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Obesity: Worksite Programs

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 47 studies (search period 1966 - 2005). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to obesity prevention and control.

Context

  • Informational and educational strategies aim to increase knowledge about a healthy diet and physical activity. Examples include:
    • Lectures
    • Written materials (provided in print or online)
    • Educational software
  • Behavioral and social strategies target the thoughts (e.g. awareness, self-efficacy) and social factors that effect behavior changes. Examples include:
    • Individual or group behavioral counseling
    • Skill-building activities such as cue control
    • Rewards or reinforcement
    • Inclusion of co-workers or family members to build support systems
  • Policy and environmental approaches aim to make healthy choices easier and target the entire workforce by changing physical or organizational structures. Examples of this include:
    • Improving access to healthy foods (e.g. changing cafeteria options, vending machine content)
    • Providing more opportunities to be physically active (e.g. providing on-site facilities for exercise)
  • Policy strategies may also change rules and procedures for employees such as health insurance benefits or costs or money for health club membership.
  • Worksite weight control strategies may occur separately or as part of a comprehensive worksite wellness program that addresses several health issues (e.g., smoking cessation, stress management, cholesterol reduction).

Summary of Results

Forty-seven studies qualified for the review and included three outcome measures: body mass index (BMI), weight, and percent body fat.

  • The most common intervention strategies included both informational and behavioral skills components (32 studies). Few studies (4 studies) looked at policy and environmental changes in the worksite.
  • Effects on the three outcomes consistently favored:
    • The intervention group compared to the controls (31 studies)
    • Those receiving more intensive versus less intensive strategies (9 studies).
    • In individually randomized controlled trials, results showed that compared with control groups after 12 months, participating employees lost an average of 2.8 pounds (9 studies) and reduced their average BMI by 0.5 (6 studies).
  • No one focus, diet or physical activity, or combination of both appeared to be better than others in terms of its effect on weight loss.

Summary of Economic Evidence

  • The range of cost-effectiveness estimates from three studies varies from $1.44 to $4.16 per pound of loss in body weight (reported in 2005 dollars).
  • One study conducted a cost-effectiveness analysis of a worksite weight-loss program consisting of three competitions held in business/industrial settings in which participants received a behavioral treatment manual at each weigh-in.
    • Intervention costs for the three competitions were $6149, $1377, and $762, respectively, and included material costs and personnel time for management, employees, and program staff to organize and supervise the program.
    • The cost per pound of weight lost in these three competitions was $4.16 for a 12-week program involving employees of three banks, $2.19 for a 13-week program, and $1.60 for a 15-week program respectively, with the last two competitions involving employees of two manufacturing companies. The lower cost per pound lost in Competitions 2 and 3 was due to decreased organizational expenses compared to Competition 1.
  • One study analyzed the cost effectiveness of team competitions and estimated a cost of $1.45 to lose 1% of body weight.
    • Costs included time of the committee that planned, coordinated, and administered the program, employee time, and minimal costs of photocopying manuals and material costs for posters.
  • One study assessed the cost effectiveness of a 3-month worksite weight-loss program that included concepts of competition and self-responsibility in an education-based campaign.
    • The campaign cost was $25,376 and the study reported a cost of $1.77 per pound of weight lost.
  • One study reported costs for a self-help weight loss awareness campaign where each participant was given a kit with information on how to start a safe weight-loss program. Costs included personnel time and materials for typesetting, printing flyers, and posters.
    • The intervention cost was $2634 excluding volunteer time and $3966 including 166 hours of volunteer time valued at $8.04 per hour.
    • Cost-effectiveness ratios were $2.17 and $1.44, respectively, per pound of weight lost with or without the cost of volunteer time; however, the follow-up period was much shorter than that required for the effectiveness review.
  • One study reported a reduction in disability and major medical costs of $1022.96 per participant at a worksite physical fitness program for a 1-year period, excluding costs of maternity or obstetrics-related claims.
    • The intervention costs of $75,750 included the first-year budget for operating expenses, annual cost of laboratory tests and physical examinations, and annual cost of capital investment in equipment amortized more than 20 years.
    • Although the study did not report any change in employee weight, there was a significant decline in the percentage of body fat.
    • The intervention returned $1.59 for every dollar invested in the program resulting in a net saving of $0.59 per $1.00.

Applicability

Based on the data available, the results of this review may be generalized to a white-collar workforce where both overweight and other chronic disease risk conditions exist.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

Although we found evidence that worksite programs targeting nutrition and physical behaviors confer modest, positive, weight-related benefits, important research questions remain. One of our initial review questions was only partially answered: which employee populations benefit the most from worksite health promotion interventions targeted at weight? Weight status varies considerably among employee populations. Reporting individual weight measure for employees from baseline to follow-up is not feasible in large occupational health studies. Instead, measurement of weight change in the studies we reviewed was usually presented as group mean change in BMI, pounds, kilograms, or percent body fat. Thus, we could not determine if those at greatest risk (i.e., overweight or obese) benefited more or less. Nor could we determine if a few employees lost a large amount of weight or if many employees lost small amounts. In addition to measuring mean weight change, it would also be useful to learn what percent of participants had clinically meaningful weight loss (i.e., >5% or >10 % body weight loss). Also, reporting changes in the prevalence of overweight and obesity in the employee population as a result of the intervention would provide information about intervention effects at the population-level. Highly effective interventions that reach only a small percent of the population will likely not affect the prevalence.

Forty percent the studies lacked information to determine differential effects according to blue or white collar job status. Those that did report occupational status included predominantly white collar workers. Race and ethnicity data were also limited.

A variety of worksite settings were represented in this review, which lends to the generalizability of the findings. Information on the feasibility of implementing programs across small to very large worksite settings, however, was hampered by missing workplace size data in 64% of the studies. We found no association between program effectiveness and focus of the program (e.g., CVD risk reduction, weight loss, physical fitness) or behavioral focus (diet or physical activity). Because the majority of programs used behavioral plus informational strategies, it was difficult to contrast program components with respect to effectiveness. Questions remain about the effect on employee weight status when implementation of environmental change (e.g., providing easy access to affordable, healthy foods, or modifying the physical environment to encourage physical activity) and employer policy strategies (health insurance incentives, contribution to gym membership fees, etc.) is included.

One third of the RCTs provided insufficient statistical information to allow meta-analytic pooling of effects. Only a few reported intention to treat analysis. Reporting on intervention intensity, duration, and fidelity was often ambiguous. Future studies will contribute more to the empirical knowledge base if they follow the CONSORT guidelines for reporting RCTs and TREND guidelines for reporting non-randomized studies.

Study Characteristics

  • Half the studies were conducted in the U.S.; remaining studies were conducted in Europe, Australia, New Zealand, Japan, Canada, India, and Iceland.
  • The purpose of the interventions, as stated by study authors, included CVD risk reduction (34%); weight control (26%); and physical fitness (19%).
  • The behavioral focus of each intervention included diet and physical activity behaviors (57%); diet only (21%); and physical activity only (21%).
  • Study participants were coded as white-collar or blue-collar workers based on descriptions in the studies and nature of the company. In 19 studies, this could not be determined; in 25 studies, the majority of participants (80%) held white-collar jobs; in the remaining four studies, the participants held blue-collar jobs.
  • Among studies that reported gender of participants, most included both men and women (64%).
  • Among 46 of the 47 included studies, the median sample size was 141 (range 29–3728). The final study, a WHO multicountry trial, had a sample size of 63,732.
  • Of the 39 studies reporting attrition, the median attrition rate was 17% (range: 0%–82%).

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