Promoting healthy weight: developing messages that encourage maintaining a healthy weight and using motivational interviewing to help workers commit to changing their behavior are essential to successful interventions with overweight and obese workers.

This is the second of two articles on promoting healthy lifestyles in the workplace. The previous article discussed how EAPs can help workers maintain a healthy weight and assist employers in keeping their healthcare costs under control.

Nearly 65 percent of the U.S. adult population, or two out of three adults, is overweight or obese. (1) Obesity leads to at least 300,000 deaths annually (2) and places individuals at greater risk for diabetes, heart disease, hypertension, musculoskeletal conditions, stroke, some cancers, and depression. The effects of obesity and being overweight affect health care expenditures and productivity more than smoking and alcohol use. (3)

Overweight and obese employees can have a dramatic impact on a work organization's bottom line. The total cost of obesity to U.S. companies is estimated at $13 billion per year, as follows: $8 billion in healthcare costs, $2.4 billion in paid sick leave, $1.8 billion in life insurance, and $1 billion in disability insurance. (4) Obesity is associated with 30 million lost workdays, 239 million restricted activity days, 90 million bed days, and 63 million physician visits annually. (5)

The human and financial toll of obesity on workplaces is the basis on which EAPs should position themselves to address this issue. The EA field's focus on prevention, education, and referral to appropriate resources offers natural synergies to meet employers' needs to minimize risks associated with obesity.

AN EAP RESPONSE

To address the workplace performance issues related to overweight and obese employees, ValueOptions, a national provider of behavioral health and EAP services, created a Healthy Weight Task Force as part of its EAP. The task force, which comprised EA professionals, representatives of organizational clients, medical personnel, and human resources staff, identified several key focal points, including the behavioral health considerations that negatively affect weight (such as stress) and those that encourage healthy weight maintenance (e.g., stress management skills).

The task force then framed positive messages around the concept of healthy weight rather than negatively focusing on weight and obesity. The key message was, "A balanced diet, regular physical activity and stress relief can help you stay healthy for life." The task force developed strategies to convey this message to three audiences: the work organization, the individual employee, and the EA professional community.

To support the work organization, the EAP held an employer summit to review the scope and impact of obesity on such factors as job attendance and productivity and corporate healthcare expenditures. In addition, the task force distributed a CD-ROM to each employer customer describing the costs, causes, and consequences of weight gain and obesity. The CD-ROM included a detailed communication strategy as well as an implementation plan of low-cost and no-cost activities that worksites can use to support individuals in reaching and/or maintaining a healthy weight. The materials included a timeline to help walk organizations through a series of events and activities that can be used to promote a healthy workplace.

To support the needs of the EA community, ValueOptions sponsored trainings for intake staff and EA professionals. These trainings highlighted the behavioral link between weight and psychological health using the Transtheorectical Model of Change developed by Prochaska and DiClemente. (6,7,8) The training facilitators explained that the most successful intervention strategies are those that focus on the behavioral issues associated with making a lifestyle change and include action activities as well as constant reminders and reinforcements. This strategy is based on the theory that individuals learn 10 percent of what they read, 20 percent of what they hear, 30 percent of what they see, 50 percent of what they see and hear, 70 percent of what they discuss with others, and 80 percent of what they use and do in day-to-day life. (9)

The facilitators devoted particular attention to the cultural, ethnic, gender, age- and income-related issues associated with weight gain and obesity. They provided participants with a series of interview questions and interventions matched to the appropriate stage of behavior change. They also provided information on the physical health issues associated with being overweight and obese.

SUPPORTING INDIVIDUALS

To support the individual employee, three worksite trainings were created to assist efforts toward maintaining a healthy weight and encourage employees to contact the EAP for assistance with making a healthy lifestyle change. "Stress Management and Healthy Well-Being" and "Healthy Eating and Stress Management" focused on the connection between managing stress and living a healthy lifestyle and helped raise employee awareness of the impact that unmanaged stress and behavioral issues have on physical health and, in particular, weight. "Advances in Our Understanding about Obesity and Overeating" was designed to offer participants a better appreciation of risk factors, medical, social and psychological consequences, and treatment and prevention strategies.

In addition to creating the trainings, the EAP distributed communication materials to workplaces, targeting managers and supervisors as well as the general workforce. These materials included tip sheets, posters, newsletters, e-mails, and educational seminars that built upon positive key messages, including the following:

* Making even moderate changes in eating and physical activity can significantly improve your health and well-being;

* Expect setbacks and forgive yourself, as making a change is a process, not an event; and

* A balanced diet, regular physical activity, and stress relief can help you stay healthy for life.

Advancing these messages, the EAP began working with individual employees to overcome the behavioral barriers to making healthy lifestyle changes. The EAP set the following intervention goals:

* Enable participants who are at risk of health problems due to being overweight or obese to contact the EAP for assessment, referral, follow-up, and ongoing support;

* Minimize risk factors for weight gain and obesity; and

* Reinforce the concepts of stress management, healthy eating, and regular physical activity, thereby reducing the health risks associated with weight gain and obesity.

FLEXIBLE FRAMEWORK

To meet these goals, the EAP adopted the Transtheoretical (Stages of Change) Model, which is aptly suited to healthy weight service delivery. The Transtheoretical Model is ideal for EAP use, as it is flexible enough to meet the needs of all participants and has multiple measures built into its processes to evaluate outcomes.

The Transtheoretical Model offers a flexible framework of five stages through which the participant passes in making changes. Change is viewed as a process in which a participant enters and exits a stage at any point. In this model, relapse is defined as a return to a previous stage. The five stages are as follows:

* Precontemplation. The client does not acknowledge the problem or see a need to change his/her behavior. Employees in this stage need to be made aware of the consequences of the issue or problem and offered the opportunity to express their feelings about the consequences.

* Contemplation. The client is thinking about changing his/her behavior within six months. EA professionals should help clients assess the pros and cons of their behavior, address their ambivalence, and encourage them to identify the benefits of the change.

* Preparation. The client is creating a plan to make a change and/or solve a problem within one month. The EA professional should verify the client's commitment and assess the plan.

* Action. The client is implementing a plan to change a behavior and/or solve a problem. The EA professional should offer positive feedback and encourage the use of self-rewards.

* Maintenance. The client is continuing to change his or her behavior and/or solve the problem. The EA professional should monitor the client's progress and continue to offer positive feedback.

The use of motivational interviewing is helpful in moving clients from one stage to another. Empathy and reflection are key skills. Confrontation is to be avoided at the risk of encouraging entrenchment in problem behaviors. In motivational interviewing, the goal is not to get the client to do what appears to the counselor as the right or logical course of action, but rather to determine what the client is motivated to do.

Miller and Rollnick (10) compare the counselor's role in facilitating change to a driver's role in managing an icy roadway. While veering right on an icy road, our instinct is to jerk the steering wheel to the left. We know, however, that jerking the wheel in the opposite direction of a slide only increases sliding and makes it much more difficult to regain control of the vehicle. Similarly, pushing clients to follow our recommendations to ease their distress may well have the same effect--they will move further and further away from easing their distress or solving their problems.

Motivational interviewing allows the EA professional to determine, with the client, what the client wants to change and what s/he is willing to do to make that change. The interview leads the client to describe the change that is necessary to ease distress.

Ideally, the EAP intervention supports the client's concern about weight issues, offers information that increases awareness, and directs the client to the next step in exploring the problem. A successful intervention with an individual does the following:

* Considers the impact of concerns about weight on the individual's physical and social environment;

* Acknowledges the psychological aspects of being overweight or obese, including rejecting peers, being the target of possible job discrimination, and experiencing feelings of failure, low self-esteem, and depression due to difficulty finding clothing, shoes, and furniture;

* Focuses on the client's perception of self, with and without problems with weight;

* Establishes individual belief in oneself based on previous life accomplishments and successes; and

* Plans for the environmental and psychological barriers to a successful lifestyle change

MULTIFACETED APPROACH

Because the issues associated with being overweight and obese are complex, tackling this problem requires a multifaceted approach, including the use of behavioral health techniques. Employers will experience greater success when they focus on the behavioral issues associated with making a lifestyle change and deploy the EAP to be an additional resource that can be used to support and promote a healthy workplace.

EAPs have demonstrated that they are well positioned to be responsive to organizational needs. With their strong focus on prevention, education, assessment, referral, and follow-up, they can effectively address one of our nation's fastest-growing public health concerns.

Notes

(1) U.S. Centers for Disease Control and Prevention. 2003. Chartbook on Trends in the Health of Americans. National Center for Health Statistics.

(2) Actual Causes of Death in the Unites States. 1993. Journal of the American Medical Association.

(3) Sturm, R. 2002. "The Effects of Obesity, Smoking, and Drinking on Medical Problems and Costs." Health Affairs 21(2): 245-253.

(4) Department of Health and Human Services. 2003. Prevention Makes Common Cents: Estimated Economic Costs of Obesity to U.S. Businesses. Washington, D.C.

(5) Wolf, A. M. and G. A. Colditz. 1998. "Current Estimates of the Economic Costs of Obesity in the United States." Obesity Research (6): 97-106.

(6) Prochaska, J. O. "Transtheoretical Model: Stages of Change." Cancer Prevention Research Center, University of Rhode Island.

(7) Scholl, Richard W 2002. "Transtheoretical Model of Behavior Change." University of Rhode Island.

(8) Velicer, W.F., J. O. Prochaska, J. L. Fava, G. J. Nornam, and C. A. Redding 1998. "Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change." Homeostasis (38): 216-233.

(9) Leone, Kathleen. 2001. "Demand Management Nurses: Directing the Way to Better Outcomes." IntraSpectives 1(3).

(10) Miller, William R. and Stephen Rollnick. 2002. Motivational Interviewing: Preparing People for Change. New York: The Guilford Press.

Kathy Greco is director of quality and outcomes for the Health and Performance Solutions Department in ValueOptions' Employer Solutions Division. She is responsible for quality and outcomes initiatives supporting workplace-based services and products. She can be reached at [phone] or at [e-mail].

Rich Paul is vice president of Health and Performance Solutions in ValueOptions' Employer Solutions Division. He is responsible for operations, product development, and best practices supporting workplace-based services and products. He can be reached at [phone] or at [e-mail].

Brent Pawlecki is associate medical director at Pitney Bowes Inc. His responsibilities include managing the onsite medical clinics and wellness programs and serving as a consultant for the Disability Department and the workers' compensation, safety, and benefits design groups.