Susanna Raulio Susanna Raulio Lunch eating patterns during working hours Susanna Raulio and their social and RESEARCH Lunch eating patterns during working hours RESEARCH and their social and work-related determinants work-related determinants Study of Finnish employees Study of Finnish employees and their social and work-related determinants and their social work-related determinants Lunch eating patterns during working hours

Work has a central role in the lives of big share of adult Finns and meals they eat during the workday comprise an important factor in their nutrition, health, and well-being. This study examines the contribution of various socio- demographic, socioeconomic, and work-related factors to the lunch eating patterns of Finnish employees during the working day and how lunch eating patterns influence dietary intake. This thesis utilizes three different population-based cross-sectional surveys: Health Behaviour and Health among the Finnish Adult Population survey, the National Findiet 2002 Study and Work and Health in Finland. The frequency of worksite canteen use has been quite stable for over two decades in Finland. A small decreasing trend can be seen in all socioeconomic groups. During the whole period studied, those with more years of education ate at worksite canteens more often than the others. A worksite canteen was more commonly available to employees with higher education and occupational status and to those working at larger workplaces. Employees who ate at a worksite canteen consumed more vegetables and vegetable and fish dishes at lunch than did those who ate packed lunches.

National Institute for Health and Welfare P.O. Box 30 (Mannerheimintie 166) FI-00271 Helsinki, Finland Telephone: +358 20 610 6000 68 68 2011 68 ISBN 978-952-245-522-2 www.thl.fi RESEARCH 68

Susanna Raulio Lunch eating patterns during working hours and their social and work-related determinants Study of Finnish employees

ACADEMIC DISSERTATION

To be presented with the permission of the Faculty of Medicine of the University of Helsinki for public examination in Small Hall, University Main Building

On November 18, 2011, at 12 noon

Department of Health, Functional Capacity and Welfare National Institute for Health and Welfare and Department of Public Health, Hjelt Institute University of Helsinki

Helsinki, Finland 2011

© Susanna Raulio and National Institute for Health and Welfare (THL)

Kannen kuva: Susanna Raulio Taitto: Juvenes Print – Tampereen Yliopistopaino Oy

ISBN 978-952-245-522-2 (printed) ISSN 1798-0054 (printed) ISBN 978-952-245-523-9 (pdf) ISSN 1798-0062 (pdf)

Juvenes Print – Tampereen Yliopistopaino Oy Tampere, Finland 2011

Supervisors: Docent Ritva Prättälä National Institute for Health and Welfare (THL) Department of Health, Functional Capacity and Welfare Helsinki, Finland

Docent Eva Roos Folkhälsan Research Center/ Department of Public Health, Hjelt Institute, University of Helsinki Helsinki, Finland

Official reviewers: Professor Margareta Wandel Institute for Nutrition Research School of Medicine University of Oslo, Norway

Adjunct Professor Paula Hakala The Social Insurance Institution Research Department Turku, Finland

Opponent: Adjunct Professor Jaana Laitinen Finnish Institute of Occupational Health Promotion of Work Ability and Health Oulu, Finland

Abstract

Susanna Raulio. Lunch eating patterns during working hours and their social and work-related determinants. Study of Finnish employees. National Institute for Health and Welfare (THL), Research 68, 148 pages. Tampere, Finland 2011. ISBN 978-952-245-522-2 (printed); ISBN 978-952-245-523-9 (pdf).

Work has a central role in the lives of big share of adult Finns and meals they eat during the workday comprise an important factor in their nutrition, health, and well- being. On workdays, lunch is mainly eaten at worksite canteens or, especially among women, as a packed meal in the workplace’s break room. No national-level data is available on the nutritional quality of the meals served by canteens, although the Finnish Institute of Occupational Health laid out the first nutrition recommendations for worksite canteens in 1971.

The aim of this study was to examine the contribution of various socio- demographic, socioeconomic, and work-related factors to the lunch eating patterns of Finnish employees during the working day and how lunch eating patterns influence dietary intake.

Four different population-based cross-sectional datasets were used in this thesis. Three of the datasets were collected by the National Institute for Health and Welfare (Health Behaviour and Health among the Finnish Adult Population survey from 1979 to 2001, n=24746, and 2005 to 2007, n=5585, the National Findiet 2002 Study, n=261), and one of them by the Finnish Institute of Occupational Health (Work and Health in Finland survey from 1997, 2000, and 2003, n=6369). The Health Behaviour and Health among the Finnish Adult Population survey and the Work and Health in Finland survey are nationally representative studies that are conducted repeatedly. Survey information was collected by self-administered questionnaires, dietary recalls, and telephone interviews.

The frequency of worksite canteen use has been quite stable for over two decades in Finland. A small decreasing trend can be seen in all socioeconomic groups. During the whole period studied, those with more years of education ate at worksite canteens more often than the others. The size of the workplace was the most important work-related determinant associated with the use of a worksite canteen. At small workplaces, other work-related determinants, like occupation, physical strain at work, and job control, were also associated with canteen use, whereas at bigger workplaces the associations were almost nonexistent. The major social determinants of worksite canteen availability were the education and occupational status of

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employees and the only work-related determinant was the size of the workplace. A worksite canteen was more commonly available to employees at larger workplaces and to those with the higher education and the higher occupational status. Even when the canteen was equally available to all employees, its use was nevertheless determined by occupational class and the place of residence, especially among female employees. Those with higher occupational status and those living in the Helsinki capital area ate in canteens more frequently than the others. Employees who ate at a worksite canteen consumed more vegetables and vegetable and fish dishes at lunch than did those who ate packed lunches. Also, the daily consumption of vegetables and the proportion of the daily users of vegetables were higher among those male employees who ate at a canteen.

In conclusion, life possibilities, i.e. the availability of a canteen, education, occupational status, and work-related factors, played an important role in the choice of where to eat lunch among Finnish employees. The most basic prerequisite for eating in a canteen was availability, but there were also a number of underlying social determinants. Occupational status and the place of residence were the major structural factors behind individuals’ choices in their lunch eating patterns.

To ensure the nutrition, health, and well-being of employees, employers should provide them with the option to have good quality meals during working hours. The availability of worksite canteens should be especially supported in lower socioeconomic groups. In addition, employees should be encouraged to have lunch at a worksite canteen when one is available by removing structural barriers to its use.

Keywords: worksite canteen, packed lunch, eating out of home, socioeconomic differences, working conditions

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Tiivistelmä

Susanna Raulio. Lunch eating patterns during working hours and their social and work-related determinants. Study of Finnish employees. [Työaikaisen aterioinnin sosiaaliset ja työperäiset selittäjät. Tutkimus suomalaisista työntekijöistä]. Terveyden ja hyvinvoinnin laitos (THL), Tutkimus 68, 148 sivua. Tampere 2011. ISBN 978-952-245-522-2 (painettu); ISBN 978-952-245-523-9 (pdf).

Työ on keskeisessä osassa useimpien suomalaisten elämässä ja työaikaisella aterioinnilla on suuri vaikutus työntekijöiden ravitsemukseen, terveyteen ja hyvinvointiin. Suomalaiset työntekijät lounastavat yleensä henkilöstöravintolassa tai syömällä eväitä. Suomessa annettiin ensimmäiset henkilöstöravintoloita koskevat ravitsemussuositukset jo vuonna 1971, mutta henkilöstöravintoloiden tarjoaman lounaan ravitsemuksellisesta laadusta ei ole saatavilla valtakunnallista tietoa.

Tämän tutkimuksen tavoitteena oli selvittää erilaisten sosiodemografisten, sosioekonomisten ja työolotekijöiden yhteyttä työaikaiseen ateriointiin suomalaisilla työntekijöillä sekä työaikaisen aterioinnin yhteyttä ruokavalion laatuun.

Tässä väitöskirjassa käytettiin neljää poikkileikkausaineistoa, jotka perustuivat erilaisiin väestötutkimuksiin. Terveyden ja hyvinvoinnin laitos vastaa näistä kolmesta (Aikuisväestön terveyskäyttäytyminen ja terveys -tutkimus vuosilta 1979– 2001, n=24746 ja vuosilta 2005–2007, n=5585, Finravinto 2002 -tutkimus, n= 261). Neljännestä tutkimuksesta (Työ ja terveys Suomessa vuosilta 1997, 2000 ja 2003, n=6369) vastaa Työterveyslaitos. Aikuisväestön terveyskäyttäytyminen ja terveys - tutkimus sekä Työ ja terveys Suomessa -tutkimus ovat kansallisesti edustavia, koko maan kattavia ja säännöllisesti toistettavia tutkimuksia. Tutkimustiedot on kerätty kyselylomakkeilla, ravintohaastattelulla ja puhelinhaastattelulla.

Suomalaisten työntekijöiden tapa syödä henkilöstöravintolassa on säilynyt suurin piirtein ennallaan kahden vuosikymmenen ajan. Henkilöstöravintolan käyttö on hieman vähentynyt kaikissa sosioekonomisissa väestöryhmissä, mutta koko tutkimusajan korkeimmin koulutetut työntekijät kävivät henkilöstöravintolassa useammin vähiten koulutusta saaneet. Työpaikan koko oli tärkein henkilöstöravintolan käyttöön yhteydessä oleva työperäinen tekijä; henkilöstöravintolan käyttö yleistyi työpaikan koon kasvaessa. Ammatti, työn fyysinen rasittavuus ja työnhallinta olivat yhteydessä henkilöstöravintolan käyttöön vain pienillä työpaikoilla. Tärkeimmät henkilöstöravintolan käytön mahdollisuuteen yhteydessä olevat sosiaaliset tekijät olivat koulutus ja ammattiasema. Työperäisistä tekijöistä tärkein oli työpaikan koko. Naisilla ammattiasema ja asuinpaikka olivat

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yhteydessä henkilöstöravintolassa ateriointiin silloinkin, kun henkilöstöravintolan käytön mahdollisuus oli kaikille yhtäläinen. Ylemmässä ammattiasemassa olevat ja pääkaupunkiseudulla asuvat naiset ruokailivat henkilöstöravintolassa muita väestöryhmiä useammin. Henkilöstöravintolassa aterioivat työntekijät valitsivat lounaalla lautaselleen useammin tuoreita kasviksia ja kasvis- ja kalaruokia verrattuna eväitä syöviin työntekijöihin. Lisäksi henkilöstöravintolassa ruokailevien kasvisten käyttö oli runsaampaa päivätasolla verrattuna muihin työntekijöihin.

Tämän väitöskirjan perusteella perusedellytys henkilöstöravintolan käytölle on sen saatavuus, mutta myös muut tekijät, kuten työpaikan koko, työntekijän ammattiasema, koulutus ja asuinpaikka, ovat tärkeässä asemassa yksilön lounaspaikan valinnassa.

Työnantajien tulee huolehtia siitä, että työntekijöillä on mahdollisuus ravitsemuksellisesti laadukkaan lounaan nauttimiseen työaikana. Henkilöstöravintolan käytön mahdollisuutta tulee edistää erityisesti matalammissa sosioekonomisissa väestöryhmissä ja henkilöstöravintolassa aterioinnin mahdollisuutta tulee lisätä poistamalla sen käyttöön liittyviä esteitä.

Avainsanat: henkilöstöravintola, eväät, ruokailu kodin ulkopuolella, sosioekonomiset erot, työolot

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Contents ABSTRACT ...... 4 TIIVISTELMÄ ...... 6 LIST OF ORIGINAL PUBLICATIONS...... 10 ABBREVIATIONS ...... 11 1 INTRODUCTION ...... 12 2 DEFINITIONS OF MEAL CONCEPTS...... 14 3 WORKSITE MEALS IN FINLAND ...... 17 4 SOCIAL AND NUTRITIONAL DIMENSIONS OF EATING...... 19 4.1 Eating out of home ...... 19 4.2 Determinants of eating ...... 20 4.2.1 Life choices and structural chances ...... 21 4.2.2 Socio-demographic factors ...... 21 4.2.3 Work-related factors ...... 22 4.2.4 Socioeconomic position ...... 24 4.3 Determinants of worksite eating...... 25 4.3.1 Socio-demographic factors ...... 25 4.3.2 Work-related factors ...... 25 4.3.3 Socioeconomic position...... 26 4.4 Nutritional quality of canteen meals ...... 26 5 SUMMARY OF LITERATURE...... 27 6 SCOPE AND PURPOSE...... 28 7 DATA AND METHODS ...... 29 7.1 Data sources ...... 29 7.1.1 Health Behaviour and Health among Finnish Adult Population survey (AVTK)...... 29 7.1.2 Work and Health in Finland –survey ...... 33 7.1.3 The National FINDIET 2002 Study...... 33 7.2 Variables...... 35 7.2.1 Independent variables ...... 35 7.2.2 Dependent variables...... 37 7.3 Statistical analyses...... 38 8 RESULTS ...... 42 8.1 Trends in worksite canteen use ...... 42 8.2 Lunch eating patterns according to occupation and working conditions ...... 46 8.3 Availability of a worksite canteen...... 50 8.4 Nutritional quality of lunches in worksite canteens ...... 55 9 DISCUSSION...... 59 9.1 Main findings ...... 59 9.1.1 Trend in worksite canteen use in 1979–2001 ...... 59 9.1.2 Social and work-related determinants of worksite canteen availability 61

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9.1.3 Social and work-related determinants of worksite canteen use...... 62 9.1.4 Nutritional quality of canteen meals...... 64 9.2 Methodological considerations...... 65 10 CONCLUSIONS AND IMPLICATIONS ...... 69 ACKNOWLEDGEMENTS...... 71 REFERENCES ...... 73 ORIGINAL PUBLICATIONS ...... 85

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List of original publications

This thesis is based on the following original articles referred to in the text by their Roman numerals.

I. Raulio S, Roos E, Rahkonen O, Prättälä R. Twenty year trends of workplace lunches in Finland. Food Service Technology 2005;5(4):57–66.

II. Raulio S, Roos E, Mukala K, Prättälä R. Can working conditions explain differences in eating patterns during working hours? Public Health Nutrition 2008;11:258–70.

III. Raulio S, Roos E, Prättälä R. Sociodemographic and work-related variation in employees’ lunch eating patterns. International Journal of Workplace Health Management, accepted for publication.

IV. Raulio S, Ovaskainen M-L, Roos E, Prättälä R. Food use and nutrient intake at worksite canteen or in packed lunches at work among Finnish employees. Journal of Foodservice 2009;20:330–41.

The articles are reproduced with the kind permission of their copyright holders.

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Abbreviations

OR odds ratio CI confidence interval (95%) SEP socioeconomic position EOH eating out of home

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1 Introduction

Research on human nutrition and public health has long focused on daily nutrient and food intake, despite the growing awareness of the potential to prevent nutrition- related diseases by incorporating healthy food habits into individuals’ lifestyles (Oltersdorf, Schlettwein-Gsell et al. 1999). When studying food habits from a health perspective, it is important to take into account the social and cultural aspects of food habits, i.e. attitudes and motives behind food choices. Moreover, in order to yield information for policy makers and nutrition educators, it is necessary to study people’s food behavior in a more holistic way instead of merely focusing on nutrient intake.

Meal patterns have been studied in Finland mostly within the contexts of ethnology, sociology, and nutritional and medical science (Prättälä and Roos 1999). In the field of public health, meal research is sparse, even though the tendency to eat out of home is increasing worldwide. As foods prepared out of home, convenience foods, and ready-to-eat meals have become more popular (Carrigan, Szmigin et al. 2006; Orfanos 2007) and comprise an increasingly significant portion of people’s total energy intake, their nutritional quality and consequences to public health become more of a concern.

Health promotion by means of health education aims to improve public health by influencing people’s health-related behaviors, like eating patterns. Health lifestyle – which is the interplay between health-related behaviors and resources – consists of life choices and structural possibilities (Abel, Cockerham et al. 2000; Prättälä 2003). Both choices and life chances need to be taken into account when trying to affect people’s health behavior.

Of health behaviors, eating patterns are one of the alterable determinants of chronic diseases, and scientific evidence increasingly supports the view that modifications of diet have both immediate and delayed effects on health throughout the life course (World Health Organization 2003). One important nutritional factor is the low consumption of fruits and vegetables, which is among the ten most important risk factors for global mortality (Lock, Pomerleau et al. 2005).

Worksites are a central arena (Downie, Tannahill et al. 1996) for promoting health among working-age people (Dubois, Strychar et al. 1996; Patterson, Kristal et al. 1997; Braeckman, De Bacquer et al. 1999; Emmons, Linnan et al. 1999; Chu, Breucker et al. 2000; Cook, Simmons et al. 2001), since they spend eight hours on average at their worksite on every weekday. Worksites also offer access to a large

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proportion of the adult population and enable interventions at individual, interpersonal, organizational, and policy levels (Sörensen, Linnan et al. 2004). The possibility of reaching this large group of people can yield important public health benefits, even if the intervention effect is modest (Sörensen, Emmons et al. 1998).

Environmental strategies at workplaces, such as reducing barriers to healthy eating, may help employees to follow the guidelines for a healthy diet (Thorsen, Lassen et al. 2009) and improve the quality of their diet. A worksite canteen is an example of a benefit that an employer can offer to employees in order to enhance the possibility of eating a healthful meal that is balanced in line with dietary guidelines (National Nutrition Council 2005).

To be able to further evaluate the public health relevance of eating patterns during working hours, more information is needed on the frequency of the use of worksite canteens and of the factors determining their use. This multidisciplinary study approaches eating from different fields of research: occupational health, public health, and nutrition. First, the literature review defines the main concepts. Then previous studies on worksite meals and eating outside home are reviewed. Due to the lack of scientific knowledge on the determinants and dimensions of eating during working hours, research questions for the empirical study originate from studies on eating out of home, and not only from research on eating during working hours. The empirical study consists of four substudies. They examine socio- demographic, socioeconomic, and work-related determinants of eating patterns during working hours among employed Finns. Also, the association between having a lunch at a worksite canteen and dietary quality is assessed as well as the frequency of and changes in worksite canteen use over time.

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2 Definitions of meal concepts

Our food intake includes different eating events such as meals and snacks. There are no established definitions for these concepts in the academic community and therefore the essential concepts used in this thesis are defined in the following chapters.

Eating event and eating pattern An eating event means any occasion during the day when a person eats or drinks anything at all (Oltersdorf, Schlettwein-Gsell et al. 1999). Meals and snacks of any kind are thus eating events.

An eating pattern consists of several eating events over time. An eating pattern is thus the temporal distribution of eating across a 24-hour day, meal size, and meal location. The concept covers the time and number of eating events, as well as the alternation of hot and cold meals and snacks (Kjærnes, Ekström et al. 2001).

Meal The cultural meanings of “food” and “meal” differ between countries and between social groups within countries (Douglas 1975). The definition of a meal is thus bound to the cultural context. Aspects of meals are determined by the culture we live in: how often we eat, when we eat, what we eat, and with whom we eat (Douglas 1984; Meiselman 2008).

Defining the word “meal” is difficult because it means different things to different people (Meiselman 2000) and in different disciplines of science. In both English and Finnish, the word “meal” refers both to the eating event and to what is eaten (Meiselman 2008). Thus, “meal” does not have a universal definition in science (Gatenby 1997), but it has at least physiological, psychological, nutritional, anthropological, sociological, and culinary dimensions (Meiselman 2000). A multidisciplinary approach is therefore required in studying meals.

Every society, culture, and social class has meals, but the meaning of what constitutes a meal can be different in all of them (Meiselman 2000). In Finland, laypeople define a proper meal as cooked food (hot dish) accompanied by raw vegetables (green salad) (Mäkelä 1996). Also, the company of other people is an essential part of a proper meal in Finland (Mäkelä 1996). The composition of the Finnish meal has remained relatively unchanged over the past few decades, except for the addition of green salad. The basic components of a Finnish meal are meat or fish, rice or pasta, green salad, and perhaps other vegetables, all

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served on the same plate (Mäkelä 1996). Nordic meals consist of the center (meat, fish, vegetables), staple (potatoes, rice, pasta, beans, and lentils), vegetables (cabbage, carrot, cucumber, pulses, lettuces, onion, tomato, sweet pepper, etc.), trimmings (hot and cold sauces, pickles, preserves, condiments, etc.), bread, and beverages (alcoholic beverages, hot beverages, juice, milk, buttermilk, water, other) (Mäkelä 2001). A meal can be any combination of those components.

Scientific definitions of what constitutes a meal also vary according to the discipline in question. In medical research, a meal is defined as any eating event (Franceschi, La Vecchia et al. 1992), in sociological studies a meal is a social event (Douglas 1975; Meiselman 2008) structured by time, space, and social aspects (Rotenberg 1981; Mäkelä, Kjærnes et al. 1999; Fjellström 2004), and in nutritional studies a meal is often defined in terms of time (e.g. breakfast, lunch, dinner), with snacks being defined as eating occasions between meals (de Graaf 2000; Ovaskainen, Reinivuo et al. 2006). Nutritional studies on meals usually focus on food consumption and both energy and nutrient intake (Lennernäs, Åkerstedt et al. 1993; Lennernäs and Andersson 1999; Meiselman 2000).

According to Mäkelä et al., three dimensions of meals can be distinguished in sociology: meal format, eating pattern, and the social organization of eating (Mäkelä, Kjærnes et al. 1999). First of all, the meal format is the composition of the main course and the parts of the whole meal (starter, main course, and dessert). Eating pattern is defined by the time, the number of eating events, and alternation of hot and cold meals and snacks. Last, the social organization of eating refers to where and with whom the meal is eaten, and who did the cooking (Mäkelä, Kjærnes et al. 1999). Oltersdorf et al. have summarized the criteria used by many researchers for defining meals: the time of day, energy content of the meal, social interaction, food combinations, and combined criteria (Oltersdorf, Schlettwein-Gsell et al. 1999).

In this thesis, the respondents define their meals in terms of the time of the day.

Lunch and packed lunch Lunch is a meal that is eaten in the afternoon, usually between 11 am and 1 pm (Gronow and Jääskeläinen 2001) or 3 pm (Mäkelä 2001). In Finland, lunch has traditionally been a hot meal, unlike in many other European countries, where it is usually a cold, snack-type meal, such as a sandwich and coffee or tea (Johansson, Solvoll et al. 1997; Marshall 2000; Prättälä 2000; Gronow and Jääskeläinen 2001; Kearney 2001; Meiselman 2008).

The essential components of a lunch served at worksite and school canteens are, besides the main course, bread, bread spread, fresh vegetables, milk, and sour milk or other drink (Hasunen 1994; Hasunen, Kalavainen et al. 2004; National Nutrition

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Council 2008). Moreover, the current Finnish nutritional recommendations (National Nutrition Council 2005) and the national recommendations for school lunches (National Nutrition Council 2008) state that the lunch served at the school or workplace should provide one third of the daily energy requirement.

In Finland, a packed lunch (“eväät” in Finnish) refers to any kind of food that is taken to work and eaten at the workplace, but not in the worksite canteen. Typically, it consists of bread with vegetable fat spread, cheese or cold cuts, salads, fruits, yoghurt, leftovers, or convenience foods.

In this thesis, the respondents define a lunch as a meal eaten at a certain time of the day.

Eating out of home Eating out of home (EOH) or eating away from home has been defined in two main ways in the international literature: 1) all food items sourced from external eating locations, irrespective of place of consumption (Burns, Jackson et al. 2002); and 2) all food items consumed at external locations, regardless of whether they were prepared in or outside the home (Riboli and Kaaks 1997; Kearney 2001; Orfanos 2007).

In Finland, one of the most common ways of EOH is having a lunch at the worksite canteen (see below).

Worksite canteen In Finland, one of the most common ways to eat outside home is to have lunch at the worksite canteen during the workday (Laitinen 2000; Ovaskainen, Reinivuo et al. 2008). A worksite canteen – “työpaikkaravintola” in Finnish, directly translated as “workplace restaurant” – is a specific place, located near or at the workplace, that serves a main course with bread, bread spread, salad, and drink to employees at a reduced fixed price. The canteen can be operated by the employer or an outside contractor, in which case the employer subsidizes the cost of the meal, providing the restaurant and kitchen facilities at no charge.

In addition to “worksite canteen”, terms such as “workplace cafeteria/canteen”, “staff canteen”, “worksite cafeteria” or just “canteen” are used in international studies. The lack of a fixed term reflects the scattered nature of the research field and the different practices in different countries.

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3 Worksite meals in Finland

Public catering services have a long history in Finland and an important role in Finnish food culture (Raulio, Roos et al. 2010). In total, 810 million meals are served by large-scale catering kitchens in Finland yearly, equating to 153 meals per person (A.C. Nielsen 2008). Worksite canteens account for about 10% of this figure (A.C. Nielsen 2008).

The model for worksite canteens in Finland has institutional roots, being based on army, prison, and hospital canteens (Tainio and Tarasti 1995). Some efforts were made in Finland to provide optional factory canteens for employees as early as in the 1890s (Tainio and Tarasti 1995). Workers were slow to start using factory canteens, since many of them ate at home or had packed lunches. Nevertheless, some of the biggest industrial establishments managed to operate workplace canteens (Tainio and Tarasti 1995). After Finland gained its independence (1917), factory canteens became more common, and after World War II every other factory had its own canteen. Provisioning was arranged at forest working sites in the 1920s and in the 1930–1940s also at reconstruction sites. Industrial safety legislation in 1930 laid down a number of regulations about provisioning at worksites (Tainio and Tarasti 1995) and in the 1940s the goal was to ensure that every employee could have a decent meal during working hours (Hasunen 1994).

Public catering services have been developed since the 1940s as part of health and social policies (Prättälä 2000). The first idea to introduce such activities – a public school meal service – was introduced in Finland during World War II. It was necessary for women to join the labor force during the war and after the war in order to rebuild society. Due to the high proportion of women in full-time jobs outside the home, a need for various catering services emerged, including school, kindergarten, and worksite canteens. Since 1948, Finnish municipalities have arranged a free lunch for all pupils enrolled in compulsory education in elementary schools.

The development of catering services at workplaces gained momentum in the 1970s when the Finns who had become accustomed to free school lunches entered the labor force (Prättälä 2000). Meal provision was included in trade union agreements in both the public and private sectors for the first time in the 1970s (Hasunen 1987). In 1971, the Finnish Institute of Occupational Health gave the first recommendation for workplace meals (Laakkonen 1972) based on the International Labor Organization’s (ILO) Welfare Facilities Recommendation (International Labour Organization ILO 1956). The recommendations stated that every employee in Finland should be able to eat a proper meal during the working day, since well-

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planned mass catering at workplaces has major effects on public health, the well- being of employees, the nutrition education of the employees, and the improvement of workplace safety.

The Finnish economy boomed in the late 1980s and then underwent a deep recession in the early 1990s, which influenced the employment rate. Many workplaces were lost and unemployment was common. In the early 1990s, the state’s and employers’ support for workplace canteens diminished due to changes in trade union agreements and due to the new value added tax of 22% introduced in 1995 (Seppänen 1995). Since the price is one of the most important factors affecting food choices (Perlmutter and Gregoire 1998; de Almeida, Graca et al. 2001), a decrease in the use of worksite canteens was expected.

In Finland, lunches during the workday are today mostly eaten in worksite canteens (Laitinen 2000; Ovaskainen, Reinivuo et al. 2008) or, especially among women, as packed meals in workplace break rooms (Gronow and Jääskeläinen 2001; Ovaskainen, Reinivuo et al. 2008). In a study of employees of the City of Helsinki, 54% of men and 48% of women reported that they usually had lunch at a worksite canteen, whereas 19% of men and 39% of women with a worksite canteen had a packed lunch (Roos, Sarlio-Lähteenkorva et al. 2004).

In the summer of 2010, the value added tax was lowered to 13% and the prices in canteens were decreased as well. The effect of this price reduction on the consumption of canteen meals remains to be seen. Even though the economic support given to workplace meals has diminished since the peak years of the 1980s, workplace canteens or restaurants are still supported by different tax agreements and subsidies.

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4 Social and nutritional dimensions of eating

This literature review examines central studies concerning the determinants of eating patterns, as well as the determinants of lunch eating patterns at workplaces or elsewhere outside home, and the nutritional quality of meals offered at worksite canteens.

4.1 Eating out of home As mentioned earlier, EOH has two primary classifications: firstly, all food items sourced from external eating locations, irrespective of the place of consumption (Burns, Jackson et al. 2002); and secondly, all food items consumed at external locations, regardless of whether they were prepared in or outside the home (Riboli and Kaaks 1997; Kearney 2001; Orfanos 2007; Ribas-Barba, Serra-Majem et al. 2007). To interpret the results of earlier studies, one needs to pay attention to how the concept has been defined in the study in question.

Out of home meals have grown in popularity all over the world (Guthrie, Lin et al. 2002; Kant and Graubard 2004; Carrigan, Szmigin et al. 2006; Orfanos 2007; Ribas- Barba, Serra-Majem et al. 2007). Since they comprise an increasingly significant proportion of people’s total energy intake, their nutritional quality has become a concern in the public health sector.

The nutritional quality of foods prepared out of home has been assessed repeatedly in scientific literature in Europe and in the US. EOH is frequently associated with increased energy (Bowman 2004; Kant and Graubard 2004; Orfanos 2007; Vandevijvere, Lachat et al. 2009) and fat intake (Le François, Calamassi-Tran et al. 1996; French, Harnack et al. 2000; Guthrie, Lin et al. 2002; Paeratakul, Ferdinand et al. 2003; Satia, Galanko et al. 2004), and with decreased fruit and vegetable intake (McCrory, Fuss et al. 1999; Paeratakul, Ferdinand et al. 2003; Satia, Galanko et al. 2004; Vandevijvere, Lachat et al. 2009). Convenience foods in turn are characterized by a high number of flavorings and food additives (Alexy 2008).

Furthermore, the portion sizes of the foods eaten outside home have increased over the years (French, Story et al. 2001; Young and Nestle 2002; Diliberti, Bordi et al. 2004; Ledikwe, Ello-Martin et al. 2005; Vandevijvere, Lachat et al. 2009) and it is thus easy to overconsume them (Rolls, Morris et al. 2002; Ebbeling, Sinclair et al. 2004).

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However, we need to bear in mind that in Finnish society the most common way of EOH is eating in mass catering facilities. We can assume that the nutritional quality of foods served at worksite canteens is not as unsatisfactory as in other restaurants, since there are nutrition recommendations for mass catering, unlike for other restaurants or fast-food facilities in Finland.

EOH poses greater challenges to healthy diets than eating at home, since customers too often have insufficient access to nutrition information to make an informed choice (The Keystone Center 2006). Menu labeling has been observed to improve the quality of customers’ diets (Mayer, Heins et al. 1986; Williams and Poulter 1991; Kreuter, Brennan et al. 1997; Perlmutter, Canter et al. 1997; Driskell, Schake et al. 2008). Customers thus have to make a greater effort to identify healthy food choices when eating outside home.

4.2 Determinants of eating This literature review describes relevant factors for eating during working hours. Studies concerning food choices, meals, consumption of single foodstuffs, nutrient intake, and nutrient density are reviewed. All food-related phenomena among humans vary according to socio-demographic and other background factors, and this variance is somewhat similar regardless of the studied phenomenon.

Food choices depend fundamentally on the cultural characteristics of a country or society. The cultural meaning of food differs between countries and between social groups within countries (Douglas 1975), and both the culture and religion in each society define what is edible and what is not (Meiselman 2000). Cultures do not define all nutritionally edible plants or animals as edible, and foodstuffs are understood to be palatable only if they are culturally approved (Ilmonen 1990). Insects, dog meat, or sparrows are not considered to be edible in Western countries, but in some parts of the world they are commonly consumed. Food is also one way to distinguish oneself from others and to express one’s belonging to a certain group (Lupton 1996).

Furthermore, food access and availability depend on political and social issues. Food supply and pricing policies affect which foodstuffs are available and which are affordable for people in different population groups (Robertson, Brunner et al. 2006). The nutritional security of individuals depends on macroeconomics, local accessibility, affordability, individual preferences, and other influences on food choices. National food and nutrition policies have a major role in the nutritional security of citizens in each country. Such policies need to encompass agriculture, the

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environment, rural affairs, health, social welfare, education, employment, and economic affairs.

4.2.1 Life choices and structural chances Determinants of eating patterns can be approached using Weber’s theory on lifestyle. According to Weber, it is assumed that people have both life chances and life conducts (Abel 1991; Cockerham, Abel et al. 1993; Cockerham, Rutten et al. 1997; Abel, Cockerham et al. 2000). Life chances represent the structural conditions, the factors that one has no control over, while life conduct means values, beliefs, and social skills, i.e. behavioral choices that one has control over.

Health lifestyles are defined by William Cockerham (Cockerham 2000) as “the collective patterns of health-related behavior based on choices from options available to people according to their life chances”. For example, people have needs, aims, and urges that control their (food) choices, but they also have different life chances and circumstances that may limit or promote their possibilities to make a particular choice. The choices that people make are thus associated with their background, for instance their education, occupation, family status, income, and place of residence.

Examples of structural conditions that affect food choices include food access, availability, and affordability. Structural conditions, like the availability of a canteen, working conditions, occupation, and working time arrangements, play a big role when considering the use of worksite canteens. Once one has the possibility, one also needs to make an individual choice to have a lunch at the worksite canteen. This choice is affected by factors such as one’s values, knowledge, and beliefs, which reflect education and social circumstances.

4.2.2 Socio-demographic factors

Gender Nutrition knowledge and attitudes toward food are gender-specific around the world. Women not only have better nutrition knowledge (Turrell and Kavanagh 2006; Grunert, Wills et al. 2010), but also have more positive attitudes toward healthy eating than men (Kearney, Kearney et al. 2000). Women thus tend to follow healthy diets more closely than men (Turrell 1997; Roos, Lahelma et al. 1998; Johansson, Thelle et al. 1999; Fraser, Welch et al. 2000; Rafferty, Anderson et al. 2002; Dynesen, Haraldsdottir et al. 2003; Kiefer, Rathmanner et al. 2005; Forshee and

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Storey 2006; Prättälä 2007; McNaughton, Ball et al. 2008; Miura, Giskes et al. 2009; Simunaniemi, Andersson et al. 2009).

Age and marital and parental status Age has in many studies been found to be associated with the quality of diet. Older people tend to have a diet that is more in line with nutrition recommendations than younger people (Johansson, Thelle et al. 1999; Rafferty, Anderson et al. 2002; Robinson, Crozier et al. 2004; McNaughton, Ball et al. 2008; Malon, Deschamps et al. 2010).

Consumption of butter on bread in Finland is more common among younger (25– 34 y) than older women (55–64 y), whereas older men eat butter more commonly than younger males (Helakorpi, Laitalainen et al. 2010). The recommended consumption of fish as well as raw vegetables and fruits or berries is linear according to age in Finland both among men and women (Helakorpi, Laitalainen et al. 2010). The probability of choosing healthy eating as an important factor in food selection was higher among older Irish people (Kearney, Kearney et al. 2000). Differences in eating habits in different age groups could be due to different situations in life and health issues, since individuals with young children have better food habits than those without and older people have more health issues than younger ones.

Marital and parental statuses are associated with people’s health behaviors like eating patterns. Women living without a partner are at a higher risk of poor compliance with nutrition recommendations in France (Malon, Deschamps et al. 2010). Also, previously married Finnish men and women have less healthy food habits than those who are married (Roos, Lahelma et al. 1998). On the other hand, Finnish women with small children have more healthy food habits (Roos, Lahelma et al. 1998). Living in multiperson households including children is associated with better diets also in Denmark (Dynesen, Haraldsdottir et al. 2003), unlike in the UK (Robinson, Crozier et al. 2004).

4.2.3 Work-related factors Food choices during the workday are influenced by the availability of food in the worksite and the surrounding neighborhood, workplace policies, organizational issues, and social norms among co-workers (Faugier, Lancaster et al. 2001; Sörensen, Linnan et al. 2004). Food sources near or at the workplace are, for example, worksite canteens, vending machines, other restaurants, and grocery stores (Larson and Story 2009). Workplace policies that affect eating behavior include the

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amount of time reserved for lunch as well as lunch price subsidies. In Sweden, for example, one project aiming to improve the diets of the employees has three goals: to offer meals to employees at a reasonable price, to have meal breaks that last at least 40 minutes, and to ensure that 80% of the employees use the worksite canteen (Jørgensen, Arsky et al. 2010).

However, policies at worksites are not always fair, since those with blue-collar jobs and with odd working hours are less likely to be provided with organized and healthy meal schemes (Jørgensen, Arsky et al. 2010). Wandel and Roos (Wandel and Roos 2005) studied men in three different occupations (carpenters, engineers, and drivers) in Norway. Researchers found differences in benefits related to food at work; those in higher positions received more benefits, like free or subsidized healthy meals and fruit baskets, than those in lower positions (Wandel and Roos 2005).

The choice of where to eat lunch could be a way to strengthen one’s sense of belonging to a certain social group or to differentiate oneself from other groups (Lindén and Nyberg 2009). For example, lunch has been found to have an important social meaning for male employees in Norway (Wandel and Roos 2005). Men tended to eat with their peers: office workers shared the same table, while “blue- collar” workers ate packed meals elsewhere. Furthermore, Uusitalo and her colleagues (Uusitalo, Prättälä et al. 1996) found in their study on Finnish male blue- collar workers that they chose to eat packed lunches in the same break room as their workmates instead of going to the canteen alone or in other company.

Working conditions are associated with employees’ diet (Marmot, Stansfeld et al. 1991; Wickrama 1995; Hellerstedt and Jeffery 1997; Laitinen 2000; Lallukka, Sarlio-Lahteenkorva et al. 2004; Ovaskainen, Reinivuo et al. 2006). Job demands (Hellerstedt and Jeffery 1997) and high workload (McCann, Warnick et al. 1990) are positively associated with high fat intake among male employees in the US whereas mentally strenuous work and high job control are associated with healthy diet among Finnish female employees (Lallukka, Sarlio-Lahteenkorva et al. 2004). Low job control is associated with unhealthy diet among men in the US (Wickrama 1995) as well as low job status among civil servants in the UK (Marmot, Stansfeld et al. 1991). Physically demanding jobs in turn are associated with a snack-dominated meal pattern in male employees in Finland (Ovaskainen, Reinivuo et al. 2005). In addition, some structural conditions (Abel 1991; Cockerham, Rutten et al. 1997; Laaksonen 2002), like lack of time, shift work, and lunch possibilities at work, may affect lunch choices during working hours (Stewart and Wahlqvist 1985; Faugier, Lancaster et al. 2001; Devine, Farrell et al. 2009). Lack of time during the workday has been found to force employees to skip lunches, or eat packed meals at their desks (Faugier, Lancaster et al. 2001; Devine, Farrell et al. 2009). Devine and her

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colleagues argue that among working adults with low or moderate income in the US, work is perceived to impose many barriers – inflexible hours and night work for example – to healthy eating (Devine, Connors et al. 2003; Devine, Farrell et al. 2009).

4.2.4 Socioeconomic position Factors defining socioeconomic position (SEP) can be classified into material resources – income, property, level of housing, etc. – and the instruments used to provide those material factors – education, occupation, and job status. All of the abovementioned factors are associated with food choices and the eating patterns of individuals. In dietary research, all of those factors have been used as determinants of SEP, while all of them reflect different social processes and cannot necessarily be used as proxies for one another (Galobardes, Morabia et al. 2001; Turrell, Hewitt et al. 2003; Vlismas, Stavrinos et al. 2009). Education has an influence on lifestyle behaviors, problem-solving capacity, and values (Liberatos, Link et al. 1988); in addition, it captures the person’s nutrition knowledge and comprehension of nutritional information and food labeling (Galobardes, Morabia et al. 2001). Income reflects the availability of economic and material resources (Turrell and Kavanagh 2006): housing, diet, and access to medical care. Occupation in turn measures prestige, responsibility, physical strain (Winkleby, Jatulis et al. 1992), and work exposures as well as creates environmental and social structures (Galobardes, Morabia et al. 2001). Nevertheless, if only one determinant of SEP can be chosen, education is valued as the best of those three, at least when it comes to health (Winkleby, Jatulis et al. 1992).

People differ in their food habits according to their socioeconomic status, whichever indicator of SEP has been used. Those with lower status and the economically disadvantaged are less likely to report healthy food habits (Roos, Lahelma et al. 1998; Johansson, Thelle et al. 1999; Fraser, Welch et al. 2000; Galobardes, Morabia et al. 2001; Dynesen, Haraldsdottir et al. 2003; Huot, Paradis et al. 2004; Robinson, Crozier et al. 2004; Giskes, Turrell et al. 2006; Lallukka, Laaksonen et al. 2007; Malon, Deschamps et al. 2010; Mullie, Clarys et al. 2010; Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010) or purchase foods that are in accord with dietary guidelines (Turrell, Hewitt et al. 2002; Turrell, Hewitt et al. 2003). Especially, disadvantaged people consume less fruits and vegetables compared with higher socioeconomic groups (Smith and Brunner 1997; Fraser, Welch et al. 2000; Irala- Estevez, Groth et al. 2000; Groth, Fagt et al. 2001; Lindström, Hanson et al. 2001; Dibsdall, Lambert et al. 2003; Rose and Richards 2004; Prättälä 2007; Monsivais and Drewnowski 2009; Prättälä, Hakala et al. 2009; Helakorpi, Laitalainen et al. 2010).

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The observed SEP gradient in diet quality may be mediated by attitudes (Bihan, Castetbon et al. 2010; Mirmiran, Mohammadi-Nasrabadi et al. 2010), nutrition knowledge, and interest in healthy eating (Variyam, Blaylock et al. 1996; Wardle, Parmenter et al. 2000; Kearney, Gibney et al. 2001; Grunert, Wills et al. 2010; Mirmiran, Mohammadi-Nasrabadi et al. 2010), as well as affordability and accessibility (Morland, Wing et al. 2002; Wrigley, Warm et al. 2003; Rose and Richards 2004). The lowest-cost diets are usually also the least healthy (McAllister, Baghurst et al. 1994; Cade, Upmeier et al. 1999; Schroder, Marrugat et al. 2006). In general, diets with high energy density are associated with lower costs (Darmon, Briend et al. 2004), whereas nutrient-dense diets are associated with higher costs per megajoule (Andrieu, Darmon et al. 2005; Maillot, Darmon et al. 2007; Monsivais and Drewnowski 2009).

4.3 Determinants of worksite eating There are very few previous international studies about determinants of worksite canteen usage. The number of Finnish studies in this field is also very limited.

4.3.1 Socio-demographic factors

Gender Men are more likely to eat in worksite canteens than women in Norway (Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010) and in Finland (Roos, Sarlio-Lähteenkorva et al. 2004). In Norway, 37% of men eat in their worksite canteen three times or more per week, whereas 25% of women frequently eat there (Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010). Among employees from the City of Helsinki, 54% of men and 48% of women reported that they usually had lunch at a worksite canteen (Roos, Sarlio-Lähteenkorva et al. 2004).

Age, marital and parental status Odds of eating frequently in worksite canteens decrease with age in Norway (Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010) and Finland (Helakorpi, Laitalainen et al. 2010). Women with pre-school children are more likely to have lunch at a worksite canteen than other women in Finland (Roos, Sarlio-Lähteenkorva et al. 2004).

4.3.2 Work-related factors Structural conditions that affect the lunch place choices of individuals at work are, for example, the availability of a canteen (Faugier, Lancaster et al. 2001; Roos,

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Sarlio-Lähteenkorva et al. 2004; Wandel and Roos 2005), distance from it, lack of time (Faugier et al., 2001), and shift work (Stewart and Wahlqvist 1985; Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010). Another factor is that, the foods offered at the canteen are naturally associated with the quality of the meals eaten (Lachat 2008; Thorsen, Lassen et al. 2009).

Company size, corporate financial support, and distribution of gender at the workplace affect the availability of healthy meals at worksite canteens in Denmark (Thorsen, Lassen et al. 2009). Healthy menus are frequently available at larger worksites and those where the majority (>75%) of employees are female. In addition, corporate financial support is positively associated with healthy meal options (Thorsen, Lassen et al. 2009). Job satisfaction is associated with more frequent use of a worksite canteen in Finland (Laitinen 2000).

4.3.3 Socioeconomic position In Norway, those with the highest education are least likely to use worksite canteens frequently, but income is positively associated with canteen use (Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010). In Finland, the situation is opposite, since employees with higher educational level are more likely to have lunch at a worksite canteen (Roos, Sarlio-Lähteenkorva et al. 2004). In France, university students with higher SEP eat more frequently at their university canteen than did the other students (Guagliardo, Lions et al. 2011).

4.4 Nutritional quality of canteen meals A recent study in Belgium compared the nutritional quality of canteen meals consumed at Ghent University with the Belgian recommendations (Lachat 2008). The theoretical meal combinations supplied too much protein and fat but not enough carbohydrates. In addition, only a few meals contained fruits and some meals contained no vegetables. In Denmark, France, and Belgium, the salt content in worksite canteen meals is high in comparison with the recommended daily intake (Noël, Leblanc et al. 2003; Lachat, Verstraeten et al. 2009; Rasmussen, Lassen et al. 2010). Having a lunch at the university canteen in France is positively associated with the consumption of at least five servings of fruits and vegetables daily and one serving of meat/fish daily but not with either restricting fatty food or never or rarely adding salt to food (Guagliardo, Lions et al. 2011). In Finland, eating at a canteen is associated with more frequent consumption of vegetable and fish dishes (Lallukka, Lahti-Koski et al. 2001; Roos, Sarlio-Lähteenkorva et al. 2004).

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5 Summary of literature

The goal of this literature review is to show the gaps in previous scientific knowledge of eating patterns at workplaces. Previous literature on the determinants of worksite canteen usage and the associations of lunch eating patterns with food habits and nutrient intake is very limited; in fact, there is an almost complete lack of international literature on this subject. Also, most of the earlier Finnish studies concerning worksite canteen use are limited to small or unrepresentative population groups (Laitinen 2000; Roos, Sarlio-Lähteenkorva et al. 2004). Therefore, previous studies about EOH are reviewed more widely instead of concentrating solely on eating at work.

According to the previous literature, gender, SEP, company size, corporate financial support, shift work, the availability of a canteen, distance from it, and lack of time are associated with eating during working hours. Economic and social changes in Finland might have influenced the use of worksite canteens over the years. The economic depression in the 1990s might have limited the use and availability of canteens, whereas the increasing educational level of Finns and urbanization might have promoted it.

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6 Scope and purpose

The goal of this study is to shed light on the eating habits of Finnish employees during the working day. Worksite canteens and other catering services are widely used in Finnish food culture, but research concerning them is quite sparse. There is no regular surveillance system for them either, which leads to a lack of knowledge about the availability of canteens for employees, amount of canteen users, factors associated with the availability of canteens and canteen use, and the nutritional quality of the meals offered at the canteens.

Another popular way of having a lunch during working hours in Finland is a packed meal, and we know even less about them than about canteen meals. To be able to evaluate the public health relevance of lunch eating patterns during working hours, we need more information on them.

The main aim of this thesis is to examine the contribution of various socio- demographic, socioeconomic, and work-related factors to the lunch eating patterns of Finnish employees during the working day and how lunch eating patterns influence dietary intake.

This aim is pursued by conducting four substudies on the following topics, referred to in the text by Roman numerals:

(I) To study whether the trends in the eating patterns of Finnish employees representing different socioeconomic groups are similar during working hours over time, 1979–2001. (II) To study if the differences in eating patterns during working hours can be explained by working conditions, such as occupation, social support, mental strain, physical strain at work, and job control. (III) To study the availability of canteens among Finnish employees, and the associations between the availability of a canteen and the employee’s socio-demographic background and the characteristics of the workplace. (IV) To examine whether the use of a worksite canteen or packed lunches is associated with the nutritional quality of the employees’ diets.

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7 Data and methods

The data used in this thesis is obtained from three different cross-sectional health surveys conducted repeatedly by different research institutions in Finland. Inclusion criteria for those surveys are national representativeness and versatility. The results of this thesis are based on secondary analysis of these surveys.

7.1 Data sources Data from the Health Behaviour and Health among Finnish Adult Population surveys of 1979–2008 are used in substudies I and III. The data from the Work and Health in Finland surveys of 1997, 2000, and 2003 are used in substudy II, whereas in substudy IV the data from the National Findiet 2002 and FINRISK 2002 studies are used (Table 1).

In this study, only employed people, inclusive of students, aged 19 or 24 to 64 are included in the analysis. In addition to the unemployed, farmers, housewives, and pensioners are excluded because they do not usually have the possibility to have their lunch at a worksite canteen.

7.1.1 Health Behaviour and Health among Finnish Adult Population survey (AVTK) The study material in substudies I and III is obtained from the data of the Health Behaviour and Health among Finnish Adult Population survey (Helakorpi, Prättälä et al. 2008). The data of this cross-sectional survey have been collected annually since 1978. Each year, a random sample of 5000 Finns aged 15 to 64 years is drawn from the national population register maintained by Statistics Finland. A decreasing trend has been observed in response rates year by year. The questionnaire, which is mailed to respondents, has remained basically the same over the years.

In the first (I) substudy, data from 1979 to 2001 are used. The data originally includes 49976 men and 45833 women and the response rate in those years varies between 60 and 86%. Employed Finns from all possible workplaces (except farmers) or respondents with student status, aged 25 to 64 years, are selected for analysis. Altogether 24292 men and 24746 women are included in the analysis, of whom 641 (3%) and 860 (4%) are students, respectively.

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In the third (III) substudy data from 2005, 2006, and 2007 are analyzed. The data consists of 4419 men and 5368 women and the response rates are 66%, 65%, 65% respectively. For analysis, only employed Finns, excluding farmers, aged 19 to 64 years are selected. Altogether, the final data consists of 2659 men and 2926 women.

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5 72 28 22 48 30 30 32 27 11 23 41 16 15 53 47 29 28 43

4 75 26 22 49 29 24 31 34 11 19 40 23 14 50 50 15 28 57

5 73 27 22 46 32 28 33 29 11 23 39 19 15 52 48 22 29 49

7 73 27 21 48 32 32 34 24 10 23 43 13 15 55 45 33 29 38

6 67 34 22 49 29 36 29 22 13 27 42 10 15 54 46 44 27 29

%

Study period period Study

78 22 19 48 33 32 32 25 11 27 36 13 10 13 54 46 35 30 36

78 22 20 51 29 25 31 31 13 24 36 13 13 14 49 51 18 34 48

78 22 20 47 34 29 31 29 11 27 34 13 11 14 51 49 26 33 41

9 77 23 19 47 34 33 34 22 10 25 38 15 12 51 49 37 30 33

9 80 20 18 48 34 37 32 22 10 31 35 12 12 60 40 49 24 27 7640 6431 5677 4544 24 292 6330 6747 6433 5236 292 24746 24 7640 6431 5677 4544 1979–84 1985–90 1991–96 1997–2001 TOTAL 1979–84 1985–90 1991–96 1997–2001 1997–2001 TOTAL 1991–96 1985–90 1979–84 TOTAL 1997–2001 1991–96 1985–90 1979–84

1 Having children under 18 years of age 18 years under Having children Others Helsinki capital area Other cities Rural areas or cohabiting Married Yes No

Table 1. Characteristics of the respondents in Health Behaviour and Health among Finnish Adult Population survey (I), 1979–2001 (I), survey Population Adult Finnish among Health and Behaviour Health in respondents of the 1. Characteristics Table WOMEN MEN group Age 25–34 years 35–44 years 45–54 years 55–64 years education of Years 0–9 years 10–12 years or more 13 years of residencePlace status Marital statusParental place Lunch choice Home n 1 Worksite canteen Restaurant or bar Other Do not eat lunch

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Table 2. Characteristics of the respondents in Health Behaviour and Health among Finnish Adult Population survey (III), 2005–2007 Men Women % Age groups 19–24 6 5 25–34 19 18 35–44 28 27 45–54 29 32 55–64 19 19 Education, years 0–9 12 9 9–12 35 27 >13 53 64 Place of residence Helsinki capital area 21 24 Other cities with 100 000 inhabitants and over1 10 11 Cities with 50 000–99 999 inhabitants2 15 17 Other cities 53 48 Occupational class Upper white-collar worker 25 20 Lower white-collar worker 13 26 Skilled blue-collar worker 35 35 Unskilled blue-collar worker 13 12 Employer, private enterpriser 13 7 Marital status Married or cohabiting 77 74 Parental status3 Yes 43 43 Size of the workplace 1–19 persons 36 39 20–249 persons 36 39 More than 250 persons 27 22 Degree of physical burden of respondent's job Job mainly involves sitting 38 42 Work involves quite a lot of walking 23 28 Work involves much of walking and lifting 25 26 Work is physically very demanding 14 3 n 2659 2926 1 Oulu, Tampere, Turku 2 Joensuu, Jyväskylä, Kotka, Kuopio, Lahti, Lappeenranta, Pori, Rovaniemi, Vaasa 3 Having children under 18 years of age

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7.1.2 Work and Health in Finland –survey The study material in the second (II) substudy consists of the data from the cross- sectional Work and Health in Finland survey conducted by the Finnish Institute of Occupational Health triennially since 1997 (Kauppinen, Aaltonen et al. 1997; Kauppinen, Heikkilä et al. 2000; Kauppinen, Hanhela et al. 2003). Every third year, a random sample of 5000 people aged 25 to 64 years is drawn from the national population register maintained by Statistics Finland. About 60% (approx. 3000) of the original sample is then interviewed by telephone.

The survey data used in this substudy are collected in 1997, 2000, and 2003. The original data consist of 4499 men and 4934 women and the response rates are 67%, 58%, and 71% respectively. Employed Finns from all possible workplaces, except farmers, are included in the analysis. A total of 3096 men and 3273 women have been selected for substudy II.

7.1.3 The National FINDIET 2002 Study In the fourth (IV) substudy, data from the National FINDIET 2002 Study (Männistö, Ovaskainen et al. 2003) are used. The FINDIET Study is conducted by the National Public Health Institute (KTL) as a substudy of the National FINRISK Study (Laatikainen, Tapanainen et al. 2003). Subjects in an age- and gender-stratified random sub-sample (n=3181) from five regions in Finland, aged 25–74 years, were invited to participate in a 48-hour dietary interview. Of those invited, 64% participated (n=2045), and 98% of these interviews were subsequently accepted (n=2007). Details of that dietary interview have been published earlier (Männistö, Ovaskainen et al. 2003).

The study analysis involves only those participants who were at work on both of the days included in the dietary recall (n=609) and who had their lunches on both days in the same place, i.e. they ate either at the worksite canteen or had a packed lunch on both days (n=261). These limitations have been set to ensure that the eating place categories compared are pure and no mixed categories are analyzed. Finally, a total of 108 men and 153 women are included in the analysis.

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Table 3. Characteristics of the respondents in Work and Health in Finland –survey (II) Men Women % Age group (y) 25–34 26 21 35–44 31 33 45–54 32 34 55–64 11 12 Educational level Low 70 57 Medium 14 26 High 16 18 Place of residence Helsinki area 19 21 Other cities 61 61 Rural areas 20 19 Size of the workplace, # of employees 1–30 52 56 >30 48 44 Occupation Transportation and industry 44 10 Trading and service 17 23 Health and social welfare 4 27 Science, arts, management, office work 35 41 Working time Shift work 73 75 Regular day work 27 26 Social support Very high 27 26 High 26 26 Low 20 22 Very low 27 26 Mental strain Very low 31 25 Low 22 27 High 20 23 Very high 27 25 Physical strain Very low 26 25 Low 27 24 High 23 26 Very high 24 25 Job control Very high 23 21 High 20 28 Low 32 24 Very low 25 27 n 3096 3273

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Table 4. Characteristics of the respondents in the National FINDIET 2002 Study (IV) Men Women % Age 25–34 25 26 35–44 25 31 45–54 31 27 55–64 19 16 Place of residence Northern Finland1 65 57 Southern Finland2 35 43 Educational level Low3 29 24 Medium4 36 32 High5 35 44 Marital status Married or cohabiting 73 72 Other 27 28 Type of work Manual 34 7 Non-manual 66 93 n 108 153 1 North Karelia, North-Savo and Oulu 2 The metropolitan area of Helsinki and the Turku area 3 <9 years 4 9–13 years 5 >13years

7.2 Variables

7.2.1 Independent variables The main independent variables of this study are: gender, age, place of residence, education, parental status, and marital status.

Socio-demographic variables When studying the eating patterns of individuals, socio-demographic and socioeconomic factors need to be taken into account. Socio-demographic determinants such as gender, age, place of residence, marital status, and parental status are major determinants of eating patterns (Turrell 1997; Roos, Lahelma et al. 1998; Laitinen 2000; Roos, Sarlio-Lähteenkorva et al. 2004). Socioeconomic factors, like education and income, have also been found to be associated with the

Lunch eating patterns during THL –- Research 68/2011 35 working hours and their social and work-related determinants

eating habits of an individual (Roos, Lahelma et al. 1998; Johansson, Thelle et al. 1999; Fraser, Welch et al. 2000; Galobardes, Morabia et al. 2001; Lallukka, Laaksonen et al. 2007).

In this thesis, the following socio-demographic and socioeconomic determinants are used in all substudies either as background variables or confounders: 1) Age; 2) Gender; 3) Place of residence; 4) Marital status; 5) Parental status; 6) Education; and 7) Occupation.

Work-related factors (II, III, IV) In this thesis, the following work-related factors are used to explain anticipated differences in lunch eating patterns among Finnish employees: 1) Size of the workplace (substudies II, III); 2) Occupation (II); 3) Occupational status (III); 4) Working time (II); 5) Type of work (IV); 6) Social support at work (II); 7) Mental strain at work (II); 8) Physical strain at work (II); and 9) Job control (II).

The last four variables are sum variables constituted based on factor analysis. Variables that have factor loadings higher than 0.5 are selected from each factor, and sum variables are built based on these different dimensions.

The first sum variable ‘Social support at work’ is based on the following original questions (Cronbach's ! 0.71): 1) What are the relationships like between the employees at your workplace?; 2) Do you receive help from your colleagues when needed?; 3) Do you receive help from your boss when needed?; and 4) How satisfied are you with your job?

The second sum variable ‘Mental strain at work’ is constituted from four original questions (Cronbach's ! 0.77): 1) Do you feel stressed right now?; 2) How often do you need to hurry to get your work done on time?; 3) Do you think that you have not managed to complete all the tasks you should have?; and 4) How mentally demanding is your job?

Again, the third sum variable ‘Physical strain at work’ consists of four questions (Cronbach's ! 0.64): 1) Is there dust at your workplace?; 2) Do you use solvents in your job, and do they bother you?; 3) Do you sweat when you are working?; and 4) How physically demanding is your job?

The fourth sum variable ‘Job control’ is based on the following original questions (Cronbach's ! .71): 1) Can you influence issues at work that relate to you?; 2) Can

Lunch eating patterns during THL –- Research 68/2011 36 working hours and their social and work-related determinants

you influence the order in which you do your tasks?; 3) Can you influence your workload?; and 4) Can you influence the length of your workday?

All sum variables are categorized into four classes, with the first category defined as the best and the fourth as the worst. The variables ‘Social support at work’ and ‘Job control’ were categorized as follows: ‘very high’; ‘high; ‘low’; and ‘very low’, the first one being the reference class. The other two sum variables: ‘Mental strain at work’ and ‘Physical strain at work’ are classified as follows: ‘very low’; ‘low’; ‘high’; and ‘very high’, the first one, again, being the reference category.

Time period (I) The survey data is classified into four time scales: 1) 1979–1984; 2) 1985–1990; 3) 1991–1996; and 4) 1997–2001. These eras are selected according to the following phases of the Finnish economy: the early 1980s was an era of constant economic growth, from 1985 to 1990 the economy boomed, whereas from 1991 to 1996 Finland went through a deep economic recession, after which the economy recovered.

7.2.2 Dependent variables The dependent variables of this study are somewhat different between the substudies and they are presented in Table 1.

Lunch place choice during the workday (I, II, III, IV) The location of the lunch place is determined by the following question in substudy one (I): “Where do you usually have lunch during working hours (between 10:00 a.m. and 3:00 p.m.).” The answer choices are: 1) At Home; 2) At a restaurant or bar; 3) At the worksite canteen; 4) Other location; and 5) I do not have lunch. The basic distribution of all of the abovementioned lunch place choices is first shown according to study period. In further analyses, worksite canteen is used as a dependent variable.

In substudy two (II), the lunch place is determined as follows: “Where do you usually eat during working hours?” The answer choices are: 1) I do not have a lunch; 2) At home; 3) At a restaurant or cafe; 3) At the worksite canteen; 4) I have a packed meal; and 5) At some other place. The basic distribution of all of the abovementioned lunch place choices is shown first. In subsequent analyses, the worksite canteen and having a packed meal are used as dependent variables.

Lunch eating patterns during THL –- Research 68/2011 37 working hours and their social and work-related determinants

In substudy three (III), the location of the lunch place is defined by the following question: “Where do you usually have lunch during working hours (between 10:00 a.m. and 3:00 p.m.)?” The answer choices are: 1) At home; 2) In a restaurant or a bar; 3) At the worksite canteen; 4) I have a packed meal; 5) Elsewhere; and 6) I don’t eat a meal at noon. The basic distribution of all of the abovementioned lunch place choices is shown first according to canteen availability. In subsequent analyses, the workplace canteen and having a packed lunch are used as dependent variables.

In the dietary interview (substudy IV), the lunch place is identified by “Selection of the lunch site on working days?” The possible answers are 1) At home; 2) At the worksite canteen; 3) At another restaurant; 4) I have a packed lunch; and 5) I do not have lunch. Participants are divided into three categories according to their lunch place choice over a two-day period. The categories of the new variable are: 1) Two lunches at the worksite canteen; 2) Two packed lunches; and 3) Other lunch place combinations1. Firstly, the basic distribution of all of the abovementioned lunch place choices is shown. In subsequent analyses, the workplace canteen and having a packed lunch are used as dependent variables.

The quality of the diet (IV) The Finnish food composition database, Fineli (National Institute for Health and Welfare (THL)), is used to calculate the energy and nutrient intakes of the participants.

The nutritional factors analyzed are: fat E%, protein E%, carbohydrates E%, sugar E%, fiber g/Mj, vitamin C mg/Mj, vitamin A µg/Mj RE, and carotenoids µg/Mj. These nutrients were selected because they provide a coarse overview of the nutritional quality of the meals studied. In addition, fat and fiber intake has been one of the areas of nutrition needing the most improvement in the diets of Finnish adults. Earlier studies have shown that the fat intake of Finnish adults is too high, whereas their fiber intake is too low (Findiet 1997 group 1998).

7.3 Statistical analyses All the analyses in substudies I to IV are carried out separately for males and females, since practices and attitudes toward food are gender-specific. The basic results in all studies are presented as proportions (%), means, and standard deviations (SD). The results of logistic regression are presented as odds ratios (OR)

1 Two lunches at home, two lunches at a restaurant, two times no lunch, one lunch at home + one lunch at a restaurant, one lunch at home + no lunch, one lunch at a restaurant + no lunch

Lunch eating patterns during THL –- Research 68/2011 38 working hours and their social and work-related determinants

and 95% confidence intervals (CI), and the results of linear regression are presented as regression coefficient, p-value, and 95% confidence intervals (CI).

In substudy I, the time trend in the frequency of worksite canteen use among Finnish employees is first described using age-adjusted averages. Thereafter the frequency of worksite canteen use is described according to age, education, and place of residence at the time. Socio-demographic differences in the frequency of worksite canteen use are analyzed with logistic regression models. The overall effect is added first, followed by age, study period, education, place of residence, marital status, and number of children. In order to assess the stability of the individual-level relationships over time, the interactions of study period with age, education, and urbanization are included separately into the fully adjusted main effects models.

In substudy II, frequency of worksite canteen use and the use of packed meals are first analyzed by cross-tabulations. Secondly, the analyses are performed with logistic regression models. The interaction between the size of the workplace and working conditions is tested, and if an interaction is found the data is stratified according to the size of the workplace. The overall effect is added to the model first, followed simultaneously by age, years of education, and place of residence. Subsequently occupation and work-related factors are added to the model.

In substudy III, the proportions of different lunch place choices among Finnish employees according to canteen availability are first described. Socio-demographic and work-related differences in the availability of worksite canteens are then analyzed with the logistic regression model. Subsequently, the use of both the canteen and packed lunches is analyzed according to canteen availability, also using logistic regression analyses. The overall effect is added first, followed by age, years of education, place of residence, marital status, number of children, and work- related factors.

In substudy IV, differences in the frequency of worksite canteen use and packed lunch use are first described by cross-tabulation according to selected socio- demographic variables. Next, the associations between the eating place and energy- adjusted food and nutrient intake between those employees who ate both of the surveyed meals either at the worksite canteen or as a packed lunch are tested by t- test. Also, the difference in proportions of the daily users of fresh vegetables, fresh fruits and berries, and rye bread between lunch places is analyzed using Pearson’s "2 test. Finally, the differences in food use and nutrient intake according to the lunch place choice (either canteen or packed lunch) are analyzed by means of a linear regression model. We use food consumption and nutrient intake as dependent variables, lunch place as an independent variable, and having two lunches as a

Lunch eating patterns during THL –- Research 68/2011 39 working hours and their social and work-related determinants

packed meal as a reference group. All variables – lunch place, age, place of residence, and education – are added to the model simultaneously.

All analyses in substudies I, II, and III are made using the PASW Statistics 17.0 statistical package (SPSS Inc., Chicago, IL, USA), and analyses in substudy IV are conducted with the Stata statistical package version 9.2 (StataCorp LP, Collage Station, Texas, USA).

Lunch eating patterns during THL –- Research 68/2011 40 working hours and their social and work-related determinants

Health Behaviour and Health and Health Behaviour Health and Health Behaviour Health Work and Health in Finland 1997, 1997, Work and Health in Finland 2000, 2003 n = 6369 Study n = 261 among Finnish Adult Population Adult Population among Finnish 1979–2001 n =24746 Adult Population among Finnish 2007 2005, 2006, n = 5585 The National FINDIET 2002 The National FINDIET

ratifications ratifications n years, study set, Data Gender, the of size workplace Gender Gender Gender

support, mental

strain at work,strain physical strain at the of size control, work, job time workplace, working Study period, gender, age, gender, Study period, of residence, education, place parental status marital status, place Age, education, of residence, occupation, social place Age, education, of residence, parental status, marital status, class, size of the occupational work at strain physical workplace, canteen of worksite availability place Age, education, of residence, having type of work, marital status, a at worksite canteen, having lunch lunch packed Dependent variables Dependent variables Independent St canteen canteen canteen meal Having packed day work during the canteen Having at worksite lunch canteen lunch, fat, protein, sugar, carbohydrates, vitamin fibre, vitamin C, carotenoids A, and Logistic regression Logistic regression worksite at Having lunch Logistic regression worksite at Having lunch Logistic regression worksite of Availability Linear regression from energy Proportion of method

Table 5. Statistical methods, variables and data sets used in substudies substudies in used sets data and variables methods, Statistical 5. Table Substudy Statistical I II III IV

Lunch eating patterns during THL –- Research 68/2011 41 working hours and their social and work-related determinants

8 Results

The following results section will present and summarize the main results observed in all the substudies (I, II, III, and IV). Tables 6–13 and Figures 1–5 display the main results of each substudy. The focus in reporting the key findings is to show the most notable results. Only the results that remain statistically significant after adjustments are mentioned in the text.

Another approach to these results is to address the aims and review the results in accordance with the main and the specific aims (see Chapter 5) set up to conduct this study.

8.1 Trends in worksite canteen use Frequency of worksite canteen use has been fairly stable in Finland over two decades under study (Fig. 1). Women ate at the worksite canteen slightly more often (38–45%) than did men (33–38%) during the whole time period studied (Table 6). After adjusting for age, education, place of residence, marital status, and parental status a slight decreasing trend in the frequency of worksite canteen use was found both among men and women (Table 6).

Figure 1. Having lunch at worksite canteen among Finnish men and women 1979–2001

Educational level Differences in the frequency of worksite canteen use between educational levels have been relatively stable (Figure 2). Worksite canteen use has decreased mostly (from 53% to 45%) among women with higher education (13 school years or more)

Lunch eating patterns during THL –- Research 68/2011 42 working hours and their social and work-related determinants

from 1985–1990 to 1991–1996, after which the decline leveled off. Employees with higher education used worksite canteens more often than did those with lower education during the whole time period studied. Educational level seemed to be strongly associated with worksite canteen use (p<0.001) (Table 6). The higher the educational level, the higher the frequency of worksite canteen use among both men and women.

Place of residence In the Helsinki capital area, worksite canteen use was much more common than in other towns or rural areas. About half of the people living in the capital area ate at worksite canteens and the difference has remained quite steady over the study years (Figure 3). The place of residence was strongly associated with worksite canteen use (p<0.001) (Table 6).

Lunch eating patterns during THL –- Research 68/2011 43 working hours and their social and work-related determinants

Women over

or

years

13 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 0 years

60 50 40 30 20 10 12 Year ‐ 10 years

9 ‐ 0 Men 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 0 60 50 40 30 20 10 % Figure 2. Having lunch at worksite canteen among Finnish men and women according to school years, 1979–2001 years, school to according women and men Finnish among canteen worksite at lunch Having 2. Figure

Lunch eating patterns during THL –- Research 68/2011 44 working hours and their social and work-related determinants

THL

–- –- Helsinki capital area Other cities Rural areas Research 68/2011 Men Women 60 60

50 50

40 40

30 30 % 45

20 20

10 10 and work

working hours and their 0 0 Lunch eating patterns during 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 Year - related determinants Figure 3. Having lunch at worksite canteen among Finnish men and women according to the place of residence, 1979–2001 social social

Table 6. Odds ratios and 95% confidence intervals for having lunch at worksite canteen in Finland, 1979–2001

MEN WOMEN Single model1 Full model2 Single model1 Full model2 OR 95% CI OR 95% CI OR 95% CI OR 95% CI Study period, ref. 1979– 1984 1985–1990 1.0 0.88–1.03 1.1 0.98–1.14 1.1 1.02–1.18 1.0 0.88–1.03 1991–1996 1.1 1.00–1.17 0.8 0.76–0.89 1.1 1.03–1.20 0.7 0.67–0.78 1997–2001 0.9 0.86–1.02 0.8 0.75–0.89 1.0 0.89–1.04 0.7 0.66–0.78 Education, years, ref. 0–9 years 10–12 years 1.3 1.21–1.40 1.4 1.25–1.46 1.3 1.23–1.41 1.4 1.31–1.53 13 years or over 2.4 2.22–2.54 2.4 2.23–2.58 2.0 1.88–2.15 2.2 2.00–2.32 Place of residence, ref. Helsinki capital area Other cities 0.6 0.54–0.62 0.6 0.60–0.69 0.6 0.59–0.67 0.7 0.63–0.73 Rural areas 0.5 0.47–0.54 0.6 0.55–0.64 0.6 0.54–0.63 0.7 0.61–0.71 Marital status, ref. Married or cohabiting Others 1.1 1.03–1.17 1.1 1.01–1.17 1.2 1.16–1.29 1.1 1.05–1.19 Parental status3, ref. Yes No 1.1 1.03–1.15 1.0 0.95–1.09 1.2 1.11–1.24 1.1 1.00–1.14 1 Adjusted for age 2 Adjusted for all the variables in the model 3 Having children under 18 years of age

8.2 Lunch eating patterns according to occupation and working conditions All logistic regression models were fitted separately to small (less than 30 employees) and large (30 employees or more) workplaces, since statistically significant (p<0.001) interaction between the size of the workplace and working conditions was observed when studying worksite canteen use.

Occupation Worksite canteens were used more frequently by employees who worked in healthcare and social welfare, or any kind of office work in small workplaces (Table 7). At small workplaces, male workers in trading or service and in various office

Lunch eating patterns during THL –- Research 68/2011 46 working hours and their social and work-related determinants

jobs had packed meals less often than workers in other occupations (Table 8). At large workplaces, both women and men in trading or service and office work ate packed meals less often than workers in other occupations (Table 8).

Working conditions Female employees who had a regular day job ate at worksite canteens more often than those who had irregular working hours, regardless of the size of the workplace (Table 7). At large workplaces, male employees who did not get social support at work and who had low mental strain used the worksite canteen more often than the others (Table 7). Both male and female employees with physically demanding jobs ate more often at a canteen, especially at small workplaces. At small workplaces, female employees with low job control ate at worksite canteens more often than their colleagues (Table 7).

At small workplaces, male employees ate more packed meals if they had a regular day job and physically demanding work, and when mental strain at work was high (Table 8). At large workplaces, male workers had packed meals less frequently when employed in regular day jobs and when the social support at work was low (Table 8). Female employees working at small workplaces with low job control ate packed meals less frequently than those with high job control (Table 8).

Lunch eating patterns during THL –- Research 68/2011 47 working hours and their social and work-related determinants

Table 7. Odds ratios and 95% confidence intervals for eating a meal at workplace canteen among 24 to 64-year-old Finnish employees Men Women Small1 workplace Large2 workplace Small1 workplace Large2 workplace OR3 95% CI OR3 95% CI OR3 95% CI OR3 95% CI Occupation, ref. Transportation and industry Trading and service 1.3 0.85–2.04 0.9 0.64–1.35 1.6 0.84–3.13 1.6 0.98–2.48 Health and social 3.0 welfare 1.61–5.68 1.6 0.85–3.10 2.4 1.27–4.66 1.0 0.63–1.60 Science, arts, 2.1 management, and office work 1.37–3.20 1.4 0.99–2.02 3.3 1.69–6.34 1.5 0.95–2.31 Working time, ref. Shift work Regular day work 1.4 0.99–2.02 1.2 0.87–1.54 1.4 1.00–1.84 1.6 1.17–2.23 Social support, ref. Very high High 1.0 0.69–1.59 1.1 0.78–1.46 1.3 0.92–1.81 1.0 0.72–1.42 Low 1.4 0.90–2.08 1.2 0.88–1.75 1.0 0.66–1.38 1.3 0.94–1.91 Very low 1.0 0.69–1.58 1.5 1.06–2.04 1.2 0.84–1.70 1.2 0.88–1.68 Mental strain, ref. Very low Low 1.2 0.84–1.83 0.9 0.70–1.29 0.7 0.52–1.01 1.2 0.86–1.68 High 1.1 0.67–1.67 0.8 0.58–1.21 0.7 0.47–0.93 1.1 0.79–1.57 Very high 1.0 0.66–1.61 0.7 0.49–0.99 0.7 0.51–1.00 0.9 0.65–1.25 Physical strain, ref. Very low Low 1.2 0.83–1.81 1.3 0.92–1.82 1.9 1.33–2.63 0.9 0.63–1.25 High 1.7 1.13–2.49 1.4 1.01–2.06 1.6 1.16–2.33 1.0 0.73–1.44 Very high 1.6 1.09–2.50 1.0 0.72–1.47 1.6 1.12–2.27 1.0 0.71–1.48 Job control, ref. Very high High 0.9 0.62–1.40 1.2 0.84–1.69 1.6 1.12–2.41 1.2 0.86–1.57 Low 0.8 0.54–1.16 0.8 0.59–1.12 2.3 1.52–3.51 1.1 0.77–1.60 Very low 1.0 0.64–1.44 0.8 0.57–1.06 2.6 1.75–3.91 1.1 0.73–1.54 1 < 30 employees 2 30 employees or more 3 Adjusted for age, education, place of residence, and all the other variables in the model

Lunch eating patterns during THL –- Research 68/2011 48 working hours and their social and work-related determinants

Table 8. Odds ratios and 95% confidence intervals for eating a packed meal at work among 24 to 64-year-old Finnish employees Men Women Small1 workplace Large2 workplace Small1 workplace Large2 workplace OR3 95% CI OR3 95% CI OR3 95% CI OR3 95% CI Occupation, ref. Transportation and industry Trading and 0.7 0.50–0.97 0.6 0.42–0.98 1.0 0.69–1.59 0.6 0.39–0.94 service Health and social 0.9 0.51–1.66 0.8 0.40–1.75 1.0 0.69–1.59 1.6 1.02–2.43 welfare Science, arts, 0.4 0.29–0.61 0.6 0.39–0.89 0.7 0.42–1.00 0.7 0.45–1.03 management, and office work Working time, ref. Shift work Regular day work 1.6 1.23–2.16 0.6 0.47–0.85 1.2 0.93–1.51 0.8 0.58–1.09 Social support, ref. Very high High 0.9 0.62–1.17 1.0 0.68–1.34 1.1 0.84–1.46 1.1 0.79–1.55 Low 0.5 0.38–0.76 0.8 0.55–1.19 1.3 0.97–1.73 0.8 0.56–1.15 Very low 0.8 0.55–1.07 0.6 0.41–0.88 1.3 0.96–1.71 0.8 0.57–1.10 Mental strain, ref. Very low Low 1.1 0.77–1.59 1.2 0.86–1.81 0.9 0.69–1.19 0.9 0.65–1.27 High 1.5 1.03–2.22 1.2 0.79–1.83 1.0 0.74–1.30 0.9 0.64–1.29 Very high 1.5 1.06–2.22 1.5 0.99–2.19 1.1 0.81–1.41 1.0 0.69–1.32 Physical strain, ref. Very low Low 1.2 0.90–1.71 0.9 0.59–1.38 1.0 0.74–1.31 1.6 1.13–2.32 High 1.4 0.97–1.88 1.1 0.69–1.61 1.2 0.88–1.55 1.4 0.99–2.02 Very high 1.8 1.26–2.44 1.3 0.83–1.92 1.1 0.83–1.45 1.4 0.94–2.00 Job control, ref. Very high High 1.1 0.79–1.58 0.9 0.62–1.41 0.6 0.47–0.86 0.8 0.56–1.05 Low 1.1 0.78–1.48 1.2 0.82–1.70 0.5 0.35–0.68 0.9 0.60–1.25 Very low 1.2 0.87–1.73 1.2 0.86–1.75 0.5 0.34–0.64 0.8 0.56–1.19 1 < 30 employees 2 30 employees or more 3 Adjusted for age, education, place of residence, and all the other variables in the model

Lunch eating patterns during THL –- Research 68/2011 49 working hours and their social and work-related determinants

8.3 Availability of a worksite canteen A worksite canteen was available for 70% of female employees and 60% of male employees. A worksite canteen was more often available to employees with higher education and in a higher occupational class, and to those working at bigger workplaces in jobs that were somewhat physically demanding (Table 9, Figure 4).

Of those employees who had an opportunity to have lunch in a worksite canteen, 53% of men and 49% of women did so (Figure 5). Among female employees it was also very common (40%) to eat packed lunches, whereas only 22% of male workers did so. If the employees did not have a canteen available, they mostly had packed lunches (41% of male workers and 60% of female workers) (Figure 5). Male workers also ate to some extent at other restaurants or at home, whereas women ate at home. In addition, skipping lunch was more common among those men and women who did not have a canteen available. Due to some reason, a few people reported that they had lunch at a canteen even though they did not have the possibility to do so.

When a worksite canteen was available, it was used more often by employees in a higher occupational class (Table 10). A canteen was also used more often among those female employees who lived in the capital area and who had semi-active jobs or were working at small workplaces (Table 10). Men other than those who were married or cohabiting, worked at larger workplaces, and had jobs that were not physically demanding ate in canteens more often than those who were married, worked at smaller workplaces, and had physically more demanding jobs (Table 10).

Even when a canteen was available to employees, men with lower education and in a lower occupational class had packed lunches more often than those with higher education and in a higher occupational class (Table 10). Women in a lower occupational class had packed lunches more often than those in a higher occupational class (Table 10).

Men who were married or cohabiting and who had physically demanding jobs more often ate packed lunches even when a canteen was available (Table 10). Women living in other parts of Finland than in the capital area ate packed lunches more often (Table 10).

Lunch eating patterns during THL –- Research 68/2011 50 working hours and their social and work-related determinants

Table 9. Odds ratios and 95% confidence intervals for worksite canteen availability among 19 to 64-year-old Finnish employees Men Women n=2224 n=2557 OR1 95% CI OR1 95% CI Education, years, ref. >13 0–9 0.7 0.47–0.97 0.6 0.39–0.82 9–12 0.6 0.46–0.75 0.7 0.59–0.94 Place of residence, ref. Helsinki capital area Other cities with 100 000 inhabitants and over2 0.6 0.41–0.87 0.9 0.65–1.32 Cities with 50 000–99 999 inhabitants3 0.9 0.65–1.27 0.8 0.62–1.15 Other cities 0.7 0.54–0.92 0.8 0.59–0.98 Marital status, ref. Married or cohabiting Other 1.1 0.80–1.39 1.0 0.79–1.24 Parental status4, ref. No Yes 1.0 0.81–1.30 1.0 0.84–1.29 Occupational status, ref. Upper white-collar worker Lower white-collar worker 0.8 0.52–1.08 0.9 0.70–1.28 Skilled blue-collar worker 0.7 0.47–0.90 0.7 0.53–0.98 Unskilled blue-collar worker 0.4 0.29–0.66 0.3 0.22–0.49 Employer, private enterpriser 0.3 0.23–0.49 0.2 0.15–0.36 Size of the workplace, ref. More than 250 persons 1–19 persons 0.1 0.07–0.13 0.1 0.09–0.18 20–249 persons 0.3 0.24–0.42 0.3 0.23–0.44 Degree of physical burden of respondent's job, ref. Job mainly involves sitting Work involves quite a lot of walking and/or 1.3 1.05–1.69 1.8 1.45–2.28 lifting Work is physically very demanding 0.8 0.55–1.10 1.2 0.74–2.09 1 Adjusted for age and all the other factors in the model 2 Oulu, Tampere, Turku 3 Joensuu, Jyväskylä, Kotka, Kuopio, Lahti, Lappeenranta, Pori, Rovaniemi, Vaasa 4 Having children under 18 years of age

Lunch eating patterns during THL –- Research 68/2011 51 working hours and their social and work-related determinants

THL 100

–- –- Men n=1574 Women n=2000 90 Research 68/2011 80 90 86 80 81 70 76 77 74 75 70 71 70 69 70 69 69 68 68 68 68 69 60 66 66 62 64 58 59 59 60 57 56 50 53 55 53

52 49 51 49 46 45 40 38 % 30 30 32 26 20

10

0

Yes 0–9 >13 area over

cities

lifting sitting 10–12

worker worker worker walking

worker persons persons

persons

and

of and cohabiting

inhabitants demanding enterpriser Other capital

250

collar or 1–19 collar collar lot

collar ‐

‐ ‐ ‐ involves a

20–249 999 very

than

blue walking

blue private

white white Helsinki

inhabitants quite of

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working hours and thei More 000–99 Lunch eating patterns during 000 Job Skilled Lower physically Upper

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Unskilled is

100 involves Employer,

with

Work with -

Work involves related determinants

Cities cities

Work Other

Education, years Place of residence Occupational class Size of the workplace Degree of physical burden of Marital Children r

social social respondent's job status under 18 years of age

Figure 4. Worksite canteen availability among 19 to 64-year-old Finnish employees by background variables

In a restaurant or a coffee shop In worksite canteen Packed lunch in workplace 70,0 60,1 60,0 52,7 48,8 50,0 40,7 39,7 40,0 % 30,0 25,8 22,4 20,0

10,0 7,0 6,1 1,0 2,3 1,6 0,0 Available Not available Available Not available n=1437 n=999 n=1817 n=867

Men Women

Availability of worksite canteen Figure 5. Lunch place choice by the availability of worksite canteen

Lunch eating patterns during THL –- Research 68/2011 53 working hours and their social and work-related determinants

THL

Table 10. Odds ratios and 95% confidence intervals for worksite canteen use among 19 to 64-year-old Finnish employees, canteen available –- –- Men, n=2040 Women, n=2338 Research 68/2011 Model 11 Model 22 Model 11 Model 22 OR 95% CI OR 95% CI OR 95% CI OR 95% CI Education, years, ref. >13 0–9 0.4 0.29–0.63 0.7 0.40–1.10 0.6 0.41–0.91 0.9 0.52–1.42

9–12 0.6 0.48 –0.77 0.9 0.64–1.22 0.7 0.55–0.87 0.9 0.72–1.23 Place of residence, ref. Helsinki capital area Other cities with 100 000 inhabitants and over * 0.8 0.56–1.24 0.8 0.52–1.23 0.5 0.39–0.77 0.6 0.41–0.84 Cities with 50 000–99 999 inhabitants** 0.8 0.58–1.18 1.0 0.68–1.46 0.6 0.45–0.81 0.6 0.43–0.82 Other cities 0.7 0.55–0.93 0.9 0.69–1.25 0.5 0.43–0.69 0.6 0.44–0.74 54 Occupational class, ref. Upper white-collar worker

Lower white-collar worker 0.7 0.51–0.95 0.8 0.59–1.22 0.5 0.38–0.63 0.5 0.36–0.63 Skilled blue-collar worker 0.4 0.32–0.55 0.6 0.43–0.90 0.5 0.36–0.59 0.4 0.28–0.53 Unskilled blue-collar worker 0.4 0.25–0.54 0.5 0.32–0.91 0.3 0.18–0.41 0.3 0.15–0.43 Employer, private enterpriser 0.5 0.30–0.77 0.7 0.42–1.30 0.3 0.18–0.56 0.2 0.10–0.39 and work

working hours and their Size of the workplace, ref. More than 250 persons Lunch eating patterns during 1–19 persons 0.6 0.42–0.75 0.7 0.47–0.96 1.0 0.79–1.29 1.5 1.13–2.04 20–249 persons 0.7 0.52–0.83 0.7 0.55–0.93 0.8 0.66–1.03 1.0 0.80–1.32 - related determinants Degree of physical burden of respondent's job, ref. Job mainly involves sitting Work involves quite a lot of walking and/or lifting 0.5 0.41–0.64 0.7 0.50–0.87 1.0 0.81–1.18 1.4 1.10–1.82

social social Work is physically very demanding 0.5 0.31–0.68 0.8 0.46–1.24 0.9 0.49–1.69 2.0 0.98–4.05 1 Adjusted for age 2 Adjusted for all the variables in the model

8.4 Nutritional quality of lunches in worksite canteens When the composition of the lunches eaten at worksite canteens or as a packed meal was compared, some differences were found at the foodstuff level (Table 11). Those males who had both lunches at worksite canteens chose fresh vegetables, fat-free milk, and salad dressing more often than did those who had two packed lunches. Those women who ate at the canteen had more fresh vegetables and vegetable foods, boiled potatoes, fish dishes, sauces, and fat-free milk compared with those who ate packed lunches. Eaters of packed lunches had more rye bread, cheese, and fresh fruits and berries (only women) than did canteen users (Table 11).

The differences in nutrient intake between worksite canteen users and packed lunch eaters were modest (Table 12). Energy, vitamin A, and carotenoid intake from lunch was higher among those male employees who had their lunches at the worksite canteen. Among women, the worksite canteen users got more energy and fat, but fewer carbohydrates and less sugar and fiber from the lunch.

When the nutrient intake was set against nutrition recommendations, we noticed that the fat and protein intakes from canteen lunches were higher, and carbohydrate intake was lower than recommended (Table 12). Fiber and vitamin C intake were too low among men, but not in women.

When the differences in food selection between worksite canteen users and packed lunch eaters were compared over the whole day, some of the differences were still seen (Table 13). For example, consumption of fresh vegetables and salad dressings was higher among male worksite canteen users, and consumption of fresh fruits and berries was higher among female packed lunch eaters. Differences were also found in the number of those who ate fresh vegetables daily between those men who had lunch at the canteen (77%) and those who ate packed lunches (30%) (p<0.001).

The only differences in nutrient intake over the whole day were the higher carotenoid intake in males and the lower protein intake in females, both worksite canteen users (Table 13). Furthermore, female canteen users got more energy from their diet than did those who ate packed lunches.

Lunch eating patterns during THL –- Research 68/2011 55 working hours and their social and work-related determinants

THL TABLE 11. The effect of having lunch at a worksite canteen on food consumption at lunch: regression coefficient, corresponding p-value and 95% CI (2 lunches eaten as a packed lunch as a reference group) (FINDIET 2002) –- –- Food consumption g/Mj Men Women Research 68/2011 n=108 n=153 2 lunches eaten at a worksite canteen1 Constant Coeff. p-value 95% CI Constant Coeff. p-value 95% CI Rye bread 14.19 -5.2 0.049 -10.32– -0.03 17.41 -7.9 0.001 -12.59– -3.14 Wheat bread 17.63 3.5 0.508 -6.88–13.80 11.60 4.3 0.186 -2.11–10.77

Fresh vegetables -3.28 23.2 <0.001 13.02–33.44 21.71 14.4 0.041 0.61–28.19 Vegetable foods 2.16 4.9 0.414 -6.93–16.71 1.68 15.6 0.006 4.56–26.55 Fresh fruits and berries 12.93 -8.5 0.065 -17.59–0.53 19.87 -28.5 <0.001 -39.77– -17.25 Potatoes, boiled 11.81 4.4 0.479 -7.83–16.55 12.21 13.3 0.001 5.72–20.82 Fish dishes 4.43 3.7 0.433 -5.60–12.95 5.14 9.0 0.014 1.86–16.14

56 Meat dishes 29.86 5.7 0.493 -10.79–22.25 21.55 12.9 0.051 -0.03–25.84 Poultry 0.95 2.3 0.463 -3.86–8.41 5.24 3.8 0.094 -0.66–8.30

Sausage dishes 2.79 -2.7 0.338 -8.30–2.88 -0.61 0.4 0.635 -1.11–1.81 Milk, fat free 0.48 12.3 0.044 0.34–24.17 12.19 12.4 0.045 0.29–24.42 Soft drinks 0.35 -2.6 0.216 -6.75–1.55 – – – – Hard cheeses 4.33 -1.8 0.018 -3.33– -0.32 2.90 -1.9 0.010 -3.29– -0.46 and work working hours

Lunch eating patterns during Butter 1.00 -0.3 0.201 -0.87–0.19 0.29 0.0 0.822 -0.29–0.36 Vegetable fat spreads 1.91 0.1 0.901 -1.21–1.37 1.49 -0.3 0.332 -0.95–0.32 Salad dressings -0.67 1.7 <0.001 0.79–2.68 1.64 0.7 0.236 -0.44–1.77 - related determinants Sauces 0.96 0.3 0.800 -2.13–2.76 1.67 1.2 0.014 0.25–2.23

and their 1Adjusted for age, place of residence and education

social social

THL TABLE 12. The effect of having lunch at a worksite canteen on nutrient intake at lunch: regression coefficient, corresponding p-value and 95% CI among men (2 lunches eaten as a packed lunch as a reference group) (FINDIET 2002) –- –- Nutrient intake Men, n=108 Women, n=153 Research 68/2011 2 lunches eaten at a canteen1 Constant Coeff. p-value 95% CI Constant Coeff. p-value 95% CI Energy kj 2491.87 978.3 <0.001 525.36–1431.18 1798.49 356.9 0.001 142.49–571.30 Fat E % 40.11 2.6 0.170 -1.15–6.41 31.34 7.5 <0.001 3.93–11.15 Protein E % 17.18 -0.5 0.602 -2.49–1.45 21.87 -1.0 0.346 -3.13–1.11

Carbohydrates E % 42.83 -1.8 0.323 -5.39–1.79 46.77 -6.6 <0.001 -10.07– -3.04 Sugar E % 11.87 0.9 0.536 -2.06–3.94 20.32 -7.9 <0.001 -11.38– -4.40 Fiber g/Mj 2.49 -0.2 0.352 -0.77–0.28 3.70 -0.8 0.009 -1.46– -0.21 Vitamin A μg/Mj RE 68.01 81.2 0.001 32.82–129.50 100.42 90.2 0.152 -33.64–213.94 Carotenoids μg/Mj 350 771.6 0.003 265.95–1277.22 1511 503.7 0.236 -333.38–1340.69 57 1Adjusted for age, place of residence and education

and work working hours Lunch eating patterns during - related determinants and their social social

THL

–- –- TABLE 13. The effect of having lunch at a worksite canteen on food consumption and nutrient intake in a whole day: regression coefficient,

Research 68/2011 corresponding p-value and 95% CI (2 lunches eaten as packed lunch as a reference group) (FINDIET 2002) Food consumption g/Mj Men, n=108 Women, n=153 2 lunches eaten at a canteen1 Constant Coeff. p-value 95% CI Constant Coeff. p-value 95% CI Fresh vegetables 3.35 8.8 <0.001 4.99–12.59 15.71 4.5 0.074 -0.44–9.53 Fresh fruits and berries 8.73 -5.9 0.048 -11.78– -0.05 15.92 -8.9 0.021 -16.37– -1.35

Salad dressings -0.29 0.8 <0.001 0.41–1.24 0.36 0.3 0.098 -0.07–0.76

Nutrient intake Energy, kj 10460.83 97.2 0.855 -952.23–1146.65 7100.67 646.6 0.037 39.88–1253.31 Protein, E% 15.50 0.3 0.597 -0.91–1.58 19.53 -1.6 0.005 -2.78– -0.51

58 Carotenoids, μg/Mj 499 252.4 0.031 22.98–481.72 1273 126.5 0.401 -170.03–423.01

1Adjusted for age, place of residence and education and work working hours Lunch eating patterns during - related determinants and their social social

9 Discussion

9.1 Main findings This thesis has four main findings. The first main finding suggests that the frequency of worksite canteen use has been quite stable for over two decades in Finland. The second main finding emphasizes that the size of the workplace is the most important work-related determinant associated with the use of the worksite canteen. The third main finding is that worksite canteen availability is associated with the education and occupational status of an employee as well as the size of the workplace. Those with higher occupational status and those living in the Helsinki capital area eat in canteens more frequently than the rest of the population. The fourth main finding suggests that employees who eat at the worksite canteen consume more vegetables and vegetable and fish dishes at lunch than those who eat packed lunches.

9.1.1 Trend in worksite canteen use in 1979–2001 This study (substudy I) shows that worksite canteen use has remained relatively stable in Finland from the late 1970s to the early 2000s. Differences in worksite canteen use according to education, place of residence, and age remained quite stable as well. However, some decrease in canteen use was found among female employees with higher education.

Some decrease in canteen use in the late 1990s was expected, since Finland went through an economic recession in the early 1990s and many families struggled financially. At the same time, the prices in worksite canteens increased, because the state’s and employers’ support for workplace catering diminished due to changes in trade union agreements (Seppänen 1995) and a new value added tax of 22% was introduced.

Since the price is one of the most important factors affecting food choices (Perlmutter and Gregoire 1998; de Almeida, Graca et al. 2001) and decisions about whether to eat at a canteen (Viinamäki 2010), a decrease in canteen use could be expected when the prices increased. Reductions in subsidies for catering services have in fact been found to be associated with decreases in the number of meals eaten at canteens (Prättälä 2000). However, because the price and quality at worksite canteens are still very competitive with those of other restaurants, canteen use decreased only slightly during the economic recession.

Lunch eating patterns during THL –- Research 68/2011 59 working hours and their social and work-related determinants

An increase in canteen use during the whole study period could have been expected, because educational level, which according to previous studies is strongly associated with canteen use (Roos, Sarlio-Lähteenkorva et al. 2004), increased in Finland during the two decades studied. This study (substudy I) showed that those with higher education reduced their canteen use slightly more than those with lower education. This could have leveled off the effect of education.

During the whole study period, those with more years of education ate at a worksite canteen more often than the others. Our results are in line with earlier studies, in which the use of worksite canteens has also been associated with higher education in the Finnish population (Roos, Sarlio-Lähteenkorva et al. 2004). In Norway, however, the situation is opposite (Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010). This could be explained by several factors. The main reason could be the differences in lunch patterns between Finland and Norway; in Finland, lunch is traditionally hot, whereas in Norway it is a cold meal and dinner is the main meal of the day (Mäkelä, Kjærnes et al. 2001). The traditional lunch in Norway consists of different kinds of sandwiches with various spreads, pastries, crisps, vegetables, and fruits (Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010).

Another possible explanation for more frequent canteen use – especially among Finnish employees with higher education – is habit. Finnish people, who have spent more years studying, become accustomed to eating balanced, nutritious, and affordable meals first in elementary school, then in secondary school and finally at university (Raulio, Roos et al. 2010), and they keep up that habit when starting working life. Employees with higher education also have better financial possibilities to eat at a canteen, as they are more likely to work at locations with a proper worksite canteen, and they are more health-oriented (Kearney, Gibney et al. 2001; Grunert, Wills et al. 2010; Mirmiran, Mohammadi-Nasrabadi et al. 2010).

Differences in worksite canteen use between the capital area and other parts of the country remained rather stable over the years. The frequency was much higher in the capital area than in other areas of the country during the whole study period. One explanation is that the availability of canteens in the capital area is better, as was confirmed in this thesis (substudy III). However, the results of substudy III also emphasize that among female employees the differences in canteen use among those living in different places of residence persisted even when the canteens were equally available. Earlier studies suggest that Finns living in the Helsinki area tend to eat out of home more often than people living in other cities or rural areas (Minkkinen 2008). It has also been suggested that Finnish urban dwellers have slightly better health behaviors than rural residents (Fogelholm, Valve et al. 2006).

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Thus, the habit of having lunch at a worksite canteen seems to have resisted major changes in working and living conditions since the 1970s and the economic recession in the early 1990s. Our study, which included only employed people, indicates that the economic recession did not affect the participants enough to change their meal patterns.

9.1.2 Social and work-related determinants of worksite canteen availability According to this study, employees’ chances to eat at a canteen varied in terms of SEP, since those with more education and in white-collar occupations had a possibility to eat at a canteen more often (substudy III). The size of the workplace was also an important determinant of canteen availability; employees working at bigger workplaces more frequently had a canteen than those working at smaller workplaces. The same has been noticed in Denmark (Jørgensen, Arsky et al. 2010). A Norwegian study found differences between occupational status in benefits related to food at work; employees in higher positions received more benefits, like free or subsidized healthy meals and fruit baskets, than those in lower positions (Wandel and Roos 2005). In Scandinavian countries, organized and healthy lunch options at work were less likely to be available for blue-collar workers and employees with irregular working hours (Jørgensen, Arsky et al. 2010).

To our knowledge, there are no earlier studies concerning the determinants of the availability of worksite canteens. Our data only allows us to speculate about why canteen availability was better at larger workplaces. At smaller workplaces, it is challenging to arrange lunch opportunities, since small enterprises cannot afford a canteen of their own. This problem could probably be solved by buying canteen services from a bigger company’s canteen or by arranging canteen services through cooperation between two or more small enterprises.

The fact that those with higher SEP had better possibilities to eat at worksite canteens is due to differences in types of jobs and workplaces; many employees with higher education and occupational class work in big office buildings whereas those with lower SEP often work, for example, as construction workers, lorry drivers, or cashiers, jobs in which lunch possibilities are limited. Employees with higher SEP also became accustomed to having lunch at a canteen during their student years and they probably expect to have a canteen at their workplace.

Lunch place choice when a canteen is not available When no canteen was available, employees mostly ate packed lunches or at home or at other restaurants (substudy III). Employees skipped lunch more often when they

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did not have a chance to eat at a canteen. Similar behavior has been seen in earlier studies in the US. Devine et al. (Devine, Farrell et al. 2009) found in a small sample of American employees that 25% of the employees did not have access to healthful, reasonably priced, and/or good-tasting food at or near their workplace. Male employees who did not have access to such food were more likely to report skipping lunch or eating while working.

When there is no canteen at the workplace, employees are more prone to make unhealthy lunch choices. The nutritional quality of a packed lunch is dependent on the nutritional knowledge of the person who prepared it and the employee’s motivation to have a healthy meal. It is of course possible to have a nutritionally balanced packed lunch, but it requires more effort and thought. On the other hand, in Finland, a canteen meal should be prepared according to nutritional recommendations (National Nutrition Council 2005). Provided that the recommendations are met, eating at a canteen is an easy way to confidently be certain that one can eat a healthy lunch during working hours, which has been the target of Finnish health and social policy for decades (Prättälä 2003).

9.1.3 Social and work-related determinants of worksite canteen use

Work-related determinants of canteen use Work-related factors are important structural conditions that can either hinder or promote better food choices during working hours. Workplaces can give employees easier opportunities to make healthy choices or they can hinder these choices with various barriers. A worksite canteen is an example of a benefit that an employer can offer to employees in order to enhance the possibility of eating a healthy cooked meal during the workday.

In other studies, major structural work-related barriers to canteen use, apart from availability, have been distance from it, lack of time, price, and shift work (Stewart and Wahlqvist 1985; Faugier, Lancaster et al. 2001; Lindén and Nyberg 2009; Jørgensen, Arsky et al. 2010; Viinamäki 2010).

This thesis (substudy II) emphasizes that at small workplaces work-related determinants, like physical strain at work and job control, were associated with canteen use. Employees with physically demanding jobs or with low job control ate at a worksite canteen more frequently. In earlier Finnish studies, job satisfaction has been found to be associated with more frequent use of a worksite canteen (Laitinen 2000) whereas physically demanding jobs were associated with a snack-dominated meal pattern (Ovaskainen, Reinivuo et al. 2005). Intense time pressure at work, shift

Lunch eating patterns during THL –- Research 68/2011 62 working hours and their social and work-related determinants

work, and the distance between canteen and workplace have been found to be barriers to canteen use (Faugier, Lancaster et al. 2001; Lindén and Nyberg 2009; Viinamäki 2010). When work is hectic and employees cannot influence their timetables, they tend to eat as fast as possible, sometimes without even leaving their desks.

Devine and her colleagues suggest that American employees’ working conditions could be associated with food choice coping strategies (Devine, Farrell et al. 2009). In their study concerning a small sample of American working parents, male employees with low job satisfaction were less likely to report keeping food on hand at work. Those male employees who usually worked long or overtime hours, or had nonstandard hours or schedules, reported more take-out main meals, convenience foods, and more eating while working. Female employees who worked long or nonstandard hours in turn reported that they ate more restaurant meals and convenience foods.

Social determinants of canteen use In addition to more often having a canteen, employees with higher SEP also ate there more frequently than those with lower SEP. In substudy II, it was noticed that worksite canteens were used more frequently by employees in healthcare and social welfare, or other kind of office work, independently of educational level. As was seen in the results of substudy III, even when the availability of a canteen was equal, especially female employees with lower SEP – measured as occupational class – ate packed lunches instead of a canteen meal. Among the respondents who had an opportunity to choose between a worksite canteen and other lunch place alternatives, higher occupational class was associated with canteen use. Upper white-collar workers used worksite canteens more often while those in lower occupational classes mostly ate packed lunches instead. This could be because upper white-collar workers have higher job control (Marmot, Stansfeld et al. 1991; Bosma, Marmot et al. 1997), i.e. more freedom and flexibility in their jobs and more possibilities to influence their own timetables (Karasek 1979) and thus better chances to eat wherever they choose.

The results of this thesis thus suggest that the most important indicator for canteen non-use, besides its availability, is an employee’s SEP. The importance of SEP in the choice of lunch place could reflect the social importance of this choice, since the social aspects of meals and food consumption are known to differ between socioeconomic groups (Lindén and Nyberg 2009). The social aspects of food and meals reflect class membership and food consumption can be seen as a marker of class and status (Lindén and Nyberg 2009). The choice of the lunch place could also be a way to strengthen one’s sense of belonging to a certain group or to differentiate

Lunch eating patterns during THL –- Research 68/2011 63 working hours and their social and work-related determinants

oneself from other social groups (Lupton 1996). Lunch has, for example, been found to have an important social meaning for male employees in Norway and Finland, as men tended to eat with their peers: office workers shared the same table, while workers ate packed meals elsewhere (Wandel and Roos 2005), and blue-collar workers ate packed lunches in the same break room as their workmates instead of going to the canteen alone or with employees whose occupational status differed from theirs (Uusitalo, Prättälä et al. 1996).

9.1.4 Nutritional quality of canteen meals The results of this thesis suggest that the use of worksite canteens in Finland is associated with healthier food habits; employed people eating lunch at a worksite canteen consumed more vegetables and vegetable foods as well as fish dishes compared with those having packed lunches (substudy IV). Also, the daily volume and proportion of vegetable consumption is higher among those male employees who had their lunch at a canteen. These results are in line with previous studies (Lallukka, Lahti-Koski et al. 2001; Roos, Sarlio-Lähteenkorva et al. 2004) in Finland and in France (Guagliardo, Lions et al. 2011).

Worksite canteens in Finland thus seem to promote healthy food habits by serving healthier meals. Among French university students it has also been noticed that having lunch at the university canteen is associated with the daily consumption of fruits and vegetables (Guagliardo, Lions et al. 2011). On the other hand, in Belgium only 5% of the meals available at the university canteen complied with the optimal nutritional profile (Lachat 2008) and in Norway lunches served at the canteen consisted of fat-rich foods, fast foods, and red meat (Råberg Kjøllesdal, Holmboe- Ottesen et al. 2010). In Denmark (Rasmussen, Lassen et al. 2010) and in France (Noël, Leblanc et al. 2003), it has been found that the salt content of canteen meals exceeds recommendations. In Denmark, the size of the workplace, corporate financial support, and female gender of employees were associated with healthier meal options at worksite canteens (Thorsen, Lassen et al. 2009), and generally the variety of foods in canteens does not follow the dietary recommendations (Jørgensen, Arsky et al. 2010).

Increased vegetable consumption could be due to easy access; green salads are appealing when they are pre-prepared, ready-to-eat, and deliciously on offer (Lassen 2007). At many Finnish canteens, lunch is offered as a buffet where diners serve themselves fresh vegetables, bread, and drinks. A buffet setting (Lassen 2007) and set-priced meals instead of item-priced meals (Meiselman 2008) were earlier observed as being good ways to increase vegetable consumption at lunch, and our results seem to confirm that observation.

Lunch eating patterns during THL –- Research 68/2011 64 working hours and their social and work-related determinants

In this study, it was found that worksite canteens do not fully meet nutrition recommendations. The amounts of fat and protein received from canteen lunches were a little bit higher than the recommendations, whereas the intake of carbohydrates was somewhat lower. Parallel results have also been found earlier in Finland (Vanhala, Hasunen et al. 2004) and in university canteens in Belgium (Lachat 2008). The nutritional profile of the meals eaten at canteens depends not only on the choices made by customers but also on what is provided in the canteen (Lachat 2008). If the meals offered at the canteen do not meet the nutrition recommendations, it is impossible for the customer to choose a healthy meal.

There are nutrition recommendations (National Nutrition Council 2005) for canteen meals in Finland, but no systematic, national monitoring of the nutritional quality of the foods served in these canteens (Vanhala, Hasunen et al. 2004; Raulio, Roos et al. 2010). The situation seems to be the same in Norway and Belgium, since they have recommendations for canteens, but no legally established regulations (Lachat 2008; Råberg Kjøllesdal, Holmboe-Ottesen et al. 2010). Guilland (Guilland 2003) concluded in her study that 68% of Finnish catering services assess the nutritional quality of meals offered at least once a year, but these results are not made public.

Development and monitoring of catering services is currently on the political agenda in Finland. The Finnish government included the development of catering services in its four-year policy program for health promotion, which was launched in 2007 (Ministry of Social Affairs and Health 2007). As part of this program, the Finnish Ministry of Social Affairs and Health set up a specific working group on catering services. One goal of the working group was to improve the nutritional quality of meals offered by catering services (Ministry of Social Affairs and Health 2010).

9.2 Methodological considerations Several methodological aspects should be kept in mind when interpreting the results of this thesis. Firstly, we need to remember the cross-sectional nature of the data sets. This could be considered to be a problem especially in the first substudy, which examined the time trends in worksite canteen use. However, our aim was to study the time trend in canteen use as a reflection of societal changes in the community instead of changes in individual behavior as such. In other words, our aim was not to follow a particular individual over the years of the study, in which case we would have applied a follow-up design. Instead, we examined the changes in worksite canteen use and its determinants over time.

There is one more important methodological problem concerning the study of time trends: the educational system has changed and the average educational level has

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increased over time in Finland. The education system in Finland has thus been different for the older and younger age cohorts in our study. In general, the younger age cohort (born in 1976) has a higher educational level compared with the older age cohort (born in 1915). Those born in 1915 lived in a completely different world than those born in 1976; they experienced the wars, and only children from wealthy homes were able to attend senior high school in those days. Because of this, the use of years of education as the determinant of education could have biased our results in substudy I. However, as we had large population-based datasets, we can assume that this had only minor effects on our results. The bias could have been reduced by categorizing the years of education based on birth cohorts, as has been done in later studies (Tolonen, Laatikainen et al. 2010).

The definition of educational level varied in the substudies: in substudies I, III, and IV, education was measured as years of education, and in substudy II different degrees, such as primary, secondary, and tertiary, were used as indicators of education. The rationale for this was simply that different questions were asked in the surveys. Despite the different definitions of education, the basic associations between education and use of a worksite canteen were similar in all substudies.

Besides the educational level, occupational class was used as an indicator of socioeconomic position in this thesis (substudies II and III). Unfortunately, we had no access to data on the income of our respondents. Occupation is of course strongly associated with education, but it was assumed to have an independent effect, especially on worksite canteen availability and on canteen usage as well, as a proxy for working conditions.

The validity of the different measurements of socioeconomic data should also be considered. We only had access to self-reported socioeconomic indicators: education (all substudies) and occupation (substudies II and III). Even though self-reported indicators are not as trustworthy as register-based indicators, they have been noticed earlier to be quite consistent with register-based socioeconomic indicators (Mäkinen 2010).

The question concerning lunch place choice differed slightly in the substudies according to the survey data used. However, the answer categories were so similar that it most likely had no impact on the results of this thesis. The most important limitation concerning the indicator of lunch place is the lack of information on the availability of a canteen in three substudies (I, II, IV). The results of these three studies are, however, for the most part congruent with the results of the third substudy, where the indicator of canteen availability was on hand. In the third substudy, those respondents who said they do not have a possibility to use a canteen, but reported having lunch there anyway, should probably have been removed from

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the final dataset. However, there were so few of these answers (1%) that their effect on the results is minimal.

The dietary data (substudy IV) was collected by 48-hour dietary recall. Two-day recall is the minimum requirement when the aim is to measure the distribution of nutrient intake apart from mean nutrient intake at the group level (Brussaard, Lowik et al. 2002). This method has a number of weaknesses, like reliance on memory and the need for a highly trained interviewer. Underreporting, for example, is a common cause of recall bias in dietary assessment methods, including 48-hour dietary recall (Beaton, Burema et al. 1997; Kubena 2000). We have, however, no reason to assume that the proportion of under-reporters is different between lunch places. Even so, if underreporting exists, the difference between lunch places remains similar. The study method has also been validated; the validation of the 48-hour dietary recall was compared with five-day dietary information from a 20% random sample of the Findiet subjects (Männistö, Ovaskainen et al. 2003).

In addition, the following issues concerning the data might have caused some biases in the results. Firstly, our data is based on the customers’ self-reports on choices in the canteen, not on the composition of the meal offered at the canteen. Secondly, the information on the quality of the fat used in canteen meals is based on customer interviews, not on exact recipes used in canteens. Thirdly, the National FINDIET Study data is not designed for analyses of this kind and we needed to restrict our data rather severely in order to ensure that the eating place categories are as pure as possible. That said, the comparability of our results with earlier studies (Lallukka, Lahti-Koski et al. 2001; Roos, Sarlio-Lähteenkorva et al. 2004) means that we can be reasonably confident of the representativeness of the data.

Non-response might have affected our results as well. In the trend analysis (substudy I), the results may have been affected by the declining response rate. According to non-response analyses from the Health Behaviour and Health among Finnish Adult Population Survey, non-respondents were more likely to be young, low-educated, and males (Tolonen, Helakorpi et al. 2006). In the National FINRISK Study, the non-respondents in the original population sample were more likely to be young and male, and living in the capital area (National Institute for Health and Welfare 2002). In the National FINDIET Study, the non-respondents were more often men, especially young men, and those living in the capital or the Turku area (Männistö, Ovaskainen et al. 2003). Also in the Work and Health in Finland survey, non- respondents were more often men, especially young men, and those living in southern Finland (Piirainen, Elo et al. 2000).

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Recent guidelines recommend adjusted prevalence ratios instead of odds ratios when the outcome is common (Zhang and Yu 1998; Deddens and Petersen 2008). However, logistic regression models were preferred in this thesis because almost all of the odds ratios in the substudies were smaller than 2.5 or bigger than 0.5. With such odds ratios, the use of logistic regression is considered acceptable, even when the prevalence of the studied outcome is common (Zhang and Yu 1998).

Finally, the use of several datasets could be seen as a strength of this thesis since they all provided information on worksite canteen use and its socio-demographic and work-related determinants. Principally, all the datasets were quite large with reasonably fixed variables and were nationally representative. The Health Behaviour and Health among the Finnish Adult Population survey provided an annually repeated and nationally representative cross-sectional dataset to examine 20-year trends in worksite canteen use and its major socio-demographic determinants. In addition, the data of this survey yielded information on the availability of worksite canteens among Finnish employees.

The Work and Health in Finland survey provided a triennially repeated and nationally representative cross-sectional dataset about diverse work-related topics concerning Finnish employees. From this data, we examined work-related determinants of canteen use, like occupation, the size of the workplace, and working conditions. The National FINDIET Study yielded a cross-sectional dataset from five regions in Finland to study food use and nutrient intake according to the lunch place choices of Finnish employees.

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10 Conclusions and implications

Life chances – i.e. structural determinants such as the availability of a canteen, education, occupational status, and work-related factors – play an important role in lunch place choices among Finnish employees. The most basic prerequisite for choosing to eat at a canteen is that one is available, but there are also a number of underlying determinants. Occupational status and place of residence are major structural factors behind individual choices concerning lunch eating patterns. In order to increase the frequency of worksite canteen use, one should influence not only individual choices, but also the underlying structural conditions.

As worksite canteens serve good quality meals that play an important role in employees’ diets and thus in their health and productivity at work, employees should be encouraged to eat there. As the results of this thesis showed, having a lunch at a worksite canteen makes a positive contribution to the nutritional quality of the diets of Finnish employees, since at canteens employees choose to eat nutrient-rich, low- energy foods, such as vegetables, fish, and low-fat dairy products. Eating at a workplace canteen improves the diets of Finnish employees by increasing their vegetable intake significantly. However, the intake of fat and protein from canteen lunches was a little bit too high, and the intake of carbohydrates was too low.

Eating at a canteen is thus an easy way to have a healthy lunch during working hours, which has been the target of Finnish health and social policy for a long time (Prättälä 2003). Back in 1971, the Finnish Institute of Occupational Health gave recommendations based on the International Labor Organization’s (ILO) Welfare Facilities Recommendation (International Labour Organization ILO 1956) for eating arrangements at workplaces to ensure that all employees have an opportunity to eat properly during working hours.

Development and monitoring of catering services is also currently on the political agenda in Finland and the Finnish government included the development of catering services into its four-year policy program for health promotion, which was launched in 2007 (Ministry of Social Affairs and Health 2007). The Finnish Ministry of Social Affairs and Health set up a specific working group on catering services as part of this program. The goal of the working group was to improve the availability, quality, and monitoring of catering services. The working group published its report, including several proposals for action, in early 2010 (Ministry of Social Affairs and Health 2010).

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This thesis and the abovementioned report imply that the availability of worksite canteens should be supported in lower socioeconomic groups, at different workplaces, and for both genders equally. To achieve progress in social equality in terms of nutrition at work, collaboration between employers, employees, the catering industry, and the public sector is needed. In addition, various means are required to encourage those employees who have made different lunch place choices to eat at a canteen instead. These could be for example removing work-related barriers, such as those affected by shift work, long distance to the canteen, and haste at work, or to ensure financial subsidies for canteen meals from the state and employer.

In future studies, qualitative methods should be used to more closely examine the motives of canteen non-users and determinants behind their choices. Furthermore, in order to arrive at more accurate conclusions about the contribution of worksite lunches to employees’ nutrition, the methodological problems encountered in this study should be solved. This study was based on individual self-reports, and in order to get more reliable information on the nutritional quality of canteen meals, we need register-based information to analyze what is offered in different types of canteens. Moreover, experimental studies on different workplaces instead of population surveys should be conducted to find out what employees in fact choose to eat at canteens.

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Acknowledgements

This thesis was completed at the National Institute for Health and Welfare (THL) within the Department of Health, Functional Capacity, and Wellbeing under the Health and Welfare Inequalities Unit. I am truly grateful to the National Institute for Health and Welfare and the Department for the excellent research facilities and a pleasant and supportive atmosphere. In addition I am deeply appreciative to those who have collected and managed the datasets that I have been able to utilize in my dissertation.

I want to express my greatest gratitude to my supervisors who without this thesis would not have been possible. Docent Ritva Prättälä, thank you for guiding my first steps in the word of research and giving me a push to start my PhD studies. You have always been willing to comment on my work and support me when needed. Docent Eva Roos, I owe my deepest appreciation for your constructive comments and support as well as guidance over the years. I want to thank you both for sharing your knowledge and valuable time for the benefit of my thesis.

The pre-reviewers of this study, Professor Margareta Wandel and Adjunct Professor Paula Hakala are gratefully acknowledged and appreciated for reading the manuscript and for they constructive comments that helped me to improve this summary. I also want to thank Soile Ylitalo, who carried out the language revision of this summary.

Some important co-authors have substantially contributed to the substudies of this thesis. My deepest gratitudes go to Docent Ossi Rahkonen, Ministerial Counsellor Kristiina Mukala, and Docent Marja-Leena Ovaskainen. You have all significantly contributed to this thesis by sharing your experience within the specific study areas of my work. Your critical and encouraging comments have been important when writing the sub-studies. I feel privileged that I had a chance to work with all of you.

Several colleagues, other researchers and peers have been in an important role during this journey. With many of you, I have had several splendid conference trips, postgraduate seminars and courses as well as shared many coffee moments full of joy and laughter. I owe my sincere thanks to Laura, Kirsi, Tomi, Elina, Nelli, Johanna S, Marja, Clarissa, Johanna M O, Sari, Hanna K and Hanna O just to mention some of you. It has been an honor to share this process with all of you.

I express my thanks to the Doctoral Programs in Public Health (DPPH) for giving me a paid position for two years. Without this opportunity it would have been

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impossible to finish my PhD studies. I would also like to thank the DPPH for giving me several travel grants and opportunity to further extend my scientific skills and networks abroad over the years.

To all my non-work-related friends, thank you for the good and relaxing times outside the world of science. I want to thank all my airborne friends, especially members of my late teams “Caipiroskat”, “HV Helsinki” and “Hanna ja lapset”; it is simple impossible to worry about work issues when diving out of the airplane. My thanks go to Hanna, Anne, Taina, Max, Pete, Hely, Riikka, Pekka, Jussi, Rauli and Anni. My deepest gratitude goes to the co-owners of our beautiful horse Moneypenny; especially Kaanu who has always been willing to offer horse therapy when needed. I want to thank my colleague and friend Annika for encouraging me to start my PhD studies even before I have thought about it by myself. You have really given me faith to complete this assignment. I thank Marianne for many good trips and enjoyable get-togethers. I also wish to thank members of RaKo for the delightful meetings around the food and wine over the years. We have certainly examined a bunch of restaurants in this city!

Finally, I want to thank my family – Mother, Father and Johanna, my brothers-in-law Antti and Erkka, as well as my adorable nephews Aku and Joona – for supporting me when needed. Special thanks go to my younger sister Mari, for sparring me over the years when we both struggled with our PhD studies.

Helsinki, September 2011

Susanna Raulio

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