Workplace dietary improvement initiatives ought not to be discouraged by modest returns from low-intensity interventions.

Workplace dietary improvement initiatives ought not to be discouraged by modest returns from low-intensity interventions We would like to thank Maes and colleagues for their timely and comprehensive summary of European-based studies on the effectiveness of workplace-based interventions to promote healthy eating. 1 Their broad inclusion in particular, of a wide range of study designs and efforts to grade both study reporting and intervention quality are to be commended. However, they may be doing their own efforts a disservice, in that their discussion and conclusions seem overly cautious and conservative. For example, the results cited include: 18 of 30 studies showing positive effects on dietary behaviour 6 of 7 multi-component studies of dietary behaviour reporting improvement 5 of 17 'nutrition only' interventions seeing sustained positive changes, at 6-month post-intervention follow-up. Given the widely acknowledged difficulties around implementing sustainable dietary behaviour change, we feel that the review as presented should be considered as encouragement for further workplace-based interventions, aimed at improving dietary quality. Another recent review not restricted to European-only studies also found that worksite health promotion programmes were associated with moderate improvements in dietary intake. 2 For the current review, in the classic prevention paradox territory of Geoffrey Rose, 3 extrapolating the marginal individual-level gains to a broader population platform might well translate into worthwhile behaviour changes or health benefits. Of course, publication bias is possible, although the authors highlight that this was not their general impression from the spread of findings within the identified reports. On study quality, although 11 of the 30 European studies included were of the relatively weak 'case-study' or 'before and after' designs, that proportion still implies that the majority were of more robust designs. Additionally, as the authors themselves acknowledge in the penultimate paragraph of the discussion, there is now a real consensus around the limitations of randomized controlled trial designs for the evaluation of complex public health interventions such as workplace-based programmes. And yet the grading system used within the review is almost entirely constructed around the extent to which randomized controlled trial-derived evidence was available. Other potentially more appropriate evidence appraisal systems, such the Obesity Prevention Framework, developed by Swinburn and colleagues, 4 which is based around 'levels of promise' linked to likely population impact, are appropriately referred to in the discussion. We recently used a modification of this framework in combination with Swinburn et al's ANGELO matrix (Analysis Grid for Environments …