The “Food Education Program” (FEP) is developed in the hospital in the context of the Workplace Health Promotion plan addressed to the employees from 2021. This plan follows the Total Worker Health^® approach, which is defined as a strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and wellbeing (Table 1) (19).

In this scenario, FEP is designed to strike the unhealthy nutritional habits. The FEP is an individual path led by a multidisciplinary team, including the occupational physician, a nutritionist and a psychologist. The intervention is based on a double-faced approach which includes two parts: (i) a diet and (ii) a psychological and motivational support. The psychological support intervention in the Food Education Program (FEP) was structured as a series of four monthly individual or joint sessions involving both the psychologist and the nutritionist. These sessions employed evidence-based strategies to promote behavioral change and adherence to dietary recommendations. The key techniques included SMART goal setting, positive reinforcement, and the use of a food diary within an ABC model framework. Through SMART goal setting, participants were guided to establish goals that were Specific, Measurable, Achievable, Relevant, and Time-bound. This approach was chosen to enhance motivation and increase the likelihood of achieving sustainable health behavior changes (20). Positive reinforcement was employed as a motivational tool to encourage adherence to the dietary plan and to reward progress. This technique leverages principles of operant conditioning, which emphasize the role of rewards in maintaining desired behaviors (21). The use of a food diary helped participants monitor their eating habits, providing valuable insights into meal patterns and emotional triggers. Food diaries have been shown to increase self-awareness and facilitate behavior modification in dietary interventions (22). Specifically, the Antecedent-Behavior-Consequence (ABC) model was applied using food diary entries to analyze eating behaviors. Antecedents (situations or triggers), behaviors (eating patterns), and consequences (behavior outcomes) were identified to better understand and address eating habits (23). These techniques were integrated into the sessions to provide personalized feedback and foster self-regulation, empowering participants to adopt healthier eating habits and sustain long-term changes.

An accurate dietary anamnesis is carried out to collect important data on eating behavior. Usual food intake (both liquid and solid), mealtimes, intolerances and allergies, and intestinal activity are investigated to identify the most suitable Mediterranean pattern of the diet. Moreover, the psychological motivation is essential to keep the path alive. FEP is composed by the following four phases. Firstly, the enrolment of participants, on a voluntary basis, is set up by the occupational physician through a pre-intervention interview, which is useful to ascertain the inclusion criteria and motivational driver of the HCW. The inclusion criteria are represented by altered metabolic parameters. According to the metabolic syndrome diagnosis (24), the following are considered: Body Mass Index (BMI) ≥ 25 (overweight condition); waist circumference > 88 cm in women and >102 cm in men; total cholesterol values > 200 mg/dL and/or LDL values > 160 mg/dL; Triglyceride values > 170 mg/dL; Systolic blood pressure values ≥ 140 mmHg and/or diastolic blood pressure values ≥ 90 mmHg; fasting blood glucose > 110 mg/dL. Exclusion criterion is participants who decided not to follow the program in any of the phases. Subsequently, the pre-FEP evaluation phase is carried out by the whole working group, aimed to obtain an initial assessment of the physical and mental health status. The intervention phase lasts 4 months, with a monthly monitoring by the nutritionist and the psychologist together. The final follow-up phase is performed 2 months after the end of the course with a post-FEP clinical evaluation.

To promote FEP's success, the canteen's food planning was modified by introducing more balanced and nutritious dishes. Vending machines available in the hospital were added on dried fruits and trail mixes as well as the standard sugar choice for coffee and other beverages was set up on the minimum level and fruit juices were eliminated.

During the pre-FEP evaluation and the post-FEP follow-up phases, three categories of data are collected, regarding:

The clinical effectiveness of the intervention is assessed by comparing the variables before and after.

A prospective pilot study was conducted in the Occupational Medicine Unit of the hospital between January 2021 and December 2023. Participants were recruited voluntarily during routine check-ups with the occupational physician. Recruitment was based on the identification of alterations in anthropometric measurements and blood parameters. A range of standard demographic and occupational variables were considered to comprehensively analyse the interaction between health outcomes and the work environment. Demographic variables included age and sex, whereas the professional category was used to classify employees in three categories (e.g., nurses, physicians, and technicians). Participants were classified according to the BMI as obese, overweight, and normal weight (25). Modifications of BMI and WHR were recorded and compared among the three groups.

Demographics and occupational variables were described in terms of mean and standard deviation for continuous variables and absolute and relative frequency for categorical variables. After found out that some of the hematological and questionnaire related data were not normally distributed through the Shapiro-Wilk normality test, the pre-post comparison was set up using non-parametric tests, assuming two tailed p-value < 0.05 as significant. Statistical analyses were performed using IBM Statistics Package for Social Sciences (SPSS) (version 26.0).

The econometric analysis was set up using SAD reduction in the 1-year period as the profit in the Return on Investment (ROI) formula (34). The invested capital was referred to the working time of the multidisciplinary team which carried out the FEP.

In our population the cardiovascular risk profile appears significantly improved after the nutrition intervention, in terms of reduced glycosylated hemoglobin, total and LDL cholesterol and WHR. Acting on reversible cardiovascular risk factors, Food Education Programs have been shown to actively prevent chronic NCDs (40).

According to literature, a proper diet should take into account both the energy and nutrient properties of the food, the type of work performed (sedentary, varied, light, heavy), the working environment (temperature, humidity, etc.), working hours (continuous, shifts), the type of habitual diet (nationality, religion, etc.), and non-work activities (sport, second job, hobbies) (18). For instance, the healthy eating guidelines established that meals eaten while working should be not too abundant, easily digestible, mainly made up of carbohydrates (bread, pasta, rice), legumes, fruit, and vegetables (foods with a high content of mineral salts) and an adequate water supply. In mental work, which is usually associated with a sedentary lifestyle, nutrition must be particularly careful as it consumes energy it is minimal. To this respect, the Mediterranean diet, been recognized by UNESCO as an intangible heritage of humanity thanks to its wide range of beneficial effects, may be the right choice (41). Studies have reported that implementing Mediterranean dietary patterns generates a significant decrease in body weight, BMI and abdominal circumference of up to 40% (42), of total and LDL cholesterol and the reduction of the WHR ratio (43, 44). This contributes to a 25–45% reduction in the risk of cardiovascular morbidity and mortality (e.g., 25–30% lower incidence of type 2 diabetes and 30–40% lower incidence of metabolic syndrome) and to a 20–30% reduction in cancer mortality (42). The Mediterranean diet is not just a way of eating, but a set of knowledge, social habits, and cultural traditions. In the choice of food to be prescribed, preference should be given to a mainly plant-based diet with a meal distribution throughout the day represented by five meals: three main meals (breakfast, lunch and dinner) and two snacks (mid-morning and mid-afternoon). According to this model, establishing a proper meal routine allows to maintain an adequate hunger-satiety rhythm throughout the day and, consequently, to follow a varied and balanced diet, preventing the risk of obesity and related chronic NCDs (41).

In our population we found a significant increase in vitamin D levels in combination with an improved perception of physical activity. In fact, in accordance with the literature, an increase in plasma vitamin D concentration occurs with both indoor and outdoor physical activity (45).

Among participants who lost weight, about 40% also stopped smoking. This result has amplifying effects on the cardiovascular risk profile, since it contributes to low systemic inflammation, as happens with increased physical activity and weight loss (46).

Furthermore, a gender difference has been outlined in fruit and vegetable consumption, which is higher in women and in olders with a higher level of education (47, 48). In literature, gender difference has been linked to psychological health, since higher consumption of fast, fried or sugary foods in women has been associated to depression (49).

In our population the individual perception of mental and general health (GHQ-12 and SF-36 scores) significantly improved.

Physical activity has been outlined as tightly correlated to nutritional aspects, since diets help weight loss. The combination of a balanced diet and regular physical activity is crucial for effective weight loss, with a better outcome than focusing on diet alone (50). Combining a low-calorie diet with regular physical activity not only facilitates achieving optimal weight management but also improves overall health, including better cardiovascular parameters and metabolic outcomes (50, 51). The broad long-term health benefits of integrating physical activity with dietary interventions reinforce the importance of a holistic approach to weight management (52). The combined approach reduces the likelihood of weight regain after initial weight loss (53). Eating schedules are one of the major protective factors for the improvement of general health. Several studies show that structured and balanced diets significantly enhance greater and more sustainable weight loss outcomes compared to unorganized dietary approaches (51, 52).

Moreover, our results underline that the risk for anxiety and depression traits significantly lowered as well as the perception of emotional role limitations improved. This highlights the important role of psychologists in the TWH system. Psychologists contribute by promoting interventions that reduce workplace stress, enhance mental health, and develop a supportive work environment. Their expertise in behavior change is crucial for designing programs that encourage healthy lifestyles and increase resilience among workers. Moreover, psychologists play a key role in organizational assessments and the implementation of policies that support holistic health approaches. Studies have shown that integrating psychological strategies into TWH initiatives leads to improved worker's outcomes and overall organizational productivity (54).

Health policy and health promotion policies in workplaces play a crucial role in safeguarding the wellbeing of employees, particularly through initiatives focused on food education to prevent cardiovascular diseases and NCDs (55).

According to our results, different actions could be implemented to counteract the consumption of fast/take-away food and increase the availability of healthy food in the workplace. For instance, in-house vending machines could be revamped to offer healthier options. Some ideas may include freshly washed and packaged fruit, natural fruit juices, low-calories snacks (e.g., whole-grain cereal bars or dried fruit), yogurt and ready-to-eat fresh salads (56). Moreover, reducing the price of healthy products could incentivise workers to make better choices (56). The availability of low-calories or hypolipidic menus in the canteens could be proposed by nutrition experts (57). Information materials near vending machines or in the canteen may encourage healthier food choices and give details about the products on sale (58). Nutrition training courses could be organized to educate employees on proper nutrition. Many communication strategies have been suggested to reach the goal of a better eating community, including brochures, motivational telephone interviews and e-mail messages (59). In the context of health policies, the role of the occupational doctor is essential to the purpose of improving the workforce's health status and healthy lifestyle behavior. During the periodical medical surveillance, informative questionnaires could be useful to collect data on eating behavior. The administration of questionnaires before the medical examination could open the opportunity to give a tailored counseling on the theme. A study showed that sending e-mail messages can positively influence eating styles in the healthcare sector (60).

Furthermore, beyond the traditional organizational health policies, the education and training of healthcare professionals could enhance the process of food literacy in the community. Knowledge and skills related to the relationship between food and people, communities, and the environment and detailed nutrition should be integrated into the university courses (61, 62), and also WHP interventions regarding food education could improve the awareness of the importance of nutrition (63). Experiential education is clinically relevant to equip future health professionals with practical skills by converting awareness of system-level issues into self-reflection, hands-on cooking and eating, and cross-disciplinary engagement (64). Moreover, a gender-focused teaching approach may be crucial for the purposes of wellness promotion and nutrition education courses (65).

Thus, integrated health policies that emphasize food education in the training of healthcare professionals in a lifelong learning in workplaces promote healthier lifestyles and reduce the incidence of chronic diseases, contributing to overall workforce health and productivity.

This study has several strengths that enhance its reliability and relevance. One notable strength lies in its methodology, which employed rigorous sampling techniques and comprehensive data collection methods. Furthermore, the inclusion of detailed statistical analyses facilitated a thorough exploration of the relationships under investigation. The study has some limitations, including the potential for recall bias among participants, particularly regarding self-reported data on lifestyle factors and health outcomes. Moreover, while the sample size was adequate for statistical power, larger samples could provide more precise estimates and further strengthen the study's conclusions. Additionally, the voluntary recruitment process, while potentially introducing selection bias by attracting highly motivated individuals, aligns with the program's focus on those willing to actively participate, thereby ensuring the intervention's feasibility and real-world applicability. Despite these limitations, the strengths of the study could provide valuable contributions to the existing literature on the importance of food education intervention on the workplace offering insights that can inform both policy and practice in occupational health and for whom in charge of health promotion interventions.