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!!!!!!

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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?

9 Source: UWV, calculations

10 Paradigm shift: from occupational health to workers health

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18 Health threats Noise Radiation Air – pollution (allergens) Chemicals Awkward postures Repetitive motions Heavy loads etc.

19 Solution

20 ‘Modern’ work conditions

21 24 hour economy Service industry Flexible, individualized labor contracts Mental demands Multi-tasking etc. ‘Modern’ labour conditions

22 Health threats Job stress Sedentary job ‘performance’ Inactive commuting ‘Double’ demands (‘juggling the kids’) etc.

23 Solution

24 So, we have experienced change in work conditions ….

25 Added to this, society has changed also………

26 primary and secondary prevention

27 Major health problems Lifestyle (health behaviour) Coping with complaints secondary prevention primary and secondary prevention

28 Major health problems Lifestyle (health behaviour) Disability for work secondary prevention primary and secondary prevention 95% at work 5% off work

29 Paradigm shift Lifestyle (health behaviour) secondary prevention primary and secondary prevention Workers health presenteeism Occupational health absenteeism Disability for work

30 BMI weight/height 2 overweight > 25 obesity > kg by 1,86 m What is the problem?

31 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

32 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

33 Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

34 Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

35 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

36 Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Males © International Obesity TaskForce 2005 % Obesity < 5 % 5-9.9% % % % ≥ 25% Obesity prevalence across Europe,

38 Males © International Obesity TaskForce 2005 % Obesity < 5 % 5-9.9% % % % ≥ 25% Self Reported data Obesity prevalence across Europe,

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41 Obesity

42 Obesity

43 Obesity

44 NL O&O trends ,6 million 36% & 12% = 48% 8,0 million 41% & 18% = 59% 8,7 million35% & 30% = 65%

45 Mixed-longitudinal development of overweight in the Netherlands, men

46 Mixed-longitudinal development of overweight in the Netherlands, women

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52 Source: King & Rewers. Diabetes Care, 1993; 16: Diabetes Mellitus: WHO regional estimates

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54 Workers health Cost of a physically inactive lifestyle

55 Million Euro% tot. health care cost Smoking Overweight Inactivity Too much sat. fat Not enough fruit Not enough vegetables Not enough fish Alcohol Total health care cost Determinants of 2003 lifestyle-related health care cost, 20 y. and older RIVM, Van Baal et al 2007

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57 Projected loss of national income due to heart disease, stroke and diabetes , billions of 1998 US$

58 Obesity and lifestyle-related disease are cost- drivers, so: STOP these diseases, f.i. by becoming physically active

59 healthy lifestylesmokesis obees Life expectancy (years)64,457,459,9 Health care cost due to smoking & obesity related disease Euro Euro Euro Health care cost due to other disease Euro Euro Euro Total health care costEuro Euro Euro Life expectancy and projected health care cost of a 20 year old who has a: RIVM, Van Baal et al 2007

60 Smoking overweight Elimination of overweight and smoking starting in 2003: % effect on health care cost of causally related disease

61 Elimination of overweight and smoking starting in 2003: % effect on health care cost of all disease overweight Smoking

62 However: people with an unhealthy lifestyle also WORK !

63 Work disability in Finns (Rissanen et al. BMJ 1990)

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67 The Netherlands: direct cost:Euro 0,5 billion per year indirect cost:Euro 2,0 billion per year RVZ, 2002

68 It makes sense to introduce worksite health promotion ………………..

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70 Evidence of effectiveness of workplace interventions Behaviour effects++ Health-related effects++ Work-related effects+/? Economic impact (health care & indirect costs)+/?

71 Results from previous reviews Cost savings from absenteeism: $2.5 to 4.9 for each dollar invested Cost savings from health care: $2.5 to 4.5 for each dollar invested Aldana, 2001

72 Results from previous reviews Based on studies of WHP: –Average 27% reduction in sick leave –Average 26% reduction in health care costs –Average 32% reduction in workers’ compensation and disability claim costs –Average $5.81 to $1 savings-to cost ratio Chapman et al. 2005

73 To summarize There are indications for a favourable effect on work-related outcomes and reduced costs, but … Lack of high quality studies (RCTs) that examined the effect of workplace PA/diet interventions on work-related outcomes, and evaluated the economic impact

74 Risk factor identification should lead to risk reduction by intervention----> RCT target population intervention vs. control follow - up outcome random- ization

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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

77 What causes the problem?

78 Need for a common denominator

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80 Glass of beer Some peanuts Croissant Chocolate cookie Energy intake of 140 kcal/week Dia geleend van Seidell

81 Energy expenditure = 21 min = 35 min = 14 min = 19 min Dia geleend van Seidell

82 Trends in Energy-intake (Kilojoules) in the Netherlands Dutch Health Council, Trends in Nutrition, report 2002/12

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85 Physical inactivity Abnormal reaction to a normal environment? Normal reaction to an abnormal environment?

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89 Deteminants of health behaviour (Aarts et al., 1997) External factors awarenesscognition (A/S/E) Behavioural intention behaviour barriers habits Social & physical environment

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

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

92 Individual environment Dutch PACE Foodsteps

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

94 Indirect cost should also be taken into account

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Results: subjects

101 Design cost-benefit analysis Intervention Effect measurements (T0, T1) Work absenteeism (1) Work absenteeism (2) mei 2000januari 2001mei 2001januari 2002

102 Intervention Written information x7 consultations, 20 minutes, trained counsellor Control GroupIntervention group 9 months: May January 2001

103 Individualized Counselling –Daily physical activity –Healthy Nutrition PACE (stages of changes) protocols Intervention

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

105 Cost-benefit analysis € Costs (€) Intervention mean (sd) Control mean (sd)  mean (95% BI) Intervention cost4300 Cost of work absenteeism year (4813)2040 (5030)-125 (-1386;1062) Total cost year (-1029; 1419) Total cost year (4666)2465 (5568)-635 (-1883; 814)

Amsterdam Lifestyle Intervention on Food and Exercise at Work Marieke van Wier 1, Caroline Dekkers 1, Geertje Ariëns 1, Tjabe Smid 1, Ingrid Hendriksen 2, Nico Pronk 3 & Willem van Mechelen 1 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

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.

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 (464)

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

Timeline T0 - Baseline T6 - 6 months T months T months T months Questionnaire Anthropometrics Questionnaire Anthropometrics Process evaluation Questionnaire Questionnaire Anthropometrics MeasurementsIntervention

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 .

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114 Body weight compared to control group, Corrected for baseline differences

115 BMI compared to control group, Corrected for baseline differences

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

117 Incremental Cost-Effectiveness Ratios Body weight Phone:€735 per kg lost Internet:€5 per kg lost Quality of life Phone:€ per QALY gained Internet:€ per QALY gained

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 TNO-VUmc

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

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

121 Intervention

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

123 Routing Motivational texts Intervention physical activity

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

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

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)

127 Results interventioncontrol number of subjects % female age (mean) hrs at work/week (mean) % higher educated BMI (mean)

128 self reported stair use median number stairs / week Results stair use

129 Intervention effect on self-reported stair use  interaction with gender: only statistically significant effect for men self-reported: β = 1.41 (objectively measured: β = 1.34)  interaction with BMI: only statistically significant effect for subjects with BMI < 25 objective: β = 1.47 Results stair use

130 Intervention effects on cholesterol levels (interaction with gender) Results cholesterol Total cholesterol12 monthsmen β = LDL cholesterol 12 monthsmen β = monthswomen β = HDL cholesterol 3 months men β = monthsmen β = 0.11

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

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?

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135 The solution lies in self-regulation?

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: , 2005

Self-regulation or the Nanny State?

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144 Food for thought

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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

148 Do all these interventions aiming at ‘voluntary’ behavioral change make Occupational Health sense?? Yes they do, but perhaps more Draconic action is needed!!

149 Sanitation: pragmatism works Johan P Mackenbach, BMJ 2006

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

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152 However, the future looks bright!

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