Effect of a Workplace Weight-Loss Program for Overweight and Obese Healthcare Workers

Abstract

Purpose:

Examining the effect of a workplace weight-loss program on weight loss, and physical, behavioral and mental well-being among overweight/obese healthcare workers.

Design:

Quasi experimental design

Setting:

Single healthcare setting

Participants:

Forty-one (48.0 ± 11.2 years) day-time shift healthcare employees with body mass index [BMI] >29 kg/m².

Intervention:

Sixteen-week program with weekly group meetings/activities and individual appointments with nutrition/health experts.

Measures:

Objective (weight, BMI, blood pressure) and self-reported measures were collected at baseline, conclusion of the intervention and 3 to 6 months post-intervention.

Analysis:

Repeated measure analysis accounting for confounders.

Results:

Participants had an average of 13 pounds (5.6%) weight loss (224.2 ± 6.4 vs. 211.6 ± 6.4 lbs.; P < 0.0001) upon program completion with significant decreases in BMI (37.7 ± 1.0 vs. 35.1 ± 1.0 kg/m²; P < 0.0001). Extreme obesity (BMI≥40 kg/m²) rate was reduced from 36.6% to 17.1% (P < 0.0001). There were decreases in diastolic blood pressure (76.0 ± 1.4 vs. 68.7 ± 1.5 mmHg; P = 0.001) and self-reported blood glucose (119.9 ± 4.4 vs. 105.5 ± 4.6 mg/dL; P = 0.03). Participants had improvements in weekly physical activity (25% change; P = 0.01), nutrition behavior (33% change, P < 0.0001), sleep quality (23% change, P = 0.005), and depression (72% change, P < 0.0001). Twenty-seven participants had post-intervention follow-up data. On average participants regained 8 pounds, which was less than the initial weight loss (16 lbs., N = 27).

Conclusion:

The results suggest the program may benefit healthcare employees. Further emphasis should be placed on post-intervention weight management to prevent weight regain.

Keywords

healthcare setting workplace weight-loss program healthcare worker obesity weight loss

Purpose

The prevalence of obesity continues to increase among adults in the United States.¹ Currently, 38% of US adults are obese with approximately 8% classified as extreme (class III) obesity (body mass index [BMI] ≥40 kg/m²).² Obesity has been associated with physical and mental health concerns, such as Type 2 diabetes, hypertension, cardiovascular diseases and depression causing burdens on the health care system.³ Encouragingly, research shows weight loss of 5% to 7% through optimal nutrition and physical activity can improve these health conditions.⁴ The workplace can be an ideal setting to promote lifestyle interventions since a large majority of an employee’s time is spent at work.⁵ Previous studies suggest that workplace wellness programs for weight loss have the potential to improve employee health,^6

-9 thereby reducing employee absenteeism, health care costs, and risk of developing chronic diseases.^10
-12

Health care professionals who are working with patients daily to improve patient’s health may neglect their own health with unfavorable behaviors such as poor dietary intake and lack of physical activity. An evaluation of 924 employees across 6 hospitals found an obesity rate of 78% among these employees.¹³ Another study demonstrated that hospital workers had higher prevalence of obesity compared to the national average possibly due to a potentially stressful environment, long work hours and overnight shifts.¹⁴ Evidence further suggests female nurses, the largest professional group in the healthcare setting, have an increased risk of cardiovascular disease¹⁵ and Type 2 diabetes¹⁶ most likely attributable to obesity, physical inactivity and sedentary behaviors.^15,16 Thus, it is critically needed for a workplace program that effectively addresses modifiable factors to reduce the risk of obesity and chronic diseases for healthcare workers.

Better Living intervention (Better Living) is an ongoing, 16-week employee weight-loss program that is group-based combined with individual appointments with nutrition/health experts in a healthcare setting. The purposes of this study were: 1) to determine whether Better Living promoted a significant weight loss (weight, BMI) among overweight and obese employees in a healthcare setting; and 2) to examine the effects of the program on metabolic health (blood pressure, glucose, and lipids), lifestyle behaviors (nutrition, physical activity), sleep duration and quality, and mental wellbeing (depression) among study participants. Although not our primary focus, we performed follow-up assessments on weight changes after the completion of the initial 16-week program to explore the patterns of post-intervention weight control.

Methods

Design

The recruitment was conducted via e-mail to Methodist Health System employees and the health system website with detailed program information. Employees completed an admission application, which was screened by the Program Director (Nurse Practitioner, NP) for eligibility requirements. Due to the availability of space and staff, the program aimed for enrolling a total of 120 eligible employees on first-come, first-serve basis with 6 repeated program sessions and a maximum of 20 employees in each session. Each program session was 16 weeks long and received the same program curriculum but had different start dates. From February 2017 to October 2018, we conducted a total of six 16-week program sessions with an average of 19 employees in each session (total of 114 employees enrolled in the program). All the program sessions were held at the Methodist Center for Diabetes and Nutritional Health, a hospital-based clinic affiliated with Methodist Hospital (Omaha, NE). Employees participating in the program were day-time shift workers (nurses, medical assistants, physical therapists and support staff) at the Methodist Health System with varying degrees of active and sedentary behaviors on the job. They attended meetings after work hours (weekdays at 5 pm). All 114 employees completed the 16-week Better Living program. Body weight along with height (for BMI calculation) were measured for all employees (N = 114) who participated in the program.

At the beginning of each 16-week program session, each participating employee was asked to participate in the research study which included completing additional pre and post measures to assess the effectiveness of the program. Forty-five employees (39.5%) agreed to participate in the research study while 69 (60.5%) declined mainly due to time constraint (for completing additional measures) and/or lack of interest. Forty-one employees (91%) completed all the pre- and post-program measures for the research study. This paper presents primarily the research study results. Since Better Living was created for programming purposes and the research study was an additional component to evaluate the program, Methodist Institutional Review Board (IRB) deemed the Better Living program including the research study exempt from IRB approval. However, written informed consent was obtained from each participant before data collection.

Sample

Study participants were recruited for the Better Living program from the Methodist Health System in Omaha, Nebraska. The Methodist Health System includes 3 hospitals, 21 clinic locations and a nursing and allied health college in the metro and surrounding areas of Omaha, Nebraska (www.bestcare.org). Eligibility criteria included: 1) being a Methodist Health System employee, 2) age of 19 years or older, 3) having a BMI >29 kg/m², 4) being enrolled in the Methodist Health System health insurance plan, and 5) currently not pregnant.

Intervention

The Better Living curriculum based on Social Cognitive Theory¹⁷ was created by the Program Director (NP) who is employed with the Methodist Health System as the director of the new weight-loss program for employees. A quasi-experimental design was used since Better Living is an employee wellness program and the intervention curriculum was required to be given to all eligible employees. Weekly group meeting topics included education to improve nutrition and physical activity, promote cognitive and behavioral changes, and improve mental health and sleep quality. Topics were presented by NP, Registered Dietitians (RD), motivational speakers, exercise specialists, and chefs (Table 1). The weekly group meetings/activities also provided employees an opportunity to form social support by sharing their positive experiences and barriers related to the weight-loss process.

Table 1.

Weekly Topics of the Better Living Program Group Meetings.

Week	Topic	Presenter^a
1	Welcome!	NP
2	Healthy Eating	RD
3	Grocery Store Tour	RD
4	“Put up Your Umbrella”	Motivational Speaker
5	Weight Lifting Class	Exercise Specialist
6	“Lifestyle: The Best Medicine”	Wellness & Health speaker
7	“Fitness: It’s a Lifestyle”	Exercise Specialist
8	Sports Nutrition	RD
9	“Transform Your Life with Exercise”	Exercise Specialist
10	“A New You”	Motivational Speaker
11	Cooking Class	RD
12	Meal Preparation Class	RD
13	“Working out at Home”	Exercise Specialist
14	Chef Cooking Class	Culinary Specialist/Chef
15	Exercise Class	Exercise Specialist
16	“Sleep and Its Role in Weight”	NP

^a NP: Nurse Practitioner; RD: Registered Dietitian.

In addition to the 16-week group-based meeting/activities, 16 individual weekly appointments were conducted with weight-loss experts (NP or RD) to measure weight, help employees set weekly behavioral goals and address individual successes and barriers in meeting the previous week’s goals. In brief, realistic and achievable weekly behavioral goals were set by participants based on individual needs with the guidance of program staff (NP or RD). A majority of goals were centered around nutrition, physical activity and sleep quality, such as “Will walk 10,000 steps daily”; “Will add one cup of low-fat dairy to dinner meal”; and “Will turn off electronics 30 minutes before bedtime.” Weekly goals were reviewed with NP or RD and categorized into “Met goals”; “Continue to meet goals”; and “Did not meet goals.” Participants either set a different goal if previous goal was met or set the same goal if the participant was still working on or did not meet the goal. Long-term weight-loss goals were set with each participant at the beginning of the 16-week program, such as “I will lose 10 to 15 pounds by the end of the 16-week program.” The overall goal for the program was for Better Living participants to lose 5% to 7% of their pre-program (baseline) weight, which is based off the American Heart Association Guidelines for weight management.⁴ Social media (e.g., Facebook) was used throughout the program to promote healthy recipes, nutrition and exercise tips and motivational statements to improve moral of employees and keep them engaged. Additional attention was given to employees to ensure engagement in the program, such as follow-up phone calls during the week, phone calls after employees missed meetings, and recorded meetings to view on Facebook. Weight, BMI (for all Better Living participating employees) and additional measures (for research study participants) were collected at baseline (1st week) and conclusion of the program (16th week). After completion of the initial 16-week programming session, employees were eligible and encouraged to participate in follow-up sessions including monthly group meetings and quarterly weigh-ins with NP or RD to promote continued weight loss or prevention of weight regain.

Measures

Anthropometrics and metabolic health indicators

Employee’s weight and height were objectively measured with light clothing and no shoes using a weight scale and stadiometer by program staff (NP or RD) and BMI (person’s weight in kilograms divided by the square of height in meters) was calculated. BMI classifications for overweight and obesity were defined according to Centers for Diseases Control and Prevention (CDC) guidelines as follow: overweight, BMI of 25-29.9 kg/m²; class I obesity, BMI of 30-34.9 kg/m²; class II obesity, BMI of 35-39.9 kg/m²; and extreme (class III) obesity, BMI of 40 kg/m² or higher.¹⁸ All participants had BMI measures greater than 29 kg/m². Blood pressures (systolic and diastolic blood pressures) were also objectively measured during the individual appointments at baseline and at the end of the intervention following a standard protocol described elsewhere.¹⁹ We also collected self-reported metabolic health indicators including blood lipids (total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides) and blood glucose. Participants reported these values based on objective lab reports from their employee wellness screening from the Methodist Health System.

Nutrition behavior and physical activity

Lifestyle behaviors were measured using a previously validated survey including nutrition (following a healthful eating plan; eating ≥5 servings of fruits and vegetables; consuming high fat foods) and exercise (participating in at least 30 minutes of physical activity; participating in a specific exercise session).²⁰ Participants reported on the frequency with which they had these behaviors over the past 7 days (day/week) and the responses were scored from 0-7 accordingly. Individual items in each of the above categories (nutrition, exercise) were summed to create a total score; reverse scoring was used for a negative item (e.g., consuming high fat foods) for total score calculation. We also measured weekly physical activity using the Block Physical Activity Screener.²¹ This brief screening tool contained 11 items including job-related as well as daily life and leisure activities based upon the National Human Activities Patterns Survey data. Metabolic equivalent of task (MET) minutes were calculated for weekly total physical activity (including low-intensity, moderate and vigorous physical activity) using the Ainsworth Compendium.²²

Sleep duration and quality

Participants completed a question about sleep time (hours of sleep per night) and a Pittsburgh Sleep Quality Index (PSQI), a self-reported and validated questionnaire that assesses sleep quality over a 1-month time interval. PSQI consists of 7 domains measuring several different aspects of sleep. Scoring of the answers is based on a 0 to 3 scale, whereby 3 reflects the negative extreme on the Scale. The global PSQI score is then calculated by totaling the 7 component scores to provide an overall score ranging from 0 to 21 points; lower scores correspond to a better sleep quality.²³

Depsression

Depression was measured using a nine-item self-administered Patient Health Questionnaire (PHQ-9). Depression severity was calculated by assigning scores of 0, 1, 2, and 3, to the response categories of “not at all” “several days,” “more than half the days,” and “nearly every day,” respectively. PHQ-9 total scores range from 0 to 27. Scores of 5, 10, 15, and 20 represent cut-points for mild, moderate, moderately severe and severe depression, respectively.²⁴

Analysis

Descriptive statistics was used to compute means or frequencies of baseline characteristics of study participants. Differences in measures at baseline versus at the conclusion of the intervention (16-week follow-up) were assessed using repeated measure analysis. Two models were performed: Model 1 did not include covariates. Model 2 was adjusted for covariates including age, sex, education (college graduates vs. non-college graduates), smoking status (current smoker vs. non-current smoker) and baseline diagnosis of metabolic conditions (Type 2 diabetes, high blood pressure, and/or high blood lipids). Chi-square test was used to compare pre- and post-intervention extreme (class III) obesity rates. Analyses for changes in outcome variables were primarily based on the 41 research study participants who completed all the post-intervention measures. We performed sensitivity analyses for weight and BMI changes (since weight and BMI were measured for all employees enrolled in Better Living) and results did not change materially with and without the inclusion of the participants (N = 4) who did not complete the additional post-intervention measures. SAS software version 9.4 (SAS Institute, Cary, NC, USA) was used for all analyses. We conservatively used 2-tailed tests, and P < 0.05 was considered statistically significant.

Power analysis

An a priori power estimate suggests that our sample size (N = 41) was adequate (>80% statistical power) for detecting medium effects (d = 0.5) of within-group changes (differences between baseline and conclusion of the intervention) on outcome measures (weight, BMI, lifestyle behaviors, etc.) assuming α = 0.05 (2-tailed) based on Cohen’s recommendations²⁵ as well as based on a previous study we conducted examining the effect of a 12-week text message intervention on lifestyle behaviors.²⁶ For post-intervention follow-up, we performed a retrospective power analysis for the subsample of participants (N = 27) who had follow-up weight data available. With a sample size of 27, we had 61% statistical power to detect large effects (d = 0.8)²⁵ of within-group changes (α = 0.05, 2-tailed).

Results

Baseline Characteristics

The mean age of employees who completed the research study was 48.0 ± 11.2 years. The majority were female (95.1%) and white (95.1%) and 41.5% had a college education. At baseline, all participants had BMI values >29 kg/m²; 85.4% were obese (BMI ≥30 kg/m²) and 36.6% were classified as extreme (class III) obesity (BMI ≥40 kg/m²). In addition, 26.8% of participants had high blood pressure, 39.0% had high blood lipids, 4.9% had Type 2 diabetes and 14.6% had prediabetes (Table 2). The demographics for research study participants (N = 41) were comparable to all the employees who participated in Better Living program (N = 114; 49.9 ± 10.5 years of age; 95.5% female; 92.7% white).

Table 2.

Baseline Characteristics of Study Participants.

Characteristics (N = 41)
Age (year)	48.0 ± 11.2
Sex (%)
Male	4.9
Female	95.1
Race/ethnicity (%)
White	95.1
Black	4.9
Income (%)
<$25,000	2.6
$25,000-$50,000	46.2
$75,000-100,000	33.3
≥100,000	17.9
High school graduation (%)	97.6
College graduation or above (%)	41.5
Current smoker (%)	7.3
BMI (kg/m²)	37.7 ± 6.7
BMI categories^a (%)
Overweight	14.6
Class I obesity	17.1
Class II obesity	31.7
Class III obesity	36.6
History of metabolic conditions^b (%)
Hypertension	26.8
High blood lipids	39.0
Type 2 diabetes	4.9
Prediabetes	14.6

Data are given as mean ± standard deviation unless otherwise specified; BMI = body mass index.

^a Overweight: BMI of 25-29.9 kg/m²; Class I obesity: BMI of 30-34.9 kg/m²; class II obesity: BMI of 35-39.9 kg/m²; class III obesity: BMI ≥40 kg/m². All participants had BMI >29 kg/m².

^b Based on self-reported data.

Effects of the 16-Week Better Living Intervention

Objectively measured weight, BMI, and blood pressure and self-reported metabolic health indicators are shown in Table 3. On average, participants lost 13 pounds (5.6% weight loss) after completing the 16-week Better Living program (from 224.2 ± 6.4 to 211.6 ± 6.4 lbs.; P < 0.0001). BMI was also significantly deceased (from 37.7 ± 1.0 to 35.1 ± 1.0 kg/m²; P < 0.0001) after the intervention. In addition, prior to the intervention, 36.6% of the participants were classified as extreme (class III) obesity which was reduced to 17.1% (P < 0.0001) at the conclusion of the intervention. There were significant decreases in diastolic blood pressure (objectively measured; from 76.0 ± 1.4 to 68.7 ± 1.5 mmHg; P = 0.001) and blood glucose levels (self-reported; from 119.9 ± 4.4 to 105.5 ± 4.6 mg/dL; P = 0.03) after 16 weeks compared to baseline. The above results remained statistically significant after adjusting for age, sex, race/ethnicity, education, smoking, and disease history. No significant differences were observed in systolic blood pressure (P = 0.07) and self-reported blood lipids concentrations (total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides; Ps > 0.05) between baseline and the conclusion of the 16-week intervention.

Table 3.

Health Indicators at Baseline and 16-Week Follow-up.

	Baseline	16-week follow-up	Percent (%) change^a	P Model 1^b	P Model 2^c
N	41	41
Body weight (lbs.)^d	224.2 ± 6.4	211.6 ± 6.4	-5.6	<0.0001	<0.0001
Body mass index (kg/m²)^d	37.7 ± 1.0	35.1 ± 1.0	-6.9	<0.0001	0.0003
Blood pressure^d
Systolic blood pressure (mmHg)	122.2 ± 2.5	116.5 ± 2.7	-4.7	0.07	0.16
Diastolic blood pressure (mmHg)	76.0 ± 1.4	68.7 ± 1.5	-9.6	0.001	0.005
Other health indicators^e
Total cholesterol (mg/dL)	188.8 ± 8.0	180.6 ± 8.1	-4.3	0.20	0.08
HDL cholesterol (mg/dL)	55.9 ± 5.4	60.6 ± 5.4	+8.4	0.33	0.32
LDL cholesterol (mg/dL)	107.4 ± 7.0	95.0 ± 7.2	-11.5	0.08	0.17
Triglycerides (mg/dL)	126.2 ± 8.5	117.2 ± 8.7	-7.1	0.22	0.13
Blood glucose (mg/dL)	119.9 ± 4.4	105.5 ± 4.6	-12.0	0.03	0.04

Data are given as mean ± standard error of the mean unless otherwise specified.

^a Percent (%) change = [(value at 16-week follow-up − value at baseline) / value at baseline] x 100%.

^b P values for differences between baseline and 16-week follow-up (post-intervention) using repeated measure analysis. Model 1 did not adjust for covariates.

^c P values for differences between baseline and 16-week follow-up (post-intervention) using repeated measure analysis. Model 2 was adjusted for age, sex, education, smoking, and baseline diagnosis of Type 2 diabetes, high blood pressure, or high blood lipids.

^d Body weight, body mass index, systolic blood pressure and diastolic blood pressure values were based on objective measures performed by program staff.

^e Based on self-reported measures.

The average weight loss among research study participants (N = 41) was comparable to all employees enrolled in Better Living (N = 114; baseline: 230.3 ± 3.7 lbs., 37.7% extreme [class III] obesity; post-intervention: 214.5 ± 3.7 lbs., 16.7% extreme [class III] obesity; 6.8% weight loss) (Figure 1). Further, 73.3% of the research study participants (30 out of 41) lost ≥5 pounds weight and 46.3% (19 out of 41) achieved the program goal for losing ≥5% of baseline weight. The rates were even higher for all the Better Living participating employees (N = 114) as 85.1% lost ≥5 pounds and 61.4% lost ≥5% of baseline weight.

Figure 1.

Body weight (A) and percentage of participants who were classified as extreme (class III) obesity (BMI≥40 kg/m²) (B) at baseline (pre) and the conclusion of the Better Living intervention (post) for employees who participated in the research study (N = 41) and all the eligible employees who were enrolled in the Better Living program (N = 114).

The scores of lifestyle behaviors (nutrition, exercise) were significantly increased after intervention (Ps < 0.01) except for intake of high fat foods. Particularly, there was an approximately 2-fold increase (from 2.5 ± 0.3 to 4.4 ± 0.3 days) in the number of days per week for consuming ≥5 servings of fruits and vegetables. In addition, weekly physical activity MET minutes were significantly higher at the 16-week follow-up (6073 ± 481) compared to baseline (4873 ± 477, P = 0.01). Further, although sleep duration did not change significantly, there was a significant improvement in PSQI scores for sleep quality (6.6 ± 0.61 versus 5.1 ± 0.6; P = 0.005; lower PSQI score indicates better sleep quality) (Table 4).

Table 4.

Nutrition, Physical Activity, Sleep and Depression at Baseline and 16-Week Follow-Up.

	Baseline	16-week follow-up	Percent (%) change^a	P Model 1^b	P Model 2^c
N	41	41
Nutrition (day/week)
Follow a healthy eating plan	4.0 ± 0.3	5.4 ± 0.3	+35.0	<0.0001	0.0001
Eat ≥5 servings fruits & vegetables	2.5 ± 0.3	4.4 ± 0.3	+76.0	<0.0001	<0.0001
Eat high fat foods	2.2 ± 0.3	2.0 ± 0.3	-9.1	0.30	0.38
Total score for nutrition^d	11.0 ± 0.7	14.6 ± 0.7	+32.7	<0.0001	0.0001
Exercise (day/week)
Participate in ≥30 min physical activity	2.7 ± 0.3	3.4 ± 0.3	+25.9	0.003	0.006
Participate in a special exercise session	1.9 ± 0.4	3.1 ± 0.4	+63.2	0.005	0.009
Total score for exercise^d	4.6 ± 0.7	7.0 ± 0.7	+52.2	<0.0001	0.005
Physical activity (MET min/week)^e	4873 ± 477	6073 ± 481	+24.6	0.01	0.01
Sleep quality
Sleep time (hr/night)	7.0 (0.5)	7.1 (0.5)	+1.4	0.35	0.52
PSQI score^f	6.6 ± 0.6	5.1 ± 0.6	-22.7	0.005	0.002
Depression
PHQ-9 score^g	7.6 ± 0.7	2.1 ± 0.7	-72.4	<0.0001	<0.0001

Data are given as mean ± standard error of the mean unless otherwise specified.

^a Percent (%) change = [(value at 16-week follow-up − value at baseline) / value at baseline] x 100%.

^b P values for differences between baseline and 16-week follow-up (post-intervention) using repeated measure analysis. Model 1 did not adjust for covariates.

^d The scores of individual items in the category (Nutrition or Exercise) were summed and the total score of the category was calculated. The negative item (eat high fat foods) was reversely scored for calculating the total score.

^e MET = metabolic equivalent of task; physical activity included low-intensity, moderate and vigorous physical activities.

^f PSQI score = Global Pittsburg Sleep Quality Index score; a lower score represents better sleep quality.

^g PHQ-9 = Total score of Patient Health Questionnaire; a higher score indicates more severe depression. Scores of 5, 10, 15, and 20 represent cut-points for mild, moderate, moderately severe and severe depression, respectively.

Depression status was also improved as significantly lower PHQ-9 scores were observed at the 16-week follow-up (2.1±0.7) relative to baseline (7.6 ± 0.7; P < 0.0001). Moderate/severe depression (PHQ-9 scores≥10) rate decreased from 33.3% at baseline to 3.0% post-intervention (P < 0.0001). Similarly, adjustment for aforementioned covariates did not change the results (nutrition, physical activity, sleep, and depression) materially (Table 4).

Post-Intervention Follow-Up

Twenty-seven (65.8%) research study participants returned for quarterly weigh-in appointments within 3 to 6 months after completion of the initial 16-week program. Due to the lack of sufficient statistical power (61% statistical power), we did not perform statistical tests to evaluate whether the follow-up weight outcomes significantly differed from weight data at baseline and at the conclusion of the intervention. However, we were able to explore the patterns of post-intervention weight changes. The mean follow-up weight (218.3 ± 7.7 lbs.) was higher than that at the conclusion of the program (210.5 ± 7.4 lbs.) but lower than baseline (227.3 ± 7.2 lbs.) (Figure 2). On average participants regained approximately 8 pounds which was still less than the initial weight loss (16 lbs.) for this subsample of 27 participants. Eight participants continued to lose weight and 3 participants gained less than 5 pounds during the post-intervention follow-up.

Figure 2.

Mean body weight at baseline, 16 weeks (conclusion of the Better Living intervention) and 3 to 6 months post Better Living intervention (post-intervention follow-up) (N = 27).

Discussion

Our study found significant decreases in weight and BMI among overweight and obese employees after the Better Living intervention. In particular, participants achieved an average of 5.6% weight loss (6.8% for all employees enrolled in Better Living), which reached the threshold (5-7% weight loss) that is considered clinically important in reducing the risk of Type 2 diabetes and other health concerns.^4,27 In addition, extreme (class III) obesity proportion was reduced from 36.6% at baseline to 17.1% at the conclusion of the intervention.

The Better Living program was novel in the following aspects. All of the Better Living participants had a BMI >29 kg/m² with a significant portion (36.6% for research study participants and 40.3% for all employees enrolled in the program) classified as extreme (class III) obesity. Improvements in weight status among employees who participated in workplace weight-loss programs have been previously documented.^6

-9 However, few studies have explored the impact of such programs for healthcare employees who were extremely obese. It has been recommended that weight-loss interventions individualize decision-making to enhance outcomes and program success.²⁷ The intervention strategies of Better Living, that is, group meetings/activities combined with individual appointments with experts were created based on these recommendations and previous successful weight-loss studies that were conducted in different populations (e.g., non-healthcare workers) and settings that were not associated with the workplace or healthcare.^28
-30 Thus, our results suggest that these intervention strategies may also be used to create a successful workplace weight-loss program for overweight and obese healthcare workers. To overcome the challenge of post-intervention weight regain, follow-up strategies such as encouraging participants to attend monthly meetings and quarterly weigh-ins were used to help participants maintain the weight loss.

In our study participants achieved more weight loss (5.6%) compared to a recent study by San Mauro Martin et al. (2.4% for women; 2.9% for men) with a similar study design that assessed the effectiveness of a 12-week workplace weight-loss intervention combining nutrition education and individualized counseling with nutrition experts to enhance behavioral changes.⁸ This could be partly due to the fact that our participants had a higher mean baseline BMI (37.7 kg/m²) compared to the study by San Mauro Martin et al. (29.4 kg/m² for women, 29.8 kg/m² for men).⁸ We also observed metabolic health indicators such as diastolic blood pressure (objectively measured) and blood glucose (self-reported) were improved after the intervention, suggesting that weight loss may have positive effects on some health conditions associated with obesity. However, due to the quasi-experimental design without the involvement of a control/comparison group and randomization, it was relatively difficult to evaluate how much of the weight loss was exclusively attributed to the Better Living intervention. That being said, since we have achieved 5.6% (for research participants) to 6.8% (for all employees who participated in Better Living) reduction in weight from baseline, it is unlikely our results on weight loss were contributed largely by factors other than the Better Living intervention. Although randomized trials are warranted to confirm the current results, the Better Living program could serve as a basis and provide valuable insights for developing more sophisticated or enhanced weight-loss interventions in the future for employees at healthcare settings since there are very few good-quality workplace programs tailored to this population.

We explored the patterns of post-intervention weight control by examining weight changes over a period of 3 to 6 months after completing the initial 16-week program. The patterns varied based on the 27 participants who returned for their quarterly weigh-in appointments. On average, participants gained approximately 8 pounds but the amount of weight regained was nevertheless half of the average weight loss after the initial 16-week intervention (16 lbs.) from the subsample of 27 participants. In addition, 8 participants (out of 27) continued to lose weight and 3 gained less than 5 pounds. Maintenance of weight loss has been shown to be much more difficult than losing weight in the first place.^31,32 While it is often stated that weight maintenance requires different strategies than those used for initiating the weight loss, research evidence suggests what facilitated the initial weight loss had to be sustained over the long-term to support weight maintenance.³³ The post-intervention weight gain observed in some of the participants in our study could be partly explained by the substantially reduced number of contacts/appointments made with weight-loss experts. For example, participants had appointments/meetings twice a week (group-based meetings and individual appointments) during the initial 16-week program session while the number of appointments was reduced to once a month after the intervention because of the work load and schedule conflict of program staff as well as participating employees. Therefore, we need to continue to explore and evaluate innovative strategies, for example using technologies (text messages, social media, etc.) to facilitate social support and motivate people to continue the weight-loss efforts after completing the program. Additionally, the post-intervention follow-up period in our study was relatively short since the follow-up weight assessment was not included initially in the research study. Thus, longer follow-up period with larger sample size would provide a more complete picture for understanding post-intervention weight control patterns and help determine whether the weight-loss intervention was successful over the long-term.

It has been well recognized that lifestyle-based weight-loss interventions improved health behaviors associated with nutrition and physical activity in addition to achieving weight loss.^7,9,34 Likewise, we found that nutrition related behaviors improved with the 16-week Better Living intervention. Especially, the number of days of eating ≥5 servings of fruits and vegetable was doubled from 2 days to 4 and half days per week. This study also observed that the Better Living program increased weekly MET minutes of physical activity as well as exercise related behaviors such as participating in ≥30 minutes of physical activity and a specific exercise session during the week. These positive changes may be the result of educational components focusing on healthy eating and physical activity. For example, having nutrition and exercise specialists to address the importance of eating healthy and being physically active, as well as having group exercise activities/sessions as part of the 16-week program. Including group exercise activities/sessions may have possibly allowed employees to be introduced to different types of physical activities and motivated employees to increase daily activity or join a fitness center and participate in a group exercise class at the fitness center.

Although the link between sleep and obesity was not conclusively established,³⁵ the importance of improving sleep quality and duration should still be addressed in weight-loss programs.³⁶ One educational session of Better Living was dedicated to improving sleep quality (e.g., strategies to reduce sleeplessness; activities to avoid before going to bed that hinder sleep quality; activities that enhance sleep quality). These efforts along with weekly goal setting with participants that focused on increasing sleep quality and quantity were evident by improved PSQI scores after the program. We did not observe statistically significant increases in sleep duration after the intervention. However, on average participants already had 7 hours of sleep per night at baseline and this level was maintained through the end of the intervention.

We found that depression scores were improved from 7.6 (mildly depressed) at baseline to 2.1 (not depressed) at the 16-week follow-up. Obesity and depression appear to be closely related; Individuals with obesity were more like to have depression compared to those with normal weight,³⁷ and the prevalence of obesity was high among adults with depression.³⁸ Better Living intervention aimed to improve both physical health and mental well-being for employees. Several classes in Better Living were dedicated to motivational speakers who overcame weight struggles and found success which is a novel addition to the weight-loss program and may have played a role in the overall motivation and increased feelings of well-being among the employees. Weekly group meetings/activities and being employed in the same workplace enabled participants to gain support from each other and feel cohesiveness in working toward weight loss as well as improved physical and mental health. Few randomized trials used integrated intervention strategies to simultaneously address weight and depression and results from these studies were ambiguous.^39
-41 Two were conducted solely in women, of which one found no effects of intervention on depression or weight³⁹ and the other reported improved depression but not weight after the intervention.⁴⁰ The most recent randomized trial by Ma et al. involving both men and women with coexistence of obesity and depression reported that a collaborative intervention integrating behavioral weight-loss treatment, problem-solving therapy, and as-needed antidepressant medications resulted in significant weight loss and improvement in depressive symptoms.⁴¹ The researchers reported their participants who were obese had moderate depression (PHQ-9 score = 13.8) at baseline.⁴¹ We also observed improvements in both weight and depression after the 16-week Better Living intervention. Our participants had similar average BMI values at baseline but lower mean PHQ-9 scores (PHQ-9 score = 7.6; mild depression) compared to what reported by Ma et al.⁴¹ However, we did not include a control group due to the nature of the Better Living program which was required to be available to all the eligible employees. Thus, our results regarding the effectiveness of the program on weight loss and depression need to be confirmed in randomized trials in the future.

One important strength of the study was that our primary outcomes including body weight, BMI and blood pressure were objectively measured by the program staff, thus eliminating bias associated with self-report. There were several limitations to this study. First, we were not able to include a control group in the study since Better Living is a workplace wellness program, that is, it is mandatory to provide the intervention curriculum to all eligible employees. Second, the follow-up weight measures were collected over 3 to 6 months after the initial weight-loss program. As a consequence, our results may not reflect the patterns of long-term post-intervention weight changes. Third, some of the metabolic health measures such as blood lipids and glucose levels were self-reported which could be subject to bias. However, we asked employees to report these values from their objective lab reports from their employee wellness screening performed by the Methodist Health System. In addition, our study participants were mostly female (representing the majority of healthcare workers) and white. Thus, our findings may not be generalized and the workplace weight-loss program may need to be modified for male healthcare employees as well as for the ethnic minority healthcare workers. Lastly, our study was conducted primarily among employees who worked a traditional day-time shift. Future studies are warranted to determine the impact of weight-loss interventions on healthcare employees who work non-traditional work hours, for example night-shift workers.

In conclusion, healthcare workers are an overlooked population with health concerns such as obesity, Type 2 diabetes, cardiovascular diseases and stress.^13

-16 The Better Living curriculum was designed to promote weight loss and improve physical and mental well-being for healthcare workers. Although our results need to be validated in randomized trials, the current findings support implementing programs like Better Living as they may benefit employees working in healthcare settings and are vitally needed for this population. Further emphasis needs to be placed on long-term weight management to prevent weight regain after the initial weight loss. Also, it is important to devote our efforts to healthcare workers who work the night shift. Because of the negative impact on health and well-being associated with shift work,^16,42,43 this segment of the population may benefit from weight-loss interventions, however, are unable to participate in programs due to work hours.

So What

What is Already known on this Topic?

Workplace weight-loss programs have the potential to promote weight loss and improve employee health. However, there is insufficient good-quality evidence for successful programs to address obesity among healthcare workers.

What does this Article Add?

The Better Living intervention is a 16-week workplace weight-loss program for healthcare employees using novel approaches, such as combining group-based meetings/activities with individual appointments with nutrition/health experts. Weight (5.6% weight loss), BMI, lifestyle behaviors (nutrition, physical activity), sleep quality and depression were improved after the intervention. However, results need to be confirmed in future randomized trials.

What are the Implications for Health Promotion Practice or Research?

Our findings support implementing programs like Better Living as they may benefit employees working in healthcare settings and are critically needed for this population. Further emphasis should be placed on long-term weight management to prevent weight regain and on night-shift healthcare workers, since they may benefit from weight-loss interventions, however, are unable to participate in programs due to work hours.

Footnotes

Acknowledgments

The authors thank Nurse Practitioner, Brenda Herrod for developing and implementing the Better Living weight management program as well as employees at the Methodist Health System (Omaha, NE) who participated in the study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Weiwen Chai,

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