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With >130 million Americans employed across the United States, workplaces provide a large audience for cardiovascular disease (CVD) and stroke prevention activities. Experience has shown that workplace wellness programs are an important strategy to prevent the major shared risk factors for CVD and stroke, including cigarette smoking, obesity, hypertension, dyslipidemia, physical inactivity, and diabetes. An estimated 25% to 30% of companies’ medical costs per year are spent on employees with the major risk factors listed above.1 Employees and their families share the financial burden through higher contributions to insurance, higher copayments and deductibles, reduction or elimination of coverage, and trade-offs of insurance benefits against wage or salary increases. When programs are successful, their influence extends beyond the individual workers to immediate family members, who are often exposed to their favorable lifestyle changes. Worksite wellness programs that can reduce these risk factors can ultimately decrease the physical and economic burden of chronic diseases, including CVD, stroke, and certain cancers.
The societal benefits of a healthy employed population extend well beyond the workplace. As such, comprehensive, culturally sensitive health promotion within the workplace can improve the nation’s health. The Healthy People 2010 goal is for 75% of all worksites, regardless of size, to develop comprehensive wellness programming.2 However, the development of comprehensive programs takes time and resources, especially for smaller employers. Because program development and initiation can be resource intensive, the American Heart Association (AHA) supports incremental efforts to achieve a comprehensive worksite wellness program to address CVD and stroke prevention and makes the following recommendations.
Summary of Recommendations
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Components of Wellness Programs
A comprehensive program aimed at improving employees’ cardiovascular and general health should include the following: Tobacco cessation and prevention, regular physical activity, stress management/reduction, early detection/screening, nutrition education and promotion, weight management, disease management, CVD education that includes cardiopulmonary resuscitation and automated external defibrillator training, and changes in the work environment to encourage healthy behaviors and promote occupational safety and health.
Programming should be integrated into the organizational structure of the workplace by use of the following proven strategies: Health education that relies on existing valid sources and is focused on skill development that is consistent with employees’ readiness to make behavior changes; initiatives that are incorporated into existing employee assistance programs; and voluntary worksite screening linked with medical care for follow-up on modifiable risk factors.
Employers should administer health risk appraisals in combination with organizational health promotion checklists that have already been developed for the worksite before initiating programming so that health needs in the workplace can be identified and employees can learn their risks and health status. Employees’ health risks must be addressed within comprehensive worksite programs.
Research should investigate the effectiveness of wellness programming and how to tailor programming and policies for maximum effect.
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Environmental Modifications
The social and physical environment of the workplace should be designed to be conducive to recommended behaviors.
Optimal environmental modifications should promote healthy behaviors while simultaneously minimizing the physical, organizational, and occupational risk in the work environment.
Occupational safety and health are integral components of worksite wellness; workplaces should be free from hazards that jeopardize cardiovascular health and employee safety and well-being.
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Regulations/Policy Approaches
The regulatory environment should allow for increased opportunity for employers to reach a greater majority of the employee population and produce health benefits.
Employers should adhere to all regulations that address hazards to employee health and safety, providing working conditions that are optimal for cardiovascular health and well-being.
Employers who choose to offer healthy lifestyle behavior incentives in the workplace, such as wellness credits and financial incentives, should provide these directly to the employee. Financial incentives should not be attached to healthcare premiums or health status.
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Vulnerable/Special Populations
Wellness programs must address the needs of all employees at a given workplace, regardless of gender, age, ethnicity, socioeconomic status, culture, job type, or physical or intellectual capacity.
Worksite wellness programs should be designed to be culturally sensitive and all-inconclusive, and employers should also consider targeted, complementary interventions for their more vulnerable employees that are specifically designed to engage those who are economically challenged, less educated, or underserved.
Worksite wellness programs should help working families balance work and family commitments and incorporate policies around child care, elder/dependent care, telecommuting, and flexible work schedules.
Research should be conducted to determine how to improve participation among employees who have the highest risk behaviors.
Wellness Programs
CVD and stroke are the leading causes of death in the United States. The estimated expense associated with all heart diseases combined is $304.6 billion, $24 and $98 billion of which is due to lost productivity from cardiovascular morbidity and mortality, respectively.3 The financial burden associated with stroke is equally weighty; in 2009, an estimated $68.9 billion in direct and indirect costs was spent to diagnose and treat strokes.4 The estimated lifetime cost for hospital stays, rehabilitation, and follow-up care to treat lasting neurological deficits is $140 048 (adjusted to 1999 dollars).4,5
Worksite wellness programs are a proven strategy to prevent major risk factors for CVD and stroke, including cigarette smoking, obesity, hypertension, dyslipidemia, physical inactivity, and diabetes. Historically, wellness programs have included education and screening programs in an effort to increase individual workers’ awareness of risk factors and suggest strategies to modify health behaviors. Recent evidence from the social sciences and behavioral medicine literature suggests that environmental modification and policy changes and approaches are more successful at producing sustained behavior change that can reach employees across varied socioeconomic groups. Worksite wellness programs represent an opportunity to prevent CVD and stroke in a large segment of the population. The AHA and its regional affiliates have a long history of participating in worksite wellness programs. Because of marked variability in the availability, content, and delivery of wellness programs, the AHA is committed to updating recommendations given current knowledge about effective programs and strategies to produce positive changes.
The Current State of Affairs
Availability
In 2004, the National Worksite Health Promotion Survey conducted 1553 interviews with worksites from different size and industry categories and found that only 6.9% of employers offered comprehensive worksite wellness programming, defined as those programs “that incorporated all of the 5 key elements outlined in Healthy People 2010: health education, supportive social and physical work environment, integration, linkage, and worksite screening and education.”6 The presence of comprehensive programming varied significantly by worksite size; programs were available at 11.3% of companies with 250 to 749 employees, but only 4.6% of companies with 50 to 99 employees had programs.
At least half of the working people in the United States do not have access to health promotion programs because they work in small companies or for employers who have employees distributed in small numbers across multiple sites. Of the 4.9 million firms in the United States, only 0.5% have >500 employees; the majority of firms (99.5%) have <500 employees.7 These larger and smaller firms employ 51% and 36% of the working population, respectively.8 There were also striking disparities in the availability of worksite wellness programs by industry type. Manufacturing and business/professional services reported having wellness programming 8.7% and 8.3% of the time, respectively, whereas wholesale/retail (5.6%), transportation (2.9%), finance (2.4%), and agriculture/mining (1.4%) were much less likely to have comprehensive programming.2
Smaller employers face a number of barriers to offering wellness programs. Many of these smaller companies do not have a central human resources function to initiate and organize programs. Moreover, the expense associated with hiring a full-time health promotion staff is difficult to justify in a smaller company. Finally, because health insurance premiums are typically community rated, meaning that premiums for smaller companies are set by the medical utilization experience of their community, reducing their medical care costs by improving the health of employees will not decrease their insurance premiums.8 Consequently, an important financial incentive to develop worksite wellness programs is missing for smaller companies.
Returns on Investment
The payback for investing in worksite wellness programs can be measured in various ways, including decreased direct healthcare costs, improved healthcare utilization, increased performance measures, lower rates of absenteeism, and a reduced prevalence of chronic disease.
Financial Returns
Employer spending on health promotion and chronic disease prevention and management is a good financial investment when it succeeds in modifying the health of employees. Migration to a lower risk status is estimated to save $53 per employee, savings that recur each year that the employee remains in a low-risk tier.9 Programs have achieved a rate of return on investment that ranges from $3 to $15 for each dollar invested, with savings realized within 12 to 18 months.10 Meta-analyses have shown a 28% average reduction in sick leave absenteeism, a 26% reduction in healthcare costs, and a 30% decrease in workers’ compensation and disability management claims costs.11 Other benefits to the companies that offer such programming are recruitment and retention of top employees, as well as an improved corporate image.10
Absenteeism/Presenteeism
Employers have to absorb the indirect expense of lost productivity from employees who have chronic illnesses when the employee is absent from the job (absenteeism) or is at the job but impaired because of a health problem (presenteeism).12 Employees with the greatest health risks, poorest emotional health, and higher percentages of adverse behaviors had much higher rates of lost workdays and lower productivity overall.13,14 In a cross-sectional analysis of 2264 employees at a single employer, the rates of absenteeism and presenteeism were estimated to range from 0% to 6.3% and from 1.3% to 25.9%, respectively, among employees with up to 8 risk factors.15 The number of workdays lost was directly associated with the number of risk factors among 2250 employees of a single petrochemical facility; the presence of 0, 1, 2, 3, and 4 or more risk factors was associated with 4.1, 6.4, 8.8, 9.3, and 12.6 days of absenteeism, respectively.13 Bank One attempted to determine whether absenteeism or presenteeism is more costly and estimated that absenteeism represented 6% of total medical costs (direct and indirect), whereas presenteeism was responsible for 63%.16
Observational studies and interventions have shown that changes in health risk factors are directly related to changes in absenteeism and presenteeism. Individuals who reduce 1 health risk factor decrease presenteeism by as much as 9% and absenteeism by 2%.17 Research demonstrates a strong relationship between changes in health risk factors with changes in presenteeism and resultant productivity. Each risk factor increased or reduced was associated with a commensurate change in productivity of 1.9% over time; the savings were estimated to be $950 per year per risk that was reduced.18
Productivity
Chronic diseases have a significant adverse influence on productivity; however, it is difficult to quantify productivity in today’s postmanufacturing economy, in which so little of what is produced can be measured.16,19 As a result, most productivity estimates are based on questionnaires that can yield widely different estimates of on-the-job productivity gains or losses even when administered in the same setting.20–25 The results of various reviews suggest that on-the-job productivity losses can approximate from 20% to >60% of total health-related costs. It is estimated that health-related productivity losses cost US employers $225.8 billion per year or $1685 per employee per year, of which 71% is due to reduced performance at work.26 Depression alone, a risk factor for new and recurrent CVD and stroke,27 costs US employers approximately $35 billion in lost productivity.28,29 Studies evaluating productivity losses show that such losses are intimately linked to presenteeism and its associated health concerns.14,19–22,24,30
Loss of productivity is related to both the severity of dysfunction caused by illness or disease and the summation of health risk factors present.15,31–33 Estimates of productivity loss are between 12% and 28% for employees with 0 to 7 or more health risk factors, respectively.34 As demonstrated in reports evaluating presenteeism, intervention trials aimed at reducing health risk factors have consistently demonstrated significant productivity gains.17,18 Moreover, others have documented the low level of treatment currently provided in the US workforce for many at-risk health conditions, including depression, and the opportunity for substantial productivity gains by undertaking worksite health promotion activities.26,28
Components of Worksite Wellness
Recommendations
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A comprehensive program aimed at improving employees’ cardiovascular and general health should include the following: Tobacco cessation and prevention; regular physical activity; stress management/reduction; early detection/screening; nutrition education and promotion; weight management; disease management; and changes in the work environment to encourage healthy behaviors and promote occupational safety and health (Table).
View this table:Table. Components of a Work-Site Wellness Program for Cardiovascular Health
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Programming should be integrated into the organizational structure of the workplace by use of the following proven strategies: Health education that relies on existing valid sources and is focused on skill development that is consistent with employees’ readiness to make behavior changes; initiatives that are integrated into existing employee assistance programs; and voluntary worksite screening linked with medical care for follow-up on modifiable risk factors.
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Employers should administer health risk appraisals in combination with organizational health promotion checklists that have already been developed for the worksite before initiating programming so that health needs in the workplace can be identified and employees can learn their risks and health status. Employees’ health risks must be addressed within comprehensive worksite programs.
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Research should investigate the effectiveness of wellness programming and how to tailor programming and policies for maximum effect.
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When possible, planning and implementation of worksite wellness programs should optimize use of on-site personnel, physical resources, and organizational capabilities to make it easier for employees to participate.
Content
Tobacco Cessation and Smoking Prevention
Direct and environmental (ie, secondhand smoke) exposure to cigarette smoke is associated with substantial morbidity and mortality due to CVD and stroke. Cigarette smokers are 2 to 3 times more likely to die of CVD35 and twice as likely to die of stroke.36 Nonsmokers who are exposed to secondhand smoke at home or at work have a 25% to 30% greater likelihood of developing heart disease.37
Tobacco use in the workplace costs US businesses an estimated $92 billion per year.38 Losses stem from increased healthcare utilization by employees who smoke, decreased productivity, and the exposure of nonsmoking employees and customers to secondhand smoke. On average, smokers miss 6.2 days of work per year compared with nonsmokers, who miss 3.9 days per year.39 The American Productivity Audit of the US workforce reported that tobacco use was a stronger correlate of lost production time among employees than age, alcohol consumption, family emergencies, or education; lost production time increased in a dose-dependent manner in relation to the amount smoked.39 Studies conducted in the 1970s and 1980s (before the implementation of workplace smoking ordinances) estimated that environmental smoke exposure was responsible for an additional $490 in healthcare expenditures per smoker per year.40,41
A combination of strategies have been used to educate workers about the health consequences of smoking and to help employees stop smoking through interventions that have proved effective in other settings.42 A Cochrane review of workplace interventions for smoking cessation identified 51 studies in the literature covering 53 interventions between 1966 and 2008.43 Most of those interventions (n=37) were focused on modifying the behavior of individual workers through group therapy, self-help materials, individual counseling, pharmacological treatment for nicotine addiction, and social support. The remaining studies included interventions aimed at modifying the workplace and included incentive schemes and company competitions. In general, treatments that targeted individual smokers, in particular group counseling and pharmacological agents, were the most successful. Participant quit rates and sustained cessation rates for 6 to 12 months after the intervention were comparable to those when interventions were implemented in other settings.43 Incentive schemes and company competitions did not generate high levels of employee participation, nor did they significantly reduce the prevalence of smoking.
Clean indoor air laws have had an important influence on smoking in the workplace. These laws have spread across the country, blanketing most of the working population with smoke-free air and lowering smoking rates. City and statewide legislation prohibiting indoor smoking has decreased smoking prevalence.44 These notable successes suggest that organizational or policy interventions may decrease smoking and have the greatest benefit for the largest number of people. Although smoking inside the workplace is not as common today in the United States as it was in the 1970s and 1980s, only 77% of indoor workers reported that their workplace had policies that restricted smoking behaviors.45 According to the 2004 National Worksite Health Promotion Survey, 40% of worksites completely prohibited smoking on worksite property, and another 56.5% restricted smoking to outside areas only.6 The prevalence of smoking is higher in minorities and persons in lower socioeconomic and occupational classes, and these same groups and women are more likely to be exposed to secondhand smoke.37,46 Blue collar workers are less likely than white collar indoor workers to be covered by smoke-free policies, and workers in certain occupations, such as trucking and fishing, are not covered by smoke-free air laws.47–49
In summary, interventions that target individual smokers are successful, but to achieve maximum effectiveness, they should be used in combination with workplace policies, including complete worksite smoking bans.
Physical Activity
Regular physical activity is recommended to promote and maintain health and to prevent the development of cardiovascular risk factors and related chronic diseases.50 Opportunities for physical activity can be sought during leisure time, can be acquired during active transportation, or can arise in response to occupational duties; however, the likelihood of the workplace serving as a significant source of physical activity has declined, because contemporary work environments are sedentary. Physically demanding work has been reduced or eliminated in many sectors and replaced by labor-saving devices focused on speed, rapid communication, improved efficiency, and increased productivity. Physical inactivity and sedentary behaviors are associated with higher rates of clinical CVD (relative risk of 1.9 for inactive versus active persons in a meta-analysis of 43 studies),51 CVD risk factors,3 and stroke.52,53 Consequently, an important strategy by which employers can lower CVD risk is to provide opportunities for activity in the workplace.
There are a number of strategies whereby companies have tried to promote activity in the worksite, including educating employees about the benefits of activity, providing access to safe spaces for activity, and modifying the built environment so that employees can incorporate activity into their work days. A pioneering study of an at-work stair-climbing program in healthy men showed that an appropriate daily training stimulus (approximately 25 flights for a 70-kg man) resulted in a significant increase in aerobic capacity.54 More recently, investigators reported that sedentary adults who exclusively used stairs instead of elevators at work demonstrated increases in cardiorespiratory fitness and reductions in body weight, waist size, and blood pressure.55 The average daily number of floors ascended or descended by each participant increased from 5 to 23 per day.
Worksite physical activity counseling has positive effects on daily energy expenditure and cardiorespiratory fitness.56 Studies outside the occupational setting indicate that increasing activity by relatively small amounts can have substantial health benefits in at-risk populations. In the Dose Response to Exercise in Women trial,57 previously sedentary overweight women who met even 50% of the consensus recommendations for physical activity over the 6-month intervention improved their fitness.50 A worksite intervention that provided pedometers to employees to achieve 10 000 steps daily succeeded in increasing physical activity and weight loss and reducing blood pressure.58 Using similar technology, another study reported that the combined use of an accelerometer (a portable watch-sized device to capture movement in both the vertical and horizontal planes compared with just the horizontal plane that a pedometer captures) and World Wide Web site that tracked activity also improved physical activity behaviors in previously sedentary employees.59
The adverse influence of sedentary behavior on health has received increased attention. Hamilton and colleagues60,61 have shown that sedentary behaviors alone, especially sitting, are associated with higher rates of morbidity and mortality, cardiovascular risk factors, type 2 diabetes mellitus, and metabolic syndrome, as well as the physiological derangements that adversely influence lipid metabolism. An employee sitting at a desk is expending 1 metabolic equivalent (1 metabolic equivalent=3.5 mL O2 · kg−1 · min−1), whereas even the slowest walking (eg, <1 mph) increases an employee’s metabolic rate to 2 metabolic equivalents.62 Nonexercise activity thermogenesis, the spontaneous physical activities of daily living (including fidgeting while sitting and standing while reading), is a source of energy expenditure for most people.63 When matched with individuals with similar cardiovascular risk profiles, those with highly active ambulatory jobs can have nonexercise activity thermogenesis values >1000 kcal/d higher than their sedentary counterparts.64 Thus, efforts to reduce sitting time through innovations in worksite design and policies can have a significant influence on decreasing sedentary behaviors.
Standing workstations and vertical computer desk designs with slow-moving treadmills placed underneath represent innovative workstation designs that can substantially increase nonexercise activity thermogenesis. Treadmill walking at extremely slow speeds (<1 mph) generally does not interfere with a workers’ ability to use the computer or talk on the telephone. Most importantly, workers reported that they enjoyed using the contemporary workstations and that they supported their use in their own work environment.65 Additional means for increasing physical activity that can be integrated into the workplace include stepping devices,66 basic resistance training equipment, standing workstations, encouraging the use of stairs, centralizing office resources so employees have to walk to access them, encouraging employees to stand while talking on the telephone, walking to deliver messages or have conversations with colleagues versus e-mailling, and holding walking meetings. Many of these activities can be tailored to employees with physical disabilities, highlighting their universal applicability.
In summary, habitually sedentary and/or unfit men and women should be counseled to improve their exercise tolerance by starting and maintaining a regular physical activity program that includes structured exercise, increased lifestyle activity, or both. Organizational interventions may include modified workstations that encourage standing or moving and readily available places for activity in the workplace, such as well-lit staircases to promote active ambulation.
Stress Management/Reduction
Although workplace stress can be attributed to numerous sources, including job insecurity, long working hours, work scheduling, and organizational restructuring, it is most commonly defined as an imbalance between job demands and control (ie, job strain). Work-related stressors that demonstrate robust associations with CVD in the research literature include job strain (ie, high-demand–low-control work), effort-reward imbalance (ie, high work efforts combined with low rewards such as support, respect, security, and income), long work hours, and shift work. These stressors reduce employees’ ability to work by diverting their attention away from job responsibilities to addressing or coping with the stresses.67 Additionally, high levels of stress have been associated with the development of cardiovascular risk factors and impaired job performance.68 Worldwide, approximately one quarter of working women and 18% of men report high levels of job-related strain.69–71 A 2004 comprehensive review of studies of the association of job strain with CVD risk factors concluded that the weight of evidence suggests that job strain is a CVD risk factor.72 However, a more recent prospective study, which was composed largely of women, did not find a significant association of job strain with ischemic heart disease; rather, low job control is correlated with a significant doubling in the risk of developing heart disease.73 Although further research is required to identify which components of job stress are most strongly associated with heart disease, recommendations to implement stress management programs at both the individual and organizational level are warranted.
The 2004 National Worksite Health Promotion Survey reported that one quarter of worksite wellness programs included stress management programming.6 Individual-centered approaches involve teaching employees skills for managing pressures and demands. Such strategies include cognitive behavioral therapy, relaxation techniques, and individual counseling focused on adopting healthy lifestyles.74 A systematic analysis of the literature on job-stress interventions revealed that the greatest impact occurred when the intervention was both organizationally and individually focused.75 Although individual-centered approaches may favorably modify behavioral issues such as smoking cessation or sedentary behaviors, they are less likely to reduce workplace stress because they do not address the organization of the workplace management approach.76
In a systematic review of organizational-level interventions designed to improve employee control, workers experienced health benefits. Egan et al77 reviewed 18 relevant studies, 11 of which noted improvements in health and none of which reported adverse health effects; however, the authors acknowledged that the organizational interventions were complemented by health education efforts.
Approaches that target management within a workplace have proved modestly successful. One study78 used a unique approach and provided a randomized (by worksite) World Wide Web–based supervisor training program on worksite mental health, supervisor support, and psychological distress among subordinate workers. Subordinate workers at the intervention (n=81) and control (n=108) sites completed a brief job stress questionnaire at baseline and at 3-month follow-up.78 Although workplace autonomy and overall job stressors did not differ between subordinate workers at the intervention or the control sites, the item score for a friendly workplace atmosphere increased significantly (P=0.02) at the intervention site, whereas there was no change at the control site.
A prospective study of ischemic heart disease events associated with employees subjected to different approaches to supervision gives insight into potential interventions and the role of organizational policy. Employees whose supervisors provided clarity in goals and role expectation, communicated well and offered feedback about performance, and encouraged employee participation and control were significantly less likely to experience acute myocardial infarction, unstable angina, and cardiac deaths over a 10-year follow-up period.79
There are methodological challenges inherent in these interventional studies. The workplace is frequently changing because of closings, mergers, downsizing, or restructuring, and these changes should be considered when interventional research about job stress is planned. Fundamental restructuring of the workplace influences the effectiveness of the intervention and raises serious questions about the analysis and interpretation of the research results.80
Comprehensive approaches that address both the organizational origins of workplace stress and the behavioral symptoms exhibited by employees are more likely to lead to favorable sustainable outcomes.81 The organizational focus has the added benefit of reaching employees across job classes. Lower-paid and less-educated workers in typical blue collar positions are commonly segregated into low-control/high-demand positions that are at greater risk of exposure to occupational stress. Historically, these workers have not responded to individual-centered wellness initiatives,74,82 and they are more likely to experience benefits through organizational and occupational changes that make the workplace safer, institute rules and policies about working hours, and provide the protection of worker organizations to advocate for employee rights.
Screening and Early Detection
Health screening in the employee population requires significant resources but can serve as an investment for employers. Guidelines from the AHA and other public health organizations stress the importance of increasing awareness, prevention, treatment, and control of major risk factors for CVD and stroke.83 Regular recommended screening for heart disease and stroke may identify risk factors such as diabetes, obesity, hypertension, or abnormal blood lipids, allowing for lifestyle/behavior change and effective use of medications to address these before the manifestation of disease sequelae. If adverse cardiovascular signs or symptoms have developed, there is opportunity for disease management.
According to the US Census Bureau, 37 million employed persons were without health insurance in 2007,84 which diminished the likelihood that they would seek preventive health services, including disease screening. Wellness programs that incorporate screening can fill an important national healthcare void by identifying treatable conditions. In order for disease screening to be effective, the diagnostic testing must have high rates of sensitivity and specificity.85 It is important to minimize false-positive results that may lead to further unnecessary and costly evaluations and potential complications.
The 2004 National Worksite Health Promotion Survey grouped screenings offered at the workplace and through employee health plans to estimate and rank the prevalence of such programming in the United States. Blood pressure, cholesterol, and diabetes were the most commonly reported CVD screenings, at 36.4%, 29.4%, and 27.4%, respectively, with alcohol and drug abuse support and cancer screenings also frequently provided.6 Despite the recommendations by the US Preventive Services Task Force for simple screening for obesity,86 adiposity measures were not reported in the National Worksite Health Promotion Survey. Given the prevalence of overweight and obesity and its role in the development of CVD, not assessing the height and weight of employees represents a missed opportunity. Screening programs were most common in the largest worksites. Screening programs were present in 62% of the largest workplaces (>750 employees) and only 16% of workplaces with 50 to 99 employees.
According to a recent report on 20 000 employees in 13 US workplaces, self-testing stations for blood pressure and body weight are an attractive screening tool for any size workplace.87 One fifth (21.7%) of employees used the health station at least once during the first 18 months it was installed, with many returning for repeated visits. The value of such stations is that employees can privately screen themselves for adverse health conditions, and if used in combination with existing wellness programming, employees could self-identify themselves as needing additional lifestyle and/or pharmacological interventions. Additionally, research supports the use of blood pressure measurement outside of clinical offices as an important supplement to these readings to provide a more comprehensive assessment of 24-hour blood pressure modulations.88
In summary, workplace screening for CVD and stroke risk factors has the potential to identify workers who are at risk for disease and who should be encouraged to participate in risk-reduction behavior change programs. The identification of workers with latent disease early in the course of disease provides the opportunity to delay cardiovascular complications and thus decrease the resulting time away from work and the less productive time at work displayed by workers with chronic diseases.
Nutrition Education and Weight Maintenance
A healthy diet and other lifestyle practices are the cornerstone of the AHA’s prevention and treatment activities. The AHA’s diet and lifestyle recommendations89 promote healthy diet and lifestyle practices to reduce major CVD risk factors (eg, overweight and obesity, high low-density lipoprotein cholesterol and triglycerides, low high-density lipoprotein cholesterol, and elevated blood pressure and blood glucose levels). Controlling these major risk factors with recommended lifestyle behaviors markedly reduces the risk of CVD and stroke.90 The Centers for Disease Control and Prevention estimated that a 10% weight loss will reduce an overweight individual’s lifetime medical costs by $2200 to $5300 by lowering costs associated with the treatment of hypertension, type 2 diabetes mellitus, heart disease, stroke, and high cholesterol.91
Reducing these chronic diseases and underlying risk factors through good nutritional practices may result in economic benefits, decreased healthcare costs, and greater employee productivity in the workplace. The AHA has issued guidelines with strategies for promoting healthy diets for all adults. Those that can be adopted in the workplace include ensuring access to healthy foods (eg, fruits, vegetables, whole grains, skim milk dairy products, fish, lean meats and poultry, and plant-based meat alternatives); increasing offerings of food choices that are low in saturated fat, trans fat, sodium, added sugar, and calories; and providing nutrition labeling at the point of purchase (eg, in the cafeteria and vending machines).89,92
Two reviews evaluated studies detailing the effects of worksite wellness interventions and reported the following benefits: Availability of nutritious foods, point-of-purchase information, systematic reminders and training of healthcare providers to provide nutrition counseling, and incentives to encourage the purchase of nutritious foods.93,94 The intervention strategies varied from providing health education opportunities, changing the availability of healthy foods, and providing incentives such as lower prices, games, and prizes, most of which were associated with favorable outcomes.94 Other studies have shown that when trying to reach high-risk populations, it is important to address job hazard exposures and other areas of job security to gain credibility, which in turn, increases audience receptivity and participation.95–97
A national survey of approximately 3000 employees was conducted online on 2 occasions in July 2007 by HarrisInteractive for the AHA to assess the role that leadership plays in creating an atmosphere in which employees feel free to actively take advantage of worksite wellness programs.98 The participants reported improvements in a number of health outcomes as a result of worksite wellness programs. Those related to nutrition were as follows: Feel better (40%), eat healthier (36%), lost weight (32%), lowered cholesterol (19%), and lowered blood pressure (18%). Employees also reported positive work performance outcomes: Fewer sick days (47%), better productivity (36%), improved quality of work (25%), and higher job satisfaction (21%). In addition, they valued nutritious food choices and effective weight loss programs. Employees reported that nutrition and weight loss programs had the biggest positive influence on health or health habits at 39% and 38%, respectively. These results demonstrate the benefits of worksite wellness programs in individuals who elected to respond to the survey (21% and 11% in the 2 samplings), which leaves questions about the impact in the nonrespondents. However, HarrisInteractive attempted to control for this by demographic weighting using data gathered from previous research.
Because most of the adult population is overweight or obese (66.7%), weight loss and weight maintenance programs are an important component of worksite wellness and health promotion.3 Interactions between work, obesity, and occupational safety and health, in cases in which obesity may be associated with adverse work conditions, may increase when employees are in demanding, low-control jobs with long hours.99 Concomitantly, obesity adds to the escalating cost of health insurance and is linked to the number of people who are either uninsured or underinsured.100 Medical spending on obese employees is 37% higher than for people of normal weight.101 Severely obese women experience more than double the absenteeism of normal-weight women.102 As prevalence data demonstrate, obesity rates are higher in lower socioeconomic groups, an issue that is especially relevant for employers who hire a greater percentage of low-income workers. Employers whose workers fall within the lower socioeconomic classes may pay greater healthcare premiums or anticipate higher healthcare utilization.
A recent analysis of employer and employee attitudes toward weight loss programs in the workplace found that both groups view weight loss programs as appropriate and effective. They favored positive financial incentives as motivation for employers and employees to participate in these programs and strongly opposed punitive financial penalties. Employers, especially smaller companies, favored tax incentives for businesses that incorporate weight loss treatment and weight maintenance incentives into worksite wellness.100
In summary, an assessment of worksite wellness nutrition programs indicates that these are generally effective in favorably modifying dietary practices consistent with current recommendations and in reducing major cardiovascular risk factors such as overweight/obesity, hypercholesterolemia, and hypertension. These findings reinforce the need to accelerate worksite nutrition education and weight management activities. Moreover, a Task Force on Community Preventive Services has recommended a combination of nutrition and physical activity programs for worksite–based interventions to prevent and control overweight/obesity.103 The implementation of a dietary modification in the worksite can simultaneously target multiple CVD risk factors that are closely linked with dietary intake and obesity.
CVD Education and Automated External Defibrillator/Cardiopulmonary Resuscitation Training
Each year, CVD claims the lives of >864 000 Americans, which makes it the leading cause of death in the United States; there are at least 265 100 Americans each year who experience out-of-hospital cardiac arrests and need emergency care before they reach a hospital.3 Many of these lives can be saved if employees are educated about the chain of survival, in which workplaces are equipped with automated external defibrillators and employees are trained in how to phone 911, begin cardiopulmonary resuscitation, and deliver early defibrillation. The provision of defibrillation on-site with an automated external defibrillator can dramatically increase survival rates for cardiac arrest. Employers should offer classes and/or provide materials that educate employees about CVDs, stroke, and emergency response, including management of risk factors, signs and symptoms of stroke or cardiac arrest, and appropriate emergency response.
Delivery
The education of employees about risk factors for and signs and symptoms of CVD and stroke is an integral component of worksite wellness programming. Resources for educating employees about risk factors for CVD and stroke are readily available from credible sources, including the AHA104 and the Centers for Disease Control and Prevention.105,106 However, worksites should modify the content as needed to deliver it in a manner that is targeted to the employees’ level of health literacy. Education should additionally focus on skills development so that employees have strategies for making healthy changes. To further promote uptake, content should be delivered in stages that are consistent with the employees’ stage of readiness for behavior change.107 The incorporation of behavioral theories from the behavioral medicine literature that are appropriate to employees’ background knowledge and readiness for change will ensure maximum success.
Other Aspects of a Worksite Wellness Program
Numerous additional features can improve the implementation and uptake of worksite wellness programs.108 The development of a mission statement for the program can help clarify program goals and desired outcomes. Engaging employees to develop the statement can help with buy-in to the program. The performance of health risk assessments before implementation of a wellness program can be an effective way to raise employees’ awareness of their health risks and to engage them in a wellness program. Repeating assessments at regular intervals can determine the progress and success of the wellness program in the employee population. To maximize the effectiveness of health risk appraisals, they should incorporate questions about socioeconomic status and education, because these factors are established correlates of poor health and may inform intervention strategy. Health risk assessment surveys can be supplemented with organizational health promotion checklists (eg, Heart Check Lite109) that have already been developed for the worksite.
To reassure employees that wellness programs are for their benefit and not related to their job performance or responsibilities, procedures should be in place to ensure confidentiality and privacy. Employers should engage employees in the development and implementation of the program. To reach all employees, wellness programs should have specific policies that address employees who telecommute or work from remote locations.
Each program should be an active learning system in which outcome evaluation is an integral component. Regular, timely, personalized communication is an essential component of a program (eg, a powerful Internet interface that registers, engages, tracks, and evaluates each eligible participating member). Employees should have the opportunity to participate in programming individually when possible through self-help modules or group sessions where applicable. Program outcomes should be assessed annually. The administration of additional surveys for employees who express interest in wellness programs to gauge important constructs such as readiness to change, interest in participating in specific programs, health risks, and current preventive care can ensure that programs are tailored to be of the greatest interest to as many employees as possible.
Environmental Interventions
Recommendations
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The social and physical environment of the workplace should be designed to be conducive to recommended behaviors.
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Optimal environmental modifications should promote healthy behaviors while simultaneously minimizing the physical and organizational risk in the work environment.
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Occupational safety and health are integral components of worksite wellness; workplaces should be free from hazards that jeopardize cardiovascular health and employee safety and well-being.
Modifying the Workplace to Encourage Positive Behavior Change
Raising awareness about healthy lifestyles through education is paramount, but it is also important for wellness programming to build supportive environments and implement policies to encourage healthy lifestyles. Environmental interventions are defined as those “that do not require individuals to self-select into defined educational programs but are implemented for all employees.”111 A number of environmental modifications have proved successful at facilitating healthy behaviors and decision making, such as modifying the physical plant to encourage physical activity or ensuring available healthy food options in the cafeteria or vending machines.
Engbers et al112 reviewed 13 randomized controlled trials published between 1985 and 2004 that included environmental modifications in health promotion programs at worksites. Four studies focused on cardiovascular risk factor reduction, 8 on cancer risk reduction, and 1 on a healthy lifestyle in general. All of the interventions had multiple components (education and environmental); 3 focused on physical activity; and all studies used environmental modifications to increase consumption of fruit, vegetable, and fiber and to reduce fat intake. The investigators found significant effects of environmental interventions on dietary intake and inconclusive evidence that physical activity was favorably modified. The National Heart, Lung, and Blood Institute has supported environmental interventions to prevent overweight and obesity at worksites.113 One-year results from 1 of those studies suggest that such interventions, when superimposed on existing education programs at the worksite, can lower body mass index.
One successful strategy to increase consumption of lower-fat foods is to reduce prices. French114 found that price reductions of 10% to 50% on lower-fat foods (eg, low-fat snacks and vegetables) resulted in a 9% to 93% increase in sales of those items. Numerous studies (for instance, those reported by the Robert Wood Johnson Foundation’s Active Living Research program) have demonstrated that the built environment influences associated physical activity patterns. For example, open and accessible stairwells and on-site physical activity facilities at worksites increased the physical activity of employees.115,116
Reducing Health Risk in the Work Environment
An increased risk of adverse cardiac events has long been associated with chemical and physical hazards at work. For example, occupational exposure to carbon monoxide (often from gasoline combustion) may cause both angina and acute myocardial infarction. Methylene chloride (used in furniture stripping) is metabolized to carbon monoxide, which can trigger cardiovascular events. Lead exposure and noise have been associated with hypertension in some investigations.117 Environmental tobacco smoke in workplaces such as casinos and bars poses a health risk to employees.118 Environmental studies have long identified exposure to fine particulates as posing cardiac risk in the general population,119,120 and toxicology studies have identified potential mechanisms for this risk.121 Controlled exposure to dilute diesel exhaust elicits myocardial ischemia in men with coronary artery disease.122 All of these exposures can be monitored and controlled.
Work shift, work pace, and work organization may also pose risks for CVD. A review of 17 studies of working atypical shifts concluded that shift workers had a significant increase in CVD risk (40%) compared with day workers.123 Shift work is also associated with sleep disturbances that may increase CVD risk. Unusual bursts of vigorous physical activity can be hazardous, particularly in workers with underlying coronary artery disease. Bursts of activity in untrained or at-risk workers combined with particulate exposure may explain the increased risk of on-the-job cardiac events reported in some studies of firefighters.124
Regulatory Oversight of Worksite Wellness Programs
Policy Recommendations
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The regulatory environment should allow for increased opportunity for employers to reach a greater majority of the employee population and produce health benefits.
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Employers should adhere to all regulations that address hazards to employee health and safety, providing working conditions that are optimal for cardiovascular health and well-being.
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Regulatory provisions should provide wellness credits for employers who choose to provide healthy lifestyle behavior incentives in the workplace (eg, health promotion services, smoking cessation programs, exercise facilities on site, weight loss programs, or voluntary screenings), and financial incentives can be paid directly to the employee. However, financial incentives should not be attached to healthcare premiums or health status.
Legislative/Regulatory Oversight of Worksite Wellness Programs
Worksite wellness programs are affected by state laws and major federal laws, including the Americans With Disabilities Act of 1990, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Age Discrimination in Employment Act of 1967, the Genetic Information Nondiscrimination Act of 2008, the Occupational Safety and Health Act of 1970, the Consolidated Omnibus Budget Reconciliation Act of 1985, the Employee Retirement Income Security Act of 1974, the Mental Health Parity Act of 1996, and the Pregnancy Discrimination Act of 1978. Conversations about health reform have led to a specific review of the HIPAA nondiscrimination provisions and a debate about whether employees who engage in unhealthy behaviors should be held accountable via an increase in their healthcare premiums or an adjustment to their deductibles. HIPAA provisions generally prohibit a group health plan from charging individuals different premiums based on a health factor. However, Congress did not want to prevent the many promising efforts that are using health-plan–related incentives to encourage worksite health promotion, so it permitted group health plans to establish premium discounts or rebates or modification of otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.125 Subsequent regulation delineated between participation-only programs that have no outcome requirements and those programs that require an employee to achieve a certain standard.126 Participation-only programs do not have to meet additional requirements provided they are available for all relevant employees; however, programs that are standard-based must meet additional benchmarks.126,127
The Americans With Disabilities Act regulations are administered by the US Equal Employment Opportunity Commission, which covers all civil rights and disability legislation affecting employment.126 The Equal Employment Opportunity Commission126 has expressed concern about incentives and other components of worksite wellness programs, including completion of an annual mandatory health risk assessment; the use of monetary incentives connected to program participation or wellness activities; mandatory medical examinations or testing; employers making inquiries about obesity, heart disease, diabetes, or other disabilities; triggers for refusal to participate in disease management or behavior change programs; and employer inquiries concerning prescription drug use. At this time, the Equal Employment Opportunity Commission has not issued formal opinions on these issues. Consequently, employers who develop programming that violates these initial rulings risk Equal Employment Opportunity Commission–imposed prosecution and fines.
Financial Incentives
Behavior change is difficult, especially over the long term, and voluntary programs to encourage lifestyle modification are not consistently effective.128 Employee wellness program managers generally find that once the newness and curiosity about a health promotion/wellness program wears off, employee participation drops off in a dramatic way.8 The proportion of employees taking advantage of such programs falls short of the Healthy People 2010 goal of 75% participation, with average participation rates of only 61%.108 Accordingly, employers are increasingly using incentives to maintain program participation and enhance compliance.129
Incentives provide the employee with an immediate and tangible reward that helps make it easier to modify behaviors that may yield long-term benefits.130 Studies show the favorable outcome associated with the use of financial incentives to foster long-term behavior change, such as quitting smoking or losing weight, especially if the financial incentives are sufficient.131–134 Finkelstein and colleagues133 found that a 3-month incentive-based intervention led to weight loss in employees who were provided 2 levels of incentives ($7 and $14 per percentage point of weight loss), which suggests that modest financial incentives can be effective in motivating overweight employees to lose weight. These programs indicate that employers could use incentives (eg, price reduction, monetary incentives, awards, and prizes) to encourage employees to undertake health improvement practices. Other studies have not found incentives to be effective; however, many of these studies are limited by small numbers of participants, cross-sectional designs, and/or very modest awards.135
Traditionally, incentives have been directed toward providers of healthcare services through pay-for-performance programs. There is a growing consensus that incentives should be provided directly to the individual who is engaging in the behavior change.132,136 Additional studies are needed to determine the true efficacy of incentive rewards within worksite wellness programs and whether these promote robust, long-term behavior change, whether incentives should be linked to the associated outcomes, and whether positive or negative incentives are more effective. Accordingly, the regulatory environment should provide employers the latitude to offer incentives that are not discriminatory and are appropriate for employees, incorporate serial outcome evaluations, determine the influence on disparate populations, and include an analysis of unintended consequences.
Although the AHA supports financial incentives paid directly to employees, there is significant concern with incentives tied directly to health insurance premiums or deductibles. Premium surcharges or other cost-sharing measures can make coverage less affordable for those who need it most and increase health disparities among low-income and minority populations. People who cannot afford coverage may have reduced access to therapies and interventions that can help curb unhealthy behaviors (eg, prescription smoking cessation therapy, medically supervised weight loss programs, and medications to control cholesterol and blood pressure). When policies cover a family, the surcharge penalizes every family member.
The current regulatory environment allows employers to offer a premium discount or waiver of a cost-sharing requirement based on participation in a program of health promotion or disease prevention. These programs have not been evaluated to determine whether (1) reduced costs result from improved health outcomes or segmentation of the insurance pool, (2) individuals with chronic conditions who may have medical or physical limitations have been treated fairly with regard to these policies, and (3) privacy issues and individual autonomy in the workplace have been protected.
Vulnerable Populations
Policy Recommendations
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Wellness programs must address the needs of all employees, regardless of sex, age, ethnicity, socioeconomic status, culture, job type, or physical or intellectual capacity.
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Worksite wellness programs should be designed to be culturally sensitive and all-inconclusive, and employers should also consider targeted, complementary interventions for their more vulnerable employees specifically designed to engage those who are economically challenged, less educated, or underserved.
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Worksite wellness programs should help working families balance work and family commitments and incorporate policies around child care, elder/dependent care, telecommuting, and flexible work schedules.
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Research should be conducted to determine how to improve participation among employees who have the highest-risk behaviors.
Blue Collar/Service Workers
Lower socioeconomic status is an established risk factor for CVD and stroke,137 yet blue collar workers, who predominantly fall into those lower socioeconomic classes, are often overlooked. Blue collar and service workers generally have less access to worksite wellness programs and are at greater risk of practicing lifestyle behaviors that place them at higher risk for coronary heart disease and stroke.138 Lower-income, less-educated, and lower-job-status employees have a higher burden of CVD than their higher-status counterparts.121,133,139 Although social conditions outside of work contribute to their disease experience, so do factors associated with their jobs, including higher levels of job stress, job insecurity, long working hours, sedentary work, work scheduling issues, shift work, bullying, and harassment.71,140 These factors underscore the need to specifically target employees with lower income and less education in worksite wellness programs.141,142
Blue collar workers and lower-paid workers are, for example, more likely to smoke than those who are white collar or higher paid143 and are less likely to participate in worksite fitness programs.144 The combining of efforts at worksite health promotion with improved worksite protection appears to overcome some of these obstacles. A prospective controlled investigation of smoking cessation in blue collar manufacturing workers demonstrated significantly higher quit rates and cessation maintenance through a program that addressed both individual behavior change and risk reduction in the work environment.82 A controlled investigation of a comprehensive intervention in matched groups of Dutch manufacturing workers showed significantly greater cardiac risk reduction in the cohort that underwent individual- and organizational-level interventions.145
Race/Ethnicity
A limited number of intervention studies have specifically addressed issues unique to race and ethnicity in the working population. One group-randomized study in Hawaii found that after a 2-year intervention, Pacific Islanders, men, and those in managerial positions had a higher body mass index than women and other ethnic groups.146 Cultural barriers and roles within the workplace were considered obstacles to weight loss. In North Carolina, the Centers for Disease Control and Prevention provided Racial and Ethnic Approaches to Community Health 2010 funds to the Eastern Band of Cherokee Indians to develop a community-based intervention to improve the health of a rural, mountainous community with a Native American population that has higher rates of obesity and type 2 diabetes mellitus than the state or the US general population. The program had a significant worksite wellness component for adults. During the first year, team members conducted formative research, formed coalitions, and developed a culturally appropriate community action plan to prevent type 2 diabetes mellitus. Participants in the worksite wellness component met dietary and physical activity goals, demonstrated reductions in body weight, and enjoyed the program. These results led to an expanded worksite wellness initiative to achieve further healthcare cost reductions.147
Women
Women in the workplace are often overlooked as a vulnerable population despite unique challenges posed by pregnancy, family responsibilities, and menopause, a transition associated with heightened cardiovascular risk. A worksite wellness program that focused on middle-aged women working in the healthcare environment148 found that a preponderance of the women had undiagnosed hypertension, abnormal lipid profiles, glucose intolerance, and/or obesity. Thus, an employee population that would typically be well educated about personal health, wellness, and disease prevention was characterized by numerous unhealthy behaviors, unrecognized disease, inadequate use of preventive health screenings, and numerous obstacles to program participation and follow-up.
Time pressures continue to represent major challenges for women (and men) balancing professional, family, and personal commitments and should be considered when worksite wellness programs are developed. In 2002, 77% of single mothers, just over 60% of married mothers with children under the age of 6 years, and 76.8% of married mothers with school-aged children were in the labor force.149 Because working mothers and families balance time spent in their personal commitments and job responsibilities, workplace policies should incorporate child care, flexible schedules, and elder/dependent care as a key feature of workplace health promotion.150
Additional Research
Few data are available regarding the effectiveness of worksite wellness programs in diverse populations. Often, the most disadvantaged workers, who have the greatest need for preventive screenings, health promotion, and/or worksite wellness programs, have the least access and are the most reluctant to participate in these programs.142,151 The fundamental causes of vulnerability are rooted in employees’ daily lives and are most often beyond the scope of public health.152 It would be beneficial for employers to engage with nontraditional partners to consider ways to reduce health disparities in communities and improve employee well-being overall. Additional research is needed to determine how best to reach and engage underserved populations and optimize worksite wellness for employees of all races, ethnicities, and income levels. Research should focus on whether worksite wellness programs in high-risk and vulnerable populations improve health and reduce health disparities.
Conclusions/Summary
Successful worksite wellness programs engage employees in activities that maximize their potential for health and well-being, grow rapidly in response to their perceived value, and prove sustainable as they establish the business case for their existence. As such, government agencies could have a substantial influence by supplementing private sector investment in large-scale, objective, longer-term studies on programming and outcomes research to better inform the development, implementation, and evaluation of worksite wellness programs.153 Government agencies should also model worksite wellness programs and serve as laboratories for testing research-based lifestyle interventions. The health outcomes for high-risk and health-disparities populations should be particularly scrutinized. The Centers for Disease Control and Prevention recently developed the Healthy Workforce Initiative, a World Wide Web site designed as a resource for worksite health promotion program planners in state and federal government that is also an excellent resource for planners in nongovernment workplaces.154 Federal and state governments should encourage employers to offer programming by providing tax incentives for employers who implement comprehensive worksite wellness programs.
Even the most well-designed and well-intentioned worksite wellness programs are ineffective if employees do not participate. Employers should seek to reduce or eliminate barriers that discourage use of worksite wellness programs to increase participation and employee engagement. One of many obstacles for programs to overcome is the low participation rate among those most likely to have greater health risk. Offering health promotion services such as fitness centers, weight loss programs, and exercise classes on site and providing healthy vending and food choices throughout the workplace environment are small steps. More innovative and forward-thinking employers might consider providing a convenient time and location for exercise and wellness programs during the workday and offering employer-provided paid time off during the workday for exercise, health screenings, or prevention/wellness programs.155
Programs that combine individual and organizational changes boast the greatest success rates in part because combined approaches engender a reciprocal relationship in which employees have a perception that their needs are valued.156 An Institute of Medicine exploration of the design of worksite health programs has embraced this kind of comprehensive approach,157 and the National Institute for Occupational Safety and Health recommendations for effective worksite programs endorse comprehensive efforts that combine health protection and promotion.158 However, continued research is needed to determine the effectiveness of comprehensive programs compared with programs that provide only selective services. Additionally, more work is needed to assess the effectiveness of programs on hard outcomes such as ischemic heart disease and stroke.
Visionary employers are looking beyond healthcare costs to consider the total value of health. They understand the importance of establishing work environments that engender fulfillment, improve quality of life, forge positive links with the community, and increase productivity. An effective worksite wellness program can attract exceptional employees, improve on-the-job decision-making and work efficiency, enhance employee morale and organizational commitment, decrease turnover, and reduce organizational conflict.108 Despite the numerous and varied documented benefits of incorporating programming to promote healthy lifestyles in the workplace, such programming has not achieved adequate penetration into the workplaces of America.
Acknowledgments
Disclosures
Writing Group Disclosures
Reviewer Disclosures
Footnotes
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The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
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This statement was approved by the American Heart Association Advocacy Coordinating Committee on September 3, 2009. A copy of the statement is available at http://www.americanheart.org/presenter.jhtml?identifier=3003999 by selecting either the “topic list” link or the “chronological list” link (No. KJ-0733). To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.
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The American Heart Association requests that this document be cited as follows: Carnethon M, Whitsel LP, Franklin BA, Kris-Etherton P, Milani R, Pratt CA, Wagner GR; on behalf of the American Heart Association Advocacy Coordinating Committee; Council on Epidemiology and Prevention; Council on the Kidney in Cardiovascular Disease; and Council on Nutrition, Physical Activity and Metabolism. Worksite wellness programs for cardiovascular disease prevention: a policy statement from the American Heart Association. Circulation. 2009;120:1725–1741.
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Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier=3023366.
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Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier=4431. A link to the “Permission Request Form” appears on the right side of the page.
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