering systems in various settings.

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54 Appendices:

Appendix A: The Study Time-line

55

Appendix B: Sample informed consent form טופס הסכמה מדעת להשתתפות

במחקר תזונה בקיבוצים

למשתתף / משתתפת שלום !

אני החתום מטה: שם פרטי ומשפחה מס' תעודת זהות מספר טלפון נייד כתובת

מצהיר בזה כי אני מסכים/ה להשתתף במחקר כמפורט במסמך זה. מצהיר בזה כי הוסבר לי על ידי: שם החוקר המסביר:

כי המחקר הנ"ל קיבל אישור מועדת האתיקה באוניברסיטת בן גוריון. כי המחקר נערך בנושא : פיתוח והערכה של תכנית לקידום אכילה בריאה בחדרי אוכל בקיבוצים. כי אני חופשי/ה לבחור שלא להשתתף במחקר, וכי אני חופשי/ה להפסיק בכל עת את השתתפותי במחקר. כי במקרה של מילוי שאלון – אני רשאי/ת שלא לענות על כל השאלות שבשאלון, או על חלק מהן. כי מובטח לי שזהותי האישית תשמר סודית על ידי כל העוסקים והמעורבים במחקר ולא תפורסם בכל פרסום, כולל בפרסומים מדעיים. כי בכל בעיה ושאלה המתעוררת בנוגע למחקר זה אוכל לפנות לאופירה כ"ץ-שופן בטלפון 052-4326540 או במייל [email protected] הנני מצהיר/ה כי נמסר לי מידע מפורט על המחקר לפי הנושאים להלן: מטרות המחקר: לבנות ליישם ולבדוק יעילות ותועלת של תכנית לקידום אכילה בריאה בחדרי אוכל בקיבוצים. התקופה הצפויה למשך ההשתתפות במחקר: 6 חודשים. הנדרש מהמשתתף במסגרת המחקר: במהלך תקופת המחקר ייערכו שינויים במנות המוגשות בחדר האוכל, יופיע סימון תזונתי ויופץ פרסום לעידוד צריכת מזון בריא. כל משתתף במחקר ישתתף ב 3 מפגשי הדרכה, יידרש לענות על 5 שאלונים ב 3 נקודות זמן, וייבדק על ידי תזונאית לאמידת משקל, גובה והקף מותן. בנוסף יתבקש המשתתף לצלם את מגש האוכל שלו באמצעות הטלפון הסלולרי האישי או באמצעות צוות המחקר, במשך 3 ארוחות צהריים בשבוע מסוים, ב- 3 נקודות זמן. סה"כ 9 תצלומים לאורך המחקר אי הנוחות העלולה להיגרם למשתתף- אובדן זמן. היתרונות הצפויים למשתתפים כתוצאה מהמחקר: קבלת משוב אישי בכתב )בהמשך לבקשת המשתתף( על התזונה שלך ועל המדדים האישיים שלך, כפי שמשתקפים מהמדידות ומהשאלונים והתמונות. הנני מצהיר/ה בזאת, כי את הסכמתי הנ"ל נתתי מרצוני החופשי וכי הבנתי את כל האמור לעיל. כמו כן, קיבלתי עותק של טופס הסכמה מדעת זה, נושא תאריך וחתום. אנו מודים לך על השתתפותך במחקר ,ומעריכים את עזרתך. אופירה כ"ץ-שופן, פרופ' דנית שחר וד"ר צחית סימון תובל.

הצהרת המשתתף :

אני החתום/ה מטה מצהיר/ה כי קראתי את טופס ההסכמה במלואו ,וכי בחתימתי אני מביע/ה את הסכמתי להשתתף במחקר.

תאריך שם פרטי + משפחה חתימה

הצהרת החוקר :

אני החתום/ה מטה מצהיר/ה כי אני מחויב לשמור על סודיות מלאה .כל המידע הרלוונטי יהיה חשוף לצוות המחקר בלבד ולפי המוסבר בטופס זה.

תאריך שם פרטי + משפחה חתימה 56 Appendix C: Measurement Units Add details for the calculation in detail and unit of measurement

Unit of measure Estimated volume

Teaspoon 5ML / 5 gr

Tablespoon / 15gr ML 15

Cup 200ML / 200 gr

 price were measured by 1 kg / 1 liter

57 Appendix D: General Information: from a questionnaire on general and demographic information

58

59

60 Appendix E: food frequency questionnaire

61 62 63 64

65 Appendix F: Nutritional and physical activity knowledge evaluation

66

67

68

69

70 Appendix G: Lifestyle questionnaire

71

72

73

74

75

76

77

78

79

Appendix H :Nutrition Quality Score

Questio Score Question n Question Topic Answer Score range Sign In SPSS 1 Daily Vegetables 0 not eating at all 0-3 Ifood_1 consumption 1 1-2 servings/day 2 3-4 servings/day 3 5 servings or more/day 2 Daily Fruits consumption 0 not eating at all 0-3 Ifood_2 1 5 servings or more/day 2 1-2 servings/day 3 3-4 servings/day 3 Daily Vegetable-Oils 0 not eating at all 0-3 Ifood_3 consumption 1 5 servings or more/day 2 1-2 servings/day 3 3-4 servings/day 4 What do you add to your 0 artificial sauce 0-3 Ifood_4 salad? 1 nothing 2 Olive oil 3 lemon juice or vinegar 5 What do you drink when 0 A diet drink 0,3 Ifood_5 you are thirsty? 0 Soft drink 0 Fruit juice 3 Water or soda 6 How many glasses of 0 Does not drink water 0-3 Ifood_6 water do you drink a day? 1 1-2 cups 2 3-5 cups 3 6 cups and more 7 When you want fruit - ** something sweet you Sweet yogurt Candy, cookie, cake or chocolate usually prefer: energy snack Other 8 Usually what's inside your Chocolate, jam or honey - ** sandwich? Yellow cheese Chickpeas or tahini Cheese up to 5% fat Chickpeas or tahini or cheese up to 5% fat plus vegetables 9 Do you eat a variety of 0 I eat the same foods every day 0-3 Ifood_9 foods? 1 I usually eat the same foods. Variety once or twice a week 2 Most days I diversify my food 3 I make sure to diversify my food and eat differently every day 10 How do you usually eat 0 while watching TV, another 0-3 Ieat_1 most of your meals? screen, or reading 1 while walking or traveling 2 standing 3 sitting at a table 80 11 Usually, how much time 0 Less than 1 hour 0-3 Ieat_2 does it take between 1 More than 5 hours 2 3 to 5 hours eating and eating? 3 1 to 3 hours

12 Do you skip meals? 0 Every day 0-3 Ieat_3 1 Often 2 Rarely 3 Never 13 The main reason you eat 0 Anger, stress or any other emotion 0,3 Ieat_5 is: 0 boredom 0 pleasure 3 Hunger 14 Usually you stop eating 0 I feel blown up 0-3 Ieat_10 1 I feel the food is heavy in my stomach when: 2 I feel really satiety, a sense of fullness 3 I feel light, not quite full 15 What is the closest 0 Eating fast, chewing little, swallows 0-3 Ieat_11 the description to how you food eat? 1 Fast eating for partial chewing 2 Eating very slow, good and thorough chewing 3 Slow eating, chewing a lot, putting the fork or sandwich while chewing 16 Your shopping cart 0 salty pastries and tips - ** includes: 0 cakes, cookies and sweets, 0 Processed food products and prepared food 3 Fruits and vegetables, bread, dairy products and meat products  ** This question was taken out of the calculation of the score because in filling the manual questionnaires, most people listed several answers.  Min Score: 0 Max Score: 39  To calculate fruit and vegetable consumption in grams * per day, we calculated as follows:  0 = not eating at all = 0 grams.  1 = 1-2 servings = 120 grams.  2 = 3-4 servings = 280 g.  3 = 5 servings or more = 480 g.  * (Assuming the average fruit / vegetable serving = 80 g)

81 Appendix I: Mediterranean Diet Score Food Group/ Line Components Foods Included: number in Way of Scoring the FFQ 1 Monounsaturate >median/gender=1 d /Saturated fatty median/gender=1 chickpeas 95, median/gender=1 Granola, Quaker, 51,53, median/gender=1 nuts 109-111 median/gender=1 98 median/gender=1 median/gender=0 8 Dairy products Dairy products 3-14 median/gender=0 9 Alcohol Alcohol 125-127 =0<10-50gr/day(men) =1<=0 =0<5-25gr/day(women) =1<=0

 Min Score: 0 Max Score: 9

82

Appendix J:Examples of recipes רוטב צ'ילי מתוק חומרים: 500 גרם פלפל צ'ילי – ללא הגבעול 3 שיני שום קלופות 750 מ"ל חומץ בן יין לבן 645 גרם סוכר אופן הכנה:

1. חוצים וקוצצים גס 100 גרם מכמות הפלפלים – ולא מנקים מגרעינים. מניחים את הפלפלים במעבד מזון או בבלנדר. 2. חוצים, מנקים מגרעינים וקוצצים את יתרת כמות הפלפלים – ומוסיפים למעבד המזון או לבלנדר, ביחד עם שיני השום הקצוצות ו250- מ"ל מהחומץ. מעבדים עד שהפלפלים קצוצים דק דק. 3. מעבירים את תערובת הצ'ילי, יתרת החומץ והסוכר לסיר בינוני ומבשלים על להבה נמוכה, תוך כדי ערבוב, עד שהסוכר נמס )בערך 5 דקות(. מגבירים את הלהבה, מביאים את הרוטב לרתיחה – ואז מיד מנמיכים את הלהבה ומבשלים על אש קטנה, ללא מכסה, במשך 35 עד 50 דקות – עד שהרוטב מסמיך. חשוב לערבב את הרוטב מפעם לפעם. 4. מעבירים את הרוטב לבקבוק או צנצנת אטומים שחוטאו היטב במים רותחים. הרוטב המוכן יכול להישמר בקירור ארבעה חודשים בקירוב. *אין צורך להסמיך את הצ'ילי עד שהוא מגיע למרקם של ריבה – מדובר ברוטב נוזלי. אם תטעמו אותו ישר מהסיר הוא יהיה מאוד חריף, נוזלי למדי )וחם(. אחרי יום של מנוחה במקרר החריפות תרגע מעט והמרקם יתייצב.

מתכון לרוטב טריאקי חומרים 1 כוס סויה 1 כוס מים מיץ מתפוז אחד ½ כוס סוכר חום 2 ס”מ שורש גינגר טרי קצוץ דק 1 שן שום קצוצה דק 1 כפית צ’ילי גרוס 4 כפות קורנפלור מעורבבות ב- 2/1 כוס מים קרים אופן ההכנה: בסיר מביאים לרתיחה את כל המרכיבים פרט לקורנפלור. לאחר הרתיחה מנמיכים את האש ומוסיפים את המים עם הקורנפלור. מערבבים בעזרת מטרפה היטב ומבשלים כ5- דקות על אש בינונית נמוכה עד שהרוטב מסמיך. הרוטב יראה דליל מעט היות והוא חם אך הוא יתמצק כשיתקרר לכן אין צורך ביותר מ5 דקות בישול.

מתכון לרוטב פד תאי זמן הכנה רבע שעה חומרים )4 מנות(: 3/1 כוס רוטב סויה 4/1 כוס חומץ אורז 3/1 כוס סוכר או סילאן 2 כפות רוטב דגים )לא חובה, אבל מוסיף מאוד( מעט צ’ילי )לא חובה( אופן ההכנה: מבשלים את כל החומרים יחד כ10- דקות או עד שמתקבל רוטב אחיד. מצננים ושומרים בצנצנת במקרר.

83 Appendix K: Estimate of incremental cost following the recipes’ changes

*quantity of portions of portions *quantity purchased name Recipe in components Change Removing components Adding components cost incremental Total 125 Replace the type of meat to grind from the muscle (chest 450.00 1197.00 or shoulder so there will be less fat) and grind in place. 733.54 Homemade -Reduce the amount of meatballs / seasoning of grilled chicken 0.76 0.38 beef patties / in half

beef and - Reduce the amount of soup 16.77 8.38 turkey patties powder in half -Reduce the amount of bread 114.00 57.00 crumbs in half Add oat bran instead of 52.30 reduced bread crumbs 63.2 - Reduce the amount of soup 20.96 10.48 powder in half - Replacement of tomato paste to reduce sodium (tomato paste concentrates 146.30 390.49 without sugar and salt, Grand bolognese 302.36 Italy - Rami Levy price)

- Add grated vegetables:

onion 8 kg 23.20 Carrots 3 kg 3.45 Zucchini 7 kg 42.00 43 - Replace yellow cheese 38% fat to 9% fat in the same 15.10 57.75 amount Cheesecake - Sweet cream replacement 41.55 42% in cooking cream 15% in the same amount 9.00 7.90

- Burekas - Replace yellow cheese 38% cheese and fat to 9% fat in the same 15.10 57.75 41.55 mushrooms amount 84 - Sweet cream replacement 42% in cooking cream 15% 9.00 7.90 in the same amount 86 - Prepare the teriyaki sauce 23.94 25.96 independently - Change sweet chili sauce to 11.83 40.29 a self-prepared sauce Turkey -Reduction of half the amount breast - 0.34 0.17 of salt 34.74 Change Reduce the amount of components seasoning of grilled chicken 5.04 2.52 in half - Change soy sauce to 4.98 11.92 reduced sodium sauce - - Replace yellow cheese 38% fat to 9% fat - in the same 15.10 57.75 Stuffed amount 33.85 zucchini - Sweet cream replacement 42% in cooking cream 15% 72.00 63.20 in the same amount - - Replace yellow cheese 38% fat to 9% fat in the same 15.10 57.75 amount Cannelloni 33.85 Sweet cream replacement 42% in cooking cream 15% 72.00 63.20 in the same amount 117 - Prepare the teriyaki sauce 22.45 24.34 independently - Change sweet chili sauce to 11.83 40.29 a self-prepared sauce -Reduction of half the amount Butterfly 0.34 0.17 Chicken - of salt - Change soy sauce to 29.38 Change 4.98 11.92 components reduced sodium sauce - Reduce the amount of seasoning of grilled chicken 5.04 2.52 in half - Reduce the amount of soup 10.48 5.24 powder in half - Turkey - Prepare the teriyaki sauce 7.48 8.11 wings - independently 21.54 Change - Change sweet chili sauce to 1.89 3.22 components a self-prepared sauce 85 - Reduce the amount of soup 6.97 3.49 powder in half Reduce the amount of seasoning of grilled chicken 5.04 2.52 in half - Change soy sauce to 2.49 5.96 reduced sodium sauce - Reduce the amount of silane 11.44 5.72 in half 12.3 - Change soy sauce to 2.49 5.96 reduced sodium sauce Stir-fried - Change to self-assembled tofu - Change 1.25 3.82 10.59 Pad Thai sauce components - Change sweet chili sauce to 1.89 6.45 a self-prepared sauce 25 Change of Bolognese Meat Roll according to 84.83 93.65 8.83 recommendations: 6 kg - - Change 5 kg bolognese according to the 70.69 78.05 Shepherd pie recommendations 7.90 -Reduction of half the amount 0.14 0.68 of salt 18.6 - Change sweet chili sauce to 1.89 6.45 a self-prepared sauce - Change soy sauce to 2.49 5.96 reduced sodium sauce - Prepare the teriyaki sauce Stir-fried - 7.48 8.11 Change independently 5.30 components - Reduce the amount of soup 4.19 2.10 powder in half Reduce the amount of seasoning of grilled chicken 2.52 1.26 in half - - Reduce the amount of soup 16.77 8.38 powder in half - Addition of vegetables: - 1.5 kg of zucchini 15.38 Chicken -0.5 kg carrot 3.09 cutlets - 2 kg onions Reduce the amount of bread 85.50 42.75 crumbs in half Add oat bran instead of 39.23 reduced bread crumbs 86 Reduce the amount of seasoning of grilled chicken 0.76 0.38 in half - Spicy carrot - Change sweet chili sauce to 0.71 2.42 salad - a self-prepared sauce 1.68 Change -Reduction of half the amount 0.06 0.03 components of salt - --Reduction of half the chicken liver 0.27 0.14 -0.14 amount of salt - Spicy carrot - Change sweet chili sauce to 0.71 0.35 salad - a self-prepared sauce -0.38 Reducing -Reduction of half the amount 0.06 0.03 Components of salt 12.3 - Reduce half the amount of 2.49 1.24 soy sauce Stir-fried - Reduce half the amount of tofu - 1.25 0.63 the Pad Thai sauce -2.81 Reducing Components - Reduce half the amount of 1.89 0.95 chili sauce

27 Reduce the amount of bread 171.00 85.50 crumbs in half Add oat bran instead of 78.45 reduced bread crumbs -Reduction of half the amount Veal cutlet 0.34 0.17 -7.85 of salt Reduce the amount of seasoning of grilled chicken 1.26 0.63 in half 29.5 Reduce the amount of seasoning of grilled chicken 5.04 2.52 Chicken in half skewers - -8.46 Change - Reduce half the amount of 13.15 6.58 components barbecue sauce - Prepare the teriyaki sauce 7.48 8.11 independently 86 - Reduce half the amount of 23.94 25.96 Turkey teriyaki sauce breast - -9.08 Reducing - Reduce half the amount of 11.83 5.91 Components chili sauce 87 -Reduction of half the amount 0.34 0.17 of salt Reduce the amount of seasoning of grilled chicken 5.04 2.52 in half - Reduce half the amount of 4.98 2.49 soy sauce 18.6 - Reduce half the amount of 1.89 0.95 chili sauce - Reduce half the amount of 2.49 1.24 soy sauce Stir-fried - - Reduce half the amount of 7.48 3.74 Reducing teriyaki sauce -9.29 Components - Reduce the amount of soup 4.19 2.10 powder in half Reduce the amount of seasoning of grilled chicken 2.52 1.26 in half 29.5 Reduce the amount of seasoning of grilled chicken 5.04 2.52 chicken in half skewers - - Reduce half the amount of -12.84 Reducing 13.15 6.58 barbecue sauce Components - Reduce half the amount of 7.4825 3.74 teriyaki sauce - - Reduce half the amount of 7.4825 3.74 teriyaki sauce - Reduce half the amount of 1.892 0.95 chili sauce - Reduce the amount of soup 6.97 3.49 Turkey powder in half wings - Reduce the amount of -17.66 Reducing seasoning of grilled chicken 5.04 2.52 Components in half - Reduce half the amount of 2.488 1.24 soy sauce

- Reduce the amount of silane 11.44 5.72 in half

- - Reduce half the amount of 5.986 2.99 teriyaki sauce - Reduce the amount of silane Kotelt pork 27.8 13.90 -23.57 in half - Reduce half the amount of 4.976 2.49 soy sauce 88 - Reduce the amount of soup 8.384 4.19 powder in half 117.3 - Reduce half the amount of 22.447 11.22 teriyaki sauce

- Reduce half the amount of 11.825 5.91 chili sauce Butterfly -Reduction of half the amount of 0.3375 0.17 Chicken - salt -27.55 Reducing - Reduce half the amount of soy 4.976 2.49 Components sauce

Reduce the amount of seasoning 5.04 2.52 of grilled chicken in half

- Reduce the amount of soup 10.48 5.24 powder in half *The quantity of portions that were purchased on average in three weeks, depending on the number of weeks in which the dish was served. (On the following dates: 2-6.4.17, 23-27.4.17, 4-8.6.18)

Appendix L: The change in nutritional values after application of recommendations for improvement of recipes Energy Saturated fat Carbohydrate Sodium Cheesecake -23.86 -1.82 0.01 7.69 Burekas cheese and mushrooms -10.18 -0.78 0.01 3.28 Stuffed zucchini -60.66 -4.22 0.07 7.47 Stir-fried Reducing tofu Components -0.62 0.00 -0.27 -55.69 Stir-fried Change tofu components -0.52 0.00 -0.09 -68.66 Cannelloni -55.43 -3.88 0.10 4.01 Veal cutlet -215.55 -3.78 -1.82 -30.45 Bolognese -29.96 -0.66 -2.11 -486.23 Shepherd pie -13.06 -0.30 -0.87 -393.87 Kotelt pork 16.43 -0.50 -3.45 -169.69 Homemade meatballs / beef patties / beef and turkey patties -25.01 -1.11 -2.34 -288.91 Meat Roll -12.73 -0.28 -0.89 -206.61 89 Butterfly Reducing Chicken Components 0.09 0.03 -1.43 -223.41 Butterfly Change Chicken components -6.38 -0.01 -1.39 -346.01 Turkey wings Reducing Components 0.23 0.13 -2.25 -174.02 Turkey Change wings components -5.35 0.06 -2.23 -256.44 Stir-fried Reducing Components -8.18 -0.09 -0.35 -116.21 Stir-fried Change components -2.35 0.00 -0.60 -154.11 chicken liver 0.96 0.01 0.04 -141.89 Chicken Reducing skewers Components -0.08 0.01 -0.27 -78.51 Chicken Change skewers components -1.77 0.00 -0.50 -113.03 Turkey Reducing breast Components 1.09 0.04 -0.97 -146.34 Turkey Change breast components -3.98 -0.01 -0.93 -232.66 Chicken cutlets -32.15 -0.35 -4.18 -264.44 Spicy Reducing carrot Components salad -0.39 0.02 -0.44 -387.65 Spicy Change carrot components salad 0.08 0.01 -0.04 -413.14 Decrease in levels (%) 76.9 53.8 80.8 84.6 Increase in levels (%) 23.1 30.8 19.2 15.4 Without change (%) 0 15.4 0 0  Nutritional values are shown for 100 grams of product.

א

אוניברסיטת בן- גוריון בנגב הפקולטה למדעי הבריאות המחלקה לבריאות הציבור

מוגש בתאריך: ______

נושא המחקר:

מחקר התערבות קהילתי לבדיקת העלות וההשפעה של התערבות תזונתית משולבת על שינוי באיכות התזונה ומשקל של סועדים חיבור לשם קבלת תואר מוסמך בבריאות הציבור

הסטודנטית המגישה: לירון סבג ) שרון( , סטודנטית לתואר שני בבריאות הציבור

המנחות: פרופ' דנית שחר וד"ר צחית סימון-תובל

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תקציר רקע: העלייה במגפת ההשמנה במהלך 3-4 העשורים האחרונים מיוחסת בעיקרה לצריכת מאכלים עשירים באנרגיה ובאיכות תזונתית ירודה, המעלה את הסיכון לתחלואה כרונית. על פי גישת המסגרות לקידום בריאות ) setting approach(, לקידום תזונה בריאה ואיכותית תוך שינוי סביבתי ללא התערבות התנהגותית אינדיבידואלית עשוי להיות יתרון, כיוון שהוא מבוסס על יצירת סביבה מאפשרת ושיפור הנגישות למזון בריא, תוך הימנעות מעימותים ישירים והפעלת לחץ על הפרט. תכנית התערבות משולבת ברמת מערכת ההסעדה נבדקה במחקר הנוכחי. פערי מידע: מחקרים מעטים העריכו את השפעתן של תכניות התערבות מותאמות סביבתית הכוללות שינויים ברמת הקייטרינג וסביבת האכילה על איכות הדיאטה ועל העדפות הבחירה של הסועדים. בנוסף, מעט מחקרים אמדו את העלות התוספתית של תכניות אלה מנקודת המבט של מערכת ההסעדה. מטרות עיקריות: 1. להעריך את ההשפעה של התערבות תזונתית משולבת ברמת מערכת ההסעדה וברמת חדר האוכל על שינוי באיכות הדיאטה ומשקל הסועדים. 2.להעריך את העלות התוספתית של שינוי תזונתי בארוחה המוגשת במערכת הסעדה בקיבוץ מנקודת מבט של מערכת ההסעדה. שיטות: ניסוי קליני בחן את אסטרטגית התערבות סביבתית ברמת מערכת ההסעדה . קבוצת התערבות )n=67(: קיבוץ מגן נחשף להתערבות שכללה: שינוי בתפריטים, תיוג מזון, ומסרים בריאותיים באמצעות מדיה אלקטרונית בזמן ארוחת הצהריים ובנוסף הרצאה בנושא תזונה בריאה אחת לחודש. קבוצת ביקורת )n=67(: קיבוץ ניר-יצחק נחשף להתערבות שכללה רק הרצאה אחת לחודש. שתי הקבוצות הושוו מבחינת: הרגלי האכילה, הצריכה התזונתית והמשקל. מדדי המחקר נאספו בתחילת המחקר ולאחר 3 חודשי התערבות. קריטריונים להכללה: סועדים בני גיל 30 ומעלה, שאוכלים ארוחת צהריים במערכת ההסעדה של הקיבוץ לפחות 3 ימים בשבוע. כלי המחקר כללו: שאלון מאפיינים דמוגרפיים וחברתיים-כלכליים, שאלון ידע בנושא תזונה ופעילות גופנית, שאלון תדירות צריכת מזון, שאלון אורח חיים וכן מדידות אנתרופומטריות. תכנית ההתערבות פותחה במסגרת עבודת הדוקטורט של אופירה כץ שופן. ערכים תזונתיים של מנות נבחרות הושוו להנחיות התזונה של ועדת הרגולציה של משרד הבריאות בישראל לסימון מזון מ 2016. הערכת העלות התוספתית של שיפור איכות התפריט התייחסה להחלפה של מרכיבים במרכיבים בריאים יותר ו/או לשינוי אופן ההכנה. תוצאות: לא נמצא הבדל באיכות התזונה של משתתפי המחקר לפי אומדן התזונה הים תיכוני )Med Diet Score( וציון איכות התזונה )Diet Quality Score(. על-פי שאלון תדירות צריכת מזון )FFQ(, לא נמצא הבדל משמעותי בצריכת פירות וירקות, אך לפי שאלון אורח חיים, לאחר ההתערבות חלה בקבוצת ההתערבות עלייה של 55 גרם בצריכת פירות וירקות )P = 0.058( ועליה של 32 גרם בצריכת פירות )P = 0.008(. לעומת זאת, בקבוצת הביקורת שבה לא חל שינוי בצריכת הפירות והירקות )P = 0.975( ולא חל שינוי בצריכת הפירות )P = 0.351(. על-פי ה FFQ, נמצאה לאחר ההתערבות ירידה בצריכת שומן טרנס בקבוצת ההתערבות )P = 0.031(. ירידה דומה חלה גם בקבוצת הביקורת, אם כי זו הייתה על גבול המובהקות הסטטיסטית )P = 0.058(. בנוסף, נמצאה בקבוצת ההתערבות ירידה באחוז הקלוריות הנצרכות מקבוצת הלחם והדגנים )P = 0.049( וירידה באחוז הקלוריות מצריכת בשר על

ג

גבול המובהקות הסטטיסטית )P = 0.058(. לעומת זאת, בקבוצת הביקורת לא חל שינוי באחוז הקלוריות מלחם ודגנים )P = 0.235(, ומצריכת בשר )P = 0.562(. ניתוח רב-משתני לניבוי שיפור במדדים שונים של איכות התזונה לאחר ההתערבות, העלה כי קבוצת ההתערבות הייתה משתנה בלתי תלוי שניבא שיפור באיכות התזונה רק בהקשר לצריכת בשר. בפרט, הסיכוי לדיווח על ירידה בצריכת הבשר היה גבוה יותר בקבוצת המחקר בהשוואה לקבוצת הביקורת )OR = 2.99, 95% CI [1.10, 8.09], P = 0.031(. לבסוף, לא חל שינוי משמעותי במשקל המשתתפים לאחר ההתערבות הן בקבוצת ההתערבות )P = 0.654( והן בקבוצת הביקורת )P = 0.422(. ניתוח העלות התוספתית הכרוכה בשיפור התזונתי של המתכונים העלתה ששיפור המרכיבים של תפריט ו/או אופן ההכנה היה כרוך בעלות תוספתית שנעה בין הפחתה של 27.5 שקלים ועד עליה 733.5 שקלים. ברב המתכונים ששונו )57.7%( נאמדה עלות תוספתית חיובית. עם זאת, ב n=256( 48.6%( מ 547 המנות ששונו ונרכשו בפועל בתקופה של 3 שבועות במהלך המחקר, העלות התוספתית הייתה חיובית. אם השינוי במתכון היה כרוך בהחלפת רוטב מוכן ברוטב בהכנה עצמית, העלות התוספתית הייתה חיובית ב n=490( 89.6%( מהמנות שנרכשו בפועל בתקופה זו. השיפור התזונתי בתפריט הוביל לירידה ברמות נתרן ב84.6% מהמתכונים, לירידה בכמות הפחמימות ב80.8% מהמתכונים, לירידה בכמות השומן הרווי ב53.8% מהמתכונים ולירידה בכמות הקלוריות ב76.9% מהמתכונים. לבסוף, נמצא כי הפחתה בשומן הרווי ובערך הקלורי של המנות הייתה קשורה לעליה בעלות התוספתית הכרוכה

בשינוי המתכון )rs=-0.610, P = 0.001, ו rs=-0.582, P = 0.002, בהתאמה(. עם זאת, הפחתה בנתרן )- = rs

P = 0.814 ,0.049(, ובפחמימות )rs = 0.133, P = 0.518(, לא היו קשורות לעלייה בעלות התוספתית הכרוכה בשינוי המתכון. מסקנות: תכנית התערבות המבוססת על שינויים סביבתיים במערכת ההסעדה נמצאה יעילה באופן חלקי בשיפור איכות והרגלי התזונה של הסועדים, אך לא יעילה בשינוי המשקל של הסועדים בטווח הקצר. עלות תוספתית חיובית )גדולה מאפס( נבעה בעיקר מהמעבר להכנה עצמית של רטבים על-פני שימוש ברטבים מוכנים. שיפור ערכי השומן הרווי והערך הקלורי של המתכונים היה קשור לעלייה בעלות התוספתית, אך הפחתה בנתרן ובפחמימות לא הייתה קשורה לעליה בעלות התוספתית. מחקר זה עשוי לתרום לפיתוח התערבויות ברמת מערכת ההסעדה ויכול לשמש מודל להתערבות סביבתית דומה במערכות הסעדה שונות המבוססת על גישת המסגרות לקידום בריאות. יש מקום למחקר המשך, אשר יבחן את ההשפעה של התערבות המשלבת אסטרטגיות מותאמות אישית ואסטרטגיות סביבתיות, ויאמוד את השיפור באיכות התזונה באמצעות מדדים אובייקטיביים ומדויקים. מילות מפתח: התערבות תזונתית, מערכת הסעדה, משקל, עלות תוספתית.

אוניברסיטת בן- גוריון בנגב הפקולטה למדעי הבריאות המחלקה לבריאות הציבור

מוגש בתאריך: ______

נושא המחקר:

מחקר התערבות קהילתי לבדיקת העלות וההשפעה של התערבות תזונתית משולבת על שינוי באיכות התזונה ומשקל של סועדים חיבור לשם קבלת תואר מוסמך בבריאות הציבור

הסטודנטית המגישה: לירון סבג ) שרון( , סטודנטית לתואר שני בבריאות הציבור

המנחות: פרופ' דנית שחר וד"ר צחית סימון-תובל