Nutritious food intake:a new competitive advantage

for organizations?Jeffery Houghton

West Virginia University, Morgantown, West Virgina, USA

Christopher NeckDepartment ofManagement, Arizona State University, Tempe, Arizona, USA, and

Kenneth CooperThe Cooper Aerobics Centre, Dallas, Texas, USA

AbstractPurpose – The purpose of this paper is to suggest that nutritious food intake is a somewhatoverlooked yet essential aspect of corporate wellness that has the potential to help provideorganizations with a sustainable competitive advantage.

Design/methodology/approach – The paper first discusses the resource-based view, identifyingways in which nutritious food intake across an organization may serve to create rare and inimitableorganizational resources leading to a competitive advantage. It then presents a basic overview of thefundamentals of nutritious food intake. It proceeds to review the transtheoretical stages of changemodel in the context of tailored nutrition interventions in organizations, providing a detailed overviewof key individual behavior focused and environmental focused change strategies along with adiscussion of types of technical delivery systems.

Findings – The paper suggests that an organization may be able to use a tailored stage-basednutrition intervention as part of a comprehensive wellness program in order to help create asustainable competitive advantage based on the nutritious food intake of its members.

Research limitations/implications – Future researchers should continue to examine theeffectiveness of stage-based computer tailored nutrition interventions and their delivery systems,particularly in the context of comprehensive corporate wellness plans and the extent to which thisserves to create a competitive advantage through lower direct healthcare costs and higher workerproductivity.

Practical implications – Organizational leaders should carefully consider the strategies andmethodologies presented in this paper when designing and implementing nutrition interventions aspart of a broad corporate wellness program.

Originality/value – This paper makes a valuable contribution to the organizational literature byrecognizing the potential for the application of the transtheoretical stages of change model from thefield of nutrition education within the context of the resource-based view of organizations.

Keywords Nutrition, Employees, Competitive advantage, Employee assistance programmes

Paper type Conceptual paper

Doctors are always working to preserve our health and cooks to destroy it, but the latter arethe more often successful (Denis Diderot, eighteenth century Philosopher).

Corporate wellness programs are rapidly gaining in popularity. According to a recentworldwide survey of employers representing approximately 7 million employees,

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International Journal of WorkplaceHealth Management

Vol. 2 No. 2, 2009pp. 161-179

q Emerald Group Publishing Limited1753-8351

DOI 10.1108/17538350910970228

wellness plans are a “growing global phenomenon” (Gurchiek, 2007). Wellness plans or“worksite health promotion programs”, as they are sometimes called in the literature, canbe defined as the educational and environmental factors that create conditions of livingbeneficial for health, including strategies aimed at reducing barriers or increasingopportunities for making healthy lifestyle choices (Engbers, 2007; Glanz andSeewald-Klein, 1986; Green and Kreuter, 1991). Corporate wellness programs fall withina broader “settings”-based approach to public health (Dooris, 2006). The settings-basedapproach makes the basic assumption that good health is created and maintained in theeveryday contexts in which people live, work and play (Green et al., 2000). Indeed, theWorldHealthOrganization (WHO) has strongly supported the settings-based approach asan effective framework for general health promotion (WHO, 2005). Corporate wellnessprograms are an excellent example of using an everyday setting (the workplace) topromote good health within an organization or population.

Although programs vary considerably from company to company, there are threebasic types of approaches to wellness interventions (Engbers, 2007; Kahn et al., 2002).Informational approaches seek to change attitudes and knowledge levels regarding theopportunities for physical activity and healthy dietary choices alongwith the associatedbenefits. Behavioral approaches aim to provide organizational members with thebehavioral management skills necessary for facilitating health-related behavioralchange. Finally, environmental approaches attempt to change the organizationalenvironment to provide nutritious food choices and/or attractive and convenientfacilities for physical activity (Kahn et al., 2002).

Although more popular in the USA where 86 percent of companies report havingsome type of offering, wellness plans are becoming more prevalent in Asia and Europewhere approximately a quarter of all employers offer programs (Gurchiek, 2007). Thispopularity appears to be well-merited. Recently, Steelcase, Inc. of Grand Rapids,Michigan, USA, reported a 53 percent reduction in health-claim costs over nine yearsafter implementing a wellness plan, while Travelers Insurance of Hartford, Connecticut,USA, claimed US$143 million in wellness-related savings over 15 years (Evert, 2006).Similarly, American Standard Companies of Piscataway, New Jersey, USA, estimates asavings of US$1.1-1.6 million in savings on chronic disease management and isconsidering introducing similar programs in their European subsidiaries (Marquez,2006). In addition, empirical research findings suggest that wellness programs aresignificantly related to lower levels of absenteeism and health care costs, along withincreased health knowledge and improved physical activity and nutrition levels amongemployees (Aldana, 2001; Aldana et al., 2005; Watson and Gauthier, 2003). Indeed, bysome estimates employee wellness programs generate as much $3-6 of long-term costsavings for every dollar invested (Migliore and Merz, 2002). The popularity of wellnessplans in not based upon cost savings alone, however. In Canada and many parts ofEurope, where socialized health care is the norm, companies see wellness programs as away to differentiate themselves from their competitors in order to attract and retainexcellent employees and as away to reduce productivity losses due to employee sicknessand disability (Gurchiek, 2007; Marquez, 2006).

A plethora of research suggests that exercise and nutrition are both essentialcomponents in any regimen designed to prevent chronic diseases and/or promoteoptimal health (Blair et al., 1996; Singh, 1992). Yet, many corporate wellness programsfocus primarily on providing well-equipped physical fitness facilities, paying relatively

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little attention to encouraging healthy eating habits (Erfurt et al., 1992). Global surveysindicate that the number of employers offering on-site fitness centers is approaching50 percent, while far fewer offer any type of nutritional intervention (Butcher, 2008).There are two primary reasons for the popularity of this limited model of wellness(Erfurt et al., 1992). First, exercise facilities are perceived as a valuable benefit byemployees, although only a small fraction of employees may actually use such facilitieson a regular basis. Second, this type of model is relatively easy to implement incomparison to nutritional and dietary workforce interventions.

In this paper, we will suggest that nutritious food intake is a somewhat overlookedyet essential aspect of wellness that has the potential to provide organizations with asustainable competitive advantage. We begin by providing a basic overview of thefundamentals of nutritious food intake. We will then discuss the resource-based viewalong with the specific ways in which nutritious food intake across an organization’sentire workforce may serve to create rare and inimitable organizational resources thatmay help lead to a competitive advantage, before turning our attention to a discussionof the most effective approaches for making nutritional and dietary interventions inorganizations. We will conclude with some thoughts on practical implications anddirections for future research in this area.

The fundamentals of nutritious food intakeImproper nutrition is clearly a widespread problem and a healthy diet is an absoluteprerequisite for building up the endurance, muscle power, and cognitive functionalitythat will enable organizational employees to perform at optimal levels. Yet, officialrecommended daily nutritional guidelines often differ from country to country and theabundance of diet-related books on the best selling lists have generated a certainamount of confusion regarding exactly what should be included in a nutritional plancapable of leading to superior employee performance. In the following sections, we willclarify our conceptualization of the term “nutritious food intake”, which is largelybased upon the Executive Summary of the 2005 Dietary Guidelines for Americans (USDepartment of Health and Human Services and US Department of Agriculture, 2005).

Fat and cholesterol intakeA primary objective for a healthy diet is to lower the consumption of unhealthy fats(e.g. saturated fats and trans fats) and cholesterol (Neck et al., 2004). Consumption ofsaturated fats has been linked to a number of negative health outcomes such as elevatedcholesterol, colon cancer, and other diseases, while lower cholesterol levels appear tolessen the risk of heart disease and strokes (de Vries and van Noorden, 1992; Dwyer,1993). A gram of fat contains more calories (nine) than does a gram of protein orcarbohydrates (four calories each). Thus, people who consume diets high in fat are morelikely to become obese than people who follow low fat diets. Not all fat is bad for yourhealth, however. The monounsaturated fats in nuts and olive oil and the omega-3 fattyacids found in fish and flaxseeds may help to boost mood and energy, quell hunger, andcontrol blood cholesterol levels (Neck et al., 2004). In contrast, research findingsconsistently suggest that saturated fats raise blood cholesterol levels and should beavoided (Norum, 1992). Trans fat or hydrogenated fat, found primarily in processed andfried foods, is perhaps the worst type of fat to consume (Neck et al., 2004). Trans fat isdifficult to avoid entirely, but by reading nutritional labels and avoiding hydrogenated

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and partially hydrogenated fats, consumers can substantially reduce the amount oftrans fats consumed. Guidelines concerning the daily intake of fats, carbohydrates,protein, and cholesterol for adults over the age of 30 are summarized in Table I.

The nutritional labels on packaged foods provide a breakdown of calories, amountof calories from fat, and the percentages of fat that are monounsaturated,polyunsaturated, and saturated. These labels can aid consumers in making healthyfood choices. Although all foods are not packaged with nutritional labels, vegetablesand fruits are almost always a good choice because they are usually fat-free. However,foods containing palm and coconut oil should be avoided because they are high insaturated fats. Beef and pork have relatively high levels of saturated fat and shouldtherefore be eaten only occasionally. Indeed, a recent study appearing in the Journal ofthe American Medical Association of 148,610 adults suggested that high intake of redand processed meat was associated with higher risk of colon cancer (Chao et al., 2005).In contrast, chicken, turkey and other poultry (white meat with skin removed) isgenerally low in fat when properly prepared (e.g. broiled not fried). Fish also tends tobe low in fat, although shellfish is relatively high in cholesterol.

Fiber intakeOne effective strategy for reducing fat and cholesterol intake is to increase theconsumption of high-fiber foods such as fruits, vegetables, whole-grain products, andcereals (Neck and Cooper, 2000; Neck et al., 2004; Schneeman and Tietyen, 1994).High-fiber foods contain a greater percentage of complex carbohydrates and a lowerpercentage of fat (especially saturated fats). There are two main sources of fiber:insoluble and soluble. Insoluble fiber does not dissolve in water and has been shown tobe effective in preventing and treating various health problems including colon cancer,diverticulitis, constipation, and obesity (Neck et al., 2004; Schneeman andTietyen, 1994).Foods high in insoluble fiber include wheat bran and whole grain cereals, corn bran,nuts, seeds, and crunchy vegetables like broccoli and carrots. In contrast, soluble fiber isfound primarily in oats, oatbran, oatmeal, apples, citrus fruits, dried legumes, beans,lentils, barley, peas, potatoes, raw cabbage, strawberries, and dietary fiber supplementssuch asMetamucilq. The soluble fiber found in oat bran and oatmealmay help to reducethe level of cholesterol in the blood and is, therefore, considered an important food forlowering the risks of atherosclerosis, heart disease (Schneeman and Tietyen, 1994),and high-blood pressure (Streppel et al., 2005). Experts recommend consuming at least

Daily nutrition guidelines1. No more than 20-25 percent of daily calories from fat, with the intake of saturated and trans fats

kept to a minimum2. About 50-70 percent of calories from complex carbohydrates (e.g. fruits, vegetables, legumes, and

whole grain products), with the intake of simple carbohydrates (e.g. candies, desserts, simplesugars, etc.) kept to a minimum

3. About 10-20 percent of calories each day from protein sources (e.g. fish, poultry, or meats)Daily consumption of cholesterol in foods should be 300milligrams or less for those without bloodcholesterol problems and 200milligrams or less for those with blood cholesterol problems.A “nonproblem range” would include adults with total cholesterol of less than 200milligrams perdeciliter

Source: Cooper (1996)

Table I.Guidelines for the dailyintake of fats,carbohydrates, protein,and cholesterol for adultsover the age of 30

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20-35 grams of fiber per day with about half coming from soluble fiber and half frominsoluble fiber (Neck and Cooper, 2000; Neck et al., 2004).

Calcium intakeAdequate calcium intake is essential for healthy teeth and bones and also plays a key rolein protecting adults from osteoporosis, cardiovascular disease, and colon cancer (Bunker,1994; Marcus, 1986; Toss, 1992). Adults should consume between 1,000 and1,500milligrams of calcium per day (Neck et al., 2004). The best dairy sources of dietarycalciumare skimand low fatmilk (300-325milligramsper 8 ounce glass), plain and low-fatyogurt (415milligrams per cup), Ricotta cheese (340milligrams per 1/2 cup), Swiss cheese(270milligrams per ounce), cheddar, Monterey, provolone cheese (200-214milligramsper ounce) and American cheese (150-180milligrams per ounce). Nondairy sources ofcalcium include sardineswithbones (324milligramsper 3 ounce can in oil), canned salmonwith bones (180milligrams per 3 ounce can), tofu (108milligrams per 3 ounces), and frozenchopped broccoli (94milligrams per 1/2 cup). Although the recommended daily calciumintake can be achieved through diet alone, calcium supplementsmay be used if necessary.

Antioxidant intakeAntioxidants reduce or eliminate damage caused by dangerous, out of control moleculesknown as free radicals (Cooper, 1994). Free radicals are essential to the properfunctioning of the immune system, but in excessive amounts they can cause damage thathas been linked to a number of negative health outcomes including coronary arterydisease, various forms of cancer, premature aging, early onset of Parkinson’s disease,and eye problems such as cataracts (Cochrane, 1991; Cooper, 1994; Kanter, 1994).Increases in free radicals can be caused by several common environmental factors suchas stress, cigarette smoke, air pollution, ultra violet light, and even certain drugs (Cooper,1994). Although the body produces a variety of antioxidants to fight free radicals,additional antioxidants are usually necessary and may be provided througha well-managed diet and supplementation program. The most powerful antioxidantsfound in both foods and supplements are vitamin C, vitamin E, beta-carotene (theprecursor to vitaminA), folic acid, vitamins B6 and B12, and selenium. A large number ofscientific studies support the idea that antioxidant supplements can help to prevent thedamage and associated health problems caused by free radicals in the body (Block, 1992;Kanter, 1994).

Nutritious food intake as a sustainable competitive advantageFor many years the industrial-organization view, which considers an organization’sexternal environment to be the primary determinant of organizational success, was thedominant paradigm in organizational research (Porter, 1980). More recently, however,a competing resource-based view of the organization has been steadily emerging(Barney, 2001). According to this view, an organization’s internal assets representresources that are capable of providing the organization with a competitive advantage(Wernerfelt, 1984). To the extent that an organization can manage, develop andcapitalize on these unique internal assets it can create hard-to-duplicate resources thatmay lead to higher performance through competitive advantages (Barney, 1991).

An organizational resource may be defined as anything that could be considereda strength of the firm (Wernerfelt, 1984) and may include any input used in the

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production of goods and services, extending well beyond conventional “hard assets”(Amit and Schoemaker, 1996). To the extent that they are rare, valuable and inimitable,these resources may confer competitive advantages to the firm in the form of highereconomic rents (Barney, 1991). However, companies rarely derive a competitiveadvantage from a single strategic resource. More often, a collection of resources cometogether to provide the competitive advantage (Barney, 1991). Although these resourcesmay be either intangible or tangible, tangible assets can usually be bought and sold quiteeasily in the marketplace and thus cannot be depended upon to provide a distinctcompetitive advantage (Grant, 1991). On the other hand, intangible resources such asculture and knowledge are often idiosyncratic and exclusive to a given organization(Barney, 1991). In order to fully constitute a competitive advantage, such intangibleresources must be rare, valuable and not easily duplicated by other organizations in thecompetitive environment (Barney, 1991). We contend that nutritious food intake acrossan entire organization has the potential to constitute a rare, valuable, and inimitableintangible resource that, when appropriately grouped with other organizationalresources, may help to create a competitive advantage resulting in higher organizationalperformance and greater economic returns.

Nutritious food intake is an organizational resource that may create competitiveadvantages in a number of ways, including direct cost savings related to obesity andrelated chronic diseases. Obesity is becoming widespread problem globally.The majority of the population in developed countries such as the USA, Great Britain,The Netherlands and Australia are overweight or obese with a body mass indexgreater than 25 (Engbers, 2007; Haslam and James, 2005; Leopold, 2005; Visscher andSeidell, 2001). The problem of obesity is also increasing in many parts of Africa, Asia,and Latin America (Asfaw, 2006; Engbers, 2007; Popkin, 2008). Cultural and socialnorms relating to physical activity and nutrition have contributed greatly to thisproblem. Over the past few decades, the human environment has transitioned from aphysically demanding tomechanically dominated environment focused on convenience,which has resulted in significant declines in physical activity (Engbers, 2007).Simultaneously, nutritional habits have changed along with the increasing availabilityof energy dense, nutrient poor convenience foods (Popkin et al., 2005), resulting in aso-called “obesogenic” environment in which the choice to make healthy decisions hasbecome increasingly more difficult and less obvious (Swinburn and Egger, 2004).The problem of obesity is clearly being driven by both the increasing levels of caloricintake and decreasing levels of caloric expenditure in the general population as a resultof these environmental changes.

A number of chronic diseases such as cardiovascular diseases, cancer, and type IIdiabetes have been linked with obesity (Haskell et al., 2007) and obese people incur up to$1,500more in annual health care on average thanpeople of healthierweights (Boss, 2005).By some estimates, obesity related health problems lead to 39.3million lostworkdays, 239million restricted activity days and 62.7 million doctor visits (Strong, 2004). The NationalBusiness Group on Health estimates that obesity related health problems cost USemployers approximately $13 billion a year (Leopold, 2005). For example, a company of10,000 employees would have approximately 6,400 overweight or obese employeesleading to approximately $9.6 million in additional medical costs per year (Boss, 2005).Nutritious food intake across an organization could have a substantial impact on theorganization’s bottom line by reducing these kinds of unnecessary health care costs.

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Nutritious food consumption may also have indirect effects relating to individualworker productivity that could also help lead to a competitive advantage. For example, theworkplace health consulting firmVielife has estimated that people in “poor” health are 20percent less productive than people in good health (Paton, 2005). Improper nutrition isclearly a contributing factor to poor health. Furthermore, research suggests thatcertain key nutrients have a direct relationship to brain functionality (Bourre, 2006a, b).Likewise, a recent study suggested that a healthy lifestyle (including a healthy diet) wasrelated to cognitive function and brain metabolism (Small et al., 2006). Along these samelines, Greenwood andWinocur (2005) reported a significant relationship between chronichigh-fat diets and deficits in cognitive performance. Finally, a separate study found thatshift workers demonstrated better cognitive performance following a low-fat (28 percent),high-carbohydrate (56 percent) meal than after a medium-fat (42 percent),medium-carbohydrate (46 percent) meal (Love et al., 2005).

To summarize, we have suggested that nutritious food intake across an organizationmay constitute a rare, valuable, and inimitable intangible resource that may be bundledwith other organizational resources to help create a competitive advantage. We furtherpropose that this potential competitive advantage may arise in part from the short-termbenefits of healthy food intake on productivity through factors such as increasedalertness and improved cognitive performance, along with long-term benefits includingpotential cost savings associated with the prevention of chronic diseases.

Nutrition interventions in organizations: theory and practiceAn organization whose employees were to follow the dietary recommendations presentedearlier would likely experience a number of direct and indirect benefits includingsignificant reductions in health care costs and health-related absenteeism along withincreases in overall employee productivity. However, research from the medical andhealthcare fields suggests that simply providing employees with information similar tothat presented above in the context of a general wellness programmay not be sufficient tofacilitate the behavioral changes in nutritional intake necessary to help create a long-termsustainable competitive advantage. For example, experimental studies in organizationalsettings have shown that computer-tailored nutrition interventions provide significantlybetter results for lowering fat intake and raising fruit and vegetable consumption amongorganizational members than non-tailored general-information interventions (Brug et al.,1996; Campbell et al., 1994). Until recently, most nutrition education interventions weregeneric in nature and did not attempt tomeet the uniqueneeds of each individual. In recentyears, however, behavioral change theories have been incorporated into nutritioneducation research in an effort to more fully understand and shape dietary behaviorthrough tailored intervention programs. In the following section, we will review thetranstheoretical stages of change literature and its application in the context of tailorednutritional intervention programs. The majority of this literature comes from the fields ofhealthcare and nutrition education and has not yet been widely incorporated into theorganizational literature, particularly in the context of organizational wellness programs.

The transtheoretical stages of change modelThe transtheoretical stages of change model has its roots in efforts to synthesize andconsolidate multiple competing theories of psychotherapy and behavioral change(Prochaska, 1979), thus the term transtheoretical. By the early 1980s, behavioral change

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theory research was largely focused on smoking cessation processes. Researchersdiscovered that changes in smoking behaviorswere not dichotomous, but rather evolvedthrough a series of stages reflecting the extent of the person’s readiness to stop smoking(DiClemente and Prochaska, 1982). This research stream ultimately resulted in thedevelopment of a five stage model of change that includes precontemplation,contemplation, preparation, action, and maintenance (Prochaska and DiClemente, 1982,1983). In the precontemplation stage, the individual has no intentions of making achange and usually lacks information regarding the need for change. Individuals in thecontemplation stage are considering making a change sometime in the future, usuallywithin the next sixmonths, and are involved in the process ofweighing the pros and consof the change. The preparation stage is the point at which the individual intends tomakea change quite soon, usually within the next 30 days, and has already taken somebehavioral steps in this direction. People in the action stage have implemented actualchanges in behavior, which have been occurring for less than six months. Finally,individuals in the maintenance stage have sustained a behavioral change for more thansix months and are gaining confidence in their ability to avoid a behavioral relapse. Thetranstheoretical stages of change model is shown in Figure 1.

Over the past decade, nutrition experts increasingly have utilized the stages ofchange model as a theoretical tool for tailoring nutrition interventions (Kristal et al.,1999; Molaison, 2002). Using this approach, personalized nutritional information can beprovided on the basis of the individual’s stage of readiness for change. Shortalgorithms consisting of a series of yes/no questions have been developed that placeindividuals into one of the five stages of readiness to change. For instance, Curry et al.(1992) developed a six-item algorithm designed to measure stage of readiness forchanging levels of fat intake. Information gathered using algorithm measurement

Figure 1.The transtheoreticalstages of change model

PrecontemplationNo intention to take

action in next 6 months

ContemplationIntends to take action in

next 6 months

PreparationIntends to take actionwithin next 30 days

ActionHas changed overt behavior

for less than 6 months

MaintenanceHas changed overt behavior

for more than 6 months

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techniques can subsequently be used to provide stage appropriate resources,assistance and information to intervention participants.

The stages of change model incorporates three additional constructs that help toexplain the behavioral change process across the five stages (Glanz and Rimer, 1997).Processes of change refers to the ways and means by which an individual attempts tomove through the stages of change. Decisional balance refers to the process ofexamining the pros and cons of a given behavioral change along with an assessment ofpossible barriers to change and ways to overcome them. Self-efficacy refers a person’sbelief in their ability to perform a given activity (Bandura, 1986, 1991). Self-efficacy hasreceived particular attention from nutrition education researchers as a key mechanismfor facilitatingmovement across the stages of change and for facilitating actual changesin dietary behaviors (O’Hea et al., 2004; Shannon et al., 1997).

The nutritional intervention component of the average corporate wellness programconsists of providing information and materials developed for participants who areready to take action. However, as the stages of change model suggests, not allparticipants are ready for change at any given point in time. Therefore, programmaterials must be carefully tailored to suit the needs of each participant relative to his orher stage of readiness for change. For example, information tailored for those in theprecontemplation stage should focus on increasing awareness of the need for a change,which may be accomplished by individualizing the risks and susceptibilities associatedwith their current behaviors (Sigman-Grant, 1996). Likewise, information tailored forthose in the contemplation stage should focus on providing strategies for overcomingperceived barriers to change, while materials provided to those in the preparation stageshould facilitate the change frommerely thinking about to actually changing behaviors(Sigman-Grant, 1996).

Because individuals in the early stages of change aremore likely to engage in processesof change that involve acquiring knowledge, early stage intervention education shouldfocus on facilitating activities such as consciousness raising (increasing knowledge),self-reevaluation (examining habitual behaviors), social reevaluation (examiningenvironmental barriers that could prevent change), and dramatic relief (feelings ofsatisfaction resulting from positive changes in behavior) (Glanz and Rimer, 1997;NiMhurchu et al., 1997). In terms of decisional balance, perceived barriers will usually begreater than perceived benefits for people in the early stages of change. Thus,the intervention materials tailored for people in these stages should attempt to minimizethe barriers while maximizing the benefits in order to facilitate a progression through thechange stages (Sigman-Grant, 1996). Finally, self-efficacy is usually low for people inthe early stages of change. Thus, insomuch as self-efficacy appears to be a primarymechanism for facilitating progression through the stages of change and ultimatelychanging behaviors (O’Hea et al., 2004), early-stage tailored intervention materials shouldfocus on increasing participant self-efficacy levels (Glanz and Rimer, 1997).

For participants who have already moved into the later, action-oriented stages ofchange, intervention efforts should focus primarily on preventing relapses and copingwith temporary regressions (Sigman-Grant, 1996). In terms of the processes of change,activities such as self-liberation (belief in one’s ability to maintain change), helpingrelationships (social support), counter-conditioning (finding healthy substitutes),stimulus control (removing negative cues), and reinforcement should be encouraged(Glanz and Rimer, 1997; NiMhurchu et al., 1997). Participants in the later stages of

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changewill likely have higher levels of self-efficacy andwill tend to perceive the benefitsof change as being significantly higher than the barriers (Henry et al., 2006; Herrick et al.,1997). Efforts here should be focused on the continued recognition and expansion of thelist of change benefits along with the encouragement of overall feelings ofself-confidence in the ability to maintain the change. The primary objective of stagesof change based on behavioral intervention is to move participants into the action andmaintenance stages and help them to remain there (Glanz and Patterson, 1998).Appropriate nutrition interventions for each stage of change are summarized inTable II.

Since the late 1980s, the transtheoretical stages of change model has become thedominant framework for health promotion in the USA, Great Britain, Australia andelsewhere (Bunton et al., 2000). It is not, however, the only framework recommended forhealth promotion. For example, the health action model is another framework designedto facilitate the delivery of specialized health-related information (Nieto-Montenegroet al., 2006, 2008). The health action model takes into consideration all of the social andenvironmental factors that help to shape individual behavior. The five systemsincluded in the health action model, all of which influence behavior, include:

(1) the knowledge system-basic knowledge;

(2) the normative system-norms and rules;

(3) the motivational system-motivational elements in the workplace;

(4) belief system-values and beliefs of the target individual; and

(5) worksite environmental system-physical conditions of the worksite(Nieto-Montenegro et al., 2008).

The health action model considers all relevant social and environmental factors thatcan facilitate or hinder behaviors in order to provide the necessary resources to changethe surrounding conditions leading to desired behaviors. The health action model hasbeen used in a number of context to deliver health-related information. For example,Nieto-Montenegro et al. (2008) utilized the model as a framework for developing food

Stages of change Appropriate nutrition intervention

1. Precontemplation Increase awareness of need for changeIndividualize risks associated with current behaviors

2. Contemplation Increase knowledge of personal riskIncrease self-confidence that a change can be madeProvide strategies for overcoming perceived barriers to change

3. Preparation Provide materials designed to facilitate actual change behaviorsEnhance self-efficacy beliefs for making a behavioral changeMake specific suggestions for easy dietary changesAcknowledge possibility of relapse to avoid discouragement

4. Action Encourage feelings of self-liberation and self-efficacy beliefs for maintainingthe new behaviorProvide social supportReinforce behavior

5. Maintenance Suggest healthy substitutes for unhealthy behavior to prevent relapseRemove environmental cues that may lead to a relapse into unhealthybehavior

Table II.Appropriate nutritioninterventions for eachstage of change

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safety educational materials for Hispanic workers in the mushroom industry. Thehealth action model is just one example of an alternative framework for facilitatinghealth and nutrition interventions. Although we acknowledge that other models havebeen used successfully to facilitate health-related behavioral interventions, it is beyondthe scope of the current paper to provide a complete review of all of the possiblealternative frameworks. Certainly, the transtheoretical stages of change model hasbeen among the more popular and widely utilized of these models (Bunton et al., 2000).

Despite its impressive popularity, the transtheoretical stages of changemodel has beenthe subject of somedegree of criticism. For example,West (2005) has argued that themodelstages are arbitrary rather than genuine, that individuals are not always rational orplanful, that stage definitions are not coherent and that model predictions are oftenincorrect. Proponents of the model have countered these kinds of claims, providingtheoretical arguments and empirical evidence in support of the model’s efficacy(Prochaska, 2006). Indeed, a number of empirical studies have specifically examined theeffectiveness of the stages of changemodel for facilitating behavioral change in the contextof a tailored nutrition intervention. Although Nasser et al. (2006) recently reported findingno significant differences between a tailored stages of change based intervention and anon-tailored general education approach for decreasing dietary fat intake, the balance ofthe evidence supports the effectiveness of the stage-basedmodel fornutrition interventions(Irvine et al., 2004; Nothwehr et al., 2006). For example, Verheijden et al. (2004) found thatstage-matched nutrition counseling promotes the progression through the stages ofchange and results in a reduced fat intake. Likewise, a numberof studieshave reported thatstage-based interventions are effective in increasing participant fruit and vegetable intake(Campbell et al., 1998; Henry et al., 2006; Richards et al., 2006). Finally, recent studiesexamining non-tailored nutrition interventions that did not utilize the stages of changemodel report largely ineffective outcomes (Engbers et al., 2006; Holdsworth et al., 2004).

Taken together, these studies provide substantive evidence in support of theeffectiveness of stage-based tailored nutrition intervention. However, all of these studieswere clinical trials that did not involve any type of workplace-based nutrition intervention.We found only one example of aworkplace-basednutrition interventionutilizing the stagesof changemodel. The next step trialwas a randomized, controlled trial ofworksite nutritionand colorectal cancer screening promotion at 28 worksites with 5,042 employees (Tilleyet al., 1999). In a study based on a subset of the next step trial data involving 2,764autoworkers, Glanz et al. (1998) reported that stage of change was significantly associatedwith fat, fiber, and fruit/vegetable intake, and concluded that the stages seem to serve as aprimary mediating factor for dietary changes. These findings indicate a tremendousuntapped potential for a wider application of the stages of change model inworkplace-based nutrition interventions. Indeed, many organizations would be wellserved by utilizing the transtheoretical stages of change framework to create stage-basedtailored workplace nutrition interventions as an integral part of their corporate wellnessprograms. In the following sectionwewill outline somespecific strategies for implementingthis type of nutrition intervention as part of a larger corporate wellness program.

Workplace-based nutrition intervention strategiesThere are two basic types of organizational nutrition interventions that may beincorporated into a comprehensive corporate wellness program: individual behaviorfocused interventions and environmental change focused interventions (Strong, 2004).

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Both types of interventions may be useful in facilitating nutritious food intake amongemployees and they may be used in combination with one another. In this section, wewill provide a brief overview of these two categories of nutrition interventions.

Individual behavior focused interventions. Individual behavior focused interventionstailored on the basis of stages of change may be facilitated by a number of technologiesincluding the internet, CD-ROM, and e-mail. Although computer-based informationdelivery systemsmaynotworkwell in everyworkplace andmay even contribute to healthinequalities in situations where computer or internet access is limited, research evidencesuggests that computer tailored interventions delivered via the internet may be moreeffective in many situations than more traditional methods because they result in betterinformation exposure and more thorough information processing (Brug et al., 2003).Computer tailored and internet delivered information is more often read in its entirety,discussed with others, and read more thoroughly than general printed nutritionalinformation (Brug et al., 2003). Indeed, Kreuter et al. (1999) found that computer tailoringled to more intense information processing and resulted in more positive thoughts, morepersonally relevant thoughts, stronger motivational thoughts, and more self-assessmentthought relative to weight-loss related behaviors. Similarly, Oenema et al. (2001) reportedthat a computer tailored intervention delivered via the internet was appreciated better,was viewed as more personally relevant, and had more subjective impact on behavioralchange intentions than non-tailored general nutrition information.

Tailored individual behavior focused interventionsmay also be delivered via CD-ROM(Campbell et al., 2004). CD-ROMs enjoy several important advantages when compared toweb-based interventions. They are portable, cost-effective, have no bandwidth orconnectivity restrictions, and are capable of delivering high-performance media such asvideo, audio, and animation (King et al., 2004). In addition, they are not as vulnerable asweb-based programs to external interference such as viruses and network failures. Theyare also easily controlled (via password) and can be easily packaged for widespreaddissemination (King et al., 2004). On the other hand, CD-ROMs are much more rigid andless flexible in terms of making changes and revisions in comparison to an internet basedsystem. Likewise, CD-ROMs may require specialized hardware, software, and userexpertise that would not be needed to use a web-based system (King et al., 2004).

Finally, recent studies have suggested that e-mail may serve as a simple yeteffective delivery system for tailored individual behavior focused interventions(Plotnikoff et al., 2005). For example, in a field study, Block et al. (2004) reportedsignificant increases in fruit and vegetable consumption and significant decreases infat intake among participants in a stage-based tailored nutrition intervention deliveredentirely via e-mail. They also found high levels of satisfaction with the program andsignificant improvement for stages of change among participants. The primaryadvantage of an e-mail delivery is the low cost and relatively high exposure.Regardless of the type of delivery system employed, research suggests that individualbehavior focused interventions are generally more effective when they are interactive(e.g. food sampling, contests, multimedia, etc.) rather than passive (e.g. printedmaterials, one-time events, presentations, etc.) (Irvine et al., 2004; Patterson et al., 1997).

Environmental focused interventions. Environmental interventions also play animportant role in efforts to increase nutritious food intake in organizations. In thecontext of the stages of change framework, environmental intervention efforts focusprimarily on creating more opportunities for action by reducing barriers to pursuing

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a healthy diet (Glanz and Mullis, 1988). There are five main types of organizationalinterventions including: changes in the food supply, point of choice nutritionalinformation, collaboration with private sector food vendors, worksite nutrition policiesand incentives, and changes in the structure of health and medical care related tonutrition (Glanz and Mullis, 1988). Many organizations today use some combination ofthese strategies to remove barriers and promote healthy food choices among employees.

For instance, Humana, Inc., a Fortune 500 company based in Louisville, Kentucky,USA, that markets and administers health benefit consumer services, recentlyintroduced “Just 4 You”, a program developed in conjunction with Aramark, thecontractor that oversees the foodservice at Humana’s locations in Louisville, Green Bay,Wisconsin, and Miramar, Florida, USA (Boss, 2005). “Just 4 You” features online menusthat include full nutritional information. Healthy items are offered at a discount in thefoodservices and in onsite vending machines. Although Humana subsidizes the cost ofthe discounted healthy items, sales have increased by 19.3 percent, completely offsettingthe cost of the subsidy (Boss, 2005). Similarly, a recent study targeted Swedish lorrydrivers with an environmental nutrition intervention that included an informationcampaign, healthier “Today’s Specials” choices, and lottery tickets as incentive rewardsfor making healthy food choices (Gill andWijk, 2004). Results indicated that the driverstended to choose the healthier food alternatives and were more aware of theiravailability. Along these same lines, the Heartbeat Award (HBA), a national nutritionallabeling scheme, was implemented across six workplaces in Leicestershire, England, aspart of a recent nutrition intervention study (Holdsworth et al., 2004). The results showedsignificant positive changes in the intervention workplaces, including an increase in theconsumption of fruit, a reduction the consumption of fried foods and sweet puddings,and a change to lower fatmilks. Taken as awhole, the strategies discussed in this sectionrepresent some powerful and practical approaches for designing and implementingstage-based nutrition interventions as part of a comprehensive wellness offering.

Summation and conclusionThis paper makes a valuable contribution to the organizational literature byrecognizing the potential for the application of the transtheoretical stages of changemodel from the field of nutrition education within the context of the resource-basedview of organizations. More specifically, we have suggested that an organization maybe able to use a tailored stage-based nutrition intervention as part of a comprehensivewellness program in order to help create a sustainable competitive advantage based onthe nutritious food intake of its members. We began by examining the currentpopularity and effectiveness of corporate wellness programs, suggesting thatnutritious food intake is a somewhat overlooked yet essential aspect of wellnessthat has the potential to help organizations create a sustainable competitive advantage.We next provided a brief overview of the resource-based view along with a discussionof the ways in which nutritious food intake across an organization’s entire workforcemay serve to create rare organizational resources that could result in a competitiveadvantage. We then presented a basic outline of the fundamentals of nutritious foodintake before discussing the application and effectiveness of the stages of changemodel in the context of tailored nutrition interventions.

This paper has important implications for organizational leaders and humanresource professionals with respect to the development and implementation of a tailored

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nutrition intervention as part of a comprehensive corporate wellness program. Wehave provided a detailed overview of behavioral change strategies and theirapplication in the context of tailored nutrition interventions. We have presentedsuggestions for both individual behavior focused and environmental focused changeinterventions, along with a discussion of types of technical delivery systems.Exemplary efforts such as Humana’s “Just 4 You” program in the USA and the HBAprogram in England should be carefully noted and expanded upon. In short,organizational leaders should carefully consider the strategies and methodologiesdiscussed herein when designing and implementing nutrition interventions as part of abroad corporate wellness program.

This paper also has significant implications for future empirical research in thisarea. Future researchers should continue to examine the effectiveness of stage-basedcomputer tailored nutrition interventions and their delivery systems, particularly inthe context of comprehensive corporate wellness plans. Future researchers should alsoattempt to assess the extent to which nutritious food intake across an organization’sworkforce may serve to help create a competitive advantage through lower directhealthcare costs and higher worker productivity. In this manner, the value of nutritiousfood intake, not only to individual health but also to the overall health of theorganization, may be more fully realized.

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Corresponding authorJeffery Houghton can be contacted at: jeff.houghton@mail.wvu.edu

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