Active Caribbean 2009 Workshop, Barbados

1. Worksite Health Promotion: Lessons Learned by CDCThomas L SchmidPhysical Activity and Health BranchCenters for Disease Control and Prevention Active Caribbean 2009 Workshop, Barbados

2. Public Health has many views

3. 1900 1996 Pneumonia Heart Disease Tuberculosis Cancer Diarrhea/Enteritis Stroke Heart Disease Chronic Lung Disease Stroke Accidents Liver Disease Pneumonia/Influenza Injuries Diabetes Cancer HIV Senility Suicide Diphtheria Chronic Liver Disease 0 10 20 0 5 10 15 20 25 30 35 Percentage Percentage The 10 Leading Causes of Death as a Percentage of All DeathsUnited States, 1900 and 1996 The average life expectancy in 1900 was 47.3 years of age. In 1993, it was 75.7 years of age. SOURCE: CDC, National Center for Health Statistics

4. Most Common Causes of Death, United States, 1996* Actual Causes of Death, United States, 1990† Total cardiovascular disease (includes ischemic heart and stroke) Tobacco Poor diet/lack of exercise Cancer Chronic obstructive pulmonary disease and allied conditions Alcohol Infectious agents Injuries Pneumonia/influenza Pollutants/toxins Diabetes Firearms HIV infection Sexual behavior Suicide Motor vehicles Chronic liver disease/cirrhosis Illicit drug use 0 5 10 15 20 Percentage (of all deaths) Percentage (of all deaths) Chronic Diseases and Related Risk Factors *National Vital Statistics Report; 47 (9) November 10, 1998 †McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207-12 Note: Dark shading denotes conditions and behaviors addressed by NCCDPHP

5. U.S. Department of Health and Human Services SECRETARY Administration for Children & Families Food & Drug Administration Centers for Disease Control & Prevention Agency for Toxic Substances & Disease Registry Administration on Aging Program Support Center Health Resource & Services Administration Indian Health Service Health Care Financing Administration Substance Abuse & Mental Health Services Administration National Institutes of Health Agency for Health Care Policy & Research

6. Healthy People in a Healthy World, Through Prevention

7. Centers for Disease Control and Prevention (for now) CO for Global Health CC for Health Information& Service NCHS, NCPHI, NCHM Office of the Director CC for Environmental Health &Injury Prevention ATSDR, NCEH, NCIP CO for Terrorism Preparedness & Emergency Response CC for Health Promotion NCCDPHP, NCBDDD, Office Genomics CC for Infectious Disease NCID, NIP, NCHSTP

8. Heart Disease & Stroke Prevention Nutrition, Physical Activity and Obesity Smoking and Health Reproductive Health Adult and Community Health Cancer Prevention and Control Adolescent And School Health Diabetes Translation Oral Health National Center for Chronic Disease Prevention and Health Promotion - CDC Office of the Director

9. Office of the Director “Nutrition” “Obesity” Division of Nutrition, Physical Activity And Obesity “Program & Evaluation” “Physical Activity” CDC-WHO CC

10. PhysicalActivity and Health Branch • Vision • Active People in an Activity-Friendly World • Mission • Understand and Promote Physical Activity to Enhance Health and Quality of Life • Guiding Principles • We are a science-driven organization. • We Focus on population-based public health research and programs. • We are accountable to our public health constituents. • We conduct our work with integrity and follow ethical standards.

13. Physical Activity- Benefits • Walking 2+ miles/day => 50% lower mortality • Exercise in 80+ y.o. women => 32% fewer falls • Strength training causes comparable reduction in Sx of depression as medication • Exercise improves smoking cessation rates • 1 case of hypertension prevented for every 26 men who walk 20+ minutes to work • 31% reduction in CVD rates if walk 35 min/day Hakim NEJM; Campbell BMJ; Fiatarone J Gerontol; Marcus Arch Int Med; Hayashi Ann Intern Med; LaCroix J Am Geriatr Soc

14. Physical Activity - Benefits • 6 bouts per day of 2-3 minutes of stair climbing improves cholesterol and fitness in college women. • Type II diabetes can be prevented (58% reduction in risk) by 30+ minutes of activity/day and appropriate diet (fat/fiber/calories) in high-risk subjects • Walking 112+ blocks/week reduces risk of dementia by 33% in older adults. • Health care costs 4.7% lower per active day per week; 49% lower in non-smoker, BMI=25, active 3 days/week Boreham Prev Med 2000;30:277; Tuomilehto. NEJM;344:1343. Yaffe. Arch Intern Med 2001;161:1703. Pronk JAMA 1999;283:3335

15. Preventive Effects • Long-standing consensus: • Cardiovascular disease, high blood pressure, diabetes, obesity, colon cancer, osteoporosis, • Substantial evidence: • depression, cholesterol & lipids, fall injuries, stroke, functional status in older adults • Emerging evidence: • gall stones, sleep, immune function, some other cancers, dementia, ‘brain health’, academic performance.

16. Therapeutic Effects of Physical Activity Clinical practice guidelines exist for physical activity in many diseases: - high blood pressure - chronic lung disease - cholesterol management - cardiovascular disease - diabetes - osteoporosis - arthritis - obesity

17. Leisure Time Physical Activity Trends 1986-1999All States Reporting Physical Activity each year, BRFSS S. Ham, CDC, 2000. Recommended Activity = Moderate or Vigorous Activity

18. Percent of Employers Offering Health Benefits to Employees 2000-2005 Source: “Employer Health Benefits 2005 Survey,” (#7315), The Henry J. Kaiser Family Foundation and Health Research and Education Trust, September 2005

19. A Costly Benefit Private industry employers’ average medical costs per employee* Portion of private industry workers in a company health plan *Includes all companies and employees, both with and without health benefits Source: Bureau of Labor Statistics, Published in the new York Times

20. Relation of Business Size and Workforce Percentage Business Size % Firms % Workforce <499 employees 99% 50% 5000+ employees .04% 32%

21. Private Business Expenditures for Healthcare as a Percentage of Business Profits 1993-2000 Source: Cowan, CA et al. (2002) Healthcare Financing Review

22. Top Five Employer Priorities for 2005 Control Healthcare Costs Provide Rewards Programs that Attract, Motivate, and Retain Talent Address Employee Willingness to Pay a Larger Portion of Benefits Coverage Increase Employee Responsibility for Managing Their Own Rewards Budget Manage Retirement Benefits Cost Source: Deloitte Consulting (2004)

23. Clinical Preventive Services by Employer Size ServiceSmallMediumLarge Nutrition counseling 19% 27% 21% Weight loss/mngmnt 17% 21% 18% PA counseling 14% 23% 11% Bondi et al. Am J Health Promotion 2006;20:214

24. Bottom Line Can’t reduce health care costs without improving the health of employees Use evidence-based recommendations to guide alignment of benefits, policies, and programs with employee health Use field studies to accelerate identification of what works Put policies in place that support employee adoption of healthy behaviors

25. ROI: Worksite Health Promotion Citibank had a savings of $8.9 million over 2 years with a program cost of $1.9 million – for $4.70:$1 benefits:cost ratio Analysis of 28 studies showed average ROI of $3.48 per $1 in cost From 1990–1999 Johnson & Johnson generated savings of about $8.5 million/year Sources: Ozminkowski et al. AJHP Jan/Feb 1999; Goetzel et al. J Occ Hlth & Environ Med 2002; Aldana AJHP May/June 2001.

26. Examples of Approaches: Physical Activity Health Checks / Fitness appraisals On-site exercise facilities / classes Health education – i.e. written materials with / without support Subsidized membership at off-site gyms / facilities Web based advise and support Stair use / Active travel

27. Public sector Government offices Police Fire service Utilities – gas / electric Private Sector – (larger) Pharmaceutical Food companies Retail companies Legal firms Banks Universities Hospitals Blue collar and White collar Types of Workplaces Often Involved Less often Retail and service industry Manufacturing industry Skilled / semi skilled Voluntary sector Small/medium size enterprises

29. CDC Projects Related to Worksites Community Guide Recs Translate Findings Focus groups Promising Practices Develop Toolkits Disseminate Implement Evaluate Develop Cost Calculator Evaluate

30. Worksites with Promising Practices

31. Preliminary SWAT Findings - What Works 1. Focus on multiple levels, including individual behavior, environmental factors and organizational policy 2. CEO’s commitment - “culture of wellness” 3. Often motivation is “the right thing to do” 4. Implement population-based interventions - tailor delivery to employee needs 5. High participation rates 6. Systematically evaluate

32. Sprint World Headquarters Overland Park, KS 66251

33. TIDE Process Field studies Field studies Field practices Gray literature Scientific literature CG review DNPA review DNPA review Task Force recs Promising practices Promisingpractices Translate and disseminate for Identify Research Gaps specific target audiences Implementation and Evaluation Set Research Agenda

34. Promising Practices • Environmental and Policy strategies • Informational and educational strategies • Behavioral strategies

35. Environmental and Policy • Address the entire workforce/population and target physical and organizational structures through worksite and public policies that support healthy behaviors. They are likely to be sustained longer than individually oriented strategies

36. Environment: Enhanced access • Example: Male employees in a university maintenance shop in a 16 week exercise intervention – fitness trail/ par course. 19 strength and aerobic activities on 1.5 mile course. 90 minute classes offered free 2 X week. Public charts displayed exercise done at and outside work. • Median effect size for 5 studies -3.4%

37. Informational and Educational • Exercise prescriptions • Specific recommendations for frequency, type and intensity of exercise. • Median effect size for 14 studies was -4.8lbs • Multi-component educational practices • Prescription plus brochures, pamphlets, electronic messages (email, text message) • Median effect size -4.8 lbs

38. Behavioral • Teaching behavioral management skills, structuring social environment to provide social support, individual/ group behavioral counseling- family friends. • Modeling, participatory skill development feedback, incentives, disincentives, pedometers, journals.

39. Behavioral- competitions and incentives • Competitions and incentives alone • Teams compete for total miles walked or weight lost. • Median effect size for 12 studies, -6.5lbs

40. Behavioral • Behavioral practices with incentives • Includes modeling, skill building, feedback social support and incentives/ disincentives. • 10 lunch hour sessions on behavioral change, goal setting nutrition ed, self monitoring, self control cognitive restructuring, contingency management, physical exercise, social support. Tailored feedback on progress. • Monetary prizes awarded at end of treatment. • Median effect for 15 studies -5.1lbs

41. Behavioral Practices • Behavioral practices without incentives • Example • Building maintenance company during work hours, employees given lectures, practical training, individual counseling, group discussion, self-education session. Individual goals set and with follow up and feedback from supervisor, spouse and family. • Median effect for 36 studies -5.8lbs

42. Promising Practices • Enhanced access to PA opportunities + health education • Exercise prescriptions alone • Use of multi-component educational practices • Use of (weight loss) competitions and incentives • Use of behavioral practices and incentives • Use of behavioral practices without incentives

43. CDC Healthy Worksite

44. CDC-wide Assets & Needs Assessment • Policies • Health promotion • Exercise (1/2 hour approved absence) • Lifestyle centers • Allow leave for preventive screenings • Food/cafeteria choices • Modify GSA contracts • Vending Choices • Tobacco-free worksite

45. CDC-wide Assets & Needs Assessment • Physical environment • Facilities audit • CDC walkability audit (e.g., Rhodes-Columbia) • Fresh produce vendor • Healthy building standards • Chamblee trail • Lactation rooms • Stairwell projects

47. Before

48. After

49. Marshall et al. Already use the stairs enough No time Too busy Too lazy Mutrie et al Barriers Too lazy Lack of Time Motivators Save time Improve Health Barriers to Stair Use

50.   Study Example: Government Office [CDC, USA] Over 3+ years Baseline data Intervention 1 Paint and carpet Added pictures ♫♪ ♫♪ ♫♪ Added Signage Added music Follow up data