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MINDFULNESS AT WORK
I
MINDFULNESS AT WORK:
ADDRESSING MEDICAL COSTS, ABSENTEEISM,
AND WORKPLACE PRODUCTIVITY
Kelley McCabe Ruff, MBA; CEO & Founder, eMindful Inc.
Dr. Ruth Wolever, PhD; Chief Scientific Advisor, eMindful Inc., Director of Research, Duke Integrative Medicine,
and Associate Professor, Dept. of Psychiatry & Behavioral Science, Duke University School of Medicine
OVERVIEW
Several decades of scientific research have confirmed that
highly stressed employees are subject to considerably greater
health risks,1,2 productivity losses3 and medical costs3,4 than
those with normal stress levels. The latter can be seen in a
peer-reviewed analysis of 12 months of claims data from a
large sample of employees from a major insurance company.
Compared to employees whose self-reported stress levels fell in
the lowest quintile, covered medical claims of the most highly
stressed employees (top quintile) was almost $2,000 greater.4
Not only is elevated stress a common and expensive part of
corporate life, but it contributes to chronic disease through
biological and behavioral pathways. In other words, stress
affects human biology in ways that negatively impact the
immune and metabolic systems. In addition, under high levels
of stress, people tend to behave in less healthy ways. Worse
still, these behavior patterns are the reason for the dramatic
increase in chronic disease.
THE CHALLENGE
Chronic diseases such as cancer, diabetes, heart disease,
and musculoskeletal pain are on the rise in the U.S. across all
demographic groups. Of note:
Highly stressed employees are subject
to considerably greater health risks,
productivity losses and medical costs
than those with normal stress levels.
Employers everywhere are looking for new solutions to the
challenge of keeping their employees healthy, present on the
job, and productive. So are health insurers, benefit brokers, and
third-party administrators, all of whom recognize that surviving
and thriving in their markets will require innovative, valueadded solutions to the growing cost and productivity crises.
MINDFULNESS: ONE SOLUTION
But all crises have solutions. And mindfulness promises
one such solution. Researchers Marlatt and Kristeller define
mindfulness as “simply bringing one’s complete attention to
their present experience on a moment-to-moment basis.”7
More than 2,000 research studies on mindfulness have been
conducted in the last three decades demonstrating:
REDUCED
STRESS
LEVELS10
§§ The total annual cost in the U.S. of cardiovascular disease
and stroke is estimated to be more than $312 billion;5
§§ The total cost in the U.S. in 2012 associated with
diagnosed diabetes was $245 billion. The average
annual cost of care for a patient with diabetes is
$13,700 — of which $7,900 is attributed specifically to
the treatment of diabetes itself;6 and
§§ A major risk factor for all of these conditions is
overweight and obesity (body mass index greater than
30 kg/m2). The prevalence of overweight and obese
adults (over the age of 20) in the U.S. is 68.2%, and of
obesity alone is nearly 35%.5
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IMPROVED
IMMUNOLOGICAL
FUNCTIONING 8,9
ENHANCED
BRAIN
FUNCTION12
IMPROVED
ALERTNESS11
MINDFULNESS
IMPROVED
PRODUCTIVITY15
IMPROVED
GLYCEMIC
CONTROL IN
DIABETES14
IMPROVED
SLEEP13
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Figure 1. Mindfulness: One Solution
IMPROVED
PHYSIOLOGICAL CONDITIONS
MINDFULNESS
COST
SELF-HEALING
RESPONSES
PRODUCTIVITY
SELF-DESTRUCTIVE
BEHAVIORS
DISABILITY
MALADAPTIVE
CHRONIC CONDITIONS
These and other benefits shown in the research literature
have many corporations scrambling to offer high-quality
programs incorporating mindfulness instruction and practice.
Increasingly, mindfulness instruction and practice is also
being offered in secondary schools, colleges, and business
schools including New York University Stern School of
Business and Harvard Business School.
The reason for employers’ interest in mindfulness practices
is clear: in addition to myriad health and well-being benefits,
there is also a direct impact on healthcare costs4 and
productivity. Increased employee productivity, and lower
costs, enhances competitive advantage.
Aetna Inc. has been a leader in demonstrating the value of
health-related mindfulness programs. In 2009, Aetna began
this journey strategically by first assessing the effectiveness
of two mindfulness-based programs of interest through
scientifically rigorous randomized controlled trials (RCTs).
Two different trials, described in more detail below, evaluated
distinct programs: a mindfulness-based stress reduction
program called Mindfulness at Work® and a program for
reversing metabolic syndrome called Metabolic Health in
Small Bytes. Confident from the results of the trials, Aetna
then offered these programs to their own 48,000 employees.
They subsequently offered the programs to their middle
market and national clients.
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Other large companies are similarly finding benefits with
mindfulness-based programs. Florida Power and Light offers
two different mindfulness programs. Kaiser Permanente
also offers mindfulness programs. The State of Arizona,
including administrators, child protective services, and
the department of transportation, has been offering
mindfulness-based programs to its 65,000 employees for
several years. The data is rapidly accumulating, and the
methodology of the studies is strong.
AETNA PARTNERS WITH eMINDFUL
eMindful Inc. delivers live, online mindfulness-based programs
that target the roots of chronic conditions that undermine
health and productivity. The programs are delivered through
a virtual classroom and are evidence-based. Aetna selected
eMindful as one of its partners for providing two different
mindfulness-based programs and rigorously evaluating
them through two randomized controlled trials (RCT): one
conducted in 2010 and the other conducted from 2011-2013.
The purpose of the 2010 RCT was to evaluate the viability
and effectiveness of two workplace stress reduction programs
designed to be evidence-based, scalable, reproducible,
and highly accessible to employees across the globe: a
mindfulness-based stress management intervention and a
therapeutic yoga-based stress reduction program.10
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MINDFULNESS AT WORK
STRESS REDUCTION:
MINDFULNESS AT WORK® PROGRAM
The Mindfulness at Work® (MAW) Program was developed
by Elisha Goldstein, PhD, a renowned expert in mindfulness
and its application for stress in the workplace, and Michael
Baime, MD, Director of the Penn Program for Mindfulness. The
12-week program meets once per week for 55 minutes. There
is also an optional 2-hour retreat available to all participants
midway through the program.
The study was the result of collaboration between a number
of partners, and was published in the Journal of Occupational
Health Psychology.10 Ruth Wolever, PhD, Director of Research
at Duke Integrative Medicine and Principle Investigator of
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Compared to the control group, both the mindfulness and
yoga interventions showed significant improvements on
perceived stress, sleep quality, current pain, and the heart
rhythm coherence ratio of heart rate variability10 — a
biological measure of how well the autonomic nervous
system processes stress. The Mindfulness at Work program
reduced participants’ self-reported stress levels by 36
percent. Sleep disturbances fell by 29 percent and reported
pain levels declined by 34 percent. Heart rhythm coherence
also improved significantly, showing that not only were
participants’ perceptions of stress, sleep, and pain improved,
but their biology confirmed these shifts. Results for the
mindfulness intervention are shown in Figure 2 below.
Figure 2. Improvements Resulting From Mindfulness at
Work Intervention
SLEEP
DISTURBANCES
PERCEIVED
STRESS
-0.33
HEART RHYTHM
COHERENCE
CURRENT
PAIN
34%
Both studies utilized rigorous scientific designs and collected
data using validated instruments and carefully constructed
protocols to evaluate the impact of the programs. The
programs themselves offer innovative ways to manage
stress and shift unhealthy lifestyle behavior patterns that
contribute to obesity and the risk factors associated with
metabolic syndrome.
THE RESULTS
29%
eMindful’s scalable delivery platform, allowing employees
across the world to participate in real-time “webinar-style”
programs, as well as eMindful’s ability to deliver appliedmindfulness programs in a timeframe (generally 55 minutes)
that is conducive to the workplace, were important to both
studies. Participants in eMindful’s programs are presented
with both didactic and experiential learning opportunities
and are provided practice assignments each week. The
virtual classroom setting allows for real-time, bidirectional
communication between instructor and students, with
provisions for complete student anonymity.
the study, designed the RCT that included 239 employees
who were randomly assigned to one of four groups: a control
group, a therapeutic yoga program, a Mindfulness at Work
program delivered “in person” in a conventional on-site
classroom, and a Mindfulness at Work program delivered in
eMindful’s live, “webinar-style” virtual classroom.
36%
The 2011-2013 RCT addressed the feasibility of
implementing a mindfulness-based behavior change
intervention delivered in the virtual classroom as a worksite
intervention for employees with metabolic syndrome.
Metabolic syndrome is a constellation of disorders that
includes central obesity (elevated waist circumference),
hypertension, elevated glucose levels reflecting insulin
resistance, low levels of high-density lipoprotein (HDL)
and high triglycerides.16 There are several similar (but not
identical) definitions currently in use, but all agree that
metabolic syndrome is a constellation of abnormalities
associated with increased risk for the development of type
2 diabetes, heart disease, and stroke.16,17 These diseases are
associated with significant costs to society, both in terms
of human suffering (excess morbidity and mortality) and
financial burden (medical and employer costs).16,17
+0.02
Moreover, the findings for participants taking the course in
eMindful’s online classroom were equivalent to the findings
of those taking the program through conventional on-site
classes. Furthermore, those taking the online program
had a superior retention rate in the study; 96 percent of
the eMindful participants completed the study, compared
to 73 percent of those who took the program through the
traditional on-site classroom.10
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ONGOING RESULTS FOR MINDFULNESS
AT WORK®:
Figure 3. Minfulness Solutions Result in Increased Productivity
Assessment
Pre-Program
Post-Program
Change
Percent
Improvement
Perceived Stress
Scale18
21.3
14.0
7.3
36.9%
Pittsburgh Sleep
Quality Index19
eMindful continues to collect pre- and post-data on program
participants. The findings on thousands of participants
reflect the results of the RCT — and the improvement in
stress has remained a consistent 36–37%. In addition
to reporting on their perceptions of stress and sleep
difficulties, participants also report on the degree to which
they encounter a number of obstacles to productivity at
work. This last construct is measured using a validated
instrument called the Work Limitations Questionnaire that
allows participants to estimate the amount of time they are
not productive at work on a weekly basis. The Mindfulness
at Work program consistently results in about an hour per
week improvement in productivity — which equates to
approximately 6 additional workdays per year.
6.8
Work Limitations
Questionnaire20
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130.1
Result
Less Stress
6
ONE
HOUR/WEEK
ADDITIONAL
WORK DAYS
PER YEAR
mindfulness-based approach that also includes nutrition
and exercise content to reduce weight and/or reverse risk
factors defining metabolic syndrome. The Metabolic Health
in Small Bytes Program is a 10-week, 20-session class that
provides a variety of techniques and strategies to become
mindful of eating and physical activity habits. It also provides
participants with numerous avenues and skills for changing
engrained patterns of behavior and perceptual habits.
To evaluate the effectiveness of the program, 569 employees
from the healthcare benefits company were randomly
assigned to one of three conditions: a control group, a
comparative online program where participants worked
through a self-paced intervention, and the Metabolic Health
in Small Bytes program. Eighteen months after enrollment,
433 participants remained in the trial, allowing for ongoing
analysis from claims data. While the final analyses are not
yet completed, a subset of the analysis can be shared on the
Metabolic Health in Small Bytes program alone.
THE RESULTS
5.3
1.5
22.1%
Better Sleep
69.1
61.0
Preliminary data analysis conducted by the healthcare
company’s internal analytics group on a subset of the sample
demonstrated a 53% reversal of metabolic syndrome.
Additional results from this study will be made available as
analysis is completed.
46.9%
Higher
Productivity
METABOLIC HEALTH IN SMALL BYTES
The Metabolic Health in Small Bytes course was developed
by Ruth Wolever, PhD who led a team of clinicians from Duke
Diet and Fitness Center and Duke Integrative Medicine to
augment and adapt lessons from her NIH-funded research
on mindful eating, utilizing decades of successful clinical
treatment. The program incorporates a cognitive-behavioral
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ONGOING RESULTS
Just as with its other programs, eMindful continues to collect
pre- and post-course data to track the effectiveness of its
programs. In addition to reporting on their stress, sleep
difficulties, and work productivity, participants also report
on their exercise patterns, and metabolic indicators. Some
companies even provide mechanisms for employees to
obtain biometric data if desired. The Small Bytes program
continues to result in significant rates of reversal of metabolic
syndrome and employees report high levels of satisfaction
with the program.
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MINDFULNESS AT WORK
Assessment
Number of Participants with
Metabolic Syndrome
Pre-Program
Post-Program
Improvement
Improvement
Percent
54
22
32
59.3%
Result
Healthier Weight
Number who completed at least 20
minutes of each type of physical
activity per week
Aerobics: 111
Strength: 65
Stretching: 88
Aerobics: 138
Strength: 90
Stretching: 117
Aerobics: 27
Strength: 25
Stretching: 29
Aerobics: 24%
Strength: 38%
Stretching: 33%
Better Physical Fitness
Perceived Stress Scale18
16.0
12.9
3.1
19.4%
Less Stress
Pittsburgh Sleep Quality Index19
5.9
5.3
0.6
10.2%
Better Sleep
Work Limitations Questionnaire20
76.5
53.2
23.3
30.5%
Higher Productivity
FINAL NOTE
“The positive results seen in these studies offer evidence
that mind-body approaches to health improvement are an
effective and targeted solution for employers who want
to lower the costs associated with stress and help their
employees achieve better overall health. Furthermore, the
studies showed that online classes and in-person delivery
showed equivalent results, and both had high engagement
rates among participants. This finding is particularly
important as it will enable the program to be offered to
customers with employees in multiple locations and among
different organizational levels.”
Kyra Bobinet, MD, MPH
President, Senior Care Solutions, Aetna
Medical Director of Health & Wellness Innovation, Aetna n
KEY INSIGHTS & IMPLICATIONS
§§ Highly stressed employees are subject to
considerably greater health risks, productivity
losses and medical costs than those with normal
stress levels. Mindfulness promises one solution.
§§ Aetna and eMindful recently implemented and
assessed two different mindfulness-based
programs: Mindfulness at Work® and Metabolic
Health in Small Bytes.
§§ The results of both studies indicate that mindfulness
programs can decrease stress and pain, and improve
sleep, productivity, and physical fitness.
§§ Mind-body approaches to health improvement are
an effective and targeted solution for employers who
want to lower the costs associated with stress and
help their employees achieve better overall health.
LINKING TO SODEXO’S QUALITY OF
LIFE DIMENSIONS
§§ Health & Well-Being: Mindfulness can improve
mental as well as physical well-being, ultimately
leading to better overall health status.
§§ Personal Growth: Mindfulness training can help
individuals improve their self-awareness and
personal insight, which in turn allows them to
achieve growth in any area they wish to improve.
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MINDFULNESS AT WORK
1. “There is medical evidence that stress can adversely affect an individual’s immune system, thereby increasing the risk
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EDUCATING THE FUTURE FM WORKFORCE
1. Willie, T. (2014, May/June). CFM as an Inevitable Trend. Facilities Management Journal, 47-50. Retrieved from http://
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3. An interview by Ashley Halligan, Property Management Analyst, Software Advice, in The Maintenance Crisis and
Innovations that are Changing It. April 12, 2012.
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