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Healthy eating
Potential to promote healthy in Baltic
eating in Baltic workplaces workplaces
Sirje Vaask
Department of Food Processing, Tallinn University of Technology, 211
Tallinn, Estonia, and
Tagli Pitsi
Estonian National Institute for Health Development, Tallinn, Estonia

Abstract
Purpose – The purpose of this paper is to define the potential to promote healthy nutrition in
workplaces in the Baltic States and to provide the strategic structure for health promotion at national
level.
Design/methodology/approach – A survey, using the telephone questionnaire method, was
conducted among the adult population in the three Baltic countries in 2007, to compare the general
eating habits of the residents in those states. The sample for the survey was random, with 500 (or
slightly more) consumers between the ages of 15 and 74 in all three countries surveyed.
Findings – The survey showed that eating habits in Estonia differ from other Baltic countries.
Estonians are the most urban consumers, who eat their lunch outside of the home; they use a broader
selection of ready-to-eat meals than Latvians and Lithuanians. The lunch choice made by Estonians is
therefore more influenced by what is offered in their workplaces. Estonian National Strategy for the
prevention of cardiovascular disease (CVD) and Estonian health are the main national public health
policy documents. The development of the Network for Workplace Health Promotion is one of the
actions carried out within above-mentioned strategies, as are county-based health councils,
responsible for management and coordination of implementation of the strategies at local level,
including cooperation with local workplaces.
Originality/value – The paper presents useful, practical examples of where changes in the
composition of food in catering have improved not only workers’ eating habits, but also their
satisfaction and commitment to work. There have been positive changes in CVD mortality in Estonia.
Still, the mortality rate in Baltic countries is considerably higher compared to the other EU
countries and this calls for the direction of the health promotion activities in workplaces in other Baltic
States also.
Keywords Baltic States, Estonia, Latvia, Lithuania, Diet, Cardiovascular disease
Paper type General review

Background
Cardiovascular diseases (CVDs) are the main reason for early loss of work capacity
(at an age below 65) and death in Baltic States (WHO Regional Office for Europe, 2006).
Estonia is a leader in CVD mortality in Europe and some positive changes have been
seen only in the past few years (Koppel et al., 2008). Every year, Estonians lose almost
400,000 healthy life years (measured according to the disability-adjusted life years
index), the main reasons for the high burden of disease are CVDs (Lai et al., 2005, 2007). International Journal of Workplace
Many campaigns and actions promoting the consumption of fruits and vegetables, rye Health Management
Vol. 3 No. 3, 2010
bread and products with a low fat and salt content targeted at young people and adults pp. 211-221
have been carried out since 1996. Although a number of positive changes have q Emerald Group Publishing Limited
1753-8351
occurred in the eating behavior of the Estonian population over the past decade, DOI 10.1108/17538351011078947
IJWHM the Estonian diet is still poorly balanced to a large extent, especially from the aspect of
3,3 cardiovascular health (Pomerleau et al., 2001; Government of the Republic, 2005).
Activities in the area of disease prevention and health promotion have been a central
concern in Estonia over recent years and significant progress has been made in the
development of public health strategies, including prevention strategies for CVD and
health, delivered at both a population and individual levels. Since 2008, the health
212 promotion and disease prevention actions at workplaces have been implemented
within the framework of the National Population Health Strategy, 2009-2020
(Government of the Republic, 2008). The implementation of the strategy is managed
and coordinated by the Strategy Council setup in the Ministry of Social Affairs, which
includes representatives of relevant ministries and other institutions, including
non-profit organizations and professional associations.
The development of the Network for Workplace Health Promotion is one of the
actions carried out within above-mentioned strategies since 2005. Information is not
enough to improve eating habits; people must be given the practical opportunity for
healthy nutrition.
The Association of the Estonian Food Industry ordered a survey into eating habits
in the Baltic States in 2007. The aim of this survey was to compare the general eating
habits of the residents in the three Baltic States.

Methods
The survey of eating habits in Baltic countries was conducted simultaneously in the
three countries in October 2007 using the telephone questionnaire method. The sample
for the survey was random, with 500 (or slightly more) consumers between the ages of
15 and 74 in all three countries surveyed. The survey questionnaire was designed to
identify the times at which people eat, which meal qualified as their main meal and the
places they eat on weekdays and weekends; the food and drinks people primarily
consume at different meal times; the food they eat as snacks between meals; and
sources of information in shaping nutritional habits. The total number of people
participated in the survey was 501 in Estonia, 507 in Latvia and 529 in Lithuania. The
survey was carried out by the professional research company Faktum&Ariko
(Association of the Estonian Food Industry, 2007).

Results
Although those who took part in the survey were representatives of various
nationalities, they will hereafter be referred to simply as Estonians, Latvians and
Lithuanians. The total number of people surveyed was 1,537, of whom 53-54 per cent
were men and 46-47 per cent women. Of the three age groups surveyed (15-34, 35-54 and
55-74) there were more respondents from the first two groups in all three countries:
37, 36 and 28 per cent, respectively, in Estonia; 38, 35 and 28 per cent in Latvia; and
38, 37 and 25 per cent in Lithuania.
The majority of respondents had secondary or tertiary education or vocational
secondary education. In terms of marital status, more respondents (approximately
60 per cent) were married or in cohabitation. Roughly, half of those surveyed in all
three countries were the main shoppers in their families. Likewise, approximately
half of respondents were salaried employees: primarily skilled workers, specialists,
managers and personal or customer service officers. About 37 per cent of those
surveyed in Estonia, 33 per cent in Latvia and 40 per cent in Lithuania had families Healthy eating
including children under the age of 16. in Baltic
Breakfast is eaten in all three countries in much the same way at home, although
there are certain differences in people’s choice of food. The breakfasts that Estonians workplaces
eat are somewhat more varied than those of their neighbours.
In total, 73 per cent of Estonians and Lithuanians and 70 per cent of Latvians eat
breakfast before 10.00 a.m. on working days. The main meal of the day in all three 213
countries is taken between 12.00 and 2.00 p.m. on working days, main meals are between
6.00 and 8.00 p.m., especially those with children. The majority of respondents in all
countries tend to eat between 6.00 and 8.00 p.m. on weekends and days off, although
lunch remains the main meal of the day and is usually eaten between 12.00 and 4.00 p.m.
The biggest differences in the main meal on working days emerge in the choice of
location (Figure 1): less Estonians eat their main meal at home, while 36 per cent eat
theirs at their work place or school, and 10 per cent eat food they have taken with them
from home. On the other hand, Estonians tend to eat out on weekends and days off less
frequently than Latvians and Lithuanians.
The most common component of the main meal in all three countries is meat, but in
the same time, significant proportion of Estonians nominated fish as the main
component compared to the Latvia and Lithuania (Figure 2). Vegetables and salad
formed the most common component of the main meals of 10 per cent of more Estonians,
than Latvians and Lithuanians. However, Estonians also represented the smallest
proportion of consumers of fruit. Estonians also consume more grain products as part of
their main meal than their neighbours, as well as dairy products, sausages and ice cream
or other dessert items. Estonians are the most urban consumers, who eat the main meal
of the day outside of the home; they use a broader selection of goods for evening meals,
including semi-processed and ready-to-eat meals.
Estonians prefer milk or fruit juice as their drink, while Latvians and Lithuanians
prefer juice or tea (Figure 3). Water or mineral water is the most popular drink
between meals in all three countries (70 per cent of in Estonia, 61 per cent in Latvia

Lithuania 61 8 24 7

Latvia 47 19 21 21 2

Estonia 44 36 10 6 13

0 20 40 60 80 100
People (%)
Home Workplace, school Figure 1.
Workplace, school (food from home) Cafe, restaurant, pub
The main place of eating
of lunch in Baltic States
Fast-food Not answered
IJWHM 100
87
3,3 90 89
85 Estonia Latvia Lithuania
80
80 77
71
70 64
People (%)
60
214 50 47
41
40 36 39
33 31 32
30 27 28 28
23 24 23
20 20
20 15
15
17
14
11
10
0
t

sh

ts

ts

es

etc

am

try
ea

ad

uc

uc

rri
Fi

s
M

re
all

es

Pa
od

od

be

-c
Figure 2.

ag
,s

pr

pr

ice
ts,

us
les

The main component of

ain

ilk

ui

Sa

t,
tab

Fr

er
M
Gr

the lunch in Baltic States

ss
ge

De
Ve

50 47
45 42
Estonia Latvia Lithuania
41
40 39 39
37
35
People (%)

30 28 28
26 27
25
25 2323
20 18
15 15
15
10 7 7 7
5
5 4
3 3 3
2 2 1
0
Figure 3.
e

er

ilk

e
hi

e
ic

Te

ffe

in
in
t

Be
wa

ep
Ju

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dr
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The drink consumed

,K

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during the meal in Baltic

ilk
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States
ur
So

and 63 per cent in Lithuania). In second place in Latvia and Lithuania is tea (32 and
33 per cent of respondents, respectively), while in Estonia second place is given to fruit
juice (31 per cent). Also, 22 per cent of Estonian respondents drink tea between meals,
and 16 per cent drink coffee. Soft drinks are only notably popular in Latvia (13 per cent of
respondents compared to just 7 per cent in Estonia and Lithuania). At the same time,
more Estonians drink milk or beer between meals (5 per cent of respondents each).
Estonians eat a warm meal at home in the evening slightly less frequently than
Latvians or Lithuanians. In total, 61 per cent of Estonians, 73 per cent of Latvians
and 71 per cent of Lithuanians eat a warm meal at home in the evening every day.
The most important factors in what people make for their warm meals in all three Healthy eating
countries were personal taste preferences and what is healthy. The third most in Baltic
important factor for Estonians and Lithuanians was the meal’s preparation time, while
for Latvians the third most important aspect is the quality of the food. Compared to workplaces
their neighbours, Estonians place greater emphasis on variety.
Compared to their neighbours, Estonians eat less light meals or snacks. The main
snacks eaten between meals in Latvia are confectionery products, sandwiches and junk 215
food. Dairy products, meat and fish products are the main snacks eaten between meals
in Lithuania.

Eating habits compared with guidelines

The dietary guidelines worked out for Baltic States are quite similar to the Nordic ones;
bread is emphasized in Estonia, Latvia and Finland (Similä et al., 2003; Vaask et al., 2006)
(Table I).
Although this survey has shown that the fruits and vegetables are consumed within
and between meals, other studies have confirmed that the majority of Estonians and
also Latvians and Lithuanians do not eat the recommended five daily portions of fruit
and vegetables.
The health behavior among adult population survey (known also as FINBALT survey)
2008 showed that only 39 per cent of respondents eat between 200 and 400 grams of fruit
per day and 36 per cent of respondents eat between 200 and 500 grams of vegetables per
day; less than 200 grams of fruit and vegetables is consumed by 31 and 37 per cent of
respondents each day, respectively, (Tekkel et al., 2009). Comparing the places in which
people eat their main meal on weekdays, it can be seen from this survey also, that
Estonians are much more urbanised than their neighbours, eating outside of the home
more, while Lithuanians tend to eat at home the most. Meat is preferred by the people in all
three countries and consumption of fish is below recommended level in all Baltic countries.
Estonians tend to have more balanced eating habits towards the food-based
dietary guidelines than Latvians and Lithuanians. More Estonians reported that
they are following nutritional recommendations (Association of the Estonian Food
Industry, 2007).
Estonians tend to eat out on weekends and days off less frequently than Latvians
and Lithuanians. This fact could be explained by the cultural differences between
Baltic States: Estonians are more career and work oriented while Latvians and
Lithuanians emphasize the time with family (Tekkel et al., 2009).
This survey has shown that the lunch choice made by Estonians is probably
influenced by what is offered in their work places, as many Estonians eat lunch outside
of the home. By increasing the amount of fruit and vegetables and fish offered in eateries,
it may be possible to persuade people to consume more. Sufficient consumption of both
food groups is important for the prevention of CVDs (Steingrı́msdóttir et al., 2002).

Description of policy initiative

Promotion of increased consumption of vegetables, potatoes, fruits, whole grain cereals
and fish tends to be an integral part of nutrition education and health promotion.
Broad national initiatives to promote the consumption of fruits and vegetables have
been launched in Nordic countries. These initiatives have included projects such as
“Fruits and vegetables against cancer”, “Fruits and vegetables at school” and
 3,3

216

Table I.
IJWHM

Summary of the
food-based dietary

and Baltic countries

guidelines in Nordic
Denmark Finland Sweden Norway Iceland Estonia Latvia Lithuania
a
Vegetables 600 gram 500 gram 500 gram 750 gram/3 p veg 5p/500 gram 3-5 p 400 gram 400 gram, 3-5 p veg/
þ pot 2 p fruit 2-4 p fruit
Fruit and berries 2-4 p
Potatoes 3-5 p 800 gram 5-11 p cereals and potatoes
Bread 6-9 sa 6-8 p of cereals
Fish 200-300 gram/week 2 x 2-3 x 2x
Notes: p – portion per day; s – slices a day; x – times in week; anot official guideline
“Green canteens at work sites”. In Latvia promotion of fruit, vegetable and bread Healthy eating
consumption has been included in healthy nutrition programs at schools and in several in Baltic
local projects. In Lithuania, promotion of vegetable and fruit consumption, as well as of
potato, cereal and fish consumption, is included in the activities of certain disease workplaces
prevention programs (Countrywide Integrated Non-communicable Disease Intervention
Program). Information is not enough to improve eating habits; people must be given the
practical opportunity for healthy nutrition. Several networks have been efficiently 217
involved in healthy nutrition initiatives, both in Nordic and in Baltic countries:
health-promoting schools and nursery schools, hospitals and cities (Similä et al., 2003;
Põlluste et al., 2007).
The Network for Workplace Health Promotion was created in 2005 in Estonia on the
basis of 20 enterprises. This initiative happened due to positive political initiatives in
the public health sector.
The Estonian National Strategy for the Prevention of CVD 2005-2020 was approved in
2005. This strategy was worked out during a long consultation process with different
ministries and stakeholders. This intersectoral public health strategy focuses on five
major areas: physical activity, nutrition, smoking, health care services and dissemination
of information and securing local capacity. The development of the Network for
Workplace Health Promotion is one of the actions financed and carried out within
above-mentioned strategy. The strategy introduced also the county-based health councils,
which are responsible for management and coordination of implementation of the strategy
at local level.
The Estonian Health Strategy is a main national public health policy document
approved in 2008 and all other public health strategies (including Estonian National
Strategy for the Prevention of CVD) have been incorporated in it. The Estonian Health
Strategy has been divided into five wider sections: social inclusion and equal
opportunities, development of health of youth and children, healthy environment,
healthy lifestyle and development of healthcare system (Government of the Republic,
2005, 2008). The Estonian Health Strategy incorporates all strategy documents in the
country that deal with or affect human health in any way. Changes in the environment
(such as changing the composition of food in catering establishments) are considered to
be one of the most effective activities and to yield the quickest results (Engbers et al.,
2005). The activities of workplace health promotion help to achieve both healthy
environment and healthy lifestyle.
The Estonian Network for Workplace Health Promotion has belonged to the
European Network of Workplace Health Promotion since 2006. For 2009, 100 enterprises
have joined the network, 50 per cent of them are enterprises with 100 or more employees.
One of the examples of the promoting healthy eating is from the water company,
Tallinna Vesi, which has been a member of the network since 2005. The company raised a
problem that the food provided in the canteen was not healthy, the price was too expensive
for the workers and the dining environment was unsatisfactory. As a result, many
workers were eating lunch at home rather than in canteen. The company announced a
contract providing affordable healthy foods and at the same time the new and renovated
dining rooms were provided. As a result of the changes, a weekly balanced menu became
an opportunity, the prices are now affordable, the canteen provides both breakfast and
lunch and even take-away meals were introduced. This increased the number of visitors to
the company cafeteria, and in particular the number of workers. The salad bar is free of
IJWHM charge and very popular among the workers. The company has carried out the employee
satisfaction surveys for many years; the questionnaire also includes meals themes.
3,3 The survey has shown that the commitment of employees increased significantly
compared to previous years in all business units. The study indicates that workers
highlight the high-quality working environment; also, the number of the sick-leave days
has been decreased (Estonian Health Insurance Fund, 2009; National Institute for Health
218 Development, 2009).
Since 2006, health promotion specialists have been working in every county in the
county government. Their responsibility is to initiate, coordinate and evaluate local
activities, but also to help local municipalities to plan and implement health supporting
policies. Health promotion specialists are important key actors in the development and
promotion of local networking on health promotion. Their involvement in the
development of strategic measures to promote health at local level and in the
implementation and assessment of activities is supported by a health council established
for this purpose.
Health issues tend to become important also among enterprises that have not joined
the network. They can also collaborate with County Health Council and National
Institute for Health Development. A good example is from a big heat supply company
Tallinna Küte; they started their health promotion program in November 2009. The aim
of the program was “Beautiful for spring, together towards healthy lifestyle and
weight”. All participating people measure their weight in the beginning and write down
their goal. These numbers are known only to the program manager. Every week the
group gathers for weighing and exchanging of information about their positive changes.
Sometimes a group meets a specialist and listens the presentations about healthy eating,
healthy weight, etc. The program will end in April with a spa-event. The feedback from
participants is very good, because doing difficult things together is more motivating
than doing them alone (National Institute for Health Development, 2009).
Expected outcome of health promotion
The main purposes of the above-mentioned strategies are to increase the duration of
life lived healthily through reducing pre-term mortality and occurrence of illnesses.
The health strategy as a frame allows coordination of the work done in the whole
country in the field of public health via one policy document, and there exists one
management structure for all public health strategies. The County Health Councils
have been working in all county governments since 2005, having representatives from
county offices, local governments and stakeholder groups (educators, general
practitioners, local opinion leaders, etc). The work of the public health specialist and
council is funded mainly by the central government. The national interventions are
planned and managed by the National Institute of Health Development; local/regional
actions are planned and managed by the County Councils. Planning and implementing
actions via the County Health Council decentralizes public health activities and allows
being flexible with local needs. The expected outcome is to have a sustainable network
for health promotion and therefore the implementation of national and regional actions
in close coordination. The Network of Health Promoting Workplaces is still
coordinated at national level by the Estonian Institute for Health Development and the
cooperation with regional councils has great potential, but is still not fully used.
There have been important changes in Estonia – politicians, other ministries and
communities have shown initiative and interest in integrating public health actions
to the political programs at national and local level: health promotion has been spread Healthy eating
out from the traditional “healthcare” sector. Good examples of integrating health in Baltic
promotion in the other sectors’ activities are the Estonian strategy for physical activity
under the Ministry of Culture and development plan “estonian food”, under the workplaces
Ministry of Agriculture.
The results of the CVD prevention strategy have shown that there have been
remarkable positive changes in CVD mortality and morbidity in Estonia, especially in 219
the working-age population (Figure 4).
Estonia has achieved, with various promotion actions, the remarkable decrease in
the CVD mortality both in men and in women compared with 2001. The decrease in
mortality in working-age population (aged 15-64) has been 28 per cent (in absolute
numbers from 1,884 in 2001 to 1,362 in 2008), so more than 500 lives have been saved
annually in Estonia. Working-aged men are considered as one of the most important
risk groups (Prättälä et al., 2007); decrease in mortality in working-age men has been
23 per cent, accordingly (Statistics Estonia, 2009).
There is no clear evidence that the positive change in Estonia on CVD mortality and
morbidity is due to the implementation of the strategy and its management structure,
or due to the health promoting networks (Põlluste et al., 2005). The results of the various
surveys have shown that health promotion has influenced people’s health behavior and
therefore this has been a prerequisite for the decrease also in the morbidity and mortality
rates (Petkeviciene et al., 2007; Tekkel et al., 2009; Estonian Health Insurance Fund, 2009).
Still, the mortality rate is considerably higher among men, people with lower
education and income status (including unemployed). This calls for the direction of the
health promotion activities towards these target groups.

Conclusions
Political commitment to the stable funding of health promotion activities through national
strategies and long-term priorities are prerequisites for successful health promotion
development. The health promotion in workplaces has shown that the positive
environment and balanced meals increase the employee’s satisfaction and commitment,

600

500

400

300

200
Estonia, males
100 Latvia, males
Lithuania, males Figure 4.
0 Mortality due to ischaemic
2001 2002 2003 2004 2005 2006 2007 2008 heart diseases, in males in
Note: Standardised death rate by 100,000 inhabitants Baltic States 2001-2008
Source: European Commission (2009)
IJWHM but could also decrease sick-leave days. In the long run, the clearly formulated
3,3 organization at the county forms the basis for all public health programs. The national
health promotion structure could support and co-operate with health promoting networks
and local enterprises.
By increasing the amount of fruit and vegetables and fish offered in eateries it may
be possible to persuade people to consume them more. Sufficient consumption of both
220 food groups is important for the prevention of CVDs. The mortality from CVDs has
been decreased in Estonia more than other Baltic States, especially in the working-aged
population. The achievements of Estonia could encourage other Baltic States and
Eastern European countries to invest in workplace health promotion.

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About the authors

Sirje Vaask has a Doctor of Philosophy degree from Tallinn University of Technology (2008) and a
Master of Public Health degree from University of Kuopio (1998). The objective of her studies is to
develop the quality of food consumption surveys in Estonia and to evaluate the impact of nutrition
promotion programs. She was WHO Nutrition Counterpart of Estonia (1997-2003) and the
coordinator in several international food consumption surveys: Baltic Nutrition Survey (1997) and
NorBaGreen Survey (2002). She is one of the authors of the new Estonian nutrition
recommendations and food-based dietary guidelines (2006). She has been teaching masters
students (Food Engineering and Product Development) the subject of “Dietology” in Tallinn
University of Technology since 2005. She is a member of the Board of the Estonian Nutrition
Society.
Tagli Pitsi has a Doctor of Philosophy degree from Tallinn University of Technology (2006).
She works at the Estonian National Institute for Health Development as a Nutritionist. Her main
task is to deal with questions about nutrition inside the institute, to communicate messages
about nutrition to the community, to prepare nutrition campaigns and to produce materials
about nutrition. She participated in creating the Estonian Diet and Nutrition Database – the
web-based database which includes national a food composition database, dietary analysis
program, survey database and intervention database. In addition to the work at the Estonian
National Institute for Health Development, she gives lectures at Tallinn Technical University.
Tagli Pitsi is the corresponding author and can be contacted at: tagli.pitsi@tai.ee

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