Statistics over the past three years have shown that obesity in the UK is steadily rising.1,2,3 Current figures indicate that 23% of men and 25% women in the UK are obese. If current trends continue,4 one-third of adults and one-fifth of two to 10-year-olds will be obese by 2010.
Occupational health (OH) nurses could be in a pivotal position to assist employees in making lifestyle changes.5 This opportunistic approach is supported by the workplace health component of the government White Paper Choosing Health and Dame Carol Black’s review of the health of Britain’s working-age population.6
Furthermore, the World Health Organisation advocates the workplace as an ideal setting for health promotion7 as it provides access to a defined population, where employees gain support from their peers, and established channels of communication already exist between clinicians, staff, and the employer.
In the project in the rail industry, a high proportion of train drivers were assessed as obese by the standard of the National Institute for Health and Clinical Excellence (NICE) guidelines8; that is they have a body mass index (BMI) greater than 30. Of more concern, this cohort of employees appeared to have associated risk factors for coronary heart disease (CHD). Train drivers, both freight and passenger, are expected to carry out train and public protection duties as part of their role , and this requires a satisfactory level of fitness and stamina (see box 1).
Significant advances in rail technology mean that train driving is now a sedentary job, and there seems to be a temptation to eat high-calorie convenience snacks while on shift work. Staff restrooms accommodate a high proportion of snack slot machines, with limited facilities for the preparation and cooking of food. Early morning shifts mean breakfast is missed, followed by grazing through the day and the consumption of a large meal before going to bed. This seems to be common practice among drivers.
A freight operating company (FOC) driver travels countrywide, often parking in sidings, therefore the driver is unable to leave the cab for meal breaks. In addition, FOC drivers often stay overnight in ‘all expenses paid’ hotels and, although some provide leisure facilities, drivers are often not motivated or confident to use the fitness suite or pool.
It seems to be commonplace with this group of drivers to over-eat and make the wrong food choices. Train operator companies (TOC) run a strict passenger timetable; hence drivers may miss meal breaks if trains are delayed, and therefore may resort to snacks.
Analysis of quantitative data collected over a 12-month period for TOC and FOC drivers attending an OH service confirmed there were a high proportion of obese train drivers. In addition, eight drivers were suspended from driving on full pay because of health issues related directly to their obesity – for example, failure to manage track-side walking due to poor fitness, and unstable diabetes.
The BMI calculation was classified further into class 1-3. Associated risk factors for CHD were also identified (see box 2). The analysis demonstrated a need to provide an evidence-based obesity management policy, which would provide continuity of care, and offer support for all drivers who attended OH throughout the organisation.
The organisation’s existing obesity management policy was reviewed and adapted based on current NICE8 obesity management recommendations. Guidelines within the OH policy now include identifying motivation levels, documenting an action plan and monitoring progress using a standardised method of measuring – for example, BMI and waist measurement within the healthcare notes agreed goals.
The introduction of waist measurements had a considerable impact on most drivers. The project highlighted that drivers had underestimated their size. This is supported by a previous study which showed men were often unaware of their true waist measurement, and had a distorted view of their body image.9
During the trial, some drivers believed they could not eat at work because the cabs were dirty, so drivers were advised to carry a ‘cool bag’ , water bottle and hand wipes, and ‘pack up’ suggestions were offered based on the normal daily recommended sugar, salt and saturated fat intake.10 Others expressed concern they were unable to undertake formal exercise because of shift work, so FOC drivers were encouraged to use hotel leisure facilities.
Drivers were asked to either purchase home exercise equipment as a possible solution – for example, a trampette, cross trainer or static bike, exercising for 10 minutes a day, or to begin brisk walking on a daily basis for a minimum of 20 minutes. The ‘little and often’ approach11 appeared to maintain motivation, and the ‘little changes make big differences’ motto was a good starting point for employees who had not undertaken any form of exercise previously.
Appropriate and current resources, such as websites and health education leaflets, were given and support group suggestions were documented in the health records. This helped to ensure continuity of care and clarity should the employer be seen by a different OH nurse on their next consultation.
A small minority of drivers (BMI>40) requested medication from their GP. Drug therapy has been approved by NICE,12 but pharmacological support should only be used to assist weight loss as part of a co-ordinated programme. There are adverse reactions and, while rare, because of the safety critical aspect of the driver’s role, drivers are suspended for one week after commencement of treatment to reduce the risk of harm.
The link between obesity and type 2 diabetes is significant,13 therefore drivers were referred to the practice nurses in their primary care trusts for fasting blood glucose and lipid profile screening. Results were documented in the OH notes to demonstrate the absence or presence of diabetes.
In the presence of a confirmed diagnosis, drivers were managed in accordance with the Network Rail and OH diabetes policy. This also combines elements from the National Service Framework for diabetic care.14
To achieve change, motivational interviewing strategies as suggested by Miller and Rollnick15 were adapted to be included in the new policy (see box 3).
The changes were implemented over a 15-month period in one centre. Because of the high incidence of obesity identified in the initial data collection, the project was extended to include two other centres during the remaining six months. Train driver data recorded CHD risk factors, BMI and waist measurement. By mutual consent, it was agreed to continue the previous practice of recalling drivers with a BMI of >33 for three consultations over a nine-month period, which historically during the 1980s had been established by the then British Rail Medical Board.
Although initial data had illustrated a high proportion of drivers with a BMI of 30-33, the OH centres did not have the capacity to recall everyone at this lower BMI level. The high volume of drivers requiring follow-up would have affected train company manpower, as drivers would require time off to attend. To negotiate and instigate a new policy directive would have been too time consuming. Drivers with a BMI of 30-33 and <30 with or without associated risk factors were given opportunistic advice supported with appropriate resources.
To evaluate the project, both qualitative and quantitative data was collected from the three centres at the end of the trial period.
Towards the end of the trial, driver numbers attending for follow-up fell due to a change in one TOC franchise and OH provider. It was not possible therefore to monitor this specific TOC and capture employee data.
Number of drivers seen with a BMI >33 = 40
Number of drivers from the 40 seen with associated risk factors in addition to obesity and sedentary lifestyle = 33
Number of drivers returning for follow-up = 33
Number of drivers post follow-up who dropped their waist size by >1 inch and BMI>1 point = 24 (72%)
Number of drivers who had begun to exercise formally >3 times weekly for 30 minutes plus = 20 (60%)
Qualitative data was collected from drivers attending follow-up by the nurses who were participating in the trial. Questionnaires were sent randomly to drivers who had attended the follow-up programme.
Driver response was disappointing – 15 were sent and only five replied. This may be due to the franchise change and, on reflection, the sample size was too small. Questionnaires should perhaps have been sent to all the drivers. The time factor, however, for administration and analysis was a significant reason for the reduced sample size.
Feedback from questionnaires completed by OH nurses was predominately positive. Issues such as appointment length were addressed by increasing the consultation time to 30 minutes. All drivers were referred to their local practice nurse for lipid profile and diabetic screening. Three were found to have a raised fasting blood sugar, and treatment was given and reviewed accordingly. Four had raised cholesterol and so were started on statin therapy. Two were enrolled by their GP into a local obesity weight management programme.
Following completion of the trial, the obesity management policy is now implemented throughout the OH organisation and is used to provide effective support for all staff, not just train drivers. Its structured approach has allowed nurses to take into consideration the driver’s own health needs, set realistic goals and offer possible solutions based on the driver’s work environment, shift pattern and motivation levels.
Recommendations to rail employers in the prevention and management of obesity are currently being explored.
In future, it is hoped that rail companies will agree to increase the time and frequency of follow-up for drivers, however cost implications to the employer may not make this possible. Conversely, however, the cost of obesity and associated risk factors to the industry may require employers to reconsider how best to promote preventive measures and provide ongoing support for existing obese staff.
While some drivers had made significant lifestyle changes during the follow-up phase, it is too early to speculate on whether they will be permanent.
Drivers with associated risk factors for CHD will continue to be followed up annually if their BMI continues to remain at >33. There is evidence to suggest that obesity management requires long-term commitment on many levels to change the way people live. Therefore, annual follow-up may not be sufficient.
Alison MacGregor undertook this project as part of her studies toward a BSc (Hons) in Specialist Nursing (Health studies – Community and Public Health)
Box 1: Train driver duties
Negotiate a three-metre drop by climbing from the cab to the trackside (in the absence of a platform and climb with the use of foot and hand holds back into the cab.
Walk briskly trackside along rough ground such as loose ballast (shingle) for 2 kilometres over a 20-minute period.
Balance and climb over electric rail and sleepers, climb up a bank or siding.
Uncouple and couple a locomotive, train carriages and freight containers, which involve lifting heavy couplings in a confined space.
Yard shunting duties, which are more physically demanding than main line work because of the significant climbing involved in moving, inspecting and refuelling trains.
Box 2: Future improvements for consultations
In future, the OHN would:
Create an environment in which drivers felt safe to express themselves – for example, by avoiding the ‘lecture approach’ and appearing non-judgemental.
Involve the driver in the content and delivery of each consultation.
Help them to set their own goals and objectives by recording an action plan at each consultation.
Involve them in the evaluating process so that they can recognise their achievement by, for example, a reduction in waist measurements.
Point them towards resources to help them change.
Box 3: Recommendations for employers
Reduce number of snack machines in restrooms and offer alternative healthier options in the machines.
Access to microwave and fridge in all staff restrooms.
Discount for corporate gym/pool membership (private and council facilities), home exercise equipment, slimming clubs and online websites.
Issuing small food storage ‘cool bags’, ice packs, drinks bottle/flask, and hand wipes as standard kit printed with the train company logo. This may encourage more drivers to bring their own ‘pack up’ and reduce the temptation to rely on fast food and snack machines.
Give OH nurses the opportunity to talk to drivers during their induction week or training days about the prevention and management of obesity.
Provide posters and leaflets in all staff restrooms and training schools and regularly replenish and update them.
Provide monthly follow-up for six months then yearly if BMI remains >33 with associated risk factors for CHD.
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2 Department of Health (2007) Health profile of England. London: DH www.dh.gov.uk [Accessed 5/1/08]
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10 British Dietetic Association WeightWise (2005) www.bdaweightwise.com/bda [Accessed 7/9/07]
11 Department of Health (2006) Your weight, your health, how to take control of your weight. The stationary office. London
12 National Institute for Health and Clinical Excellence (NICE) (2000) Technology Appraisal of Pharamcoligical Support – Full Guidance. www.nice.org.uk [Accessed 18/2/07]
13 Despres JP, Lemieux I, Pru’homme D (2001) Treatment of obesity: The need to focus on high risk abdominal obese patients. British Medical Journal 322 p716-720
14 Department of Health (2001) National Service Framework for Diabetes. The stationary office. London
15 Miller ER Rollnick S (2002) Motivational Interviewing: Preparing people for change. 2nd edition. Giuldford Press, New York