Posts from — July 2009

It is recommended that smoking cessation programs subscribe to the Code Of Practice for Tobacco Cessation Programs.

Smoking cessation programs should be multi-component with a focus on skills to build beneficial voluntary behavior change practices. Useful techniques include starting reasons for stopping, understanding the smoking habit, various techniques for stopping and remaining a non-smoker, overcoming the problems of stopping, short-term intention setting, weight management, stress management, significance of exercise, relationship of alcohol consumption to urges to use tobacco. Use no aversive or scare tactics.

In programs that use aids such as the “patch” or medications such as “Zyban” appropriate consultation must be available on the usage of these aids.

The instructor should have formal training in smoking cessation from a nationally recognized organization such as American Heart Association, American Cancer Society, American Lung Association, or a nationally recognized commercial program such as Smoke Enders.

Evaluation of success is at times very dubious in smoking cessation programs. Measurement of success ought to include participation rate, including the number beginning the program, the number completing the program, and the average number per session. Also included, number and percent who stopped smoking at the end of the program, and the number and percent who had not resumed smoking by the end of one year.

Participatory exercise programs must include education on benefits of regular exercise and risks of a sedentary lifestyle, its effect on cardiovascular health and diseases, its relationship with weight control and stress management, and aerobic exercise options. Discussion and practice of safe principles of exercise – warm up, cool down, frequency, intensity, duration, flexibility and strength components. The program follows standard procedures by the American College Of Sports Medicine.

Safety precautions ought to include the following:

• Informed consent prior to implementing exercise with clear and complete written and verbal guidelines of possible risk, purpose of exercise, exercise format to be followed, opportunity for questions, and a signed informed consent with date.
• A screening/assessment of participants to determine if medical care assessment is crucial for exercise such as the Physical Activity Readiness Questionnaire (PAR-Q, see forms).
• Measurements of Blood Pressure and resting heart rate are useful evaluation information to determine exercise readiness.
• Participants who fail screening are medically referred and ought to obtain a written clearance from their physician to exercise.
• The basic content of an aerobic fitness program should include:

Warm up   5 – 10 minutes
Aerobic exercise   20 – 40 minutes
Cool down   5 – 10 minutes

Exercise instructors should have education and training in exercise physiology, physical education, physical therapy or comparable discipline, or possess a current certification by a nationally recognized sports medicine or exercise association, and be CPR certified.

Program provided is consistent with scientific and health care recommendations for weight loss, reflects a multi-disciplinary approach which offers four components: behavioral, exercise, diet, and maintenance, and is in accordance with the document Guidance For Treatment Of Adult Obesity. It includes:

• Screening to verify that the colleague has no medical or psychological conditions which would make weight loss inappropriate, and to identify the colleague’s level of health risk, classifying participants not only on excess body weight, but also on the basis of associated medical conditions and central heath risk.
• Referral for participants who are morbidly obese who would require medical guidance for weight loss.
• Informed consent, explanation of potential physical and psychological risk from weight loss and regain, likely long-term success of program, full cost of the program, credentials of the employee.
• Identification of contributing factors to attendant’s weight status, serving as the basis for an individualized weight loss plan which includes the weight goal and plans for diet, exercise, and behavioral components.
• Weight objective of colleague is reasonable based on personal and family weight history not solely on height and weight charts; initial weight loss objective does not exceed loss of 10 percent of body weight, 1-2 pounds per week.
• Explanation of unsafe weight loss methods.
• Daily calorie level is adjusted to meet each colleague’s recommended rate of weight loss.
• Daily caloric intake is not less than 1,000 calories; if less, physician monitoring is required.
• Food plan designed so participants can choose foods which meet 100% of all the Recommended Daily Allowance (RDA) except for calories. Nutritional supplementation can be used to achieve RDAs, however ought to not greatly exceed RDAs.
• Nutrition education encouraging permanent healthful eating habits based on The Food Guide Pyramid.
• Participant involved in meal planning and diet selection.

The protein, fat, carbohydrate, and fluid content of the food plan meet safety recommendations:

Protein   Between 0.8 and 1.5 grams of protein per kilogram of intention body weight, but no more than 100 grams of protein a day.
Fat   10 – 30 percent calories as fat.
Carbohydrate   At least 100 grams per day.
Fluid   At least one liter of water daily.

• Exercise component must be a important portion of the program and be both didactic and experiential.
• Participant is appropriately screened for exercise using a screening questionnaire such as the Par-Q Readiness Assessment (see forms). Instruction on recognizing untoward responses to exercise.
• Participants work towards 30-60 minutes of exercise 5-7 days per week.
• No appetite suppressant prescriptions.
• Maintenance plan available for continued reinforcement.
• Weight control programs should be conducted by a registered dietitian or by degreed health professionals with training in nutrition with consultation by a registered dietitian.
• Trained lay leaders may support  if supervised by nutrition professional.

Note: There’s an interactive version of Guidance for the Treatment of Adult Obesity at e-Guidance for the Treatment of Adult Obesity.

A program is required to offer appropriate interpretation of cholesterol evaluation results, including a caution that a single measurement neither excludes nor establishes a diagnosis of their blood cholesterol.

Follow national standard procedures:

Total Cholesterol
Desirable cholesterol   < 200 mg/dl
Borderline cholesterol   200 – 239 mg/dl
High cholesterol   > 240 mg/dl

HDL
Desirable HDL    > 35 mg/dl
Low HDL    < 35 mg/dl

Refer cholesterol evaluation participants to health care as follows:

Total Cholesterol
< 200 mg/dl    Recheck blood lipid in five years, if history of coronary heart disease or if two or more CHD risk factors are detected refers to risk reduction program or health professionals, as appropriate.
200 - 239 mg/dl    If history of CHD or if two or more other risk factors are detected, refer to health care or risk reduction service within two months; if no published history of CVD or less than two other risk factors, reassess cholesterol status within 1-2 years.
> 240mg/dl    Refer to medical care within two months.

HDL
> 35 mg/dl   If fewer than 2 risk factors and borderline total cholesterol, refer to risk reduction service, as appropriate. Reassess HDL in 1-2 years.

Give the following:
• The relationship of blood cholesterol, elevated Blood Pressure (BP), and other risk factors.
   o Risk factors include: elevated Blood Pressure 140/90 or higher or on hypertension medication; current cigarette smoking; family history of premature CHD; diabetes mellitus; age – male > 45 years, female > 55 years or premature menopause without estrogen replacement therapy.
   o Negative risk factor: high HDL 60 mg/dl or greater (subtract one risk factor).
   o Risk factors such as family history, smoking, high fat or other unhealthy diet, and lack of exercise lead to the development of cardiovascular disease (CVD).
• Definitions and causes of elevated blood cholesterol and HDL, desirable levels, the meaning and limitations of a single measurement, the cause of variability, and the need for multiple measurements prior to diagnosis.
• Wide range of treatment options, including diet (e.g., importance of controlling fat intake less than 30% of total calories from fat, less 10% saturated fats), less than 300 mg. of cholesterol per day, well-balanced diet, weight maintenance or reduction, exercise, and medication.
• Importance of following prescribed treatment and professional advice.

Appropriate medical care or allied health professional trained in measurement of Blood Pressure, referral protocols, and delivering educational messages to colleague delivering Blood Pressure programs. These programs are necessitated to follow national ground rules.

• National ground rules for Blood Pressure (BP) protocols:
   o Calibration of Blood Pressure (BP) measuring equipment
   be done at least each year.
   o Two or more measurements of colleague’s Blood Pressure should be taken.
   o Referral of participants with elevated Blood Pressure (BP) readings to personal physician for further evaluation.

• Systolic/Diastolic Follow-Up:
   o Normal:   <130 / <85
      Action: Recheck in 2 years
   o High Normal:   130-139 / 85-90
      Action: Recheck in 1 year

• Hypertension:
   o Stage 1 (Mild):   140-159 / 90-99
      Action: Confirm within 2 Months.
   o Stage 2 (Moderate):   160-179 / 100-109
      Action: Refer to source of care within 1 month.
   o Stage 3 (Severe):   180-209 / 110-119
      Action: Refer to source of care within 1 week.
   o Stage 4 (Very Severe):   >210 / >120
      Action: Refer to source of care immediately.

• Appropriate educational messages:
   o Normal:   <130 systolic and <85 diastolic
      Action: No referral. If on treatment, then inform attendant that Blood Pressure is under good control today and ought to continue seeing and following treatment program.
   o High Normal:   130-139 systolic and/or 85-89 diastolic
      Action: Recommend that colleague have Blood Pressure (BP) rechecked within 1 year unless under treatment. Advise colleague that the readings are in a high normal range that needs rechecking. In the interim, suggest that one of the most effective means to lower Blood Pressure (BP) is to bring weight into normal range and to exercise.
   o High:   >140 systolic and/or >90 diastolic
      Action: Refer to physician for further evaluation within 2 months unless the level is within urgent, emergency, or isolated systolic hypertension levels. If already on treatment, advise attendant of readings and need to get Blood Pressure (BP) to a intention of 140/90 or less.
   o Isolated Systolic Hypertension:   140-159 systolic and < 90 diastolic in a colleague 65 years of age or older.
      Action: Advise colleague to inform physician of readings at next visit and consider advice regarding weight loss and exercise if appropriate.
   o Urgent:   180-209 systolic and/or 110-119 diastolic
      Action: Recommend obtaining medical assessment within 1 week.
   o Emergency:   >210 systolic and/or >120 diastolic
      Action: Obtain immediate medical care attention.

• Provides the following:
   o Written results, referral guidelines, and an explanation of Blood Pressure levels given to each attendant with individualized counseling, including advice about the interval of time recommended when the attendant should be checked again.
   o Utilizes the recommendations in The Fifth Report Of The Joint National Committee on Detection, Assessment and Treatment of High Blood Pressure, March 1994.
   o Written and audiovisual materials that are informative, easy to understand, and useful while containing scientifically accurate information.
   o Relationship of elevated Blood Pressure and other risk factors, such as family history, smoking, high fat and unhealthy diet, lack of exercise, in the development of cardiovascular disease, including stroke, kidney disease, heart attack, and other diseases.
   o Definition and causes of elevated Blood Pressure.
   o Importance of following prescribed treatment.

Health risk assessment programs must be carried out on a one-on-one basis by trained medical care professionals. Health risk measures must include the following:

• Blood Pressure (BP) measurements – at least two Blood Pressure (BP) measurements taken during the screening episode, using a mercury sphygmomanometers or regularly calibrated aneroids.
• Blood Pressure treatment status – ascertain whether the attendant is under a doctor’s care, on any medication, on a prescribed diet, or any other type of treatment for hypertension.
• Blood cholesterol measurement – total cholesterol and HDL-cholesterol taken either using a properly tested and maintained table top blood analyzer offering immediate feedback to the client, or sending blood to a laboratory offering feedback using a method that is as effective as immediate feedback.
• Cholesterol treatment status – evaluate whether the client is under a doctor’s care, on any medication, on a prescribed diet, or any other type of treatment for elevated cholesterol.
• Obesity – utilize an accepted method for estimating obesity. By way of example evaluate participants height and weight and use the 1959 Metropolitan Life Height/Weight charts or use Body Mass Index.
   o Identify people 20% or more above their ideal weight.
• Smoking status – assess whether the attendant currently smokes cigarettes, whether the client has quit or never smoked, and the number of cigarettes smoked/day.
• Exercise habits – assessment questions may be limited to frequency and duration exercise. Do participants exercise in a moderately vigorous fashion at least three times per week for 30 minutes or more.
• Diabetes – whether the client has diabetes, and whether or not it is currently under control. A blood glucose may be also done via finger stick and desk top analyzer. Several manufactures make available cassettes which include cholesterol and glucose measurements.
• Cerebrovascular disease or occlusive PVD – ascertain if the client has had a stroke or other kind of blood vessel disease.
• Family history of cardiovascular disease – evaluate whether any of the participants’ parents or siblings had a heart attack or sudden death due to heart disease before age 55.
• Coronary heart disease – determine if the client has had a heart attack or other sort of coronary heart disease.
• Stress – participant’s assessment of stress in work and/or personal life. A series of well-tested and validated questions assessing levels of stress are available from the Worker Health Program.
• Participant release form (see forms) – A release form is needed in which the participant authorizes the program to draw blood for testing to send information to the participant’s healthcare provider if healthcare risks are identified, and to get information from the provider about diagnosis and prescribed treatment.
• Participant interest survey – if an assessment of interest has not been gathered previously, the evaluation activity must evaluate levels of interest in programs such as: weight management, tobacco cessation, fitness or exercise, stress management, diet, self-care, cholesterol control.
• Health education messages – the screener must review with the attendant his/her identified health risks and what they mean to the attendant’s central health, and give the attendant a written record of the Blood Pressure, total cholesterol, and any other physiological measures taken.
• Referral of participants for treatment – participants with elevated risks must be referred to appropriate sources of diagnosis and possible treatment following nationally or locally recognized standard procedures for such referral.

Demographic information ought to include location of the assessment, workplace, client’s name, address, social security number, work and home phone numbers, sex, race, date of birth, relevant job information (e.g., hourly or salaried), department number, and work shift.

Program directors or providers must have a background in wellness programming and a professional health-related degree or certification. They must have expertise in content areas, planning, promotion, administration, evaluation, and ability to grow a program and tailor the program to the workplace.

Program providers must have a quality assurance program for evaluating the success of service personnel, to assess satisfaction of participants, and for personnel training and continuing education.

An overriding policy statement should be available from directors and program vendors addressing the following issues: assurance of confidentiality of health data, referral to healthcare for at-risk participants, follow-up with referred participants and those at-risk, program assessment on process and outcomes, company of the workplace for promotion of wellness and changes in corporate culture. A clear contract or letter of agreement for services should be provided.

Stay away from being the “best” or doing the “most.” Encouraging staff members to be the best or doing the most promotes excessive behavior, discourages others, and creates elitism. The best designed incentive programs are ones which are based on achieving objectives that are attainable by most people. Recognition, acknowledgment by top management, or special privileges are examples of great intangible incentives and rewards.

Incentive ideas:

• Free or Low-Cost:
   o Certificates
   o Movie passes
   o Recognition in employee newsletter
   o Mugs
   o Water bottles
   o Commendation from management
   o T-shirts
   o Hats

• Moderate Cost:
   o Entertainment tickets
   o Sweatshirts
   o Waist packs
   o Subscriptions to health magazines
   o Health and fitness books
   o Videos

• High Cost:
   o Week-end getaways
   o Dinner for two
   o Clocks
   o Watches

• Others:
   o Cash
   o Gift certificates

Utilizing posters, newsletter articles, and brochures are great means of promoting the program. Other promotional methods to consider are e-mail and announcements at employee gatherings. Ask Employee Wellness Program Committee members to recruit participants.

Once the program is kicked off you may want to provide an incentive for any employee who recruits another employee to any of the program offerings.

When selecting a program from a vendor you must ask the following questions:

• How many worksites have done the program?
• What types of employee population was the program available?
• What educational materials are used?
• Will the program meet the needs of employees?
• What are the techniques used to help change behaviors?
• Does the program help staff members move through stages of readiness to make health behavior changes?
• How do you market the program to workers?
• What follow-up do you provide?
• How do you make referrals for healthcare or other supportive services employees may need?
• How do you know the program works?
• How do you measure attendant satisfaction?