Summary of evidence
The definition of both obesity and overweight is “abnormal or excessive fat accumulation that may impair health” (World Health Organisation, 2016). To classify as being overweight an adult must have a Body Mass Index (BMI) of 25 to 29.9 or more and to be obese an adult must have a BMI of 30 to 30.9 (NHS, 2016a). Obesity is a multi-factoral condition (The British Dietetic Association, 2015) and there are many reasons why an individual may become obese; these include health reasons such as certain metabolic conditions and societal reasons such as an increase in sedentary behaviours.
It is thought that one in four adults who are of working age are obese (Black, 2016) although obese individuals are also less likely to be in employment compared to those of a healthy weight (NICE, 2013). Obesity results in not only individual health costs such as increasing the risk of developing high blood pressure but also societal costs. Annually 16 million days of sickness absence are reported due to obesity in the UK (Public Health England, 2015). Figures also suggest that annually obesity costs the NHS £6.1 billion (Public Health England, 2015). Additionally, obese individuals are also more likely to have problems with seating or equipment and may not be able to carry out certain jobs (Health and Safety Executive, 2006).
Obesity discrimination is also a challenge for both employees and employers, it is seen in many stages of the employee cycle and increases in BMI are also associated with decrease in pay (Brunello & D’Hombres, 2007). Bento, White and Zacur (2012) proposed that weight-based discrimination occurs in the workplace at virtually every stage of the employment cycle, and that ‘weightism is the new racism’. Subsequently there are many legal implications of obesity and obesity discrimination for employers. In 2014 the dismissal of a 25 stone childminder led to a European Court of Justice ruling, that under certain circumstances obesity can be counted as a disability. Although obesity is only covered under disability there are calls for obesity itself to become a protected characteristic.
Regarding addressing obesity and weight management in the workplace, interventions can be implemented at both the individual and organisational level. Research suggests that the most effective interventions are multicomponent. Multicomponent interventions combine both physical (e.g. aerobic training, fitness classes) and/or dietary components (e.g. behaviour change aids - shopping guidelines and recipes, health appraisals with feedback and counselling) and environmental components (such as point-of-choice message – signs that interrupt habitual behaviour, such as signs near lifts and stairs to encourage individuals to use the stairs). At the individual level, internet weight loss programmes that are multicomponent and low intensity phone and internet based weight loss programmes have been associated with a decrease in weight loss. Evidence has also shown that the application of commercial weight loss programmes can be effective, such as Slimming World. Furthermore, some studies have investigated the use of financial incentives to encourage weight loss and found them to be beneficial.
At the organisational level, interventions tend to be environmental (such as walking maps, team competitions, and point-of-choice messages – signs that interrupt habitual behaviour, such as signs near lifts and stairs to encourage individuals to use the stairs). Changes may also be made to the food environment such as providing more low energy and higher nutrient foods in cafeterias and vending machines. Changes to the physical activity environment may include providing fitness classes, promoting stair use and organising team walking competitions. Additionally, the social/organisational characteristics of a workplace have also been linked with nutrition and physical activity behaviours. Other organisational level interventions have included policy changes such as providing only healthy foods at workplace-sponsored events. When designing interventions it’s important to design them with employee needs and preferences in mind. Additionally, research also suggests employee advisory boards may help improve the success of an intervention.
To explore these studies in more detail, please click on [Explore the Evidence].
What is obesity?
The definition of both obesity and overweight is “abnormal or excessive fat accumulation that may impair health” (World Health Organisation, 2016). To identify if adults are obese or overweight a frequently used measure is Body Mass Index, BMI. This is an adult’s weight in kilograms divided by the square of their height in metres (kg/m2 ). However, this measurement has been criticised because it is not possible to distinguish between body lean mass and body fat mass when using BMI and the definition of obesity relates to excessive fat accumulation. Further, the BMI measurement does not enable information to be identified about where the fat is located in the body (Nuttall, 2015). To classify as being overweight an adult must have a BMI of 25 to 29.9 or more and to be obese an adult must have a BMI of 30 to 30.9. 40 or more is classified as morbidly obese (NHS, 2016a).
Causes of obesity
Many people believe that obesity is caused by an increase in calorific intake and a decrease in physical activity, however there are a number of reasons why an individual might also become obese and research suggests it is a multi-factoral condition (The British Dietetic Association, 2015). Certain metabolic conditions (e.g. an underactive thyroid) can compound obesity making it easier for an individual to gain and harder to lose weight. Risk factors have also been identified, with the highest for men and women being age, being an ex-cigarette smoker, self perceptions of not eating healthily, not being physically active and hypertension (The NHS Information Centre, 2007, p. 45). There is a negative relationship been income and obesity risk in women, but a positive relationship in men.
There are also certain societal reasons that may account for increased prevalence of obesity. In today’s society a greater number of adults spend their days participating in sedentary behaviours. Full time adults in the USA employed in sedentary occupations spend 11 hours engaging in sedentary behaviours in work and in leisure time (Tudor-Locke, Leonardi, Johnson & Katzmarzyk, 2011). An increase in sedentary behaviours has been shown to be a risk factor of chronic illness (Hamilton, Hamilton & Zderic, 2007). However, others have concluded that shift work is associated with a greater risk of obesity but that there is no significant relationship between sedentary work and obesity (Shrestha et al. 2016). In addition, many adults are not participating in enough physical activity. The NHS guidelines are that adults aged 19-64 should do at least 150 minutes of moderate aerobic activity each week in addition to doing strength exercises that work all the major muscles two or more days a week (NHS, 2016b). Sport can be one way of achieving these guidelines; in 2014/2015 in the UK 36% of adults participated in sport at least once a week however 57% did not participate in any sport in the 28 days up to responding to the survey (Health and Social Care Information Centre, 2016). Schulte et al. (2007) concluded that in jobs where there is low-control and high-demand and long working hours there may be a greater risk of obesity. These are all contributory factors to obesity and may partly account for the increase in obesity that can be seen across the globe.
Prevalence and impact of obesity in the workplace
Evidence suggests that one in four adults who are of working age are obese (Black, 2016). 68% of obese adults are in employment compared to 70% of normal weight adults, however this gap widens when examining severely obese individuals (Black, 2016). Similarly, NICE (2013) reported that obese individuals are less likely to be in employment than those of a healthy weight.
Obesity has many individual costs and is linked with numerous health problems. Individuals with obesity are at a greater risk of developing osteoarthritis, developing high blood pressure, experiencing a stroke and having coronary heart disease (Public Health England 2016a). The chances of developing Type 2 diabetes are also significantly increased and there is a greater risk of specific cancers such as breast and colon cancer (Public Health England, 2016a).
Obesity not only results in individual costs but also costs to society. Specific to the workplace, annually 16 million days of sickness absence are reported due to obesity in the UK (Public Health England, 2015). In 2007 figures suggested that the cost to the economy in lost earnings and in care was approximately £16 billion. It was predicted that this would increase to £50 billion in 2050 if the prevalence of obesity continues to grow as it is presently (Foresight, 2007). Figures also suggest that annually obesity costs the NHS £6.1 billion (Public Health England, 2015). Interestingly, the McKinsey Global Institute (2014) estimates that the UK invests merely approximately 1% of the social cost of obesity into actions that prevent obesity such as weight-management programmes and public-health campaigns.
In the workplace obesity is linked with absenteeism and presenteeism (Bustillos, Vargas & Gomero-Cuadra, 2015). Obese individuals are also more likely to have problems with seating or equipment and may not be able to carry out certain jobs (Health and Safety Executive, 2006). Additionally, studies have shown relationships between overweight and obesity and absenteeism, disability pension and overall work impairment; however, results regarding the relationship between overweight and obesity and presenteeism, unemployment and early retirement were inconclusive (Shrestha et al. 2016). Other research (e.g. Ricci et al., 2005) found that obese workers were significantly more likely than their normal-weight counterparts to report poor quality work, or limitations in the amount or type of work undertaken. The research also highlighted that obese employees also experience more disability and lost work days than normal weight individuals.
The majority of attempts to address obesity in the workplace are directed at tackling obesity itself however, this is only one part of the solution. Obesity discrimination is also a challenge for employees and employers. In their theoretical paper, Bento, White and Zacur (2012) propose that weight-based discrimination occurs in the workplace at virtually every stage of the employment cycle, and that ‘weightism is the new racism’, with anti-fat attitudes appearing to be at the stage that racism was 50 years ago, with strong empirical evidence of stigmatisation, bias and discrimination against obese people in multiple contexts, including the workplace. In the US, evidence suggests that 26% of individuals with moderate obesity and 31% of those with severe obesity experience discrimination because of their weight and appearance (Carr & Friedman, 2005).
Rudolph, Wells, Weller and Baltes (2009) conducted a meta-analysis to examine weight-based bias at work. They found a medium effect of weight-based bias amongst evaluative workplace outcomes, such as hiring, performance and promotions. Puhl and Heuer (2009) undertook a review of bias and stigma amongst overweight and obese individuals and found that obese individuals still struggle to have their weight seen as a disability, which makes it difficult to bring successful discrimination claims, and seemingly shows employers and co-workers that there is a legal freedom to discriminate among job applicants and co-workers on the basis of an individual’s weight. The Equality Act 2010 protects individuals from discrimination in the workplace and society, currently there are nine protected characteristics covered by this act, for example, age, disability, religion or belief and sex. In 2014 the dismissal of a 25 stone childminder led to a European Court of Justice ruling, that under certain circumstances obesity can be counted as a disability. Although obesity is only covered under disability there are calls for obesity itself to become a protected characteristic.
In the context of the workplace, obesity discrimination has been seen in different stages of the employee cycle. Puhl and Brownell (2006) found that amongst obese and overweight women, 25% reported that they had experienced job discrimination due to their weight, 54% reported they had experienced weight stigma from colleagues and 43% from employers or supervisors. Puhl, Andreyeva and Brownell (2008) reported that in the US, 60% of those who stated they had experienced weight discrimination in employment had experienced this on average 4 times in their life. Examples were not being hired, wrongful termination and not being promoted.
Within EU countries, Brunello and D’Hombres (2007) found that a 10% increase in average BMI was associated with a decrease in hourly pay of 1.9% amongst men and 3.3% amongst women. Additionally, a recent Public Health England (2016b) British Social Attitudes towards obesity survey showed that 28% of people agreed that ‘most very overweight people are lazy’ and that 53% agreed ‘most very overweight people could lose weight if they tried.’ Furthermore, a question asked about equally well qualified candidates for an office manager role and who out of an overweight and not overweight person would be more likely to get the job or would they have an equal chance. 75% said that the person who is not overweight would be successful, 22% said they would have an equal chance and only 1% said it would go to the very overweight person. These results demonstrate that there is an assumption obesity relates to a lack of willpower which is linked with the underlying assumption of many that it is an individual, medical problem and that the lazy stereotype exists in addition to suggesting that being obese is a disadvantage within the workplace context.
This body of evidence leads to the conclusion that obesity discrimination is a workplace problem that needs to be addressed.
We will be populating the ‘Obesity Discrimination’ topic on the Hub in 2018.
What can we do to address obesity in the workplace?
Although tackling obesity is one of Public Health England’s key aims, research within the UK that addresses obesity within the workplace is limited. However, statistics suggests that 31% of employees think that their employers should support them to lose weight (Unum, 2016). The workplace has been proposed as a good environment in which to implement interventions due to the high number of easily accessible people and the proportion of waking time that individuals spend at the workplace each week (OECD, 2016). By implementing interventions in the workplace there is also the potential for a wider impact to be had by employees influencing family and friends.
Implementing programmes in the workplace can also address one of the barriers which has often been cited which is lack of time (Dugdill, 2008). In addition, implementing interventions in the workplace will be advantageous for both the individual employee as well as the employer (Shrestha et al. 2016). In their review Shrestha et al (2016) concluded that there is no agreement on what constitutes best practice within interventions to tackle obesity and overweight. However, Cavill and Ells (2010) concluded that behavioural change approaches can be used to effectively tackle weight loss in overweight and obese individuals.
Generally, the literature shows mixed results for the success of a variety of interventions, however it is possible, at least, to conclude that multi-component interventions tend to be most successful and it is important to equip employees with knowledge, behaviour and support for an intervention to be effective. In addition, the location and timing of an intervention are critical to success.
Reviews of obesity management interventions
A number of reviews have been carried out to identify the most effective workplace interventions. It is often not possible to identify the specific elements of interventions that have made them successful however it is possible to draw general conclusions. For example, Anderson et al. (2009) concluded from their systematic review that more intensive programmes (such as providing both behavioural counselling and information and providing structured programmes i.e. scheduled sessions) showed a greater effect on weight. Verweij, Coffeng, Mechelen and Proper (2011) found that there was modest quality of evidence that showed that interventions that combine physical activity and dietary behaviour result in a significant decrease in body weight, BMI and body fat percentage. Examples of physical activity interventions are lectures on physical activity and aerobic and strength training and examples of dietary behaviour interventions are health risk appraisals with feedback and education about healthy eating, behaviour change aids – shopping guidelines, recipes and counselling. In addition, they concluded that when implementing interventions, environmental components (such as walking maps, team competitions and point-of-choice messages – signs that interrupt habitual behaviour, such as signs near lifts and stairs to encourage individuals to use the stairs) should be combined with physical and/or dietary components (e.g. aerobic training and behaviour change aids – shopping guidelines, recipes and counselling).
Archer et al. (2011) conducted a systematic review and identified six practices for the prevention and control of obesity within the workplace. These were:
- Access to physical activity and health education
- Exercise programmes
- Multicomponent educational practices e.g. health, exercise, nutrition and a pamphlet
- Weight loss competitions and incentives
- Behavioural practices with incentives e.g. teaching behavioural skills with financial incentives for participating or completing the programme
- Behavioural practices without incentives e.g. teaching behavioural skills without offering incentives
However, they highlighted that when designing such interventions the needs and preferences of the employees should always be strongly considered.
Power, Kiezebrink, Allan & Campbell (2014) concluded that interventions comprised of both a physical activity and dietary element showed the greatest decrease in body weight. Most recently, Weerasekara et al (2016) found that the most recent studies were the most effective and 6-12 month studies were most effective, perhaps this suggests that interventions being implemented recently are better designed and more effective. Weerasekara et al (2016) concluded that because effective interventions were found in workplaces in a number of different areas of the world, workplaces generally are good prospective environments for addressing obesity, once best practice is established.
A number of individual interventions have been implemented to help individuals with weight management; popular employee programmes include health risk appraisals and weight management programmes to reduce obesity (Heinen & Darling, 2009).
One such programme was an intervention based on Bandura’s social cognitive theory, this intervention involved different elements such as a study website, resources (e.g. pedometer, weight loss handbook), group based financial incentives and an information session. Research suggested this resulted in weight loss of clinical importance (Morgan et al. 2011). Individual versus group based financial incentives have also been examined (Kullgren et al. 2013). Obese employees aimed to lose 1 pound a week and were randomly allocated to a control group, an individual financial incentive group or a group financial incentive group. Participants in the individual financial incentive group were rewarded $100 on a 4 weekly basis if they met or exceeded their weekly target weight loss. In the group incentive group, each consisting of five employees, the amount ($500, $100 per person) was split among employees who weighed less than or the same as the monthly target weight. Those in the group based financial incentive intervention lost significantly more weight at 24 weeks. Differences in levels of cognitive restraint (intention to control food intake to help weight loss) were also observed which could play a key role in obesity management. The results suggest that financial incentives can encourage people to lose weight and that changing elements of the incentive will affect results.
Commercial weight loss programmes, such as Slimming World, have also been applied within a work context. Barber et al. (2015) found that there was a significant difference in baseline weight and post intervention weight. There were also positive impacts on secondary outcomes such as mental and emotional health and healthy dietary habits and physical activity. Furthermore, most of the employees found the Slimming World plan easy or very easy to follow.
As time is often a barrier to weight management, research has also investigated internet weight loss programmes. Results from an internet based multicomponent behavioural weight loss programme showed that at 6 months more than half of the employees still showed clinically significant weight loss (Ross & Wing, 2016). A low intensity phone and internet based weight loss programme has also been examined (Carpenter, Lovejoy, Lange, Hapgood & Zbikowski, 2014), the findings showed that at 12 months 39% of participants had lost at least 5% of baseline weight and 16% had lost at least 10%. The findings suggest that even if weight loss is not reported, the intervention can result in increased healthy behaviours such as higher consumption of fruit and vegetables which will also be beneficial.
Interventions can also be implemented at the organisational level. In a survey examining attitudes among employees and employers, 71% of employers and 92% of employees agreed that “it’s appropriate for an employer to include a range of obesity-related services and benefits for employees” and 80% of employees believe that “programmes related to weight management or healthy lifestyles belong in the workplace” (Gabel et al., 2009). Examples of organisational interventions include introducing healthier options in the canteen, decreasing access and availability of high-calorie food in the work environment, modifying canteen labels (e.g. traffic-light labels) and providing material incentives for improving health (e.g. discounts on insurance premiums and gym membership) (McKinsey Global Institute, 2014).
Fernandez et al. (2015) examined the impact of an environmental intervention that targeted diet and physical activity; they found there was a significant decrease in BMI at worksites with interventions and that the percentage of overweight and obese employees decreased significantly. They proposed that the employee advisory boards that helped to design the intervention may have played a key role in the success of the intervention.
Tabak, Hipp, Marx and Brownson (2015) concluded that the social/organisational characteristics of a workplace environment could be linked with nutrition and physical activity behaviours and obesity. However, they were not able to tell whether perceived organisational support for employee health results in lower employee BMI or whether those with lower BMIs are attracted to these types of workplaces. Additionally, policy changes, such as providing only healthy foods at workplace-sponsored events may have beneficial results. It has also been noted that environmental interventions may only have a small effect and this is because there are many other factors that impact employee decisions regarding physical activity and healthy dietary behaviours.
Research at the organisational level (Blackford, Jancey, Howat, Ledger & Lee, 2013) has also identified barriers and enablers, for example frequently reported physical activity barriers for work place based health promotion are “too tired” and “work commitments/long hours” and for nutrition, “unhealthy food available in office” and “lack of healthy options near office.” The research found that preferred activities for physical activity were “stretching programme at desk” and “group classes (e.g. yoga)” and for nutrition “ personalised dietary programmes” and “cooking demonstrations.” Using findings such as these and being mindful of difference preferences can help in the design of effective interventions.
Best practice recommendations have also been identified (Institute of Preventive Medicine Environmental and Occupational Health, 2009) such as conduct a needs assessment, implement both physical activity and nutrition methods, emphasise employee participation and conduct continuous evaluation. Additionally, lessons learned from workplace health initiatives suggest that elements that are key to success include management buy-in and employee ownership (C3 Collaborating for Health, 2011). Leadership support, developing a business case and defining success have also been identified as elements of successful interventions (North East Business Group on Health, 2013).
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