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1 Why employers should be doing more to get employees more active? Willem van Mechelen, MD, PhD, FACSM, FECSS VU University Medical Centre Amsterdam Why employers should be doing more to get employees more active!!!!!! Slide 2 2 www.bodyatwork.nl Slide 3 3 Slide 4 4 Slide 5 5 Slide 6 6 Slide 7 7 Slide 8 CONTENT Occupational Health Care Paradigm shift: occ. health ---> workers health What is the problem ? Cost of a physically inactive lifestyle Examples: one to one interventions/supportive environment Who is responsible? Self-regulation or the Nanny State? Slide 9 9 Source: UWV, calculations Slide 10 10 Paradigm shift: from occupational health to workers health Slide 11 11 Slide 12 12 Slide 13 13 Slide 14 14 Slide 15 15 Slide 16 16 Slide 17 17 Slide 18 18 Health threats Noise Radiation Air pollution (allergens) Chemicals Awkward postures Repetitive motions Heavy loads etc. Slide 19 19 Solution Slide 20 20 Modern work conditions Slide 21 21 24 hour economy Service industry Flexible, individualized labor contracts Mental demands Multi-tasking etc. Modern labour conditions Slide 22 22 Health threats Job stress Sedentary job performance Inactive commuting Double demands (juggling the kids) etc. Slide 23 23 Solution Slide 24 24 So, we have experienced change in work conditions . Slide 25 25 Added to this, society has changed also Slide 26 26 primary and secondary prevention Slide 27 27 Major health problems Lifestyle (health behaviour) Coping with complaints secondary prevention primary and secondary prevention Slide 28 28 Major health problems Lifestyle (health behaviour) Disability for work secondary prevention primary and secondary prevention 95% at work 5% off work Slide 29 29 Paradigm shift Lifestyle (health behaviour) secondary prevention primary and secondary prevention Workers health presenteeism Occupational health absenteeism Disability for work Slide 30 30 BMI weight/height 2 overweight > 25 obesity > 30 104 kg by 1,86 m What is the problem? Slide 31 31 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data 76 Risk factor identification should lead to risk reduction by intervention----> RCT target population intervention vs. control follow- up outcome random- ization However, true RCT not always feasible. Other designs (cluster RCT, CT, time trend) may be more appropriate Slide 77 77 What causes the problem? Slide 78 78 Need for a common denominator Slide 79 79 Slide 80 80 Glass of beer Some peanuts Croissant Chocolate cookie Energy intake of 140 kcal/week Dia geleend van Seidell Slide 81 81 Energy expenditure = 21 min = 35 min = 14 min = 19 min Dia geleend van Seidell Slide 82 82 Trends in Energy-intake (Kilojoules) in the Netherlands Dutch Health Council, Trends in Nutrition, report 2002/12 Slide 83 83 Slide 84 84 Slide 85 85 Physical inactivity Abnormal reaction to a normal environment? Normal reaction to an abnormal environment? Slide 86 86 Slide 87 87 Slide 88 88 Slide 89 89 Deteminants of health behaviour (Aarts et al., 1997) External factors awarenesscognition (A/S/E) Behavioural intention behaviour barriers habits Social & physical environment Slide 90 90 Social Ecological Model of Physical Activity (Adapted from Davison & Birch 2001) PHYSICAL ACTIVITY INDIVIDUAL Gender Age Enjoyment SOCIOCULTURAL DIETARY HABITS SEDENTARY BEHAVIOR Beliefs Social capital Physician influence Urban planning policies Social support friends Social norms Time spent outdoors Sibling PA Social isolation Social support family Ethnicity ENVIRONMENTAL/ POLICY Seasonality Area-level SES Crime rates & neighborhood safety Walking/cycling tracks Aesthetics of environment Active transport policies Access to recreational facilities Traffic (volume/speed) Someone to be active with Self-efficacy Education level SES Barriers Parental PA Peer & sibling interactions Children same age live nearby Family rules PA Cultural norms Perceptions of safety Access to parks/ playgrounds Connectivity of streets Living in cul-de-sac Stranger danger Topography Organizational PA policies Slide 91 91 Truncate high risk end of exposure distribution Secondary & tertiary prevention. Reduce risk a little risk in most people Primary & promiordial prevention Prevention Strategies High Risk vs. Population Slide 92 92 Individual environment Dutch PACE Alife@Work Foodsteps Slide 93 93 Reduction in health care cost Reduction in work absenteeism Improvement in productivity Improvement of Quality of Life Reduction of risk factors for chronic disease Slide 94 94 Indirect cost should also be taken into account Slide 95 95 Slide 96 96 Slide 97 97 Slide 98 98 Slide 99 99 Slide 100 Results: subjects Slide 101 101 Design cost-benefit analysis Intervention Effect measurements (T0, T1) Work absenteeism (1) Work absenteeism (2) mei 2000januari 2001mei 2001januari 2002 Slide 102 102 Intervention Written information x7 consultations, 20 minutes, trained counsellor Control GroupIntervention group 9 months: May January 2001 Slide 103 103 Individualized Counselling Daily physical activity Healthy Nutrition PACE (stages of changes) protocols Intervention Slide 104 Beta (SE) (95% CI) Energy expenditure (kcal. day -1 )182.7(53.9) (76.5;289.0) Physical activity, sport (1-5) 0.25(0.07) (0.12;0.38) Physical activity, leisure time (1-5) 0.10(0.05) (-0.00;0.19) Fitness (beats. min -1 ) -5.07(1.21) (-7.46;-2.68) Results: primary outcomes Slide 105 105 Cost-benefit analysis Costs () Intervention mean (sd) Control mean (sd) mean (95% BI) Intervention cost4300 Cost of work absenteeism year 1 1915 (4813)2040 (5030)-125 (-1386;1062) Total cost year 123452040305 (-1029; 1419) Total cost year 21830 (4666)2465 (5568)-635 (-1883; 814) Slide 106 ALIFE@Work Amsterdam Lifestyle Intervention on Food and Exercise at Work Marieke van Wier 1, Caroline Dekkers 1, Geertje Arins 1, Tjabe Smid 1, Ingrid Hendriksen 2, Nico Pronk 3 & Willem van Mechelen 1 Body@Work, Research Center Physical Activity, Work and Health, TNO-VUmc 1) Department of Public and Occupational Health/EMGO Institute, VU medical center, Amsterdam 2) TNO Work and Employment, Hoofddorp en 3) Health Partners, Minneapolis, USA Slide 107 107 Objectives To evaluate, among in an overweight working population, the effectiveness of a lifestyle intervention program on body weight, physical activity and dietary habits. To compare the efficacy of two different communication strategies, i.e. phone and internet To evaluate the cost-effectiveness of this lifestyle intervention program. Slide 108 108 Study population inclusion: employee, between 18 65 yrs, BMI 25 kg/m 2, adequate in Dutch, access to internet exclusion: pregnancy, diagnosis- or treatment of cancer, any disorder that makes physical activity impossible 1386 employees were eligible and randomised to three groups: 1. reference: brochures Dutch Heart Foundation (460) 2. phone: binder and counselling by phone (462) 3. internet: access to website and counselling by e-mail (464) Slide 109 109 Measurements anthropometrics (T0, T6, T24): -weight and length -20% in each group: waist circumference, body fat%, blood pressure, total blood-cholesterol and aerobic fitness questionnaire (T0, T6, T12, T18, T24) -weight -waist circumference -nutrition (fruit, vegetables, fat) -physical activity Slide 110 Timeline T0 - Baseline T6 - 6 months T12 - 12 months T18 - 18 months T24 - 24 months Questionnaire Anthropometrics Questionnaire Anthropometrics Process evaluation Questionnaire Questionnaire Anthropometrics MeasurementsIntervention Slide 111 111 Intervention The Leef je Fit intervention program takes six months and comprises 10 interactive educational modules. In each module participants fill out assignments (in a binder, respective, on internet), designed to assist them in changing their behaviour. Trained counsellors provide feedback on the assignments by either phone or e-mail. Slide 112 112 Slide 113 113 Slide 114 114 Body weight compared to control group, Corrected for baseline differences Slide 115 115 BMI compared to control group, Corrected for baseline differences Slide 116 116 Costs in Euros Control* (n=135) Phone* (n=149) Internet* (n=132) Mean (SD) Mean difference (95% CI) Mean (SD) Mean difference (95% CI) Intervention0273 (89)-277 (108)- Direct (incl. interv.) 668 (832) 1006 (842) 338 (129 to 541) 859 (778) 191 (-12 to 379) Indirect1227 (2904) 1558 (3388) 332 (-485 to 974) 1031 (2521) -196 (-774 to 480) Total1895 (3336) 2565 (3782) 670 (-377 to 1390) 1890 (2894) -5 (-785 to 753) * Participants with complete cost data Slide 117 117 Incremental Cost-Effectiveness Ratios Body weight Phone:735 per kg lost Internet:5 per kg lost Quality of life Phone:128 575 per QALY gained Internet:-18 910 per QALY gained Slide 118 Reshaping an office environment. Does it make sense? Mireille van Poppel, Luuk Engbers, Willem van Mechelen VU University Medical Center, Amsterdam Department of Public and Occupational Health Body@Work TNO-VUmc Slide 119 119 To assess the effects of environmental modifications on physical activity dietary behavior Body Mass Index Biological CVD risk indicators of office workers Aim of FoodSteps Slide 120 120 controlled trial (1 intervention & 1 control site) duration of the intervention 12 months baseline and follow-up measurements at 3 & 12 months population of office workers: Body Mass Index >23 able to take stairs contract until the last follow-up measurement Design Slide 121 121 Intervention Slide 122 122 point-of-decision-signs on elevator doors motivational texts in staircases slim making mirrors in staircases routing of people to the stairs Intervention physical activity Slide 123 123 Routing Motivational texts Intervention physical activity Slide 124 124 food labelling in canteen & vending machines (every 4 weeks a different product group) information corner (computers & brochures) FoodSteps buffet (healthy product offerings, every 2 months) Intervention diet Slide 125 125 Food labelling: caloric values of products translated into number of minutes of a certain activity 1 mars = 270 Kcal 30 minutes stair walking 2.5 hours sitting in a meeting 1 orange = 55 Kcal 6.9 minutes cycling Intervention diet Slide 126 126 Outcomes physical activity Total population: self-reported physical activity (total PA, PA at work, stair use at work) Subgroups: objectively measured stair use at work (hands free detection system & chip cards) objectively measured physical activity (MTI actigraph; total PA and PA at work) Slide 127 127 Results interventioncontrol number of subjects316325 % female37.441.7 age (mean)45.345.5 hrs at work/week (mean)35.336.6 % higher educated69.963.9 BMI (mean)26.426.6 Slide 128 128 self reported stair use median number stairs / week Results stair use Slide 129 129 Intervention effect on self-reported stair use interaction with gender: only statistically significant effect for men self-reported: = 1.41 (objectively measured: = 1.34) interaction with BMI: only statistically significant effect for subjects with BMI < 25 objective: = 1.47 Results stair use Slide 130 130 Intervention effects on cholesterol levels (interaction with gender) Results cholesterol Total cholesterol12 monthsmen = - 0.41 LDL cholesterol 12 monthsmen = - 0.31 12 monthswomen = - 0.41 HDL cholesterol 3 months men = 0.05 12 monthsmen = 0.11 Slide 131 131 Reshaping an office environment. Does it make sense? Conclusion Yes, but more for men than women more for people with lower body mass index effects are modest Slide 132 CONTENT Occupational Health Care Paradigm shift: occ. health ---> workers health What is the problem ? Cost of a physically inactive lifestyle Examples: one to one interventions/supportive environment Who is responsible? Self-regulation or the Nanny State? Slide 133 133 Slide 134 134 Slide 135 135 The solution lies in self-regulation? Slide 136 136 Unless effective population-level interventions to reduce obesity are developed, the steady rise in life expectancy observed in the modern era may soon come to an end and the youth of today may, on average, live less healthy and possibly even shorter lives than their parents. Olshansky et al. NEJM 352:1138-1145, 2005 Slide 137 Self-regulation or the Nanny State? Slide 138 138 Slide 139 139 Slide 140 140 Slide 141 141 Slide 142 142 Slide 143 143 Slide 144 144 Food for thought Slide 145 145 Slide 146 146 Slide 147 147 30 kg approx. 90 minutes swimming to get rid of 100 grams of Dutch cake Three cakes: 3,1 * 3 * 1,5 (uur) = 14 hours of swimming Slide 148 148 Do all these interventions aiming at voluntary behavioral change make Occupational Health sense?? Yes they do, but perhaps more Draconic action is needed!! Slide 149 149 Sanitation: pragmatism works Johan P Mackenbach, BMJ 2006 Slide 150 150 effective intervention does not always need accurate knowledge of disease causation environmental measures may be more effective than changing individual behaviour universal measures may be better than targeted measures in reducing health inequalities Sanitation: pragmatism works Obesity prevention: pragmatism may work also Slide 151 151 Slide 152 152 However, the future looks bright! Slide 153 153