Worksite intervention for weight control: a review of the literature

Is It Time to Re-Shift the Research Agenda? A Scoping Review of Participation Rates in Workplace Health Promotion Programs

Workplace health promotion programmes (WHPPs) are among the most important measures to improve the health and motivation of the ageing workforce. However, they are accompanied with certain challenges, such as low participation rates and higher participation levels of the more health-conscious workers, often failing to engage those who need such interventions the most. Following the PRISMA guidelines, this scoping review examined participation rates reported in articles on WHPPs to identify potential knowledge gaps. The results are worrying: participation rates are not only infrequently reported, but also low. Of the 58 articles, 37 report participation rates, with the majority (20) reporting an average participation rate of less than 50%. Reported participation rates refer either to different target groups, the type of intervention, or to single points in time, which makes it difficult to establish consistent criteria for comparison. We argue that despite the importance of WHPP efficacy, research focus should shift to the determinants of participation, as well as the issue of standardising the reporting of participation rates, alongside the potential problem of reporting bias.

Community-Based Interventions to Reduce Fat Intake in Healthy Populations: A Systematic Review and Meta-Analysis

Background:

Reducing fat intake is a major focus of most dietary recommendations aiming to prevent chronic diseases. Thus, this study aimed to summarize community-based interventions for reducing fat consumption among healthy people.

Methods:

According to PRISMA guidelines, in this systematic review and meta-analysis databases including PubMed/MEDLINE, Scopus, EMBASE, Cochrane Library, Web of Science, ProQuest, and Google Scholar were searched up to January 2021. Randomized clinical trials (RCTs) or quasi-experimental studies reporting the effect of community-based interventions to reduce fat intake in a healthy populations were included. The quality of studies was assessed using the Cochrane Collaboration tool and The Joanna Briggs Institute Critical Appraisal Checklist. Meta-analysis was performed using CMA2 software.

Results:

Our search strategy resulted in a total of 1,621 articles, 43 of which were included in the study after screening. Of the 43 included studies, 35 studies reported a significant decrease in fat intake using educational and multiple intervention methods. About 82% of studies using the technology were effective (significant decrease in fat intake) in reducing fat intake. Moreover, studies specifically designed to change fat intake were more effective than multicomponent interventions. The meta-analysis of high-quality studies showed that the differences in total fat (-0.262 g/d) and saturated fat (-0.350 g/d) intake between the intervention and control groups were statistically significant (P<0.05).

Conclusion:

Based on the high-quality studies, educational and multiple interventions are suggested in the community settings to decrease fat intake. For a concise conclusions, long-term and high frequency interventions focusing on reducing fat intake are desirable.

The Effects of Two Workplace Weight Management Programs and Weight Loss on Health Care Utilization and Costs

OBJECTIVES

The aim of this study was to compare the impact of two worksite weight management (WM [education] and WM+ [education plus counseling]) programs, on health care utilization and costs. Secondarily, compare the intervention groups to an observational control group of obese workers. Finally, evaluate the impact of actual weight loss on these outcomes.

METHODS

Estimate the change in the WM and WM+ intervention groups. Using propensity score adjustment compare the two intervention groups with the observational control group; and compare those who lost weight with those who did not.

RESULTS

No significant differences between the two intervention groups, or between these intervention groups and the observational control group. Those who lost weight reduced their overall health care costs.

CONCLUSIONS

To achieve weight loss and associated morbidity reductions, more extensive and intensive interventions, with more attention to motivation and compliance, are required.

Is overweight and class I obesity associated with increased health claims costs?

OBJECTIVES

Evaluate the relationship between body mass index (BMI) and health claims costs over the last decade, assess the strength and nature of the relationship between BMI and costs, and identify comorbidities that may drive any increased costs.

METHODS

Using 2001-2011 claims data for employees participating in annual health appraisals, annual paid claims costs were calculated. One-part negative binomial models were fit to evaluate the relationship between BMI and costs, controlling for age, gender, race/ethnicity, and calendar year period.

RESULTS

The relationship between increasing BMI and increasing health claims costs is gradual and starts already at a BMI of 19. The nature of the relationship did not change notably over time. The most important obesity-related comorbidities, expressed as percent increase in cost per BMI unit, was cardiovascular disease (males 10.53, 95% CI [6.46, 14.77], females 4.27, 95% CI [1.25, 7.38), while cardiovascular agents (7.23, 95% CI [6.08, 8.39]) were the most important driver of pharmacy costs.

CONCLUSION

In contrast to recent evidence relating to effects on mortality, we observed a gradual increase in health claims costs starting at the low end of the recommended BMI range.

Weight Loss Programs May Have Beneficial or Adverse Effects on Fat Mass and Insulin Sensitivity in Overweight and Obese Black Women

Objective

Weight loss interventions have produced little change in insulin sensitivity in black women, but mean data may obscure metabolic benefit to some and adverse effects for others. Accordingly, we analyzed insulin sensitivity relative to fat mass change following a weight loss program.

Design and Methods

Fifty-four black women (BMI range 25.9 to 54.7 kg/m²) completed the 6-month program that included nutrition information and worksite exercise facilities. Fat mass was measured by dual-energy X-ray absorptiometry, and insulin sensitivity index (S_I) was calculated from an insulin-modified intravenous glucose tolerance test using the minimal model.

Results

Baseline S_I (range 0.74 to 7.58 l/mU⁻¹•min⁻¹) was inversely associated with fat mass (r = −0.516, p < 0.001), independent of age. On average, subjects lost fat mass (baseline 40.8 ± 12.4 to 39.4 ± 12.6 kg [mean ± SD], P < 0.01), but 17 women (32 %) actually gained fat mass. S_I for the group was unchanged (baseline 3.3 ± 1.7 to 3.2 ± 1.6, P = 0.67). However, the tertile with greatest fat mass loss (−3.6 kg, range −10.7 to −1.7 kg) improved insulin sensitivity (S_I +0.3 ± 1.2), whereas the tertile with net fat mass gain (+0.9 kg, range −0.1 to +3.8 kg) had reduced insulin sensitivity (S_I −0.7 ± 1.3) from baseline values (P < 0.05 by ANOVA).

Conclusions

Black women in a weight loss program who lose fat mass may have improved insulin sensitivity, but fat mass gain with diminished sensitivity is common. Additional support for participants who fail to achieve fat mass loss early in an intervention may be required for success.

Weight gain prevention in the school worksite setting: results of a multi-level cluster randomized trial

OBJECTIVE

To describe the effectiveness, reach and implementation of a weight gain prevention intervention among public school employees.

METHOD

A multi-level intervention was tested in a cluster randomized trial among 782 employees in 12 central Massachusetts public high schools from 2009 to 2012. The intervention targeted the nutrition and physical activity environment and policies, the social environment and individual knowledge, attitudes and skills. The intervention was compared to a materials only condition. The primary outcome measures were change in weight and body mass index (BMI) at 24-month follow-up. Implementation of physical environment, policy and social environment strategies at the school and interpersonal levels, and intervention participation at the individual level were assessed.

RESULTS

At 24-month follow-up, there was a net change (difference of the difference) of -3.03 pounds (p=.04) and of -.48 BMI units (p=.05) between intervention and comparison conditions. The majority of intervention strategies were successfully implemented by all intervention schools, although establishing formal policies was challenging. Employee participation in programs targeting the physical and social environment was maintained over time.

CONCLUSION

This study supports that a multi-level intervention integrated within the organizational culture can be successfully implemented and prevent weight gain in public high school employees.

Randomized trial of nutrition education added to internet-based information and exercise at the work place for weight loss in a racially diverse population of overweight women

OBJECTIVE

Obesity in the United States is highly prevalent, approaching 60% for black women. We investigated whether nutrition education sessions at the work place added to internet-based wellness information and exercise resources would facilitate weight and fat mass loss in a racially diverse population of overweight female employees.

METHODS

A total of 199 (average body mass index 33.9±6.3 kg m(-2)) nondiabetic women (57% black) at our institution were randomized to a 6-month program of either internet-based wellness information (WI) combined with dietitian-led nutrition education group sessions (GS) weekly for 3 months and then monthly with shift in emphasis to weight loss maintenance (n=99) or to WI alone (n=100). All were given access to exercise rooms convenient to their work site. Fat mass was measured by dual-energy X-ray absorptiometry.

RESULTS

WI+GS subjects lost more weight than WI subjects at 3 months (-2.2±2.8 vs -1.0±3.0 kg, P>0.001). Weight (-2.7±3.9 vs -2.0±3.9 kg) and fat mass (-2.2±3.1 vs -1.7±3.7 kg) loss at 6 months was significant for WI+GS and WI groups (both P<0.001), but without significant difference between groups (both P>0.10); 27% of the WI+GS group achieved 5% loss of initial weight as did 18% of the WI group (P=0.180). Blacks and whites similarly completed the study (67 vs 74%, P=0.303), lost weight (-1.8±3.4 vs -3.3±5.2 kg, P=0.255) and fat mass (-1.6±2.7 vs -2.5±4.3 kg, P=0.532), and achieved 5% loss of initial weight (21 vs 32%, P=0.189), irrespective of group assignment.

CONCLUSION

Overweight women provided with internet-based wellness information and exercise resources at the work site lost weight and fat mass, with similar achievement by black and white women. Additional weight loss benefit of nutrition education sessions, apparent at 3 months, was lost by 6 months and may require special emphasis on subjects who fail to achieve weight loss goals to show continued value.

The steps to health employee weight management randomized control trial: rationale, design and baseline characteristics

BACKGROUND

The workplace can be an important setting for addressing obesity. An increasing number of employers offer weight management programs.

PURPOSE

Present the design, rationale and baseline characteristics of the Steps to Health study (STH), a randomized trial to evaluate the effectiveness of two preexisting employee weight management programs offered at Duke University and Medical Center.

METHODS

550 obese (BMI ≥30) employee volunteers were randomized 1:1 to two programs. Baseline data, collected between January 2011 and July 2012, included height/weight, accelerometry, workplace injuries, health care utilization, and questionnaires querying socio-cognitive factors, perceptions of health climate, physical activity, and dietary intake. In secondary analyses participants in the two programs will also be compared to a non-randomized observational control group of obese employees.

RESULTS

At baseline, the mean age was 45 years, 83% were female, 41% white, and 53% black. Mean BMI was 37.2. Participants consumed a mean of 2.37 servings of fruits and vegetables per day (in the past week), participated in 11.5 min of moderate-to-vigorous physical activity, and spent 620 min being sedentary.

CONCLUSION

STH addresses the need for evaluation of worksite interventions to promote healthy weight. In addition to having direct positive effects on workers' health, worksite programs have the potential to increase productivity and reduce health care costs.

Lifestyle intervention reduces body weight and improves cardiometabolic risk factors in worksites

BACKGROUND

Worksites are potentially effective locations for obesity control because they provide opportunities for group intervention and social support. Studies are needed to identify effective interventions in these settings.

OBJECTIVE

We examined the effects of a multicomponent lifestyle intervention on weight loss and prevention of regain in 4 worksites (2 intervention and 2 control sites).

DESIGN

Overweight and obese employees (n = 133) enrolled in this pilot worksite-randomized controlled trial with a 0-6-mo weight-loss phase and a 6-12-mo structured weight-maintenance phase. The intervention combined recommendations to consume a reduced-energy, low-glycemic load, high-fiber diet with behavioral change education. Outcome measurements included changes in body weight and cardiometabolic risk factors.

RESULTS

The mean ± SEM weight loss was substantial in intervention participants, whereas control subjects gained weight (-8.0 ± 0.7 compared with +0.9 ± 0.5 kg, respectively; P < 0.001), and 89% of participants completed the weight-loss phase. Intervention effects were not significant at the 0.05 level but would have been at the 0.10 level (P = 0.08) in a mixed model in which the worksite nested within group was a random factor. There were also significant improvements in cardiometabolic risk factors in intervention compared with control subjects regarding fasting total cholesterol, glucose, systolic blood pressure, and diastolic blood pressure (P ≤ 0.02 for each). No significant weight regain was observed in participants who enrolled in the structured weight-maintenance program (0.5 ± 0.7 kg; P = 0.65), and overweight and obese employees in intervention worksites who were not enrolled in the weight-loss program lost weight compared with subjects in control worksites (-1.3 ± 0.5 compared with +0.7 ± 0.2 kg, respectively; P = 0.02).

CONCLUSION

Worksites can be effective for achieving clinically important reductions in body weight and improved cardiometabolic risk factors. This trial was registered at clinicaltrials.gov as NCT01470222.

A "small-changes" workplace weight loss and maintenance program: examination of weight and health outcomes

OBJECTIVE

To compare the effect of "small-changes" and "usual care" workplace interventions on weight loss and to investigate the effect of small changes with or without maintenance on weight and health outcomes.

METHODS

Overweight/obese employees at two New Zealand worksites received a 12-month usual-care intervention (n = 53), followed by a 12-month small-changes intervention (n = 102). Small changes comprised a 12-week component, followed by 9 months of maintenance, implemented at only one worksite. Magnitudes of effects were assessed via a threshold of -5% (weight loss) and standardization (health outcomes).

RESULTS

Small changes showed beneficial weight loss relative to usual care in both worksites. For small-changes interventions, worksites reduced weight (12 weeks) and maintained lost weight (12 months). One in every three participants lost 5% or more weight. Some improvements in health outcomes were shown.

CONCLUSION

Regardless of maintenance, the small-changes intervention was successful in sustaining weight loss.

Weight Gain Prevention for College Freshmen: Comparing Two Social Cognitive Theory-Based Interventions with and without Explicit Self-Regulation Training

The college transition represents a critical period for maintaining a healthy weight, yet intervention participation and retention represent significant challenges. The objective of this investigation was to evaluate the preliminary efficacy and acceptability of two interventions to prevent freshman weight gain. One intervention provided opportunities to improve outcome expectations and self-efficacy within a social cognitive theory framework (SCT), while the other targeted the same variables but focused on explicit training in self-regulation skills (SCTSR). Methods. Freshmen (n = 45) aged >18 years were randomized to a 14-week intervention, SCT or SCTSR; both included online modules and in-class meetings. Of the 45 students randomized, 5 withdrew before the classes began and 39 completed pre- and posttesting. Primary outcomes included body weight/composition, health behaviors, and program acceptability. Analyses included independent sample t-tests, repeated measures ANOVA, and bivariate correlational analyses. Results. Body weight increased over the 14-week period, but there was no group difference. Percent body fat increased in SCTSR but not SCT (mean difference: SCTSR, +1.63 ± 0.52%; SCT, -0.25 ± 0.45%; P = 0.01). Class attendance was 100% (SCTSR) and 98% (SCT); SCTSR students (>50%) remarked that the online tracking required "too much time." Conclusions. The intervention was well received, although there were no improvements in weight outcomes.

Combining environmental and individual weight management interventions in a work setting: results from the Dow chemical study

OBJECTIVE

To evaluate the comparative effectiveness of environmental weight loss interventions alone versus in combination with an individual intervention.

METHODS

A quasi-experimental design compared outcomes for two levels of environmental interventions and for participants who did or did not simultaneously self-select into an individually focused weight loss intervention (YW8). Analysis of covariance and logistic regression techniques were used to examine risk outcomes.

RESULTS

Employees who participated in YW8 were no more successful at losing weight than those exposed to only the environmental interventions. Approximately, 13.5% of each group lost at least 5% of their body weight; overall changes in mean body weight and body mass index were negligible in both groups.

CONCLUSIONS

Simple worksite environmental modifications may help with weight maintenance, but are not likely to result in substantial weight reductions even when combined with low-intensity individual interventions.

Healthy Eating Strategies in the Workplace

PURPOSE

There is a clear link between dietary behavior and a range of chronic diseases, and overweight and obesity constitute an indirect risk in relation to these diseases. The worksite is a central venue for influencing dietary behavior. The purpose of this paper is to provide an overview of workplace influences on worker dietary patterns.

DESIGN/METHODOLOGY/APPROACH

The paper reviews the evidence of the effectiveness of dietary health promotion, and provides a brief overview of appropriate theoretical frameworks to guide intervention design and evaluation. The findings are illustrated through research examples.

FINDINGS

Through case studies and published research, it is found that workplace dietary interventions are generally effective, especially fruit and vegetable interventions. There is less consistent evidence on the long term effectiveness of workplace weight management interventions, underscoring the need for further research in this area. This paper also reports evidence that changes in the work environment, including through health and safety programs, may contribute to enhancing the effectiveness of workplace health promotion, including dietary interventions. Organizational factors such as work schedule may also influence dietary patterns. The social ecological model, the social contextual model and political process approach are presented as exemplar conceptual models that may be useful when designing or assessing the effects of workplace health promotion.

ORIGINALITY/VALUE

Using the worksite as setting for influencing health by influencing dietary patterns holds considerable promise and may be instrumental in reducing workers' risk of chronic diseases.

Second-year results of an obesity prevention program at the Dow Chemical Company

OBJECTIVE

Evaluate innovative, evidence-based approaches to organizational/supportive environmental interventions aimed at reducing the prevalence of obesity among Dow employees after 2 years of implementation.

METHODS

A quasi-experimental study design compared outcomes for two levels of intervention intensity with a control group. Propensity scores were used to weight baseline differences between intervention and control subjects. Difference-in-differences methods and multilevel modeling were used to control for individual and site-level confounders.

RESULTS

Intervention participants maintained their weight and body mass index, whereas control participants gained 1.3 pounds and increased their body mass index values by 0.2 over 2 years. Significant differences in blood pressure and cholesterol values were observed when comparing intervention employees with controls. At higher intensity sites, improvements were more pronounced.

CONCLUSIONS

Environmental interventions at the workplace can support weight management and risk reduction after 2 years.

Telephone intervention promoting weight-related health behaviors

OBJECTIVE

Recent national surveys have documented that the majority of adults in the United States do not meet the recommended levels of healthy lifestyle-related behaviors. The Nutrition and Physical Activity (NuPA) study was designed to promote fruit and vegetable consumption, physical activity, and weight management for a working population.

METHOD

Data were collected nationwide, USA, from 2005 to 2007 and analyzed in 2008. A total of 2470 employed participants were randomized into the self-help (SH: n=1191) or self-help plus telephone counseling (SH+C: n=1279) group. The SH+C group received nine structured telephone counseling sessions in addition to the print materials.

RESULTS

A series of hierarchical regression analyses for each of the health behavior outcomes in the present-at-follow-up subsample (n=1098-1148) revealed that the SH+C was effective in increasing fruit and vegetable consumption. Among the overweight and obese participants, weight loss was significant in both the SH and SH+C groups.

CONCLUSION

Using a theory-based behavioral change counseling technique and targeting multiple health behaviors among employed individuals, our findings demonstrate that the addition of telephone counseling to mailed self-help materials is effective in promoting healthy diet and weight management.

Worksite Opportunities for Wellness (WOW): effects on cardiovascular disease risk factors after 1 year

OBJECTIVE

To evaluate the effectiveness of a worksite health promotion program on improving cardiovascular disease risk factors.

METHODS

In St Louis, Missouri from 2005 to 2006, 151 employees (134 F, 17 M, 81% overweight/obese) participated in a cohort-randomized trial comparing assessments + intervention (worksite A) with assessments only (worksite B) for 1 year. All participants received personal health reports containing their assessment results. The intervention was designed to promote physical activity and favorable dietary patterns using pedometers, healthy snack cart, WeightWatchers(R) meetings, group exercise classes, seminars, team competitions, and participation rewards. Outcomes included BMI, body composition, blood pressure, fitness, lipids, and Framingham 10-year coronary heart disease risk.

RESULTS

123 participants, aged 45+/-9 yr, with BMI 32.9+/-8.8 kg/m(2) completed 1 year. Improvements (P< or =0.05) were observed at both worksites for fitness, blood pressure, and total-, HDL-, and LDL-cholesterol. Additional improvements occurred at worksite A in BMI, fat mass, Framingham risk score, and prevalence of the metabolic syndrome; only the changes in BMI and fat mass were different between worksites.

CONCLUSION

A multi-faceted worksite intervention promoted favorable changes in cardiovascular disease risk factors, but many of the improvements were achieved with worksite health assessments and personalized health reports in the absence of an intervention.

Improving diet and physical activity with ALIVE: a worksite randomized trial

CONTEXT

Healthy diets and regular physical activity confer many health benefits, but the prevalence of these behaviors is relatively low.

BACKGROUND

Cost-effective strategies are needed to increase healthy eating and physical activity in the population.

DESIGN

An RCT, conducted in 2006, of a 16-week e-mail program offered individually tailored, small-step goals; a personal homepage with tips; educational materials; and tracking and simulation tools.

SETTING/POPULATION

Seven hundred eighty-seven employees in the administrative offices of a large healthcare organization volunteered to participate.

MAIN OUTCOME MEASURES

Changes were self-reported for total physical activity; moderate physical activity (MPA); vigorous physical activity (VPA); walking; sedentary behavior; and intake of fruits and vegetables, saturated and trans fats, and added sugars in the intervention group compared to the control group.

RESULTS

In intent-to-treat analyses (conducted in 2007 and 2008) that set change in nonresponders to the follow-up questionnaire to zero, the intervention group reported increases of 28.0 minutes/week (min/wk) of MPA (SE=7.4, p=0.0002); 12.5 min/wk of VPA (SE=5.7, p=0.03); and 21.5 min/wk of walking (SE=5.5, p=0.0003) relative to the control group. Intake of both saturated and trans fats (grams/day [g/day]) declined (beta=-0.95, SE=0.36, p=0.01; beta=-0.29, SE=0.12, p=0.02, respectively). The consumption of fruits and vegetables increased significantly (p=0.03), and the consumption of added sugars decreased marginally (p=0.08). The largest changes were in participants who did not meet behavioral recommendations at baseline (increase of 55.4 min/wk of MPA and decrease of 1.15 g/day of trans fats, relative to the control group). Differences between the intervention and control groups were still observed 4 months after the intervention ended.

CONCLUSIONS

ALIVE is an effective program for achieving significant improvement in diet and physical activity.

TRIAL REGISTRATION

NCT00607009.

First-year results of an obesity prevention program at The Dow Chemical Company

OBJECTIVE

To examine first-year results from a workplace environmental obesity prevention program at The Dow Chemical Company.

METHODS

A quasi-experimental cohort study was conducted among employees at nine treatment worksites (n = 8013) who received environmental weight management interventions and three control worksites (n = 2269). Changes in employees' weight, body mass index (BMI), and other health risks were examined using chi2 and t-tests.

RESULTS

After 1 year, a modest treatment effect was observed for weight and BMI largely because the control group subjects gained weight; however, no effect was observed for overweight and obesity prevalence. Other risk factors (tobacco use, high blood pressure, and systolic and diastolic blood pressure values) decreased significantly, although blood glucose (high risk prevalence and values) increased.

CONCLUSIONS

Environmental changes to the workplace can achieve modest improvements in employees' health risks, including weight and BMI measures, in 1 year.

Effectiveness of employee internet-based weight management program

OBJECTIVE

To evaluate an employee Internet-based weight management program.

METHODS

Changes in eating habits, stage of change, body weight, and weight categories were compared between enrollment and 6 months after enrollment. Weights and weight categories were compared among a subset of participants and non-participants at 12 months.

RESULTS

Seven thousand seven hundred forty-three International Business Machines employees enrolled in the program between December 2004 and February 2006, and 74% were overweight or obese (body mass index > or =25). At 6 months, follow-up survey respondents (1639) had significantly increased most healthy eating habits (eg, 20% decrease in junk foods) and the frequency of healthy foods eaten (eg, 12% increase in fruits). The percentage of participants in the normal weight category had increased from 27.0% to 29.8%, while average weight decreased from 182.6 to 180.2 lbs (P < 0.05). Increased web site usage was associated with increased weight loss and stage of change improvements. At 12 months, a higher percentage of participants had moved into the normal weight category compared with the percentage of non-participants (+2.0% points; P < 0.05), although there were no differences in average weight change.

CONCLUSIONS

Despite issues of limited penetration and potential self-selection, this Internet-based program had utility in reaching a large number of employees in dispersed work settings, and it led to improved eating habits and improved stage of change at 6 months and more individuals moving into the normal weight category at 6 and 12 months.

A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults

In the past, interventions aimed at reducing obesity have mainly targeted at weight loss treatment in obese adults, with limited long-term effects. With the increasing number of people being obese and being at risk for obesity, there has been a shift in focus towards prevention of obesity. We conducted a systematic review of the peer-reviewed literature on the efficacy of obesity prevention interventions in adults in order to identify effective interventions and intervention elements. Pubmed, OVID, and Web of Science databases were searched from January 1996 to June 2006. Interventions aimed at primary prevention of weight gain among adults achieved by focusing on dietary intake, physical activity or the combination of both were included. The outcome measure had to be difference in change in body mass index or body weight between the intervention and the control groups. Nine studies were included, five long-term studies (at least 1 year) and four short-term (3 months to 1 year). Seven studies evaluated an intervention that focused on a combination of diet and physical activity to prevent weight gain, one on diet only and one on physical activity only. One dietary intervention (long-term), and three combined dietary and physical activity interventions (one long-term and two short-term) produced significantly positive results at end of follow-up. The two long-term, effective interventions consisted of intensive and long-term intervention implementation, including groups sessions designed to promote behavioural changes. The current evidence of efficacy of obesity prevention interventions is based on a very small number of studies. Some studies showed a positive impact on body mass index or weight status, but there was too much heterogeneity in terms of study design, theoretical underpinning and target population to draw firm conclusions about which intervention approaches are more effective than others. More research is urgently needed to extend the body of evidence.

Development of the Environmental Assessment Tool (EAT) to measure organizational physical and social support for worksite obesity prevention programs

OBJECTIVE

To describe the development, reliability, and validity of the Environmental Assessment Tool (EAT) for assessing worksite physical and social environmental support for obesity prevention.

METHODS

The EAT was developed using a multistep process. Inter-rater reliability was estimated via Kappa and other measures. Concurrent and predictive validity were estimated using site-level correlations and person-level multiple regression analyses comparing EAT scores and employee absenteeism and health care expenditures.

RESULTS

Results show high inter-rater reliability and concurrent validity for many measures and predictive validity for absenteeism expenditures.

CONCLUSIONS

The primary use of the EAT is as a physical and social environment assessment tool for worksite obesity prevention efforts. It can be used as a reliable and valid means to estimate relationships between environmental interventions and absenteeism and medical expenditures, provided those expenditures are for the same year that the EAT is administered.

Evaluation of a community-based weight control program

Overweight and obesity result from a complex interaction of behavioral, environmental, and genetic factors. The present study reports on the efficacy of a community-based weight control program in 31 overweight and obese adults. TrymGym is a multi-dimensional lifestyle behavior change program for improving both diet and physical activity (PA) related behavior with education and cognitive behavioral training. The program was evaluated using nutritional, physiological, and physical activity-related psychological factors before and after the 12 week program. Paired sample t-tests were conducted to identify significant changes. Body weight (BW) and diastolic blood pressure decreased by 3.6 and 6.4% respectively in completers of the study. Waist and hip circumferences decreased by 4.1 and 5.7% respectively. Caloric intake decreased from 1994+/-146 at baseline to 1768+/-144 in completers of the study. There was also a significant 5.2% decrease in the percentage of calories derived from fat and a 4% increase in percent of calories from protein. Although intake of vitamin C was increased at the end of the study, intake of several other micronutrients at baseline did not meet Dietary Reference Intake recommendations and were further compromised at week 12. Despite a trend toward increased participation in leisure-time and strenuous PA there was a decrease in behavioral intention to participate in future PA. Overall, this community-based weight control program was effective in fostering a significant improvement in BW, anthropometric measurements, participation in PA, and nutritional intake.

Worksite study promoting activity and changes in eating (PACE): design and baseline results

OBJECTIVE

Based on previous worksite-wide intervention studies and an ecological framework, we created a behavioral intervention program to maintain or reduce weight through healthy eating and physical activity. The design and evaluation plan of the group-randomized trial and the recruitment of worksites are described. Preliminary results regarding the dietary and physical activity behaviors associated with BMI are discussed.

RESEARCH METHODS AND PROCEDURES

The intervention used an ecological framework modified by qualitative methods that identified salient barriers and facilitators of behavioral change. Approximately 30 transportation, manufacturing, utilities, personal, household, and miscellaneous service companies in the greater Seattle area are being recruited to the trial. The study population for the present analysis consists of 18 worksites from the first two randomization waves. Dietary behavior was assessed, not by calories, but by behavioral measures related to BMI. Physical activity behaviors were surveyed. BMI is derived from reported height and weight at baseline.

RESULTS

The intervention has been developed with a specified minimum suite of strategies within the defined framework. Response rates to the baseline survey among the 18 worksites are 81% on average. After adjusting for age, gender, race, and education, BMI was associated with frequency of intensity-adjusted physical activity, sweat-inducing exercise, fast food meals, soft drinks, eating while doing another activity, and fruit and vegetable intake.

DISCUSSION

Worksite-wide intervention strategies can be adapted to target obesity prevention. Employees are willing to participate in surveys at high rates. Several measures of physical activity and eating choices are associated with baseline BMI.

Relationship of body mass index with asthma indicators in head start children

OBJECTIVE

To examine the relationship of body mass index (BMI) and asthma indicators on children with asthma in a Head Start (HS) program.

METHODS

In this cross-sectional study (November 18, 2000, to December 12, 2003) of children aged 3 to 5 years with asthma, we compared the BMI data of HS asthmatic patients (n = 213) with the data of peer control subjects from a sample (n = 816) of the National Health and Nutrition Examination Survey aged 3 to 5 years and with children in prekindergarten in Arkansas public schools (n = 1,024). Parental reports of asthma symptoms, health care use, medication use, school days missed, and quality of life were used as indicators of asthma morbidity. Categorical analysis and chi2 tests were performed to examine the relationship between BMI and asthma morbidity.

RESULTS

The prevalence of overweight (> or =95th percentile) was significantly higher in HS children with asthma compared with the National Health and Nutrition Examination Survey children (P < .001) and Arkansas prekindergarten children (P = .05). Compared with HS asthmatic children with a BMI less than the 85th percentile, HS asthmatic patients with a BMI of the 85th percentile or greater reported significantly more school days missed (P = .02), lifetime hospitalizations (P = .04), emergency department visits (P = .02), and activity limitations (P = .03) and fewer oral corticosteroid bursts (P = .04). There was also a trend for more daytime symptoms (P = .05) and lower quality of life (P = .06). No differences were observed in rescue (P = .28) or controller (P = .47) medications, environmental tobacco smoke exposure (P = .47), positive allergy test results (P = .85), and nighttime symptoms (P > .99).

CONCLUSIONS

Having an increased BMI was associated with more asthma morbidity in this group of HS asthmatic patients. Despite the lack of a clear explanation for the link between asthma and BMI, our data suggest that an increased BMI significantly affects the well-being of young asthmatic patients and should be further addressed.

Design characteristics of worksite environmental interventions for obesity prevention

OBJECTIVE

This paper describes the design characteristics of the National Heart, Lung, and Blood Institute (NHLBI)-funded studies that are testing innovative environmental interventions for weight control and obesity prevention at worksites.

RESEARCH METHODS AND PROCEDURES

Seven separate studies that have a total of 114 worksites ( approximately 48,000 employees) across studies are being conducted. The worksite settings include hotels, hospitals, manufacturing facilities, businesses, schools, and bus garages located across the U.S. Each study uses its own conceptual model drawn from the literature and includes the socio-ecological model for health promotion, the epidemiological triad, and those integrating organizational and social contexts. The interventions, which are offered to all employees, include environmental- and individual-level approaches to improve physical activity and promote healthful eating practices. Environmental strategies include reducing portion sizes, modifying cafeteria recipes to lower their fat contents, and increasing the accessibility of fitness equipment at the workplace. Across all seven studies about 48% (N = 23,000) of the population is randomly selected for measurements. The primary outcome measure is change in BMI or body weight after two years of intervention. Secondary measures include waist circumference, objective, and self-report measures of physical activity, dietary intake, changes in vending machines and cafeteria food offerings, work productivity, healthcare use, and return on investment.

DISCUSSION

The results of these studies could have important implications for the design and implementation of worksite overweight and obesity control programs.

The impact of body mass index on short-term disability in the workplace

OBJECTIVE

The objective of this study was to assess the association between body mass index and short-term disability in a working "white collar" population.

METHODS

The authors collected cross-sectional data from 19,061 health risk appraisals completed by employees of a large financial services corporation from 2000-2002. The self-reported information for demographics and job satisfaction was combined with personnel and detailed information from short-term disability events (STD) taken during the same time period.

RESULTS

After adjusting for multiple covariates, body mass index is an independent predictor for STD events. Body mass index categories of overweight and obese have odds ratios of 1.26 and 1.76 compared with normal weight (P < 0.0001).

CONCLUSIONS

The improvement of employee health and wellness should be pursued by the employer in an effort to promote healthier weight among their workers. This in turn should reduce STD events that result in the loss of worker productivity and a major cost to companies.

Cost-return prediction in morbidly obese employees following weight loss interventions: a study framework

Obesity and its many complications potentially can collapse most medical plans, unless attempts at prevention and therapy become more effective and widespread. An important incentive for providing effective treatment is proper reimbursement. We present here an evaluation of the feasibility, constrains and requirements for comparative cost-effectiveness evaluation of weight loss intervention from the payer's and employer's points of view, and propose a general framework for this type of studies toward decision making.

Participation rates in worksite-based intervention studies: health promotion context as a crucial quality criterion

Recently, a set of specific quality evaluation criteria for health promotion research has been proposed in this journal. One of the quality criteria identified is the 'health promotion context'. With this paper we would like to contribute to the dialogue by specifying the importance of this criterion on the basis of our on experience with worksite-based obesity prevention interventions. We advocate the reporting of participation rates among approached worksites in publications on worksite intervention effects. Such information will help to draw conclusions on the practical relevance of the shown effectiveness of the intervention. Health promotion practice is advised to adopt and disseminate evidence-based interventions, accompanied by a diffusion study with a minimal research burden for participants.

Building program participation: strategies for recruitment and retention in worksite health promotion programs

Building program participation is vital for all health promotion programs. There are a large variety of strategies that have been used to enhance recruitment and retention in worksite health promotion programs. Many of these strategies are examined and their significance in the design and operation of health promotion programs in worksite settings is reviewed.

Work site, physician's office, or medical university clinic: the effect of setting on success in a multidisciplinary weight-loss program

The effect of treatment setting on success in a 16-week multidisciplinary cognitive-behavioral weight-management program was examined. Twenty-seven women and six men with an average initial weight of 198.13 lb (+/-39.10) participated in the program at a medical university (MU), their primary care physician's office (PCP), or their work site (WS). The average amount of weight lost, body mass index (BMI) decrement, and number of sessions attended were compared as measures of success between programs. Results supported the hypothesis that treatment setting affects program success [F(6,40)=0.54, P<.05]. WS was more effective than PCP [Wilk's lambda=0.59, P<.05] in promoting weight loss [F(1,2)=5.22, P<.05]. Results indicate that the ongoing contingencies in the WS environment promote weight loss through more consistent adherence to suggested weight-loss strategies.

Occupational nursing service in a small manufacturing plant: interventions and outcomes

PURPOSE

To describe the health needs presented by workers in a small industrial setting, describe the occupational health nursing (OHN) services provided, and examine the effectiveness of these services.

METHODS

Data were abstracted from 491 employee records accumulated over a 7-year service period. Standardized nursing languages were used to describe employee needs and nursing interventions.

FINDINGS

Data revealed 1,368 needs were identified and 3,193 nursing interventions were administered. Health-seeking behaviors, knowledge deficit, collaborative problems, risk of infection, and impaired tissue integrity seemed most amenable to change in the context of OHN services. Altered health maintenance was the problem that seemed least amenable to change.

CONCLUSIONS

Findings present a dynamic picture of OHN services provided in an OHN program and their effectiveness. Standardized nursing languages were effective and appropriate in describing the health issues managed and interventions applied.

PRACTICE IMPLICATIONS

Further use of standardized nursing languages in occupation health can establish core functions and knowledge base.

Weight management: a comparison of existing dietary approaches in a work-site setting

OBJECTIVES

(1). To compare the effectiveness a 2512 kJ (600 kcal) daily energy deficit diet (ED) with a 6279 kJ (1500 kcal) generalized low-calorie diet (GLC) over a 24 week period (12 weeks weight loss plus 12 weeks weight maintenance). (2). To determine if the inclusion of lean red meat at least five times per week as part of a slimming diet is compatible with weight loss in comparison with a diet that excludes lean red meat.

DESIGN

Randomized controlled trial.

SETTING

Large petrochemical work-site.

PARTICIPANTS

One-hundred and twenty-two men aged between 18 and 55 y.

MAIN OUTCOME MEASURES

Weight loss and maintenance of weight loss.

INTERVENTION

Eligible volunteers were randomized to one of the four diet/meat combinations (ED meat, ED no meat, GLC meat, GLC no meat). One-third of subjects in each diet/meat combination were randomized to an initial control period prior to receiving dietary advice. All subjects attended for review every 2 weeks during the weight loss period. For the 12 week structured weight maintenance phase, individualized energy prescriptions were re-calculated for the ED group as 1.4 (activity factor) x basal metabolic rate. Healthy eating advice was reviewed with subjects in the GLC group. All subjects were contacted by electronic mail at 2 week intervals and anthropometric and dietary information requested.

RESULTS

No difference was evident between diet groups in mean weight loss at 12 weeks (4.3 (s.d. 3.4) kg ED group vs 5.0 (s.d. 3.5) kg GLC group, P=0.34). Mean weight loss was closer to the intended weight loss in the 2512 kJ (600 kcal) ED group. The dropout rate was also lower than the GLC group. The inclusion of lean red meat in the diet on at least five occasions per week did not impair weight loss. Mean weight gain following 12 weeks weight maintenance was +1.1 (s.d. 1.8) kg, P<0.0001. No differences were found between groups.

CONCLUSIONS

This study has shown that the individualized 2512 kJ (600 kcal) ED approach was no more effective in terms of weight loss than the 6279 kJ (1500 kcal) GLC approach. However the ED approach might be considered preferable as compliance was better with this less demanding prescription. In terms of weight loss the elimination of red meat from the diet is unnecessary. The weight maintenance intervention was designed as a low-input approach, however weight regain was significant and weight maintenance strategies require further development.

Grouping participants for tailored work-site weight loss programs: a signal detection approach

BACKGROUND

Although work-site obesity prevention programs have been widely promoted, they have a high rate of attrition and participants find it very difficult to maintain the decreased weight. It is necessary to develop effective work-site programs that match the type of intervention to the participants and offer the necessary support. To this end, higher-order interaction of the causal factors of obesity needs to be analyzed.

METHODS

The subjects were male, white-collar workers (20-64 years of age), in Osaka, Japan. Since conventional methods, such as regression analysis or analysis of variance, cannot deal with the interaction of many variables, signal detection analysis by Kraemer was used to identify the higher-order interaction of multiple predictors of obesity.

RESULTS

Out of 15 independent variables, a higher-order interaction consisting of 8 significant variables was identified. Consequently, the subjects were categorized into nine subgroups. It was revealed that the obesity of two groups of workers, 40 or more years old with a high degree of obesity, had different causes: one was related to working conditions, and one was related to smoking cessation. For the other terminal groups, further factors related to obesity were revealed.

CONCLUSION

Although the applicability of the findings is limited, the methodology using signal detection analysis might be applicable to other weight loss programs as a way of facilitating the matching of the type of intervention and the target group.

Evaluation of a multicomponent workplace health promotion program conducted in Japan for improving employees' cardiovascular disease risk factors

BACKGROUND

The long-term effectiveness of multicomponent worksite health promotion programs targeting cardiovascular disease risk factors remains unclear in Japan. This study was conducted to evaluate the effectiveness of such a health promotion program consisting of a main program provided over 4 days and a follow-up program provided over 1 year.

METHODS

The subjects of this randomized controlled trial were male employees working for a building maintenance company in Japan. The intervention group (n = 152) and the control group (n = 150) consisted of employees having abnormal findings in at least one of the following items at baseline health examination: body mass index (BMI), systolic (SBP) or diastolic blood pressure, total cholesterol, HDL cholesterol, triglycerides, and fasting blood glucose. Evaluation was conducted at 18 months after the main program.

RESULTS

BMI, SBP, total cholesterol, and triglycerides improved significantly in the intervention group compared with the control group (P < 0.05). When comparisons were limited to those who showed abnormality at baseline, BMI, total cholesterol, and triglycerides improved significantly in the intervention group (P < 0.05).

CONCLUSIONS

The multicomponent health promotion program provided to employees was shown to be effective in improving obesity, high blood pressure, and hyperlipidemia when evaluated 18 months after the main intervention program.

CD-ROM nutrient analysis database assists self-monitoring behavior of active duty Air Force personnel receiving nutrition counseling for weight loss

This study observed the effect of using a computerized vs manual method of self-monitoring among Air Force personnel receiving nutrition counseling for weight loss. Subjects who enrolled during the first 2 weeks of the 4-week recruitment period completed food records for 6 weeks using a CD-ROM nutrient database (intervention group) whereas those who enrolled during the last 2 weeks used a food record booklet (comparison group). Of the 42 subjects (n = 23 intervention group and n = 19 comparison group), only 113 intervention and 11 comparison group subjects (57% of study enrollees) submitted at least 1 food record during the study and were included in the analysis, which included review of pre- and poststudy questionnaires, food records, and focus group data. There were no significant differences between the number of days per week documented or average number of items recorded daily. All 9 intervention as compared to 2 comparison group subjects who completed a poststudy questionnaire searched for lower-energy and lower-fat items and reported changing their dietary intake as a result. All intervention group subjects who participated in a focus group (n=6) had favorable comments about using the CD-ROM for monitoring and changing eating habits, indicating that it is a beneficial self-monitoring tool. Participants enjoyed the immediate dietary feedback, and computerized food records may be easier to interpret by nutrition counselors. A number of computerized nutrient databases are available to assist patients and consumers in managing nutritional concerns.

Projecting future medical care costs using four scenarios of lifestyle risk rates

PURPOSE

This study predicts medical care expenditures over 10 years for Union Pacific Railroad (UPRR) under alternative health risk factor scenarios for the UPRR workforce.

DESIGN

This paper describes the development of an economic forecasting model to predict medical care expenditures assuming four different scenarios of population risk. The variables used to predict medical care expenditures are employee demographics and health risk profiles.

SETTING

UPRR is a transportation company with more than 56,000 employees in 25 states west and south of the Mississippi River.

SUBJECTS

Employees of UPRR.

MEASURES

Intermediate outcomes included health risk measures related to exercise patterns, body weight, eating habits, smoking, alcohol consumption, total cholesterol, blood glucose, blood pressure, stress, and depression. Major outcome measures included projected total annual payments by UPRR for medical care services for the decade following 1998.

RESULTS

The UPRR work force is projected to grow by 500 employees per year over the 10-year study period. The average age is expected to increase from 44 to 48 years. Without further health promotion intervention, 7 of the 11 risk factors assessed would likely worsen among UPRR's workforce. Medical care cost increases are projected to range from $22.2 million to $99.6 million in constant 1998 dollars over the next decade, depending on the effectiveness of risk factor modification programs. With an expected health promotion budget averaging $1.9 million annually over 10 years, health risks must decline at least 0.09% per year for the program to pay for itself.

CONCLUSIONS

Estimating various risk and cost scenarios can facilitate program planning and produce an economic justification for worksite health programs.

The limitations and promise of health education in managed care

Managed care has become the predominant form of health insurance in the United States. With its features of capitation, provider monetary risk, and population perspective, managed care represents a huge growth opportunity for advocates of disease prevention and health promotion, including those in the field of health education. In reality, however, health education's role has fallen far short of expectations. This article is presented to initiate a dialogue on the role of health education and its subset, worksite health promotion, within managed care. The worksite is emphasized because of its attractiveness as a site in delivering population-based medicine. Furthermore, employers exercise considerable influence in shaping the health care marketplace. A list of recommendations is presented, offering suggestions on what health education needs to do to increase its impact in the managed care movement. These arguments are posed to better position this profession in a changing health care environment.

Public health interventions for the prevention and treatment of obesity

Epidemic obesity is one of the few undesirable consequences of humanity's mastery of the environment. This article reviews public health approaches to preventing and treating obesity. The most encouraging efforts to date have been interventions targeting children in both medical and community surroundings. Treating and preventing obesity in adults has been less successful. It is suggested that taking an environmental health perspective on the obesity problem may facilitate the advancement of scientific understanding of this important health issue.

Outcomes of a traditional weight control program and a nondiet alternative: a one-year comparison

The purpose of this study was to evaluate the effectiveness of a traditional weight control program and nondiet alternative in improving behavioral (e.g., restrained, emotional, and external eating), psychological (e.g., body preoccupation, physical self-esteem), and biomedical (e.g., body weight, blood pressure, cholesterol) outcomes. There were 2 intervention groups--traditional weight control (TWC) and Diet Free Forever (DFF); a nonvolunteer comparison group; and a control group, all made up of employees of 3M (N = 357). The 2 intervention groups participated in 10-week eating programs. Outcome variables were assessed at baseline, at 10 weeks for the intervention groups only, and again at 1 year. At baseline, the 2 intervention groups had higher restrained, external, and emotional eating scores, greater body preoccupation, and lower physical self-esteem than the comparison and control groups. They also weighed more. At 1 year, both intervention groups had decreased their body preoccupation and increased their physical self-esteem. Participants in the DFF program reduced their restrained eating, whereas those in the TWC program increased their restrained eating. Neither eating program had an impact on the biomedical outcomes.

Randomized trial testing the effect of peer education at increasing fruit and vegetable intake

BACKGROUND

The National Cancer Institute recommends that Americans eat at least five daily servings of fruits and vegetables. National strategies to increase consumption may not reach minority and lower socioeconomic populations. In a randomized trial, peer education was tested for effectiveness at increasing fruit and vegetable intake among lower socioeconomic, multicultural labor and trades employees.

METHODS

Employees (n = 2091) completed a baseline survey and received an 18-month intervention program through standard communication channels (e.g., workplace mail, cafeteria promotions, and speakers). Ninety-three social networks (cliques) of employees were identified, which were pair matched on intake. At an interim survey (during months 8 and 9), 11 cliques no longer existed and 41 matched pairs of cliques containing 905 employees remained, with one clique per pair being randomly assigned to the peer education intervention. Employees who were central in the communication flow of the peer intervention cliques served as peer educators during the last 9 months of the intervention program. Fruit and vegetable intake was measured with 24-hour intake recall and with food-frequency questions in baseline, outcome (i.e., at 18 months), and 6-month follow-up surveys. All P values are two-sided.

RESULTS

By use of multiple regression, statistically significant overall effects of the peer education program were seen in the intake recall (increase of 0.77 total daily servings; P<.0001) and the food-frequency (increase of 0.46 total daily servings; P =.002) questions at the outcome survey. The effect on the total number of servings persisted at the 6-month follow-up survey when measured by the intake recall (increase of 0.41 total daily servings; P =.034) but not the food-frequency (decrease of 0.04 total daily servings; P =.743) questions.

CONCLUSIONS

Peer education appears to be an effective means of achieving an increase in fruit and vegetable intake among lower socioeconomic, multicultural adult employees.

A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1995-1998 update (IV)

The fourth in a series of critical reviews, this study examines the clinical and cost outcome evaluations of 10 worksite health promotion programs that were comprehensive, multifactorial, and directed at risk management. The studies, conducted between 1994 and 1998, indicate favorable clinical and cost outcomes and suggest characteristics of worksite interventions that may be critical for effectiveness.

Clinical and cost outcomes of multifactorial, cardiovascular risk management interventions in worksites: a comprehensive review and analysis

This paper is a critical review of the clinical and cost outcome evaluation studies of multifactorial, comprehensive, cardiovascular risk management programs in worksites. A comprehensive international literature search conducted under the auspices of the National Heart, Lung and Blood Institute identified 17 articles based on 12 studies that examined the clinical outcomes of multifactorial, comprehensive programs. These articles were identified through MEDLINE, manual searches of recent journals, and through direct inquiries to worksite health promotion researchers. All studies were conducted between 1978 and 1995, with 1978 being the date of the first citation of a methodologically rigorous evaluation. Of the 12 research studies, only 8 utilized the worksite as both the unit of assignment and as the unit of analysis. None of the studies analyzed adequately for cost effectiveness. Given this limitation, this review briefly considers the relevant worksite research that has demonstrated cost outcomes. Worksite-based, multifactorial cardiovascular intervention programs reviewed for this article varied widely in the comprehensiveness, intensity, and duration of both the interventions and evaluations. Results from randomized trials suggest that providing opportunities for individualized, cardiovascular risk reduction counseling for high-risk employees within the context of comprehensive programming may be the critical component of an effective worksite intervention. Despite the many limitations of the current methodologies of the 12 studies, the majority of the research to date indicates the following: (1) favorable clinical and cost outcomes; (2) that more recent and more rigorously designed research tends to support rather than refute earlier and less rigorously designed studies; and (3) that rather than interpreting the methodological flaws and diversity as inherently negative, one may consider it as indicative of a robust phenomena evident in many types of worksites, with diverse employees, differing interventions, and varying degrees of methodological sophistication. Results of these studies reviewed provide both cautious optimism about the effectiveness of these worksite programs and insights regarding the essential components and characteristics of successful programs.