Obesity: the big issue

With the current global emphasis in public health provision on obesity, it’s the perfect time to explore this topic as it relates to the workplace, and examine some of the evidence that is currently available on promoting physical activity at work.


This exploration of the literature has two aims: firstly that it might be useful to occupational health (OH) professionals considering promoting physical activity as an intervention in tackling obesity, and secondly, to identify strategies to consider when planning and implementing any intervention. With recent discussions on the Science Daily website about interesting ideas being considered – including the provision of an area where staff can play fitness games on the Nintendo Wii games console – it is an exciting time. The Foresight report published in 20081 indicates that based on current trends, 60% of the UK population will be obese by 2050. Similarly, the Healthy Weight Report2 makes it quite clear that although the core of the problem is simple, in that people eat too much and undertake too little physical activity to achieve a healthy balance, the solution is much more complex, as we all know only too well.


The final report by Lord Darzi3 stresses that one of the six key goals for improving health in the UK is to tackle obesity. One strategy that is suggested is to get more people physically active and to encourage companies to invest more in the health of their workforce. The benefits of that investment might not be merely financial, but could be promoted in terms of flexibility of working hours, commitment for projects, and time to support local initiatives.


Health at work


The latest guidelines on this subject from the National Institute for Health and Clinical Excellence (NICE)4 have made a series of recommendations to help employers and workplace health professionals prevent the diseases commonly associated with a lack of physical activity, such as coronary heart disease (CHD). While it is acknowledged that the recommendations will not reverse the current obesity epidemic taken in isolation, any effort made in the workplace could have a significant impact on improving health.


However, the guidance cautions that increasing levels of activity could impact on equality, since not all employees may be able to participate because of shift-working, and people with disabilities could also be excluded. This is an important consideration for OH practitioners to remember when planning a strategy.


Recommendations


The current national recommendation for physical activity is to undertake moderately intense physical activity for at least 30 minutes on five or more days per week.


It has also been suggested that the incidence of stress, common mental health problems and musculoskeletal disorders (MSDs) could be reduced by an increase in physical activity. Thus the introduction of exercise to the workplace could have more than one positive outcome. Indeed, a targeted approach to reducing sickness absence, combining work-style and lifestyle physical activity is one of the components of Condition Management programmes that are currently being evaluated by NICE.


In the literature on physical activity, concern is expressed regarding the quality of the evidence presented investigating interventions in the workplace.5 It is suggested that outcome measures are often based on self-reporting in a very limited range of settings. Gaps in knowledge have also been identified – for example, how the effectiveness of workplace interventions is influenced by size and type of workplace. This makes it very difficult to generalise findings adequately across all settings.


Interventions


According to Williams,6 health promotion activities directed at changing the working environment can be achieved through general interventions directed at individuals within groups of workers. Bernaards et al7 found that physical activity could reduce stress by increasing self-esteem. In their study they suggest that long-term adherence to exercise programmes is often low, due to lack of pleasure or barriers that may exist to regularly visiting a health club. This is a major consideration for staff engaged in irregular shift patterns.


In contrast to exercise programmes, the primary goal of physical activity interventions is to integrate moderate intensity into everyday life. This makes the workplace an ideal setting for such activity, with many people spending between 40 to 65 hours per week at work in sedentary positions.


A key feature of effective physical activity interventions seems to be that they are not prescribed by professionals, but chosen by the individual. Thompson et al8 in their observational study, consider the feasibility of introducing a walking workstation into an office environment. A number of participants in the study, which included nurses and secretaries, reported an improved energy level, while others indicated a reduction in back pain. Further research would be needed to evaluate the effect on productivity, but initial indicators appeared promising in this very innovative development.


Both Makrides et al9and Naito et al10 considered an increase in physical activity in relation to risk factors for CHD.


The first study describes a randomised controlled trial undertaken in Canada to document the impact of a lifestyle modification programme that included an element of physical activity. This was assessed at three and six months, and an increase in physical activity was found to have contributed to a significant reduction in coronary disease risk factors.


Not surprisingly, however, the benefits were not sustained over time to the same extent, confirming that long-term commitment is required when promoting lifestyle changes.


The other large-scale study, undertaken in five factories in Japan, considered the effect of a four-year workplace intervention.


An increased awareness of the benefits of physical activity is described, using what is termed environmental re-arrangement, or manipulating the environment and running health promotion campaigns, which especially target walking. One limitation noted from the four-year study concurs with the previous criticism, that changes noted in physical activity were self-assessed and could not be measured statistically.


Outcomes


Dishman et al5 state that workplace interventions have yet to demonstrate a statistically significant increase in physical activity. They conclude that positive results are often inflated by self-selection, added workplace incentives, and the inappropriate comparison of groups. Nevertheless, one strategy adopted in this study was to construct a path around the site for walking for pleasure, and providing pedometers to employees, which did produce positive results.


Women are a particular study group that needs further consideration, as more women than men are physically inactive, and the prevalence of physical inactivity seems to be greatest among women who are socially disadvantaged.11


A study undertaken in Canada by Tavares and Plotnikoff12 set out to investigate the main issues pertinent for female employees. This was a qualitative study using focus groups and semi-structured interviews in corporate employment settings. It was found that employed women are more likely than men to report a lack of time due to work as a barrier to exercise.


It is acknowledged that a gap remains in the literature concerning the particular multiple roles and responsibilities of women. In this study, findings suggested that encouragement from senior management, not just paying ‘lip service’, was required, together with flexible working patterns, the provision of changing rooms/showers and on-site facilities, or affordable access to community facilities.


However, participants in the study believed that the changes they would like to see implemented would only occur when education about the benefits of physical activity was adopted and supported.


This theme of education is picked up by Williams,6 who suggests that information on opportunities within the workplace could be communicated through posters, targeted presentations, the intranet or through websites. Vandelanotte et al13 reviewed the literature on website-delivered interventions and again found that although positive behavioural outcomes were reported, the effects were short-lived.


Naito et al10 advocated what were referred to as ‘active point’ campaigns, carried out twice a year in participating companies. Components of these campaigns included a self-report diary, a lecture and instruction on active walking, exercise and sporting events at the workplace.


A variety of suggestions that might be considered as incentives mentioned by Williams6 included monetary incentives based on additional payment or reimbursement prizes or individual gifts awards or official recognition by a company or time off to participate.


Cook et al14 tested the efficiency of a web-based health promotion package designed to improve dietary practice, increase physical exercise and reduce stress. This study was a randomised controlled trial with pre- and post-test comparisons made between two groups. One had been assigned to a web-based intervention, and the other to a printed material group.


Although both groups showed improvement, it could be argued that physical activity might have increased purely as a result of participation in the study. However, as Vandelanotte et al13 argue, one advantage of using the internet is that a user can seek advice at their convenience when compared with other modes of delivery. Ten years ago, two other studies15, 16 found that introducing signage to encourage the use of stairs was effective in the short term.


Despite the criticism of research rigour found in studies of physical exercise and the workplace, the results indicate general points that might apply in any proposed intervention.Macik-Frey et al17 state that interventions often evolve and change once they have been implemented. They acknowledge that health promotion programmes in OH settings have not demonstrated sustained changes in employee behaviours over time. They stress that individual interventions alone may not enhance health if the organisation does not offer support as well. The concept of healthy organisations means that, along with profits and productivity, the collective wellbeing of employees is just as important an outcome.


Key points




  • Commitment from senior management is important for any initiative.


  • Increased walking is a positive intervention.


  • Employers should put an emphasis on women’s needs and those of vulnerable groups.


  • Poster campaigns should promote the use of stairs.


  • Physical activity campaigns can change behaviour.


  • Employers should consider incentives to encourage physical activity.

Liz Griffiths is an OHN lecturer at Brunel University.


References


1 Government Office for Science (2007) Foresight Tackling Obesity Future Choices – Modelling future Trends in Obesity and Their Impact on Health. www.dius.gov.uk


2 HM Government (2008) Healthy Weight, Healthy Lives: A Cross-Government Strategy for England. London COI. www.dh.gov.uk/publications


3 Department of Health (2008) High Quality Care for All NHS Next Stage Review final report. London, TSO


4 National Institute for Health and Clinical Excellence (2008) Workplace health promotion: how to encourage employees to be physically active. NICE public health guidance 13 www.nice.org.uk


5 Dishman R, Oldenburg B, O’Neal H, Shephard R (1998) Worksite Physical Activity Interventions. American Journal of Preventive Medicine 15 (4) pp344-361


6 Williams N (2008) Managing Obesity in the Workplace. Oxford, Radcliffe


7 Bernaards C, Ariens G, Hildebrandt V (2006) The (cost-) effectiveness of a lifestyle physical activity intervention in addition to a work-style intervention on the recovery from neck and upper limb symptoms in computer workers. BMC Musculoskeletal Disorders, 7:80 pp1-11


8 Thompson W G, Foster R C, Eide D S, Levine J A (2008) Feasibility of a walking workstation to increase daily walking. British Journal of Sports Medicine 42 pp225-228


9 Makrides L, Dagenais G, Chockalingam, LeLorier J, Kishchuk N, Richard J, Stewart J, chin C, Alloul K, Veinot P (2007) Evaluation of a workplace health programme to reduce coronary risk factors. Clinical Governance: An International Journal. Vol. 13, No. 2, pp95-105


10 Naito M, Nakayama T, Okamura T, Miura K, Yanagita M, Fujieda Y, Kinoshita F, Naito Y, Nakagawa H, Tanaka T, Ueshima H (2008) Effect of a 4-year workplace-based physical activity intervention programme on the blood lipid profiles of participating employees: the high-risk and population strategy for occupational health promotion study. Atherosclerosis 197 pp784-790


11 Cameron C, Craig C, Stephens T, Ready T (2002) Increasing physical activity: supporting an active workforce. Ottowa, Canadian Fitness and Lifestyle Research Institute


12 Tavares L, Plotnikoff R (2008) Not Enough Time? Individual and Environmental Implications for Workplace Physical Activity Programming Among Women with and without Young Children. Health Care for Women International, 29: pp244-281


13 Vandelanotte C, Spathonis K, Eakin E, Owen N (2007) Website-Delivered Physical Activity Interventions, A Review of the Literature. American Journal of Preventive Medicine 2007 33 (1) 54-64


14 Cook R, Billings D, Hersch-Back R, Hendrickson A (2007) A Field Test of a Web-Based Workplace Health Promotion Programme to Improve Dietary Practices, Reduce Stress, and Increase Physical Activity: Randomised Controlled Trial. Journal of Medical Internet Research, v. 9(2) Apr-Jun 2007


15 Dunn A, Anderson R, Jakicic J (1998) Lifestyle Physical Activity Interventions History, Short- and Long-Term Effects, and Recommendations. American Journal of Preventive Medicine 1998 15 (4) 398-412


16 Anderson R, Franckowiak S, Snyder J, Bartlett S, Fontaine K (1998) Can Inexpensive Signs Encourage the Use of Stairs? Results from a Community Intervention, Annals of Internal Medicine. Vol. 129, No. 5, 363-369


17 Macik-Frey M, Quick, J C, Nelson D (2007) Advances in Occupational Health: From a Stressful Beginning to a Positive Future. Journal of Management, Vol. 33 No. 6, December 2007 809-840

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