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PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 6 ( 2 0 14 ) 48 4–4 92
Available online at www.sciencedirect.com
ScienceDirect
www.onlinepcd.com
Worksite Health and Wellness Programs: Canadian
Achievements & Prospects
Jean-Pierre Desprésa, b,⁎, Natalie Almérasa, b , Lise Gauvinc, d
a
Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada
Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, QC, Canada
c
Centre de recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
d
Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
b
A R T I C LE I N FO
AB S T R A C T
Keywords:
Canada has experienced a substantial reduction in mortality related to cardiovascular disease
Risk factors
(CVD). There is a general consensus that more effective and widespread health promotion
Smoking
interventions may lead to further reductions in CVD risk factors and actual disease states. In
Obesity
this paper, we briefly outline the prevalence of selected risk factors for CVD in Canada,
Physical activity
describe characteristics of the Canadian labor market and workforce, and depict what is
Interventions
known about health and wellness program delivery systems in Canadian workplaces. Our
Workplace
review indicates that there have been numerous and diverse relevant legislative and policy
initiatives to create a context conducive to improve the healthfulness of Canadian
workplaces. However, there is still a dearth of evidence on the effectiveness of the delivery
system and the actual impact of workplace health and wellness programs in reducing CVD
risk in Canada. Thus, while a promising model, more research is needed in this area.
© 2014 Elsevier Inc. All rights reserved.
CVD mortality in Canada: good and bad news
Like in many industrialized nations both with and without
universal healthcare systems, Canada has experienced a substantial reduction (about 75% since 1952 and 40% in the previous
decade) in mortality related to cardiovascular (CV) disease
(CVD).1,2 Reductions in mortality appear to be partly explained
by decreases in the prevalence of smoking (current prevalence
about 17%, down from 25% in 1999)3 and in incidence of other
established risk factors, such as hypertension (HTN)4 and
possibly cholesterol levels (even though current prevalence is
estimated at 40% of the population)5 but also the availability of
numerous medical procedures and treatments. That is, male
and female Canadian citizens enjoy a life expectancy of 79 and
83 years,6 respectively, which is superior to that reported in the
United States and almost equal to that of the Japanese
population. However, Canada displays less favorable statistics
regarding healthy life expectancy, which is about 69 and 71 years
for men and women, respectively.7 Furthermore, according to
the Canadian Health-Adjusted Life Expectancy study, men and
women with type 2 diabetes (T2D) at age 55 years had
respectively a 5.8 and 5.3 years reduction in health-adjusted
life expectancy, whereas having high blood pressure at the age
of 55 years resulted in 2.7 and 2.0 years reduction and having
had cancer by the age of 65 years was associated with 9.2 and
10.3 years reduction.8 These differences between life expectancy
and healthy life expectancy can be explained in part by the fact
that the Canadian healthcare system offers numerous medical
Statement of Conflict of Interest: see page 490.
⁎ Address reprint requests to Jean-Pierre Després, Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de
Québec, Pavilion Marguerite-D’Youville, 4th Floor, 2725 chemin Ste-Foy, Québec QC, Canada G1V 4G5.
E-mail address: [email protected] (J.-P. Després).
0033-0620/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pcad.2013.11.002
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PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S 5 6 (2 0 1 4) 48 4–4 9 2
Abbreviations and Acronyms
treatments and procedures which allow
CV = cardiovascular
for successful manCVD = cardiovascular disease
agement of highly
prevalent chronic conHTN = hypertension
ditions, thus keeping
PA = physical activity
patients alive despite
the presence of a
T2D = type 2 diabetes
chronic condition or
disease. Unfortunately, the discrepancy also illustrates limitations in “delivering the
goods associated with prevention”.9 That is, the advantageous
track record of Canada regarding the decline of CVD mortality
and relatively high healthy life expectancy could be further
improved through more extensive disease prevention and
health promotion in many life settings including the workplace.
This optimism is fueled by the success achieved in reducing
smoking through workplace bans.10
There is general recognition that poor lifestyle habits
including a low quality diet (characterized by highly processed
energy dense foods and overconsumption of sugar-sweetened
beverages) and a sedentary lifestyle promote obesity, which in
turn is responsible for the rapid growth in the prevalence of
T2D, an emerging metabolic disease and a major risk factor for
CVD. Poor nutrition and sedentary living coupled with obesity
and T2D compromise the ability to tackle CVD morbidity and
represent a major burden to the Canadian economy (estimated at $4.6 billion Canadian dollars in 2008)11 and to the
economy of many countries throughout the world.12
Given the breadth of the problem, there is consensus that
reducing the burden of CVD will require implementation of
large scale prevention interventions designed to increase
physical activity (PA) and improve healthy eating in both
individuals and populations. Action is needed along the entire
prevention continuum which ranges from primordial prevention (action on environmental and policy determinants)
through primary prevention (action to prevent the onset of
biological manifestations of disease among at-risk individuals), secondary prevention (detection and treatment of preclinical pathological changes), and tertiary prevention (reduction of impact of disease among those affected).13
In an effort to contribute to understanding how workplace
interventions might contribute to preventing CVD and increasing healthy life expectancy, we briefly outline the
prevalence of selected risk factors for CVD in Canada, describe
characteristics of the Canadian labor market and workforce,
depict what is known about health and wellness program
delivery systems in Canadian workplaces with specific
emphasis on programs aimed at PA and healthy eating, and
highlight the scientific evidence that is disseminated in
Canada while underscoring some of the literature available.
CVD risk factors in Canada: why are we on the edge
of the precipice?
Similarly to trends elsewhere in the world, the prevalence of
obesity has roughly doubled in Canada over the last 30 years
and now affects about 25% of the adult population and 8.6% of
485
youths under the age of 17 years.11 It is the highest in the
Maritime Provinces and the lowest in British Columbia. There
is also a high prevalence of obesity among aboriginal
Canadians and those with lower socio-economic status (i.e.,
lower education and income) have a higher prevalence of
poorer eating habits, less PA, and obesity. As a consequence,
the prevalence of T2D, which is also a risk factor for CVD, has
considerably increased in Canada and afflicts more than 2.4
million individuals.14
Furthermore, although it is not the purpose of this paper to
address this question, evidence shows that T2D is not only
found among obese individuals but rather specifically associated with an excess of abdominal visceral adipose tissue and
with accumulation of fat in tissues which are normally lean
(such as the liver, heart, kidney, and muscle), the latter
phenomenon being referred to as “ectopic fat deposition”.15,16
Such excess of visceral adipose tissue/ectopic fat is a powerful
risk factor not only for the development of T2D but also for
CVD.17 According to a recent study, the prevalence of
excessive abdominal fat has increased substantially in
Canada over the past 30 years.18 That is, waist circumference
exceeding thresholds for high risk of CVD and metabolic
disease increased in adults aged between 20 and 69 years
from 11.4% in 1982 to 14.2% and 35.6% in 1988 and 2007–2009,
respectively. Because of the rapidly rising prevalence of
obesity, excess visceral/ectopic fat has therefore become a
major cause of CVD in Canada as well as in several countries
around the world.
Although the relative contribution of factors associated
with its development remains debated, obesity results from
the combination of poor nutritional habits (which can now be
qualified by simple markers of nutritional quality) with a
sedentary lifestyle and lack of vigorous PA at work and during
leisure time. The landscape of modifiable risk factors has
changed in Canada with on one hand less smoking (current
prevalence about 17% down from 25% in 1999 and about 45%
in the 1970s)3 and possibly lower incidence of HTN4 (despite
higher prevalence) but with on the other hand a higher
proportion of sedentary overweight/obese individuals having
prediabetes, T2D, and high cholesterol.5
As in many other industrialized nations, the Canadian
population’s life settings are unfortunately not systematically conducive to adopting and maintaining healthy
lifestyles. That is, although major changes have occurred
due to workplace smoking bans, only selected community
environments promote active modes of travel and regular
participation in recreational PA, the plentiful offer of foods
elicits overconsumption of highly processed energy dense
foods, and social norms around healthy eating and PA are
poorly understood even though healthy eating and PA are
promoted through clinical preventive practices by
physicians.19 Finally, the universal Canadian healthcare
system in most provinces does not reimburse assessment
and management of inactivity/PA and nutritional habits. Of
particular interest to the present manuscript and as shown
below, workplace environments do not systematically offer
opportunities for healthy eating and PA. Following a brief
description of the characteristics of the Canadian labor
market and workforce, we outline what is known about the
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availability of such services and amenities by reviewing
some published and grey literature.
The Canadian labor force: a brief portrait
As of December 2011, it was estimated that there were about
2.4 million businesses in Canada20 and that about two thirds
of the working-age population (15 to 64 years) were employed
either part- or full-time representing just under 18 million
Canadians above the age of 15 years.21,22 About half of all
companies are described as “indeterminate” in that they do
not have employees and may simply contract workers,
employ family members, or are owner employed. Less than
1% of companies are large organizations of more than 500
employees but still employ about 40% of the Canadian
workforce. However, most companies employ less than 20
workers. About ¾ of jobs are provided by the service
industries whereas the other ¼ are found in goodsproducing industries. The public sector provided upwards of
2.8 million jobs in 2002.23 Work patterns have also evolved as
more workers do not work on the typical 9 to 5 pattern and
work from home. The Canadian workforce is also rapidly
aging with the median age of workers being 40 years.
Unfortunately, to our knowledge, there is no overarching
portrait of the delivery systems for health and wellness
programs in Canadian workplaces and the disparity in offer
of services and amenities across the country is also elusive.
Nonetheless, there are several milestones in healthy lifestyle
promotion in Canada and other sources of information which
provide useful information for drawing such a portrait.
Health and wellness programs in Canadian
workplaces: a complex yet rich context
There is general recognition that there have been four
phases24 in healthy policy in Canada which, for the purposes
of this paper, might shape workplace health and wellness
programs. Up until the epidemiologic transition and thus
during the early part of the last century, action on the health
of the Canadian population involved overcoming epidemics
through hygiene and vaccination. Then in the middle portion
of the last century, debate on the health of the Canadian
population revolved around the need for universal health care
which culminated with the federal government enacting the
Medical Care Act in 1968.25 This Act stipulated the principle of
cost sharing between the provinces and the federal government to provide universal health care. The Canada Health Act
of 198426 reiterated the principles around which universal
health care should be maintained in Canada namely comprehensiveness, universality, portability, accessibility, and public
administration. The provisions of these Acts are still currently
upheld. The third wave in health policy in Canada, known as
the transition to health promotion, followed the publication
of the Lalonde report in 197424,27 — an internationally known
and cited public policy document which highlighted the need
to go outside the healthcare system to promote the health of
the population. The Canadian debate around the Lalonde
report coincided with a landmark meeting wherein the
Ottawa Charter for Health Promotion was developed and
adopted. The Ottawa Charter proposed that to promote the
health of population requires building healthy public policy,
creating supportive environments, strengthening community
action, developing personal skills, and reorienting health
services. Many government health departments at both the
federal and provincial levels followed suit and began to offer
an entirely different set of programs and services involving
mainly disease prevention and health promotion. The fourth
and current phase of healthy policy in Canada builds on
existing achievements to provide universal health care and
disease prevention/health promotion programs outside the
healthcare system and aims to address the social determinants of health and reduce inequalities in health that are
associated with education and income.28
The development and implementation of health and
wellness programs in Canadian workplaces not surprisingly
coincided with the third phase (i.e., health promotion) of
health policy during the late 1970s and early 1980s. However,
other legislative initiatives and the emergence of many notfor-profit organizations also punctuated the emergence of
health and wellness programs in Canadian workplaces.
Notably, in 1961, the Fitness and Amateur Sport Act29 was
adopted by the Canadian parliament. This legislative document entrenched the responsibility of promoting fitness and
amateur sport in Canada within the portfolio of the federal
civil service. Over the past 50 years, these civil servants have
been housed alternatively in the Ministry of Amateur Sport, of
Fitness and Amateur Sport, Health Canada, and currently, the
Public Health Agency of Canada. In addition, over the past five
decades, provincial and municipal governments have also
tasked their civil servants with promoting healthy lifestyle in
partnership either with the federal government or with other
ministries at the provincial level (see for example, Ontario
Ministry of Health and Long-Term Care,30 Ministère de la
santé et des services sociaux du Québec through its network
of Health and Social Services,31 Alberta Health Services).32 A
national action plan33 for the promotion of PA is currently
under development and many provinces already have action
plans that are at different phases of implementation. Based
on the principles stated in the Toronto Charter for Physical
Activity,34,35 the national plan named Active Canada 20/20
calls upon workplaces to create environments that are
supportive of PA for their employees and to use an
evidence-based approach namely one that enacts practices
and programs that have been shown scientifically to result in
successful changes in lifestyle.
The specific notion of promoting health and wellness, and
more particularly, fitness promotion, in the workplace
emerged in earnest in the 1980s. According to the Canadian
Council for Active Living in the Workplace (http://www.
cchalw.ca/english/council.aro),36 interest on workplace active
living promotion emerged in the 1980s and was spear-headed
by civil servants in the Workplace Fitness Unit of the thenstanding Ministry of Fitness and Amateur Sport. Of course,
the creation of this Unit paralleled the rapid growth of
scientific evidence on the health benefits of healthy lifestyle
including two consensus meetings held in Toronto, Canada
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(in 1988 and 1992)37,38 and culminating in the Surgeon General
Report on Physical Activity and Health.39
In addition, the Canadian Fitness and Lifestyle Research
Institute40 was created in 1980 to educate Canadians about
the importance of leading healthy active lifestyles and to
bridge the gap between research and practice. As described
below, this Institute has been the main source of information
about the implementation of health, wellness, and PA programs in the workplace.
In subsequent years, there were calls to promote PA
and wellness in the workplace41,42 and several not-forprofit organizations emerged, notably the Canadian Council
for Health and Active Living at Work43 and Health Work &
Wellness™ Group.44 In different ways and with different
partners including the federal and provincial civil service,
these organizations have provided evidence-based guidance
in promoting healthy lifestyle in workplace settings.
Another noteworthy event was the passing of the
legislative Act to create the Canadian Centre for Occupational Health and Safety45 in 1978 whose vision it is to
eliminate work-related illness and death. Later, the National Quality Institute46 was created in 1992 through
Industry Canada (i.e., a federal government Ministry
whose mission it is to promote Canada performance on
the marketplace) to advance organizational excellence.
Through an awards of excellence programme, a set of
excellence criteria47 including the promotion of appropriate
lifestyle and health practices was developed. Annual
competitions reward companies in all domains of organizational excellence.
Finally, a “fitness industry” has emerged in Canada (see
http://fitnessbusinesscanada.com/)48 and a fitness industry
Council (see http://www.english.ficdn.ca/)49 was created in
the early 2002s to represent the owners of the approximately 5000 fitness centers available across the country.
This organization offers opportunities for voluntary certification to insure quality of fitness offerings to Canadians
but is also pursuing a public policy agenda to insure quality
fitness offerings to Canadians. Given the diversity of jobs
available in this service industry it is difficult to estimate
how many jobs are involved. However, according to
Statistics Canada there are upwards of 20,000 jobs as
program leaders in recreation and sport and another near
5000 in Recreation, Sports and Fitness Program Supervisors
and Consultants.50
In sum, the delivery of health and wellness programs in
Canada’s workplaces is achieved through a combination of
programs and services offered by civil servants, health
promotionals, and business operators across the country. In
an effort to capture this context, we depict some of the
milestones discussed above as a function of a timeline (see
Fig 1). As can be seen, we glean that the environment is both
1978
Act to create Center for Health
and Occupational Safety
Legislative
ative
Milestones
ones
1968
2002
Medical Care Act
Fitness Industry Council
1961
1984
Fitness & Amateur
Canada Health Act
Sport Act
1974
Lalonde Report
Policy Initiatives
tiatives
& Creation
on of
Organizations
ations
1986
Ottawa Charter for
Health Promotion
2010
Toronto Charter for
Physical Activity
1980s
1980s
Workplace Fitness Unit in Ministry
Canadian Council for Health
of Fitness & Amateur Sport
& Active Living at Work
Phase 1: Hygiene & Vaccination
Phases
s of
Canadian Health
Policy*
y*
Phase 2: Universal Health Care
Phase 3: Health Promotion
Phase 4: Social Inequalities
Fig 1 – Timeline of milestones influencing the development of health and wellness programs in Canadian workplaces. * See
Glouberman S, reference.24
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PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 6 ( 2 0 14 ) 48 4–4 92
rich and complex. In the following section we outline what is
known about its current status.
Health and wellness programs in the workplace in
Canada: elements of an overarching portrait
One of the first surveys of health and wellness programs in
the workplace was conducted by a not-for-profit organization called the Buffet & Company Worksite Wellness in 1979.
This not-for-profit organization was recently acquired by
SunLife Wellness Institute of Canada. Data collected in 1979
revealed the growing interest for health and wellness
programs among both employees and employers and were
thus reflective of the context prevailing at the time. Periodic
surveys were conducted in 2006 and 2009 and results of a
more recent survey of 677 companies conducted in 2011
showed that employers perceived work-related stress (56%),
smoking (35%), mental health (35%) and high blood pressure
(35%) to be the most important health risks for their
organizations.51 Yet, only about 21% of companies indicated
that they assessed the health of their employees and even
fewer indicated that they monitored the outcomes of any
health and wellness programs that might be ongoing in
their organization.
With specific reference to promoting PA, in 1992,52 the
Canadian Fitness and Lifestyle Research Institute40
conducted a survey among 4000 workplaces to examine
the extent to which Canadian organizations were promoting PA. This initial survey revealed remarkable changes in
the presence of workplace opportunities over the previous
eight years: the proportion of mid-size companies offering
sport and recreational activities and fitness promotion
opportunities increased from 44% to 71% and 13% to 34%
whereas the proportion of large companies offering such
services and amenities had increased from 28% to 84% and
14% to 65%, respectively. Despite these favorable statistics,
a subsequent survey among 2480 Canadian workers in 2001
indicated that only about 20% of workers believed that
employers had a positive attitude toward PA and that most
report little promotion for a more active lifestyle. In
addition, just over one third of workers reported having
access to amenities to support PA such as showers, change
areas, locker rooms, or bicycle racks, less than half had
received information about opportunities for PA and
actually have opportunities for PA near work, about one
quarter had access to a wellness or nutrition program at
work, but only 13% had opportunities for fitness improvement such as fitness testing or PA counseling. A follow-up
cross-sectional survey in 2006 among 2471 working Canadians did however show some interesting trends and
improvements: about half of workers indicated having
access to places to walk, jog, or exercise close to work
and where facilities were available, there was much
flexibility in using equipment and facilities. Finally, a
survey53 of the workplace in 2007–2008 showed that the
notion of providing a more physically active workplace was
gaining ground but that major changes in the services and
amenities were still lacking in workplaces.
Implementing health and wellness programs in
the Canadian workplace: literature and examples
of best practices
One of the earliest papers published in the scientific literature
pertaining to health and wellness programs in Canada54
surveyed 58 agencies from across the country in 1995 to
determine the types of agencies offering disease prevention
and health promotion services to small workplaces and to
describe the activities and strategies used. Interestingly, they
observed that many of these agencies had emerged as a result
of recent legislation (see above) and that the specific focus of
interventions involving lifestyle or organizational determinants was quite variable. Although a great deal has been
written about workplace actions and their effectiveness to
reduce tobacco demand,55–57 there is a clear dearth of papers
pertaining to other prevalent risk factors including healthy
eating, PA, HTN, hypercholesterolemia, and psychosocial
stress. However, one series of papers published in 2007
examined the implementation of health and wellness
programs58 in healthcare organizations. In reviewing both
the scientific and grey literature, Shamian and El-Jardali58
showed there had been significant changes to healthcare
environments making them more healthful for healthcare
workers as a result of legislative and policy action that
integrated evidence from the scientific literature about
healthy workplaces but that additional research, evaluation,
and changes in practices were required to achieve the ideal of
healthy workplaces in healthcare.
One example of a workplace intervention conducted in
Canada and designed to increase involvement in PA has led to
several publications. The Physical Activity Workplace Study
recruited a sample of over 2000 employees of three government organizations and two private companies to participate
in a 12-week workplace email intervention.59 The intervention was based on the stages of change model of behavior60
and involved provided information and proposed actions
steps to participants to improve their eating and physical
activity habits. They showed small but significant improvements in intentions, self-efficacy, and behavior related to PA
and healthy eating suggesting that this type of intervention
has potential as one component of a health and wellness
program. Subsequent papers61,62 emerging from this project
also showed the promise and potential impact of different
components of the email intervention for reducing CVD risk
factors among Canadian workers.
Another recent example of the potential impact of intervening in a Canadian workplace also revealed promising
findings.63 The “Tune-up your Heart” program involved screening employees working at DaimlerChrysler Corporation in
Canada and then tailoring an intervention involving goalsetting, monitoring, and companywide education initiatives.
Following the 18-month intervention, participants were shown
to have an improved CVD risk factor profile including reduced
body mass index, reduced blood pressure, more favorable
profile of PA and diet as well as reduced number of smokers.
Cost–benefits analysis also showed that there were substantial
financial savings associated with program outcomes.
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In 2008, Morrison and MacKinnon64 reviewed existing
literature on health and wellness programs and conducted a
key informant survey of seven Canadian policy experts on
health and wellness in the workplace. Their review and
interviews revealed that successful health and wellness
programs should be characterized by at least seven elements
namely, 1) Engaging stakeholders at all levels (i.e., employees,
management, unions, healthcare providers, service providers,
amenity maintainers); 2) Involving strong employee participation; 3) Integrating health and wellness promotion into the
core business of the company; 4) Favorably impacting medical
costs; 5) Favorably impacting indirect costs such as absenteeism, presenteeism, and productivity; 6) Improving quality of
life and employee satisfaction; and 7) Favorably influencing
clinical outcomes such as fitness and obesity. As this is a
recently published report, it is unclear to what extent there
has been uptake of these criteria in the implementation of
health and wellness programs in Canadian workplaces.
To our knowledge, aside from the papers outlined above,
there are no overarching reviews of the impact of Canadian
Health and Wellness programs in the workplace and as
indicated in the Buffet National Wellness survey in 2011, only
a limited number of companies evaluate the outcomes of their
programs. However, the Public Health Agency of Canada cites
examples of best practices of wellness programs led in large
Canadian companies including British Columbia Hydro,65
Vancouver International Airport,66 Desjardins Financial
Group,67 and more recently Le Grand Défi Entreprise.68,69
These best practices nicely illustrate what can be achieved in
Canadian workplaces to reduce CVD risk factors.
In sum, although there is not an abundance of scientific
literature in Canada about the outcomes of workplace
health and wellness programs, there has been a substantial
amount of action in the area of legislation and policy to
create a context that is conducive to reducing CVD risk
factors. In particular, the movement towards health promotion and the current effort to reduce social inequalities
in health has stimulated many companies and their
employees to structure workplace environments to make
them more conducive to adopting healthy behaviours that
promote lower CVD risk and to structure environments
wherein stress levels are at a manageable level. Some larger
companies have successfully integrated impactful workplace health and wellness programs. We now turn to future
directions for research and practice.
Where from here? Future directions for research
and practice
In light of the information reviewed above, we believe that
several gaps in the literature and in our understanding of the
current status of practice represent important targets for
future action. From a surveillance point of view, as we have
≥4.5 cups/day
≥2 servings of 3.5 oz/week
(≥1.1 g fibers/10 oz
carbohydrates): ≥3 servings of 1 oz/day
<1500 mg/day
≤450 kcal (<1 liter/week)
Etc.
489
Reduce inactivity
Increase overall physical activities
Increase vigorous physical
activity/exercise
Increase active transportation
Etc.
Fig 2 – Model by which assessing and targeting key behaviors such as nutritional quality and physical activity in the workplace
can eventually have favorable effects on abdominal adiposity and on cardiorespiratory fitness as clinically relevant outcomes
improving cardiometabolic health of employees.
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reviewed, there is still a dearth of ongoing evidence and
information about the nature and extent of health and
wellness programs offered within Canadian workplaces, the
characteristics of the organizations that are associated with
offering health and wellness services and amenities, the
impact of these health and wellness programs on the CVD
risk profile of the workforce, and the cost–benefits of offering
such programs. The collection of systematic information
about these issues and the conduct of an overarching Health
Impact Assessment70 of the added-value of health and
wellness programs seem warranted. Such an action would
allow for identification of the most critical targets for action
and bring together organizations and individuals to work in a
concerted and synergistic fashion.
In addition and in keeping with recommendations formulated by Morrison and MacKinnon,64 we believe that advances in
data collection are required to develop an appropriate measurement armamentarium to tap into the presence of the seven
critical elements of workplace health and wellness initiatives.
Using a combination of self-report and habitually collected
information offers the best promise for valid and reliable
instrumentation. Third, a new generation of research into the
impact of workplace health and wellness programs is required.
Like in many other areas of population health intervention
research, although it may be possible to conduct randomized
controlled trials to investigate the impact of selected health
education or counseling interventions, the feasibility of
conducting randomized controlled trials aimed at transforming
organizational environments seems remote.71 Therefore, studies adopting alternative methodologies including multisite
translational community trial methodologies, propensity score
matching techniques, natural experiments, or stepped wedge
designs also show promise for dealing with the challenging
problems of establishing the effectiveness of health and
wellness programs through field experimentation.72–74
Furthermore, in order to better capture CVD risk and the
emerging construct of ideal CV health, the AHA has identified
4 simple behavioral metrics (smoking, normal body weight,
PA and nutritional quality) to be combined with 3 “traditional”
biological risk factors to define ideal CV health.75 Studies
show an extremely low risk of CVD among individuals
meeting 6–7 criteria for ideal CV health and a spectacularly
larger risk in incidence of CVD among individuals not meeting
these 7 criteria.76,77 We believe that a new generation of
research into the outcomes of health and wellness programs
in reducing CVD risk could systematically assess and target
these 7 metrics which also consider the importance of
nutritional quality and PA (see Fig 2). Health and wellness
programs represent a remarkable opportunity for primordial
prevention of CVD. We believe that by building on current
legislative and policy initiatives in Canada as well as on the
growing literature on the impact of health and wellness
programs in industrialized nations, CV health and CVD risk
can be dramatically improved.
Statement of Conflict of Interest
All authors declare that there are no conflicts of interest.
Acknowledgments
Dr. Jean-Pierre Després is the Scientific Director of the
International Chair on Cardiometabolic Risk which is based
at Université Laval. Dr. Lise Gauvin holds an Applied Public
Health Chair on Neighbourhoods, Lifestyle, and Healthy Body
Weight which is supported by the Canadian Institutes of
Health Research and the Centre de recherche en prévention
de l’obésité.
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