Combined Diet and Exercise Intervention in

the Workplace
Effect on Cardiovascular Disease Risk Factors
by Karen White, MS, RD, LDN, and Paul H. Jacques, PhD
research Abstract
This study assessed the effectiveness of a 12-week pilot employee wellness program in reducing risk factors for coronary
heart disease. Fifty university employees with at least one cardiovascular disease risk factor participated in the program.
Interventions focused on diet, exercise, and monthly workshops. Pre- and post-intervention measurements included
weight, body composition, blood pressure, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, total cholesterol/HDL cholesterol ratio, triglycerides, and blood sugar. Twenty-five employees
had post-intervention measurements. A survey was administered to assess adherence. The correlation between adherence and improvement in cardiovascular disease risk factors was also tested. Significant differences were observed
between pre- and post-intervention measurements of total cholesterol, LDL cholesterol, total cholesterol/HDL cholesterol
ratio, triglycerides, and weight. A significant correlation existed between self-reported level of participation in the diet
aspect of the program and improvement in LDL levels. This multi-component, 12-week pilot employee wellness program
was effective in reducing cardiovascular disease risk.

early two-thirds of all deaths among adults in

the United States are attributed to coronary heart
disease, cancer, stroke, and diabetes (Centers for
Disease Control and Prevention, 2005). Diet contributes
to the development of all four (Byers et al., 2002; Grundy, Pasternak, Greenland, Smith, & Fuster, 1999; Hubert,
Feinleib, McNamara, & Castelli, 1983; Krauss et al.,
2000; Seidell, 2000; Sherwin et al., 2004; Tuomilehto et
al., 2001). When stroke, hypertension, and coronary heart
disease are included in the definition of cardiovascular
disease (CVD), CVD accounts for more than one-third of
the deaths among American adults (Hoyert, Heron, Murphy, & Kung, 2006).
To improve the health of the nation and reduce mortality from these diseases, the U.S. government and several
government agencies have published recommendations or
guidelines regarding dietary choices, weight, and physical
activity (Fletcher et al., 1996; Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure, 2004; National Cholesterol Education Program Expert Panel on the Detection, Evaluation,
About the Authors

Ms. White is a dietitian, Bird Health Center, Western Carolina University,

Cullowhee, NC. Dr. Jacques is Assistant Professor of Management, Western Carolina University, Cullowhee, NC.

march 2007, vol. 55, no. 3

and Treatment of High Blood Cholesterol in Adults, 2001;

National Institutes of Health, 1998; U.S. Department of
Agriculture and U.S. Department of Health & Human Services, 1992, 1995; U.S. Department of Health & Human
Services, 2000; World Health Organization, 1998; World
Health Organization Expert Committee, 1995). In June
2004, the American Heart Association (AHA), American
Diabetes Association (ADA), and American Cancer Society (ACS) published a joint scientific statement including
recommendations for treating diabetes, cancer, and heart
disease (Eyre, Kahn, & Robertson, 2004). The recommendations focused on four areas: diet, exercise, cigarette
smoking, and health screenings.
Worksite health promotion programs are an efficient means of improving the health of a relatively large
group of individuals (Anderson, Palombo, & Earl, 1998).
Worksite interventions are convenient and accessible for
workers and often less expensive than programs offered
in clinical settings (Glantz & Seewald-Klein, 1986; Pelletier, 1996; Sorensen & Himmelstein, 1992). Furthermore,
employers who pay for health insurance have a vested interest in maintaining the cardiovascular wellness of their
employees (Guico-Pabia, Murray, Teutsch, Wertheimer,
& Berger, 2001).
Many employers have developed and assessed work-

109

Recommended Ranges

Applying Research to Practice

A wellness program of relatively short duration focusing on diet, exercise, laboratory and
anthropometric measures, and regular educational workshops can be effective in reducing
cardiovascular disease (CVD) risk. If such
improvements in CVD risk can be maintained,
a substantial cost-savings can be realized by
employers supporting such programs.

Blood pressure

< 120/< 80 mmHg

Total cholesterol

< 200 mg/dl

LDL cholesterol

< 100 mg/dl

Triglycerides

< 150 mg/dl

Fasting blood sugar

< 100 mg/dl

BMI

< 25

LDL = low-density lipoprotein; BMI = body mass index.

site wellness programs including both diet and exercise to

reduce CVD risk factors. The National Aeronautics and
Space Administration (NASA) offered an 8-week diet and
exercise intervention program, the Cardiovascular Risk
Reduction Program, to employees annually for 10 consecutive years. The mean beginning total serum cholesterol levels of the participants were significantly reduced
each year (Angotti, Chan, Sample, & Levine, 2000).
Another workplace health promotion program targeting diet and exercise to reduce CVD risk took a different approach. The 152 employees in the intervention
group spent 4 days at a resort for intensive lectures and
training. The participants were assessed at baseline and
at 3-month intervals for 1 year after the program. Those
in the intervention group showed significant improvements in body mass index (BMI), systolic blood pressure, total cholesterol, and triglycerides (Muto & Yamauchi, 2001).
A third study compared the effect of diet and exercise on CVD risks. The low-fat diet intervention group
showed the greatest improvement in total cholesterol,
low-density lipoprotein (LDL) cholesterol, and body
weight (Pritchard, Nowson, Billington, & Wark, 2002).
One hundred sixty-seven employees identified as
high risk were enrolled in the Lucent-Takes-Heart cardiovascular health management program. The intervention included education, measurement of risk factors, and
individual counseling. At the 6-month follow-up, most
participants reported increasing exercise or changing
diet. The participants total cholesterol, LDL cholesterol,
and blood pressure were significantly improved (GuicoPabia, Cioffi, & Shoner, 2002).
A 3-month intervention for overweight individuals
consisted of a baseline survey, two counseling sessions,
and four individualized letters. Assessment measures included a food frequency questionnaire and a 3-day food
record. At the end of the intervention, participants had
significantly reduced their body weight and total cholesterol (Okuda, Okamura, Kadowaki, Tanaka, & Ueshima,
2004).
No worksite wellness programs have been developed based on the new joint AHA, ADA, ACS recommendations. This study aimed to determine the efficacy
of a 12-week worksite wellness program based on these
recommendations for reducing CVD risk. Implementa-

110

tion of the program required minimal staff, time, and

resources.
Methods
Subjects

Participants at a mid-sized regional comprehensive

university were recruited via university e-mail advertising the program. Fifty university staff and faculty with
at least one baseline measurement outside of the recommended range (Sidebar) participated in the program.
Forty-two of the 50 participants were female. The wellness program lasted 3 months. Employees were asked
to complete surveys related to the program and submit
logs of daily food servings and minutes of exercise. Preand post-intervention measurements included BMI, body
composition, blood pressure, total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, total cholesterol/HDL cholesterol ratio, triglycerides, and
blood sugar. In addition, a post-intervention survey was
administered 13 weeks after the pre-intervention measurements were taken to assess adherence to different
components of the intervention.
Twenty-five of the participants who began the program had post-intervention measurements (5 male, 20
female). Because only eight participants returned logs,
these data were not included in the analysis. A follow-up
inquiry directed at participants who did not complete the
program revealed work schedules that grew increasingly
demanding as the semester progressed and reduced discretionary time available for participation were the predominate barriers.
Interventions

Interventions associated with the wellness program

focused on dietary changes, following one of four exercise prescriptions, and participating in a minimum of
four workshops in 3 months. The interventions were
collectively referred to as the Healthy Cats pilot wellness program. The AHA, ADA, and ACS jointly recommend weight loss to achieve and maintain a healthy
weight, and physical activity for at least 30 minutes 5 or
more days each week. The Healthy Cats physical activity recommendations included four prescriptions based
on baseline activity level. At the end of 12 weeks, each

AAOHN Journal

participant was to engage in physical activity for 30

minutes 6 days each week.
The AHA, ADA, and ACS (2004) jointly advise consuming at least five servings of fruits and vegetables daily,
choosing whole grains over processed or refined grains
and sugars, substituting healthier fats for trans and saturated fats, monitoring portion sizes, and choosing foods
to maintain a healthy weight. The Healthy Cats diet plan
was adapted from recommendations in the joint statement
(Eyre et al., 2004), Dietary Guidelines for Americans (U.S.
Department of Agriculture and U.S. Department of Health
& Human Services, 1995), the food pyramid (U.S. Department of Agriculture and U.S. Department of Health & Human Services, 1992), and the Dietary Approaches to Stop
Hypertension eating plan (Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure, 2004; National Institutes of Health, 1998;
U.S. Department of Health & Human Services, 2000).
The joint initiative recommends blood pressure, BMI,
cholesterol, and blood glucose screening; clinical breast
examination and mammography; and cervical, colon, and
prostate cancer screenings. This mid-sized regional comprehensive university offers an employee health screening
every semester that includes blood pressure, BMI, body
composition, lipid profile, and fasting blood glucose. The
joint initiative also recommends smoking cessation, but
because none of the participants smoked, this was not a
focus of the intervention.
Hour-long workshops were scheduled at varying
times to accommodate participants schedules. All participants attended a 1-hour program overview session offered twice to promote attendance. The remaining workshops were designed following an interest assessment.
The most popular workshops were offered multiple times
so more participants could attend. Nineteen workshops
were offered during the Healthy Cats program covering
the following 10 topics: quick and healthy meals; stress
and eating; yoga, stretching, and Pilates; exercise overview; emerging trends in diabetes management; healthy
snack foods; surviving special occasions; the food and
mood connection; grocery shopping; and family and dieting. The most popular workshops were quick and healthy
meals, exercise overview, surviving special occasions, the
food and mood connection, and grocery shopping. The
facilitator at each workshop provided a handout and either discussed the topic and answered questions or demonstrated and led exercise sessions.
Participants received a notebook containing a meal
plan, a week of sample menus, recipes, an individualized
exercise program, a log to record food intake and physical
activity, and literature about resources related to physical
activity on campus. They received discounts for aerobics
classes offered on campus.
Overall, the wellness program was based on the
motivational principles studied by Horowitz (1985) and
Fleury (1993), wherein participants in wellness programs
are motivated to achieve positive results via personal
awareness, thought activation, self-reinforcement, social
support or social feedback, and shifting their perspectives
toward an internal locus of control.

march 2007, vol. 55, no. 3

Measures

Risk factors related to this study were measured using standard health care industry techniques. All participants were given written instructions to fast for at least
12 hours prior to both the pretest and the posttest protocol. Fasting was defined as no caloric intake for at least
12 hours. Individuals obtaining the measurements were
trained to use necessary equipment. Blood pressure was
measured with a Welch Allyn Vital Signs Monitor (Welch
Allyn, Beaverton, OR). Weight and body composition
were determined with the Tanita BF-350 Body Composition Analyzer Scale (Tanita Corporation of America, Inc.,
Arlington Heights, IL), which measures the impedance,
or resistance, of a small electrical current passing through
the body. The higher an individuals body fat percentage,
the greater the resistance. Each participants age, gender,
and height were entered into the body composition analyzer, which uses electrodes in each foot pad to send a
small electrical current throughout the body. Participants
removed their shoes and socks before stepping on the
analyzer, which was cleaned with a disinfectant wipe between participants.
BMI was calculated in accordance with procedures
defined by the National Institutes of Health (1998). BMI
is recommended when assessing overweight and obesity.
All plasma assessments used in this study (blood
glucose, total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) were by a laboratory certified by
the College of American Pathologists. The laboratory follows the standards developed by the Clinical and Laboratory Standards Institute (2006), an independent nonprofit
organization developing and promoting the use of its
laboratory methods standards. The total cholesterol/HDL
cholesterol ratio was calculated using the method defined
by Kannel and Wilson (1992), whereby total cholesterol
is divided by HDL cholesterol. Assessments of normal
blood (plasma) glucose and levels diagnostic of diabetes mellitus followed guidelines from the ADA (2006).
The Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (2004)
defines optimal blood pressure as a systolic blood pressure of 120 mmHg or less and a diastolic blood pressure
of 80 mmHg or less.
The degree to which participants followed the wellness program was measured by their responses to two
survey items: I adhered to the Healthy Cats diet program and I adhered to the Healthy Cats exercise program. Participants responded to each item separately
using a 5-point Likert scale ranging from strongly disagree to strongly agree. Scores for these two items
were averaged, thereby resulting in an indication of the
participants overall adherence to the program.
Statistical Analysis

Paired two-sample t tests for means were used to

compare pre- and post-intervention measurements for the
25 participants who had both measurements. In addition,
a post-intervention survey was administered to assess
adherence with various components of the intervention.
The correlation between adherence with various program

111

Table 1

Significant Findings Associated With Cardiovascular Disease Risk Factors

Total
Cholesterol
(mg/dl)

LDL
Cholesterol
(mg/dl)

Total/HDL
Cholesterol
(mg/dl)

Triglycerides
(mg/dl)

Weight
(pounds)

Mean pretest

207

124

3.64

170

179.7

Range pretest

150

169

3.70

808

229.4

Median pretest

216

134

3.47

135

183

33.24

32.82

0.87

133

37.68

Mean pretest

201

118

3.41

160

176.4

Range pretest

128

169

3.70

808

120

Median pretest

202

123

3.20

104

177

50 participants pretest

SD pretest
25 participants pretest

SD pretest

35.42

37.49

0.95

173

31.6

Mean posttest

179*

103

3.11

132

173.3

Range posttest

141

138

3.70

558

114

Median posttest

178

107

3.07

99

176.7

31.03

31.69

0.82

112

28.2

SD posttest

LDL = low-density lipoprotein; HDL = high-density lipoprotein.

Note. Groups of 25 participants portrayed in this table reflect those who completed the program and had valid pretest and posttest results. All reports of significance are based on tests of paired comparisons of participants pretest and posttest results.
*p < .001.

p < .01.

p < .05.

components and improvement in CVD risk factors was

also tested via simple linear regression techniques (Cohen & Cohen, 1983).
Results
Significant differences were observed between preand post-intervention measurements of total cholesterol
(p < .001), LDL cholesterol (p = .002), total cholesterol/
HDL cholesterol ratio (p = .015), triglycerides (p = .036),
and weight (p = .01). In addition, a significant correlation
was found between self-reported level of participation in
the diet aspect of the program and change in LDL levels
(p = .018). Tables 1 and 2 display pre- and post-intervention measurements.
The most noticeable improvements included a decrease in total cholesterol levels from 202 to 179 mg/dl.
This 23-point drop is clinically significant and correlates
with significant reduction in CVD risk. Only 36.7% of
participants had desirable cholesterol levels (< 200 mg/dl)
at the start of the program, but 72% of those re-tested had
desirable total cholesterol levels. Twelve (48%) of the 25
participants who completed the program had normal cholesterol levels (total cholesterol < 200 mg/dl) at the outset.
A comparison of pretest cholesterol levels with posttest
levels of these 25 showed that total cholesterol dropped

112

for 20 of them, whereas posttest levels were higher for

5. At the start of the program, only 23% of participants
had optimal LDL cholesterol levels (< 100 mg/dl); by the
end of the program, 32% of those re-tested had optimal
LDL cholesterol levels. Despite the drastic reduction in
total and LDL cholesterol levels, HDL cholesterol levels
remained essentially unchanged, leading to a significant
improvement in the total cholesterol/HDL cholesterol ratio. At the start of the program, only 60% of participants
had normal triglyceride levels (< 150 mg/dl) as defined
by the National Cholesterol Education Program (2001).
However, 88% of those re-tested at the conclusion of the
program had normal triglyceride levels.
Twenty-six participants were weighed at the end of
the program. They had lost 80 pounds combined, or an
average of 3.2 pounds each. Sixty-two percent of those
completing the program lost weight, for a total of 102
pounds, or an average of 6.4 pounds each. Nine of the 25
participants who completed the program gained weight.
Those who gained weight gained an average of 2.2 pounds
(range, 0.4 to 5 pounds).
The baseline mean blood glucose level was normal
at 87 mg/dl. Systolic blood pressure and diastolic blood
pressure were also normal at 122 and 79.2 mmHg, respectively. Statistically significant improvements were

AAOHN Journal

Table 2

Nonsignificant Findings Associated With Cardiovascular Disease Risk Factors

Body Fat (%)

Systolic
Blood
Pressure
(mmHg)

Diastolic
Blood
Pressure
(mmHg)

HDL
Cholesterol
(mg/dl)

Blood Sugar
(mg/dl)

Mean pretest

36.16

128

83

49

87.24

Range pretest

36.20

59

44

47

143

Median pretest

35.60

127

83

46

81

SD pretest

8.49

14.25

10.23

11.16

23.40

Mean pretest

36.40

127

82

51

86

Range pretest

27.8

48

41

46

94

Median pretest

38.10

126

82

53

83

50 participants pretest

25 participants pretest

SD pretest

9.05

13.12

9.58

12.22

17.69

Mean posttest

36.54

127

81

50

86

Range posttest

35.20

88

33

50

61

Median posttest

38.85

125

79

49

83

SD posttest

10.11

17.41

7.74

13.24

13.33

HDL = high-density lipoprotein.

not seen for blood sugar or blood pressure. Only three

participants had abnormal values at the beginning; none
of them changed to normal values.
A correlation existed between participation in the
diet aspect of the program and change in LDL cholesterol
levels (p < .02). This was the only statistically significant
relationship between program components and objective
outcome measurements.
Conclusion
Small sample size and low program completion rate
were limitations of this study. Although participants were
informed of the second testing date several times, many
asked for another testing date. These requests suggested
more than half of the participants completed the program
but were not available for re-testing. Despite participants agreeing to the date and time of the posttests at the
programs outset, additional dates for posttest sampling
may have reduced apparent attrition rates. However, cost
constraints precluded adding dates and times for drawing
posttest samples.
Lack of a comparison or control group was another
study limitation. Comparing results with those of a control group would further strengthen the assumption that
the wellness program was effective in reducing CVD
risk.
Selection bias may have been a limitation of the
program. Individuals choosing to participate may have
been motivated by factors unrelated to this specific pro-

march 2007, vol. 55, no. 3

gram to initiate behaviors leading to a healthy diet and

exercise.
Despite these limitations, findings were positive and
indicate the potential value of continuing this program
to determine its efficacy with larger groups. Long-term
interventions and studies investigating the link between
employee wellness programs and health insurance claims
are warranted to support expansion of such programs
throughout the United States and in countries with similar
health care systems.
Overall, these results suggest the multi-component,
12-week pilot employee wellness program was effective
in reducing weight, total cholesterol, LDL cholesterol,
total cholesterol/HDL cholesterol ratio, and triglycerides. Adherence to the dietary component was linked to
reduced LDL cholesterol. Others (Anderson et al., 1998;
Glantz & Seewald-Klein, 1986; Pritchard et al., 2002;
Sorensen & Himmelstein, 1992) have found dietary intervention effective. Of the worksite wellness interventions mentioned at the beginning of this article, four led
to reductions in total cholesterol, three to reductions in
LDL cholesterol and weight, and one to improvements
in cholesterol. Two of the interventions led to reductions
in blood pressure. The intervention of the current study
did not, but few of the participants had elevated blood
pressure.
Companies employing occupational health nurses
could coordinate similar programs. Occupational health
nurses could compile dietary guidelines and exercise pre-

113

scriptions, assess group interest, and develop workshops.

Internal or external laboratories could be used to determine changes in biological measures.
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