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Impact of Workplace Physical Activity Interventions on Physical Activity and Cardiometabolic Health Among Working-Age Women

A Systematic Review and Meta-Analysis
Originally publishedhttps://doi.org/10.1161/CIRCOUTCOMES.116.003516Circulation: Cardiovascular Quality and Outcomes. 2017;10:e003516

    Abstract

    Background—

    Cardiovascular disease is the leading cause of death among women in high-income Organization for Economic Co-operation and Development countries. Physical activity is protective for cardiovascular disease. The realities of modern life require working-age women to address work-related, family, and social demands. Few working-age women meet current moderate-to-vigorous–intensity physical activity (MVPA) recommendations. Given that working-age women spend a substantial proportion of their waking hours at work, places of employment may be an opportune and a controlled setting to implement programs, improving MVPA levels and enhancing cardiometabolic health.

    Methods and Results—

    Eight electronic databases were searched to identify all prospective cohort and experimental studies reporting an MVPA outcome of workplace interventions for working-age women (mean age, 18–65 years) in high-income Organization for Economic Co-operation and Development countries. Risk of bias was assessed using the Cochrane risk of bias tool; quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. A qualitative synthesis was performed for all studies, and meta-analyses were conducted where possible. Twenty-four studies met the inclusion criteria; 20 studies were included in the meta-analyses. Workplace interventions significantly increased minutes per week of metabolic equivalents (4 studies; standardized mean differences, 2.07; 95% confidence interval [CI], 1.44 to 2.69), but not minutes per week of MVPA (13 studies; standardized mean differences, 0.38; 95% CI, −0.15 to 0.92) or metabolic equivalents per week (3 studies; standardized mean differences, 0.11; 95% CI, −0.48 to 0.71). Workplace interventions also significantly decreased body mass (7 studies; mean differences, −0.83 kg; 95% CI, −1.64 to −0.02), body mass index (6 studies; mean differences, −0.35 kg/m2; 95% CI, −0.62 to −0.07), low-density lipoprotein (4 studies; mean differences, −0.11 mmol/L; 95% CI, −0.17 to −0.04), and blood glucose (2 studies; mean differences, −0.18 mmol/L; 95% CI, −0.29 to −0.07). These workplace interventions targeting MVPA levels and known beneficial cardiometabolic health sequelae were of lower quality evidence.

    Conclusions—

    Workplace interventions variably improve MVPA levels and related cardiometabolic health sequelae of working-age women in high-income Organization for Economic Co-operation and Development countries. Our findings underscore the need for ongoing research in this area but also increased dissemination of the existing programs and knowledge.

    Introduction

    WHAT IS KNOWN

    • CVD is the leading cause of death among women in high-income countries; physical activity is protective for CVD. The realities of modern life require working-age women to address work-related, family, and social demands.

    • Few working-age women meet current MVPA rec ommendations.

    WHAT THE STUDY ADDS

    • Workplace interventions show variable improvements in MVPA and cardiometabolic health parameters in working-age women in high-income OECD nations.

    • There is a need for ongoing research in this area but also increased dissemination of existing programs and knowledge.

    Cardiovascular disease (CVD) is the leading cause of death among women in high-income countries defined as those with a gross national income per capita of $12 476 or more (ie, Canada, United States, Finland, Italy, etc.) and is projected to be the leading cause of death worldwide by 2030.1,2 Ironically, over half of women lack knowledge of CVD risk factors; the majority (80%) are uninformed when it comes to their own level of risk.3 An alarming number of working-age women in high-income countries are overweight or obese and possess other risk factors for CVD (eg, high blood pressure, high cholesterol, and diabetes mellitus).413 Physical activity (PA) is protective for CVD. Regular PA has been shown to prevent CVD, overweight and obesity, high blood pressure, high cholesterol, diabetes mellitus, certain cancers, and premature death.1417 Current guidelines recommend that adults accumulate at least 150 min/wk of moderate-intensity aerobic PA or at least 75 min/wk of vigorous-intensity aerobic PA or an equivalent combination of moderate-to-vigorous–intensity physical activity (MVPA).18 Typical MVPA activities include brisk walking, jogging, cycling, swimming, and participation in competitive sports.

    Lack of time is one of the most frequently cited barriers to regular PA participation.19 The realities of modern life require working-age women to address multiple family, work-related, community, and social demands. Working-age women in high-income countries comprise almost half of the work force20,21 and, compared with men, contribute more to other unpaid work (eg, cooking, cleaning, and childcare)22,23 while constituting the largest proportion (80%) of single parents.24 Unfortunately, few (3%–47%) working-age women in high-income countries meet current MVPA recommendations as measured by objective PA monitors.2527 Because of the unique and varied challenges faced by working-age women and their time spent at work, places of employment may be an opportune, an efficient, and a controlled setting in which to implement programs and strategies to target PA, improve MVPA levels, and enhance cardiometabolic health. Employees with unhealthy lifestyles and chronic health conditions are less productive, more frequently absent from work, and take more sick leave.2830 The potential to reduce healthcare costs and absenteeism rates while enhancing employee health and productivity may represent a strong rationale for employers to implement workplace programs designed to increase MVPA levels.

    Although previous reviews have demonstrated the beneficial effects of workplace interventions on fitness, nutritional practices, body mass, psychosocial factors, work performance, health risks, and healthcare costs among working-age adults,3134 only a few have evaluated the impact on MVPA levels,33,34 and none have focused on working-age women within high-income Organization for Economic Co-operation and Development (OECD) nations.2,27,35,36 Given that working-age women are a unique population and CVD is the leading killer of women globally, it is critical to evaluate the effectiveness of workplace interventions for improving their MVPA levels and cardiometabolic health. The main objective of this systematic review was to examine the effectiveness of workplace interventions for increasing MVPA levels among working-age women in such settings. A secondary objective was to examine the effectiveness of these interventions in improving the known, positive, cardiometabolic health sequelae of MVPA (eg, body mass, body mass index [BMI], body composition, waist circumference, blood pressure, blood serum lipids, and blood glucose concentrations).1517,27

    Methods

    The review methodology was prospectively registered with PROSPERO (registration number: 42014009704) and has been described elsewhere.37

    Study Inclusion Criteria

    This review sought to identify all studies reporting on workplace interventions intended to increase MVPA levels among working-age women in high-income OECD nations (Table I in the Data Supplement).2,36

    Population

    Studies were included if the sample included >80% working-age women, or where female-specific data could be extracted, and participants were those with a mean age of 18 to 65 years living in high-income OECD nations.2,36

    Interventions

    Both single- and multi-component workplace interventions were included.

    Outcome

    The primary outcome was MVPA. Both objectively measured, and self-reported MVPA data were included. MVPA was defined as activity involving an energy expenditure of ≥3 metabolic equivalents (METs), ≥40% of VO2 reserve, ≥46% VO2 peak, ≥64% of peak heart rate, ≥12 rating of perceived exertion, or >100 steps per minute.3842 Secondary outcomes included body mass (kg), BMI (kg/m2), waist circumference (cm), body fat percentage (%), blood pressure (mm Hg), blood serum lipids (mmol/L), and blood glucose concentrations (mmol/L).

    Study Design

    Both prospective cohort and experimental studies (ie, randomized controlled trials [RCTs], pre/post design, and quasi-experimental investigations) were eligible. Control groups were used, when available, to compare effects; there were no restrictions placed on the nature of the control groups (ie, no PA intervention or low-intensity PA).

    Publication Status and Language

    Both published (peer reviewed) and unpublished literature were examined. No language restrictions were imposed in the search, but only English or French papers were included.

    Search Strategy

    A comprehensive search strategy was designed by a research librarian (and reviewed by a second) to identify relevant studies reporting MVPA outcomes of workplace interventions among working-age women. The strategy is illustrated using the MEDLINE search as an example (Table II in the Data Supplement); it was modified according to the indexing systems of other databases. Eight electronic bibliographic databases were searched: Ovid MEDLINE In-Process and Other Non-Indexed Citations (1946 to October 2014), EBM Reviews—Cochrane Database of Systematic Reviews (2005 to October 2014), EBM Reviews—Cochrane Central Register of Controlled Trials (1991 to October 2014), EMBASE Classic+ (1947 to October 2014), CINAHL (1981 to October 2014), Ovid PsycINFO (1806 to October 2014), SPORTDiscus (1949 to October 2014), and Dissertations and Theses (1980 to October 2014). If an article identified a measure that could capture MVPA and cardiometabolic health sequelae, but did not report these outcomes, or if an article discussed a relevant study protocol, the authors were contacted to ascertain whether the outcomes could be provided as unpublished results. If an article included working-age women who constituted <80% of the sample, the authors were contacted to determine whether the women-specific MVPA and cardiometabolic health sequelae could be provided as unpublished results. Authors were contacted on at least 2 occasions for clarification of these issues.

    Selection of Studies

    The details of each study (ie, reference type, authors, title, abstract, publication year, publication date, journal title, volume, issue, page numbers, keywords, author address, accession number, database, and retrieval date) were captured in a spreadsheet (Microsoft Excel, Microsoft Canada Inc, Mississauga, Ontario, Canada), and duplicates were removed. Two independent reviewers (J.L.R. and C.G.E.) screened the titles and abstracts of all studies to identify potentially relevant articles. The full texts of all studies that met the inclusion criteria were obtained and then reviewed independently by 2 reviewers (J.L.R., and one of C.G.E. or S.A.P.). When disagreements between reviewers arose, consensus was achieved through discussion or following a third review (C.G.E. or S.A.P.). Reviewers were not blinded to the authors or journals screened.

    Data Extraction and Analysis

    Data abstraction spreadsheets were completed by J.L.R. and verified by C.G.E. Information was extracted identifying publication details (authors, year, and country of study), participant characteristics (mean age, age range, sex distribution, chronic diseases/health states, population, and setting), sample size, study design (RCT, pre/post, quasi-experimental), intervention description, control group description (control, usual care, or wait list), blinding and randomization techniques, measurement methodology (objective and self-report measures, measurement units, and follow-up length), statistical analysis methods, MVPA results (mean differences [MDs] and standard deviations [SDs]), and cardiometabolic health sequelae (body mass, BMI, body composition, waist circumference, blood pressure, blood serum lipids, and glucose concentrations; MDs and SDs). Findings which were not reported in International System of Units were converted appropriately (eg, to kg for mass, cm for waist circumference, and mmol/L for blood lipids and glucose). Reviewers were not blinded to the authors or journals when extracting data. In cases where several publications reported results from the same primary data source, only 1 study per data source/analysis was retained. The primary outcome measure was the MD in MVPA in minutes per week after a workplace intervention. Seven studies reported METs per week or MET minutes per week as their MVPA outcome; these data were abstracted and analyzed separately. All data from studies reporting MDs were converted, where possible, to mean minutes per week of activity (eg, 5 h/wk=300 min/wk). All available data were used in the meta-analyses; sensitivity analyses were performed to ascertain where differences existed between published and unpublished results. Only 20 of 24 studies could be included in the meta-analyses (eg, data not obtained and units not comparable). A qualitative synthesis of the evidence derived from all studies was completed.

    Forest plots and meta-analyses were created using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark 2012) to compare the MDs and 95% confidence intervals (CIs) in total time spent in MVPA (minutes/week) or, separately, to compare moderate (minutes/week) or vigorous (minutes/week) intensities of activity reported in intervention and control groups. The meta-analyses did not include studies that reported units that could not be converted to minutes per week of MVPA, minutes per week of METs, or METs per week. Similarly, forest plots and meta-analyses were completed to compare the MDs and 95% CIs in the previously described cardiometabolic health sequelae between intervention and control groups. Studies that did not provide these results were not included in the meta-analyses. Some studies4347 included multiple interventions in which case the applicable intervention arms were included in the appropriate meta-analysis, and the control group was split according to the number of interventions in each meta-analysis as per the Cochrane methodology.48

    A random-effects meta-analysis was performed to provide an overall summary measure of effect (MDs) and 95% CIs for each outcome. Standardized MDs (SMDs) were used for the MVPA outcomes because of the heterogeneity of the measurement methods (eg, SMDs were calculated as differences in mean outcome between groups divided by SD of outcome among all participants). MDs were used for the cardiometabolic health sequelae outcomes because of the homogeneity of the measurement methods. A priori determined subgroup analyses were performed to test differences for unpublished (ie, unpublished findings from authors and grey literature) versus published results and self-report versus objectively measured MVPA. This review deviates from the previously published protocol37 by not examining body composition or subgroup differences in age, number of children, education, marital status, occupation, worksite, working status, income, intervention focus, intervention mode, intervention delivery, study design, or control groups because of insufficient reporting of data.

    Risk of Bias

    The risk of bias of the individual studies was assessed using the Cochrane Collaboration’s tool.48 Items in the Cochrane risk of bias assessment included sequence generation (randomization); allocation concealment; blinding of participants, personnel, and investigator; incomplete data (eg, losses to follow-up and intention-to-treat analysis); selective outcome reporting; and other possible sources of bias (including self-report measures—as self-reported PA has been shown to deviate from objective measures, especially among women49). The risk of bias assessment was performed by 2 independent assessors (J.L.R. and C.G.E.); any disagreements between assessors were resolved by consensus or through discussion with a third reviewer (S.A.P.). The review also deviates from the previously published protocol by not additionally assessing study quality using the Downs and Black Checklist.50 The vast majority of the studies examined were RCTs; the Cochrane risk of bias assessment was, accordingly, deemed appropriate.

    Quality of the Evidence

    The quality of the evidence was assessed as high, moderate, low, or very low using the Grading of Recommendations Assessment, Development and Evaluation approach51; RCTs are deemed as high-quality evidence, and observational studies are seen as low-quality evidence. Further to study design, the quality of evidence was determined after an evaluation of risk of bias, imprecision, heterogeneity, indirectness, and suspicion of publication bias. Heterogeneity was assessed using the I2 statistic with values >75%, and P value <0.10 used to indicate high heterogeneity across studies.52 A funnel plot of the included studies was used to assess the presence of publication bias. The plots were assessed visually to indicate the presence of a significant publication bias. Risk of bias of the individual studies was assessed using the Cochrane risk of bias tool and captured in Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, 2012).53

    Results

    Literature Search and Study Characteristics

    Our search identified 3284 records (Figure 1). Of these, 989 were retrieved through EMBASE, 870 through MEDLINE, 577 through Cochrane Central Register of Controlled Trials, 289 through CINAHL, 264 through SPORTDiscus, 122 through PsycINFO, 118 through Cochrane Database of Systematic Reviews, and 55 through Dissertations and Theses. An additional 19 records were identified through contacts with coauthors and colleagues. After the removal of duplicates, 1902 records remained, and after screening of titles and abstracts, 601 papers were reviewed for eligibility. A total of 103 authors were contacted on at least 2 occasions for clarification of whether women-specific MVPA and cardiometabolic health sequelae could be provided as unpublished results; a total of 61 (58%) authors responded to these contacts. Of the 601 papers, 24 studies met the inclusion criteria and were included in the qualitative analysis. The individual study characteristics are shown in Table III in the Data Supplement, and MVPA outcomes are shown in Table 1.

    Table 1. Moderate-to-Vigorous–Intensity Physical Activity Outcomes

    StudyMVPA Measurement ToolSelf-Report or Objective Measure of MVPAUnits of MeasureIntervention GroupIntervention Group: Baseline MVPAIntervention Group: Follow-up MVPAControl Group: Baseline MVPAControl Group: Follow-up MVPA
    MeanSDMeanSDMeanSDMeanSD
    Published findings
     Campbell et al54PA questionnaire assessing frequency and duration of PASelf-reportMET h/wk4.26.84.57.04.87.84.37.8
     Carr et al55Accelerometer (StepWatch 3.0)ObjectiveMPA min/wk101.5129.5163.1196.0130.2176.4121.8165.9
    VPA min/wk18.944.834.376.38.418.210.518.9
     Green et al56Godin leisure time exercise questionnaireSelf-reportMETs/wk35.244.7
     Lee and White57Stanford PA recall (hard/moderate PA)Self-reportmin/wk146.8175.5231.6229.7145.8203.7135.4151.0
     Parry et al58Accelerometer (ActiGraph GT3X)Objectivemin/wk197.58126.92221.76139.86
     Purath et al59Paffenbarger PA questionsSelf-reporth/weekday3.83.43.83.03.63.23.33.0
    h/weekend4.92.45.62.75.22.94.82.4
     Samuels et al60Accelerometer (ActiGraph 7164)Objectivemin/wk10 K20.811.234.813.6
    30 min17.49.127.213.0
    Bouts23.512.725.420.6
     Speck and Looney617-d PA recall questionnaireSelf-reportMETs/wk38.905.7738.568.12
     von Thiele Schwarz et al43Subjects recorded average time spent per wk in PASelf-reporth/wkPE1.870.863.300.891.680.682.471.42
    RWH1.841.002.641.35
    Unpublished findings*
     Aittasalo et al*457-d diarySelf-reportmin/wkCounseling283.32278.23289.70366.13181.11180.14240.63200.38
    Counseling+testing228.24196.17244.35216.52
     Aittasalo et al*62IPAQ long formSelf-reportVigorous min/wk15.725.043.658.710.020.732.388.1
     Cardinal477-d PA recall instrumentSelf-reportActivity METs/wkLEP34.832.8235.012.0734.432.9934.332.27
    7-d PA recall instrumentSelf-reportActivity METs/wkSEP34.092.2134.452.3014.7113.6717.6113.70
    Godin leisure time exercise questionnaireSelf-reportExercise METs/wkLEP20.1126.3130.6918.46
    Godin leisure time exercise questionnaireSelf-reportMETs/wkSEP17.0821.1921.9717.41
     Dishman et al*63IPAQ short formSelf-reportVigorous MET h/wk12.721.418.625.68.614.110.019.5
    Moderate MET h/wk6.011.19.214.25.610.76.913.5
     Greene et al*64SQUASHSelf-reportmin/wk2173.771317.802749.761595.161974.201102.702236.341363.61
     Hunter et al*65Godin leisure time exercise questionnaireSelf-reportmin/wk246.78365.64233.98241.19272.06333.82286.33321.72
     McEachan et al*66IPAQ short formSelf-reportMET min/wk1802.32113.82250.42264.81971.12236.41863.21780.0
     Prestwich et al*44IPAQSelf-reportMETs/wkII990222293796667297112481540
    PO3846979741510
    CII633734695821
     Priebe and Spink*46Godin leisure time exercise questionnaireSelf-reportmin/wkAppearance49.146.047.141.648.458.762.196.1
    Health23.116.923.320.4
    Normative22.721.721.218.8
     Robroek et al*67IPAQ short formSelf-reportVigorous min/wk2231274331483349
    PA without walking min/wk69737272798695100
     Slootmaker et al*68Activity questionnaire for adolescents and adultsSelf-reportmin/wk306.2294.4286.7307.6217.5179.3307.7232.6
     Sternfeld et al*69PA questionnaire adapted from the cross-cultural activity patterns questionnaireSelf-reportmin/wk276.3272.6284.2262.1287.4285.8272.7270.2
     Thorndike et al*70FitbitObjectiveActivity score663.1215.6644.8165.4626.6167.4635.0165.5
     Touger-Decker et al*71IPAQSelf-reportMET min/wk1510.781875.232117.911866.252087.502169.383257.063115.10
     von Schlumperger72Exercise behavioral checklist which includes aerobic exercise minSelf-reportmin/wk90.66170.69162.83160.5324.8622.6829.6448.27

    CII indicates collaborative implementation intentions; IPAQ, International Physical Activity Questionnaire; LEP, lifestyle exercise prescription; METs, metabolic equivalents; MPA, moderate-intensity physical activity; MVPA, moderate-to-vigorous–intensity physical activity; PA, physical activity; PE, physical exercise; PO, partner only; RWH, reduced work h; SEP, structured exercise program; SQUASH, Short Questionnaire to Assess Health-Enhancing Physical Activity; and VPA, vigorous-intensity physical activity.

    *Unpublished results provided by authors.

    Figure 1.

    Figure 1. PRISMA flow diagram.

    Twenty of these studies included MDs in MVPA in minutes per week (n=13), MET minutes per week (n=4), or METs per week (n=3) and were included in the meta-analyses. Several of these studies examined changes in body mass (n=7), BMI (n=6), waist circumference (n=5), total cholesterol (n=5), high-density lipoprotein ([HDL]; n=6), low-density lipoprotein ([LDL]; n=4), triglycerides (n=4), blood glucose (n=2), or systolic blood pressure (n=5) and were included in respective meta-analyses.

    Common reasons for excluding studies are noted in Figure 1. Investigations included in our analysis were published over a 29-year period from 1985 to 2014 and completed in 9 high-income OECD countries, the majority (54%) in the United States. Nineteen RCTs,4347,54,55,57,59,61–64,66–70,72 2 randomized trials,58,60 1 quasi-experimental trial,65 and 2 pre/post trials56,71 examined changes in MVPA levels after a workplace intervention designed to increase MVPA. All were published in English. A total of 4745 women with ages ranging from 17 to 79 years participated in investigations with sample sizes ranging from 2672 to 650.54

    Interventions

    The interventions varied widely; 21 of the 24 studies used multiple intervention strategies to increase PA. They included counseling,45,54,72 appointments with occupational nurses45 or Registered Dieticians,71 fitness testing,45 messages/emails providing feedback on PA, diet, or health promotion,54,55,62,67,69,71 stages of change–based interventions,47 personal, partner, or team goal-setting,44,56,63,64,69 self-monitoring of body mass or PA using activity monitors or questionnaires,55,56,60,6265,67,68,71 team or individual competitions,56,64,66 online social networks to connect with friends and make public postings,64 tailored web-based PA advice,68 incentives,56,63,65 PA prescriptions,43,57 knowledge quizzes,66 educational materials (eg, leaflets, posters, pamphlets, newsletters, reminders, or fridge magnets),47,62,66 educational sessions,57,69 expressions of management support,66 active workstations,58 promotion of incidental office activity,58 pedometer challenges,58 encouraged social support, enhanced self-efficacy and awareness of benefits of PA,59 reduction of perceived barriers to PA,59,67 reduced work hours,43 access to a motivational website,55 tracking and simulation tools,69 personalized diet guidelines,71 online discussion forums,71 or weekly weigh-in sessions (online or in-person).71 Three of the 24 studies used a single intervention strategy to increase PA: self-monitoring of PA using an activity monitor or monthly calendar61,70 or tailored emails.46

    Intervention Effects on PA

    Of the 12 RCTs,43,45,46,55,57,59,62,64,6769,72 2 randomized trials58,60 and 1 quasi-experimental trial65 which reported changes in minutes per week of MVPA, 8 studies43,55,57,59,62,64,69,72 showed increases in minutes per week of MVPA. Of the three RCTs44,47,61 and 1 pre/post trial56 which reported changes in METs per week, 3 studies47,56,61 showed increases in METs per week. All 3 RCTs54,63,66 and 1 pre/post trial71 which reported changes in MET minutes per week showed increases in MET minutes per week. Finally, 1 RCT showed an increase in the activity score measured using Fitbit devices.70

    Results of the meta-analyses (Figure 2) reveal that the interventions did not significantly increase minutes per week of MVPA (SMD, 0.38; 95% CI, −0.15 to 0.92; P=0.16). Significantly high heterogeneity was found among the study results (P<0.00001; I2 = 97%). Similarly, the results of the meta-analyses showed that the interventions did not significantly increase METs per week (SMD, 0.11; 95% CI, −0.48 to 0.71; P=0.71; Figure 3A). Conversely, the results of the meta-analyses showed that the interventions significantly increased MET minutes per week (SMD, 2.07; 95% CI, 1.44 to 2.69; P<0.00001) equating to a MD of ≈210 MET minutes per week (Figure 3B). Significantly high heterogeneity was found among studies evaluating METs per week (P<0.00001; I2=86%) and MET minutes per week (P<0.00001; I2=97%).

    Figure 2.

    Figure 2. Changes in min/wk of moderate-to-vigorous–intensity physical activity.43,45,46,55,57,59,62,64,65,6769,72 CI indicates confidence interval.

    Figure 3.

    Figure 3. (A) Changes in METs/wk44,47,61 and (B) MET min/wk54,63,66,71 (B) CI indicates confidence interval; LEP, lifestyle exercise prescription; METs, metabolic equivalents; and SEP, structured exercise program.

    Intervention Effects on Cardiometabolic Markers

    Results of the meta-analyses showed that the interventions significantly decreased body mass (MD, −0.83 kg; 95% CI, −1.64 to −0.02; Figure 4A), BMI (MD, −0.35 kg/m2; 95% CI, −0.62 to −0.07; Figure 4B), LDL (MD, −0.11 mmol/L; 95% CI, −0.17 to −0.04; Figure 4C), and blood glucose (MD, −0.18 mmol/L; 95% CI, −0.29 to −0.07; Figure 4D). No significant changes were observed in waist circumference (MD, −0.75 cm; 95% CI, −1.80 to 0.29; Figure 5A), total cholesterol (MD, −0.03 mmol/L; 95% CI, −0.11 to 0.06; Figure 5B), HDL (MD, −0.02 mmol/L; 95% CI, −0.08 to 0.03; Figure 5C), triglycerides (MD, 0.01 mmol/L; 95% CI, −0.07 to 0.08; Figure 5D), or systolic blood pressure (MD, −0.56 mm Hg; 95% CI, −2.12 to 1.01; Figure 5E).

    Figure 4.

    Figure 4. Changes in body mass44,55,64,65,6971 (A), body mass index (BMI)55,57,64,6870 (B), low-density lipoprotein (LDL)43,55,64,70 (C), and blood glucose43,71 (D).

    Figure 5.

    Figure 5. Changes in waist circumference44,55,57,70,71 (A), total cholesterol43,55,57,70,71 (B), high-density lipoprotein (HDL)43,55,57,64,70,71 (C), triglycerides43,55,57,64 (D), and systolic blood pressure43,55,57,70,71 (E). CI indicates confidence interval.

    Subgroup Analyses

    Differences between published and unpublished findings provided by authors and grey literature were observed for minutes per week of MVPA, MET minutes per week, and systolic blood pressure. Published (SMD, 1.54; 95% CI, 0.51 to 2.56), compared with unpublished (SMD, −0.25; 95% CI, −0.71 to 0.20), interventions identified significant increases in minutes per week of MVPA. The published studies showed a MD of ≈39 min/wk. Unpublished (SMD, 2.27; 95% CI, 1.70 to 2.84), compared with published (SMD, 1.38; 95% CI, 1.21 to 1.56), interventions recorded a significantly greater increase in MET minutes per week; however, only 1 published study reported on minutes per week of METs. Unpublished (MD, 2.60; 95% CI, 0.28 to 4.92), compared with published (MD, −1.09; 95% CI, −2.55 to 0.36), interventions reported significant increases in systolic blood pressure; however, only 1 unpublished study examined systolic blood pressure.

    Differences between studies using objective versus self-report measures were found for several cardiometabolic health sequelae. Studies which used objective (MD, −1.60; 95% CI, −1.67 to −1.53), compared with self-report (MD, −0.22; 95% CI, −0.41 to −0.02), measures showed significantly greater decreases in body mass. Studies which used objective (MD, −0.60; 95% CI, −0.62 to −0.57) rather than self-report (MD, −0.10; 95% CI, −0.44 to 0.24) measures showed significant decreases in BMI; only 1 study used self-reported BMI. All studies which reported on METs per week or MET minutes per week used self-report measures.

    Interventions in other countries (5 studies; SMD, 1.20; 95% CI, 0.37 to 2.03), compared with the United States (8 studies; SMD, −0.08; 95% CI, −0.67 to 0.52), significantly increased minutes per week of MVPA. The other countries showed a MD of ≈51 min/wk of MVPA.

    Risk of Bias

    A summary of the risk of bias for all individual studies (n=24) assessed using the Cochrane Collaboration’s Risk of bias tool can be seen in Figure 6. The largest risk of bias emanated from the use of incomplete outcome data (because of high [>10%] attrition), selective reporting (because of the high number of studies with unpublished women-specific data provided for this review), and other bias (self-report measures). The quality of evidence for the RCTs4347,54,55,57,59,61–64,66–70,72 was downgraded from high to very low as a consequence of high risk of bias (ie, >50% of included studies had high attrition bias, selective reporting, and used self-report measures); high heterogeneity for minutes per week of MVPA, METs per week, and MET minutes per week (I2 statistic = 86% to 97%, P<0.0001); and evidence of publication bias (ie, asymmetrical funnel plot). The quality of evidence for the non-RCTs (ie, randomized trials without control groups, quasi-experimental studies, and pre/post studies)56,58,60,65,71 was downgraded from moderate to very low because of a high risk of bias (ie, >50% of included studies had high attrition bias, selective reporting, and did not blind participants).

    Figure 6.

    Figure 6. Risk of bias of included studies.

    Discussion

    This systematic review and accompanying meta-analyses are, to our knowledge, the first of its kind, to examine the effectiveness of workplace interventions for increasing MVPA levels and improving the associated beneficial cardiometabolic health sequelae in working-age women in high-income OECD countries. The meta-analyses of 24 studies showed that workplace interventions significantly increased MVPA levels, as measured by minutes per week of METs. No significant increases in MVPA minutes per week or METs per week were observed; however, subgroup differences were found for minutes per week of MVPA (ie, by publication status and study country). Statistically significant improvements in several related cardiometabolic health sequelae, including body mass, BMI, LDL, and blood glucose, were also observed. Workplace interventions did not significantly improve waist circumference, total cholesterol, HDL, triglycerides, or systolic blood pressure.

    Working-age women manage multiple family, work-related, and social demands. It is thus not surprising that lack of time is a commonly cited barrier to regular PA participation19 or that many women at risk of, or with CVD, do not meet the current guidelines of at least 150 min/wk of MVPA.18 It is known that PA among women is associated with a reduced risk of CVD in a dose–response relationship; inactive women benefit from even a slight increase in PA (eg, walking ≤1 h/wk).73 Recently, Arem et al74 showed that any level of PA was associated with a significantly lower risk of mortality. Among those performing less than the recommended leisure time physical activity (ie, 0.1– <7.5 MET h/wk), a 20% lower risk of mortality was observed.74 Our findings suggest that workplaces may be an opportune and effective setting in which to implement programs and strategies to address and improve levels of PA among women; small improvements (ie, MDs≈210 MET min/wk) can positively influence cardiometabolic health.

    Our findings are consistent with the few other systematic reviews that have examined the effects of workplace interventions on PA levels and related health sequelae among working-age adults.33,75,76 Barr-Anderson et al33 showed that the interventions integrating short bouts of PA into daily routines produced modest, but consistent, improvements in PA among adults and children in school-, worksite-, and faith-based locations. Hutchinson et al76 reported large effects for specific measures of PA in studies using motivational enhancement approaches. A meta-analysis of 26 workplace PA interventions, including nearly 9000 participants in 1998, showed a small, heterogeneous mean effect of increased PA (r=0.11; 95% CI, −0.20 to 0.40)75; the authors noted that the poor quality of the literature addressing this topic precluded any conclusion that workplace interventions increase PA and identified a need for further studies using valid designs and measures.75 This systematic review and accompanying meta-analyses include 19 RCTs, but the quality of evidence continues to be low because of a high risk of bias and heterogeneity.

    Substantial evidence supports the role of MVPA in reducing modifiable CVD risk factors, including overweight and obesity, dyslipidemia, hypertension, and diabetes mellitus.7782 Our meta-analyses show that the interventions significantly decreased body mass (−0.83 kg) and BMI (−0.35 kg/m2), while overall improvements were observed in LDL (−0.11 mmol/L) and blood glucose (−0.18 mmol/L). Although no significant changes were observed in waist circumference, total cholesterol, HDL, triglycerides, or systolic blood pressure, at least half of the included studies showed improvements in waist circumference, total cholesterol, HDL, triglycerides, and systolic blood pressure. It is possible that greater increases in MVPA levels, or inclusion of more studies and thus participants, are needed to see the statistical improvements in these health sequelae. Hyperlipidemia, diabetes mellitus, and hypertension are significant health concerns among working-age women in high-income countries.8,13 Among adult women with or without CVD, the use of medications (ie, antiplatelets, β-blockers, blockers of the renin–angiotensin system, and statins) targeting these cardiovascular risk factors is greatest in high-income countries.13,83,84 Workplaces that provide health insurance plans will benefit from the lowered pharmaceutical costs that may follow the promotion of PA with resulting improvements of cardiovascular health among employees. The cost of absenteeism associated with obesity alone totals $4.3 billion annually in the United States.85 Our findings suggest that workplace interventions may enhance levels of MVPA and produce small improvements in body mass, levels of cholesterol, and glycemic control. Policymakers, health economists, and employers interested in improving the cardiovascular health of their employees may wish to explore the design and implementation of high-quality workplace interventions designed to target and increase MVPA levels.86

    Subgroup analyses showed a publication bias such that published, compared with unpublished, interventions reported significantly increased minutes per week of MVPA. Published studies demonstrated a mean improvement of ≈39 min/wk of MVPA. Studies that used objective compared with self-report measures showed significantly greater decreases in body weight and BMI. Measurement method has been shown to have a substantial impact on observed levels of body weight and BMI.87 Our findings highlight the need for accurate and reliable measures of MVPA levels in evaluating interventions targeting PA and the relationship between MVPA levels and cardiometabolic health sequelae, particularly as these data may be used by policymakers and stakeholders, including employers, to allocate resources and set priorities in health.

    We judged these workplace interventions targeting MVPA levels as lower quality of evidence because of high risk of bias, high heterogeneity, and evidence of publication bias. The high heterogeneity likely reflects the many different measures of MVPA levels and interventions. The publication bias likely reflects the substantial number of studies which provided women-specific MVPA data for this review and which were not necessarily powered to detect changes in MVPA levels between intervention and control groups in women only. Although the evidence was downgraded to lower quality, 75% (n=18/24) of the studies were in the direction of benefit. Two additional studies (8%) were in the direction of benefit depending on the specific measure of MVPA. We therefore conclude that workplace interventions are beneficial, even though the amount of benefit is uncertain.

    Initial strengths of this systematic review are the robust and sensitive search strategy developed with a research librarian, use of an a priori published protocol37 with eligibility criteria and analytic plan, use of Cochrane Collaboration tools to assess risk of bias and study quality, thorough attempts to capture all unpublished data, and many meta-analyses. Our work is timely and relevant. Few working-age women meet current MVPA recommendations, an alarming number of women experience risk factors for CVD, and over half of women lack knowledge of CVD risk factors, including their own level of risk.3 We examined the effectiveness of workplace interventions targeting MVPA levels and the impact of these interventions on many known beneficial cardiometabolic health sequelae of PA. A large proportion of the studies included in this review were RCTs. We acknowledge a high risk of bias associated with these RCTs and recognize that other study designs may provide information that adds to the existing knowledge of workplace interventions addressing MVPA. Finally, by applying the Grading of Recommendations Assessment, Development and Evaluation approach, it is possible to appropriately assess the quality of the evidence that have led to our conclusions.

    This review is not without limitations. First, many studies did not provide information on methodological quality, particularly on random sequence generation; allocation concealment; and blinding of participants, personnel, and outcome assessments. This led to a downgrading of the quality of the evidence. Second, the possible publication bias should be considered when interpreting the outcomes of our meta-analyses. Finally, we ensured a broad inclusion criteria to capture as many workplace interventions targeting PA in working-age women as possible; this led to significant high heterogeneity in the intervention components, measures to capture MVPA levels, and outcomes. The use of random-effects models and the SMDs allowed us to partly adjust for these issues.

    In conclusion, our systematic review and meta-analyses show that workplace interventions variably improve MVPA levels and related cardiometabolic health sequelae of working-age women in high-income OECD countries. Given the burgeoning evidence of the importance of addressing all aspects of an individual’s movement spectrum (ie, sedentary time, light PA, and MVPA),88,89 it is likely that greater gains in cardiometabolic health may be achieved by more comprehensive interventions that target and improve movement patterns throughout the workday (eg, reduced work hours and PA opportunities). Our findings are important for clinicians, researchers, policymakers, and stakeholders. Clinicians should encourage the participation of working-age female patients in workplace programs as an opportune and effective setting to improve their MVPA levels and cardiometabolic health. The lower quality of evidence observed calls for researchers designing and evaluating future workplace PA interventions to use RCT designs which address all elements of bias, use validated, objective measures of MVPA, and report results separately for population subgroups, including sex and gender. Our work provides a contemporary, rigorous, and reliable research base for policymakers and stakeholders to support the design and implementation of future interventions. Investing in the health of employees produces benefits for workers, families, and communities—and employers.86

    Acknowledgments

    Dr Prince was funded by a Fellowship from the Canadian Institutes of Health Research and an Endowed Research Fellowship from the University of Ottawa Heart Institute Foundation. Dr Cotie is funded by a Fellowship from the Canadian Women’s Heart Health Centre. We thank Christie Cole for her initial assistance in screening full-text articles. Dr Reed conceived the study; performed the design, article screening, data abstraction and synthesis, and data analysis; interpreted the results; and drafted and edited the article. Dr Prince participated in its design and coordination, article screening, verification of risk of bias assessments and quality of evidence assessments, interpretation of the results and editing the article. C.G. Elliott participated in its coordination, article screening, data abstraction and verification, conduction and verification of risk of bias assessments, quality of evidence assessments, interpretation of the results, preparation of the discussion, and editing the article. Dr Cotie participated in the interpretation of the results and editing the article. Drs Mullen, Hiremath, Tulloch, Pipe (senior author), and Reid (senior author) participated in its design, interpretation of the results, and editing the article. All authors read and approved the final article and have given final approval for its publication.

    Footnotes

    The Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.116.003516/-/DC1.

    Correspondence to Jennifer L. Reed, PhD, Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada. E-mail

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