Guide to community preventive services
The Effectiveness of Worksite Nutrition and Physical Activity Interventions for Controlling Employee Overweight and Obesity: A Systematic Review

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Abstract

This report presents the results of a systematic review of the effectiveness of worksite nutrition and physical activity programs to promote healthy weight among employees. These results form the basis for the recommendation by the Task Force on Community Preventive Services on the use of these interventions. Weight-related outcomes, including weight in pounds or kilograms, BMI, and percentage body fat were used to assess effectiveness of these programs.

This review found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6–12-month follow-up. A pooled effect estimate of −2.8 pounds (95% CI=−4.6, −1.0) was found based on nine RCTs, and a decrease in BMI of −0.5 (95% CI=−0.8, −0.2) was found based on six RCTs. The findings appear to be applicable to both male and female employees, across a range of worksite settings.

Most of the studies combined informational and behavioral strategies to influence diet and physical activity; fewer studies modified the work environment (e.g., cafeteria, exercise facilities) to promote healthy choices. Information about other effects, barriers to implementation, cost and cost effectiveness of interventions, and research gaps are also presented in this article. The findings of this systematic review can help inform decisions of employers, planners, researchers, and other public health decision makers.

Introduction

Obesity is a major health problem in both developed and developing countries. Many factors—genetic, behavioral, social, and economic—interact to influence the development of obesity in populations. People in societies with ample access to energy-rich foods and low physical activity levels are at increased risk of becoming overweight or obese. In occupational settings, economic and industrial innovation has resulted in far fewer workers in primary industries (e.g., agriculture, fishing, mining, or forestry); more automation and labor-saving devices in production industries; and large increases in the proportion of people engaged in sedentary industries. Workplaces are a sedentary setting for many workers and also a place where access to energy-dense food and beverages is common. Epidemiologic studies of characteristics of working conditions and worker overweight or obesity have shown associations between greater BMI and long work hours, shift work, and job stress.1 Schulte et al. recently described the association between excess body weight and risk for a range of occupational conditions, including injury, asthma, musculoskeletal disorders, immune response, neurotoxicity, stress, cardiovascular disease, and cancer.1

Considering that more than 30% of the U.S. adult population is obese and that a link between obesity and cardiovascular disease, hypertension, dyslipidemia, type 2 diabetes, stroke, osteoarthritis, and some cancers has been established, concern about the economic burden associated with obesity is growing.2, 3 In the workplace, obesity is an important driver of costs associated with absenteeism, sick leave, disability, injuries, and healthcare claims.4 Employers are keenly interested in programs and policies that improve worker health and ultimately reduce healthcare costs.5 Extant reviews, both qualitative6, 7, 8, 9 and quantitative,10, 11, 12 have yielded equivocal results on the effectiveness of worksite programs for controlling workers' weight. These reviews investigated multiple health risk outcomes besides weight status and did not attempt to quantify program impact on weight as a summary measure of effect across the bodies of evidence reviewed. The criteria developed by the Task Force on Community Preventive Services13 were used to evaluate the effectiveness of worksite interventions targeting nutrition and physical activity behaviors among employees to promote healthy weight.

The systematic review in this report represents the work of the independent, nonfederal Task Force on Community Preventive Services (the Task Force). The Task Force oversees work on the Guide to Community Preventive Services (Community Guide)14 with the support of the USDHHS in collaboration with public and private partners. The CDC provides staff support to the Task Force for development of the Community Guide.

Task Force recommendations are based primarily on the effectiveness of an intervention in improving important outcomes as determined by the systematic literature review process. In making its recommendations, the Task Force balances information about effectiveness with information about other potential benefits and harms of the intervention itself. The Task Force also considers the applicability of the intervention to various settings and populations in determining the scope of the recommendation. Finally, the Task Force reviews economic analyses of effective interventions, where available. Economic information is provided to assist with decision making but generally does not affect Task Force recommendations.

The interventions reviewed here may be useful in reaching objectives specified in Healthy People 2010,15 the disease prevention and health promotion agenda for the U.S. (Table 1). The interventions included in this review focus on these objectives and the goal of increasing the proportion of adults who are at a healthy weight and reducing the proportion of adults who are obese.

Existing guidelines on the effects of counseling and behavioral strategies in improving diet and physical activity among overweight and obese adults were developed for physicians, dieticians, and auxiliary personnel in primary care settings.16, 17, 18, 19 Counseling to increase physical activity and improve diet, and behavioral strategies to support and maintain these changes, are also relevant to worksite wellness programs. Recommendations of the U.S. Preventive Services Task Force (USPSTF) on such strategies are presented in Table 2. There is mixed evidence on the effectiveness of behavioral counseling in the primary care setting in increasing physical activity and limited evidence of the effectiveness of counseling in promoting a healthy diet among those not classified as having specific risk factors. However, among adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease, there is good evidence that intensive counseling (combined nutrition education with behavioral dietary counseling provided by a nutritionist, dietician, or specially trained primary care clinician) can produce meaningful change in daily intake of appropriate amounts of the core components of a healthy diet, including saturated fat, fiber, fruit, and vegetables. Further, the USPSTF found fair to good evidence that, in primary care settings, high-intensity counseling—about diet, exercise, or both—together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3–5 kg for 1 year or more) in adults who are obese (BMI ≥30). The effectiveness of moderate- or low-intensity counseling among obese adults could not be determined, nor could the USPSTF determine the effectiveness of counseling to promote sustained weight loss in overweight adults (BMI 25.0–29.9).

Section snippets

Methods

Community Guide methods for conducting systematic reviews and linking evidence to effectiveness are described elsewhere13 and on the Community Guide website (www.thecommunityguide.org/methods). In brief, for each Community Guide review topic, a systematic review development team representing diverse disciplines, backgrounds, and work settings conducts a review by (1) developing a conceptual approach to identify, organize, group, and select interventions for review; (2) developing an analytic

Description of Included Studies

The literature search results and identification of relevant studies is shown in Figure 2. A total of 54 candidate studies, reported in 78 papers, met inclusion criteria.27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80 Of these, seven studies74, 75, 76, 77, 78, 79, 80 were considered of limited quality of execution and were

Discussion

This review addressed the effects of worksite nutrition and physical interventions on employee weight outcomes. According to Community Guide rules,13 there is strong evidence of a consistent, albeit modest, effect. The findings are applicable to men and women in a range of worksite settings. However, some limitations should be considered when interpreting the results of this review. Although several outcome measures may be collected in worksite health promotion studies, sometimes not all are

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