Introduction and Overview of Worksite Studies

The prevalence of obesity has reached epidemic proportions in all racial and ethnic groups, with about two-thirds (or 66%) of the U.S. adult population now overweight or obese (1). Among non-Hispanic blacks, the prevalence of extreme obesity is about 2-fold that of the general population (1). This increase is likely due to environmental influences that encourage consumption of high portion sizes of energy-dense foods, sedentary lifestyle, and limited access to healthful foods (2,3). Interventions that modify these influences are promising approaches to curtailing the obesity epidemic. Worksites are settings for reaching large numbers of working adults of varying socioeconomic levels and ethnic backgrounds. Because studies testing interventions that modify the food and physical activity environments for weight control are in their infancy, formative research is useful in helping to understand the complexities associated with changing such environments. This supplement to Obesity comprises a series of papers on formative research and baseline results of studies that are testing environmental or combined environmental- and individual-level interventions to prevent and treat overweight and obese adults at worksites. The origins, rationale, and design characteristics of these studies have been published elsewhere (4). Briefly, the National Heart, Lung, and Blood Institute (NHLBI)1 funded seven separate research studies that are conducting interventions in various worksites: hotels, hospitals, manufacturing facilities, businesses, schools, and bus garages located across the United States. This supplement reports baseline results and formative research from six of the institutions and the coordinating functions by one of the study sites. The institutions are Cornell University (Lighten-up program in manufacturing facilities); Kaiser Permanente, HI [Weight, Work, and Wellness (3W) program in hotels]; Tulane University (ACTION! in elementary schools for school teachers); the University of Massachusetts Medical School (Step Ahead program in hospitals); the University of Rochester (Images of a Healthy Worksite program in medium- to large-size businesses); and the University of Washington (the PACE program for small- to medium-size businesses). To prepare this supplement, three guest editors undertook the management of the review process. We have ensured a rigorous peer review and critical input from external researchers with expertise in the following areas: formative research, worksite obesity interventions, organizational theory, community health, process evaluation, physical activity, environmental interventions, nutrition, worksite policy, and health economics. The review process is presented below. A list of potential reviewers was sent to the Managing Editor of Obesity for concurrence with the individuals selected to review for the journal. Authors sent each manuscript to the NHLBI guest editor (C.A.P.), who initially reviewed the manuscript to assess its readiness for external review. Each manuscript was submitted anonymously to three appropriate external reviewers. The NHLBI guest editor compiled the reviews and sent them to the lead author anonymously with a request to revise and respond to each comment raised by the three reviewers. Each of the three guest editors reviewed the responses to be certain the authors have responded satisfactorily to reviewers' comments. The NHLBI guest editor sent revised manuscripts to external reviewers who requested a second review. Guest editors also requested further revisions in several of the revised manuscripts. For manuscripts that included a guest editor as a lead author, the other two guest editors and an external reviewer re-reviewed the revised manuscript. The guest editors determined final acceptance. The paper by Beresford et al. (5) describes the PACE project, which is a worksite intervention to maintain or reduce weight through healthy eating and physical activity in adult employees of 30 small- and medium-size worksites in Seattle, WA. Baseline results indicated BMI was associated positively with physical inactivity, intakes of fast food meals and sweetened beverages, and eating while doing another activity. The findings suggest target areas for intervention. Williams et al. (6) describe the 3W program in 31 hotels on the island of Oahu, HI, and noted from baseline results that male Pacific Islanders and individuals employed in managerial or facility maintenance roles had higher prevalence of obesity than women and individuals in other occupational categories. Even though a worksite environmental intervention targets all employees, the findings from the 3W programs provide guidance for tailoring interventions to specific job types. Formative research in the Step Ahead is described by Zapka et al. (7). Step Ahead targets six hospitals in central Massachusetts, using an ecological intervention approach that focuses on changes at multiple levels: organizational, interpersonal work environment, and individual. Results from the formative phase identified the following as important in changing the worksite and organizational environments in multilevel interventions for weight management: worksite leadership involvement, use of advisory groups, flexibility in intervention implementation, and maintenance of a balance between theoretical approaches and practical applications of theory. Wilson et al. (8) describe formative research at each of their 12 sites in the Dow Chemical Co. The authors used multiple methods that included an environmental assessment, climate survey, focus group sessions with the worksite leadership, archival data, surveys on employee health status, and social-organizational work environment to identify targets for environmental intervention. These targets include changing vending machine food offerings, providing walking paths, training and establishing leaders at the work-group level, and developing worksite-specific goals for weight management. School teachers serve as role models for changing youth behaviors. This concept is being explored by Webber et al. (9) in school-worksite interventions for weight management of school teachers. Their paper describes formative research activities using focus groups of schoolteachers, school principal surveys, and school environment audit in an elementary school in New Orleans and a pilot study in one school to refine intervention components. The results suggest wellness committees; ACTION!-directed walking programs (e.g., safe walking paths on school grounds, enhanced school fitness facilities with physical activity resources); ACTION chats, an interactive weight loss program; and partnerships with community recreation center and health clubs were most attractive to teachers. It has been hypothesized that the obesity epidemic could be due to the low cost of energy dense foods because an inverse relationship between energy density and food cost has been reported (10). Thus, individuals with limited income purchase and consume foods that are energy-dense and high in fat and sugars that contribute to their obese status. Devine et al. (11) are testing this hypothesis in their study, “Images of a Healthy Worksite.” In their paper titled “Pizza Is Cheaper Than Salad,” the authors used formative research to assess workers’ views of an environmental intervention to provide easy access to healthful foods and reduce energy density of foods and physical inactivity among Kodak company employees. Formative research methods included focus groups, in-depth interviews with employees and administrators, and community mapping. The PRECEDE health planning model served as a guide. These formative results suggest that stress, related to company downsizing, is a major factor that could influence food intake. Intervention approaches for that company could include modifying cafeteria foods to provide healthful options, labeling foods at the point of purchase, and changing organizational culture to make healthful foods accessible to employees. Finally, Stevens and Donald (12) describe the coordinating functions of the Kaiser Permanente, OR, site, which serves all of the studies. These functions include facilitating the adoption of common measures; pooling of data on measures such as physical activity, work productivity, health care use, and return on investment for cost-benefit analyses; and pooling data from two or more studies to achieve greater statistical power. On behalf of the investigators of the worksite studies, we hope you (the reader) find these studies instructive. We also hope that you will learn from these articles the need for formative research to provide insights to better design and test environmental interventions for weight management of employees in different types of worksites. The worksite studies are being supported by NHLBI Grants R01 HL079483, R01 HL079478, R01 HL079491, R01 HL079505, R01 HL079509, R01 HL079511, and R01 HL079546. Our profound gratitude goes to the 13 external reviewers and to the NHLBI staff who reviewed the manuscripts and commented constructively on them. Guest Editors: Charlotte A. Pratt, Ph.D., R.D. (Program Director, NHLBI, Bethesda, MD); Isabel Diana Fernandez, M.D., M.P.H., Ph.D. (Associate Professor, Department of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, NY); and Victor J. Stevens, Ph.D. (Senior Investigator, Kaiser Permanente Center for Health Research, Portland, OR). Reviewers: Steven Aldana, Ph.D. (Professor of Lifestyle Medicine, College of Health and Human Performance, Brigham Young University, Provo, UT); Marilyn S. Edwards, Ph.D., R.D. (Associate Professor of Nutrition, Department of Internal Medicine, University of Texas Medical School, Houston, TX); Joel Gittlesohn, Ph.D. (Associate Professor of Public Health, Johns Hopkins School of Public Health, Baltimore, MD); Nell Gottlieb, Ph.D. (Professor of Kinesiology and Health Education, University of Texas, Austin, TX); Catherine Ann Heaney, Ph.D., M.P.H. (Associate of Public Health, Stanford Prevention Research Center, Palo Alto, CA); Robert Jeffery, Ph.D. (Professor of Epidemiology and Public Health, University of Minnesota, Minneapolis, MN); Donald Kenkel, Ph.D. (Professor of Health Economics, Cornell University, Ithaca, NY); Jared B. Jobe, Ph.D. (Program Director, NHLBI, Bethesda, MD); Laura A. Linnan, Sc.D., C.H.E.S. (Associate Professor of Health Behavior and Health Education, University of North Carolina School of Public Health, Chapel Hill, NC); Kenneth McLeroy, Ph.D. (Professor of Rural Public Health and Associate Dean for Academic Affairs, School of Rural Public Health, Texas A&M University, College Station, TX); Craig Nelson, M.S., D.C. (Director of Research, American Specialty Health, Minneapolis, MN); Eva Obarzanek, Ph.D., R.D. (Program Director, NHLBI, Bethesda, MD); James Sallis, Ph.D. (Professor, Psychology Department, San Diego State University, San Diego, CA); Allan Steckler, Ph.D. (Associate Professor of Public Health, University of North Carolina, Chapel Hill, NC); and Ron Stout, M.D., M.P.H. (Medical Director, Proctor and Gamble Company, Health Care Research Center, Mason, OH).