Rethinking Efforts to Improve Dietary Patterns Among Long-Haul Truck Drivers: Transforming Truck Stop Retail Food Environments Through Upstream Change

Abstract

A multitude of upstream occupational exposures influence poor dietary patterns that contribute to cardiometabolic health disparities among long-haul truck drivers in the United States. Herein, we delineate the unique characteristics of the truck driving profession that shape dietary patterns. Next, we discuss current health promotion efforts and why they are unlikely to be sufficient for improving population-level dietary patterns. We then advocate for prioritizing health promotion efforts that target upstream factors that influence population dietary patterns and have the potential to holistically and sustainably support drivers’ nutrition. Finally, we propose novel research directions to catalyze upstream-oriented health promotion efforts.

Introduction

The nearly two million long-haul truck drivers in the United States (U.S.) (herein: “truck drivers”) transport and deliver essential goods across the country. Due to a multitude of occupational exposures, truck drivers are noted for poor dietary patterns, which contribute to cardiometabolic health disparities endemic to truck driver populations.^1–4 Although truck driver nutrition education has been a primary target for health promotion efforts, it is our contention that upstream initiatives targeting truck stop food environments should be a higher priority to generate population-level improvements in dietary patterns.²

Below, we delineate the unique characteristics of the truck driving profession and how they shape dietary patterns in this population. Next, we discuss current health promotion efforts that address truck driver nutrition and why they are unlikely to be sufficient for improving population-level dietary patterns. We then advocate for prioritizing upstream changes that target a diverse array of truck stop retail food environments (RFEs) – where truck drivers purchase foods and beverages⁵ – to mitigate barriers to aligning dietary patterns with dietary guidelines. Finally, we propose novel research directions to catalyze the conceptualization, implementation, and evaluation of these recommendations.

An Overview of the Challenges to Healthful Eating Among Truck Drivers

Globally, a poor diet is estimated to be the largest single risk factor for early death and disability.⁶ While it is recognized that work environments influence dietary practices,⁵ the occupational characteristics encountered by truck drivers are particularly unique and salient. Not only does trucking work involve traveling vast distances along irregular and unpredictable routes,⁷ it also occurs under challenging work conditions and work organization characteristics, such as long work hours, shift work, time pressures, rigid government regulations, and low job control. These factors result in excessive psychosocial stressors and few opportunities for physical activity,^3,7 and they also shape dietary preferences toward typically less healthy convenient foods and beverages.¹

Because truck drivers spend long periods of time away from home traversing U.S. highways, they often depend on truck stops to meet basic daily needs while on the road. Thus, these settings warrant greater attention to understand how they promote or inhibit the health of trucking populations.² Previous, yet limited, research has shown reduced accessibility of foods and beverages aligned with dietary guidance in these settings.² Many truck stops are akin to convenience stores and quick-service restaurants, which are known from the broader food environment literature to be replete with nutritionally-poor options and implicated in obesity.⁸ Altogether, working condition and work organization exposures, combined with reliance on truck stop RFEs characterized by highly marketed, low-cost, and energy-dense, nutrient-poor foods and beverages, constitute environmental barriers to achieving a healthy diet among truck drivers, which adversely impacts health.^1,2

In the context of cardiometabolic health disparities experienced by truck drivers that feature increased rates of obesity, hypertension, diabetes mellitus, and metabolic syndrome when compared to the general U.S. working population,^3,4,9 ensuring that healthy food options are accessible (eg, available, affordable, convenient) is an important high-leverage strategy for improving driver health. The prevalence and incidence in cardiometabolic conditions could be expected to decrease following improvements to truck stop RFEs to encourage healthier dietary patterns, which may improve roadway safety either directly (eg, by lowering obesity rates; by reducing the prevalence of metabolic syndrome conditions)^10,11 or by reducing comorbid sleep disorders (eg, sleep apnea) that are known to degrade driving performance.¹² These improvements can also assist in reducing transportation costs, such as by reducing truck drivers’ excess medical costs associated with obesity.¹³ Finally, doing more to protect driver health by addressing truck stop RFEs could also preserve their irreplacable role in supply chains that are essential to the U.S. economy by helping to recruit and retain workers⁷ and increasing the longevity of truck drivers’ careers through reduced roadway crashes, while also drawing in new drivers by increasing the attractiveness of the profession.¹

Why Current Health Promotion Efforts for Healthful Eating Among Truck Drivers Fall Short

Numerous health promotion initiatives have attempted to improve driver nutrition and health, with the bulk focusing on modifying individual driver health behaviors.¹⁴ While existing evaluation studies report positive outcomes of such programs for dietary practices,¹⁴ the persistently poor cardiometabolic health of trucking populations indicates that these approaches have been ineffective in ‘moving the needle’ at the population-level. For example, a 2018 study found that 68.3% of truck drivers were affected by obesity⁴ – a rate nearly identical to another study published 4 years earlier.³

The inability of extant health promotion programming to generate population-level improvements in driver nutrition may be grounded in two overlapping factors. First, current health promotion program components typically overlook the accessibility of healthy food options, as only a handful of existing interventions have addressed these issues at a small scale (ie, providing healthy snacks)¹⁴—thus neglecting the upstream forces that shape driver dietary patterns (such as policies and environments).¹⁴ Second, successfully engaging in nutrition-oriented health promotion programming is a challenge for many occupations, but is especially so in the context of long haul-truck driving: Not only can truck driver populations be fairly characterized as transient and hidden,⁹ the profession is also notorious for high turnover rates¹² that may further reduce the scalability of such programming. Thus, the practical impacts of traditional workplace nutrition initiatives (eg, focused on one specific worksite or trucking company), particularly those that are focused on changing individual behavior rather than environments, are inherently limited.

Moving Upstream to Improve Truck Driver Nutrition by Addressing Truck Stop Food Environments

Given the unique challenges presented by the trucking profession, combined with ‘obesogenic’ truck stop RFEs,^1,2 we contend that the current configuration of nutrition-related prevention programming is unlikely to generate holistic and sustainable changes in dietary patterns at the population-level. Instead, truck stop RFEs should be key targets for health promotion efforts; therefore, solutions that address the upstream forces that shape those environments are needed. Fortunately, the public health nutrition literature provides several analogous examples that demonstrate the potential of upstream RFE changes for improving dietary patterns.

First, given the high exposure of truck drivers to truck stop/ convenience store settings throughout the duration of their work week(s), choice architecture and retail marketing strategies for healthier foods and beverages may be particularly influential for improving truck drivers’ dietary patterns. For example, marketing strategies – in combination with truck stop attributes or design qualities (ie, choice architecture) – influence consumer dietary choices.¹⁵ There are several examples in the RFE literature of these strategies being predominantly used to sell less healthy products¹⁶ with current evidence showing promise for altering these RFE attributes to improve consumer purchasing practices to better align with dietary guidelines.¹⁷ As one example, Winker et al (2022) found men to be particularly responsive to marketing for sugary drinks in smaller store/convenience settings (akin to truck stop RFEs) in comparison to women.¹⁸ Given the overwhelming number of truck drivers who are men, limiting such unhealthful marketing may be especially impactful. Similarly, as demonstrated by The Food Trust’s Healthy Corner Store Initative in Philadelphia, Pennsylvania (as one example),¹⁹ the implementation of healthy food retail strategies that leverage partnerships with retail businesses could be translated to elevate the prominence and ease of choosing healthier foods and beverages in truck stop RFEs. Although no examples of healthy food retail strategies in partnership with truck stop businesses are known to exist,² truck drivers are aware and concerned that unhealthful eating is the default behavior in truck stop settings, and they have previously expressed desire for more healthy food options at truck stops.¹ This information may prove integral to initiating partnerships with truck stop management to offer and test healthy food retail strategies for truck driver populations.²⁰

Second, changing policies that shape truck stop RFEs may also represent high-leverage solutions that warrant more interdisciplinary attention. For example, many established food and nutrition policies already influence attributes of truck stop RFEs; however, there is scant data on how these upstream drivers of dietary patterns impact truck drivers. Menu calorie labeling, manadated by the 2010 Affordable Care Act (P.L. 111–148) and implemented in 2018 by the US Food and Drug Administration (USDA), is one example, as it required food establishments with at least 20 locations (eg, chain restaurants located at truck stops) to post the calorie content of prepared foods alongside price. Although the specific effects of this policy change on truck drivers’ dietary patterns remain unknown, observational evidence from other contexts has indicated reductions in calories purchased,²¹ and simulation models with longer policy time horizons have demonstrated significant potential for improved population health and billions of dollars in health savings.²² The USDA Supplemental Nutrition Assistance Program (SNAP) is another policy lever with potential to improve truck stop RFEs, given many truck stops are authorized to accept SNAP benefits²³ and therefore must meet food stocking requirements. In 2016, the USDA proposed enhancing the minimum SNAP stocking standards to improve the quality of available foods in settings.²⁴ However, these standards were not enacted as originally intended,²⁵ resulting in an important missed opportunity that could have supported healthier dietary patterns among truck drivers as well as the broader public who frequent SNAP-authorized truck stop RFEs.

Novel Research Directions to Catalyze Upstream Solutions

While executing upstream changes is not without challenges, there is enormous potential for such strategies to meaningfully improving both truck driver and population health. One particularly relevant outcome is related to cost-savings²² that would generate a positive return-on-investment. For example, improving dietary patterns through upstream solutions may lower the number of overweight and obese truck drivers, both of which have been associated with significantly higher health care costs compared to normal weight truck drivers.¹³ Further, such improvements could reduce the prevalence of cardiometabolic diseases that directly and indirectly (eg, due increased prevalence of comorbid sleep disorders) increase risks of truck crashes that constitute a $20 billion economic burden annually.²⁶ Beyond monetary returns, truck crashes disproportinately burden other roadway users (ie, other drivers, pedestrians, and bicyclists), who constitute 83% of resulting fatalities.²⁶ It should also be noted that the benefits of improving healthy food accessibility within truck stop RFEs is not limited to truck drivers; rather, because truck stop patrons include a diverse array of transient workers and roadway travelers, such improvements can positively impact the broader public who also use these venues for food and fuel needs. Thus, investing in truck driver nutrition has the potential to generate substantial savings in both economic and human costs that are currently borne by society as a whole.

However, to leverage upstream changes as a means for catalyzing population-level improvements in truck driver nutrition, four novel lines of research are particularly needed. First, at the most proximal level, studies are needed to more fully understand drivers’ needs, preferences, and perspectives related to healthy food accessibility in truck stop RFEs, with particular emphasis on eliciting ideas for change (eg, which can be used to engage with truck stop RFE management and relevant policymakers for solutions). This could include innovative methodologies that are capable of ascertaining drivers’ nuanced insights, such as qualitive photovoice and community-based participatory research. Second, there is a need for high quality environmental assessments of truck stop RFEs using validated measurement tools to identify gaps and opportunities for changes to better align food offerings with dietary guidelines.² Third, drawing from insights from the two preceding lines of research, applied research is needed to identify high-leverage upstream interventions, elicit evaluation data to improve intervention implementation, and gain insights on the generalizability and scalability of these interventions. Finally, holistic, multilevel, and interdisciplinary research approaches are needed that integrate the three aforementioned lines of research into comprehensive frameworks for guiding the identification and implementation of solutions. Specifically, because truck stops are nested within an interconnected web of policies, producers, distributors, retailers, and customers that exhibit dynamic and reciprocal relationships (eg, RFEs affect people, and in turn, what people buy affect RFEs) they may be best conceptualized using complex systems frameworks.^5,27 Thus, complex systems approaches, grounded in computational modeling and simulation methodologies, could be especially useful for allowing us to test upstream solutions and better identify potential impacts of plausible solutions, including unforeseen system resistance, prior to real-world implementation.