Implications for Practice

One important implication of these results for practice is that an environmental intervention may need to be combined with individual-level intervention to help employees eat healthier and lose weight.

Individually focused interventions attempting to reduce obesity have tended to ignore the influence of the complex social and physical contexts in which individual behavioral decisions are made and have had limited success198. Such critiques have led to a new focus on ‘environmental’ exposures. Consequently, public health strategies have place increasing emphasis on environmental interventions to promote healthy behaviors within the workplace setting8. However, results from our study (and previous studies) raise questions about whether the minimum-intensity environmental interventions at worksites are sufficient for producing population-based obesity prevention and control efforts. For example, Linde and her colleagues (YEAR) assessed a worksite-based environmental intervention that focused on healthy food labeling, availability and price, physical activity promotion, scale access, and media enhancements. A majority of intervention components were successfully implemented. However, there were no differences between sites in the key outcome of weight change over the two-year study period (p = .36)106.

Another study conducted by Engbers (2007) tested a 12-month environmental intervention to stimulate healthier food choices and stair use214. No significant effects on consumption of fruits, vegetables, dietary fat or BMI were found. The author concluded that this modest environmental intervention was not effective in reducing cardiovascular risk in a population of office workers.

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Our findings in the WAY to Health study are fairly consistent with previous studies regarding the limited effects on weight change of worksite-based environmental interventions that focused on healthy food labeling and availability. As the change in individual’s diet habits and weight is a complex long-term process that involves psychological factors (e.g., self-efficacy on preparing healthy foods and resisting unhealthy foods), behavioral factors (e.g., exercise, choose low calories foods, small portion size), social norms and support (i.e., support from family and friends), and various food environments including labeling, educational information, availability and price of healthy foods at supermarkets, grocery stores, home, restaurants, worksite

cafeterias and so on, it is doubtful that a minimal intensity worksite-based environmental intervention alone would generate significant changes in individual’s dietary behaviors and weight outcomes. This is exactly why the research team chose WC alone as the comparison group in this worksite-based weight loss study. Our results confirmed it was a reasonable decision in that no change in weight (or healthy eating behaviors) was identified in the WC only intervention arm.

A meta-analysis of workplace physical activity and dietary behavior interventions on weight outcomes showed a greater reduction in body weight associated with physical activity and diet interventions containing an environmental component215, which is consistent with our findings on interactions between environmental and individual interventions. We recommend comprehensive worksite-based weight loss interventions including an environment component in order to better help overweight employees lose weight because: 1) the environmental intervention may support individual’s healthy

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lifestyle habits; 2) the clinical relevance of the pooled effects of environmental and individual interventions may be substantial on a population level.

A second implication for practice has to do with strategies for increasing capacity of the organizations to be able to adopt and implement programs like WC. Additional program training that engages multiple stakeholders and provides a variety of training options is the key.

In this natural experiment, specific WC activities designed to create

environmental changes (e.g., nutrition labeling and education and increased access to healthy foods) were only partially implemented; and, participating community colleges were more willing to implement nutrition labeling and education than increase access to healthy foods. Perceived by the campus contacts, lack of employer interest and limited capacity to implement WC were two key barriers to program implementation.

Several implications of these barriers for health promotion practice should be discussed. First, sustainable program training at worksites must be designed so that worksite staff can quickly obtain skills, information, and resources they need to implement and maintain the environmental change at worksites. Community college representatives have limited time to leave their work to attend trainings or pick up materials. In our study, while 70.6% participated in the initial training held in Chapel Hill, only 41.8% and 11.8% attended two phone conference calls designed to trouble- shoot potential problems with program implementation. Although project staff traveled to the community colleges that did not receive the WC training at the kick-off event; future studies should consider holding booster trainings at each community college, or using technology or continuing education opportunities to provide trainings that were

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easy and convenient to attend. In addition, worksite representatives told us that they would have appreciated more opportunities to see demonstrations and/or practice skills needed to prepare and label healthy foods using WC healthy eating criteria.

Another practice-based implication of our results is to reinforce the importance of intervening on multiple levels of the social ecological framework. Researchers and practitioners need to find evidence-based ways to intervene at multiple levels. Engaging with employees, managers, and key leaders is also recommended. For example, although we gained great support from top leadership, collaboration with food services personnel, at a different management level, was not always evident. This may have been due to busyness of the food service staff, conflicts between training times and work demands, or lack of interest/support.

Another level of intervention would be achieved by devising ways to identify and engage informal leaders within workplaces in addition to formal leaders such as

supervisors or managers. Specifically, if there are champions of healthy food changes in the cafeteria, it is likely that employee awareness, access to and utilization of the WC program may be increased. Although not a focus in this study, employee wellness committees may help identify program champions and secure desired support for wellness activities and environmental changes216. Finally, to accommodate employee schedules and competing demands, differing individual needs and learning styles, a variety of healthy foods and educational materials should be offered from which employees can select their own healthy foods to help them lose weight.

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The third implication for practice is that a web-based weight loss program can be more effective in helping employees lose weight if complemented by weight-loss

incentives and organizational-level interventions like WC.

The Community Preventive Services Task Force recommends technology- supported multi-component coaching or counseling interventions including web-based programs intended to reduce weight or maintain weight loss on the basis of sufficient evidence that they are effective in improving weight-related behaviors or weight-related outcomes217. Many health behavior interventions can be delivered by web-based program such as teaching behavioral management skills, modeling or demonstration, participatory skill development, and individual benchmarking (i.e., goal-setting and achievement), and provide feedback and building social support for behavioral patterns. Such practices can be even more effective if they are complemented by financial incentives, typically given for participation and completing the program218.

Incentives consist of rewards for weight loss and behavioral change to increase physical activity or improve nutrition. The incentives can vary in size and by timing (or type) and can be used for screening, enrollment, compliance (i.e., staying in the

program), completing the program, and maintenance of the changes after completing the program163. The greater difference in employee weight loss comparing the WC only group with those of WC+WPI and WC+WEB suggests that providing incentives in worksite-based interventions may strengthen the effects of the web-based weight loss program. Moreover, the organizational-level intervention (WC) may also provide support to the desirable behavioral change and reinforce the effects of the individual-level

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interventions (WEB, WPI) on weight loss. Additional research to see if these weight changes sustain over time would be beneficial.

Another important implication for practice is that worksite-based weight loss interventions should target autonomous motivation and self-efficacy as pathways to help employees make positive behavioral changes and achieve weight control.

Findings from this dissertation indicate that financial incentives combined with the web-based weight loss program may promote more autonomous motives to

participate in the WAY study, which in turn results in the reduced total calorie intake and body weight among overweight and obese employees. After reviewing empirical findings from weight control studies that have used SDT measures and assessed their association with weight outcomes, Teixeira et al (2012) suggest that if individuals fully endorse weight loss-related behavioral goals and feel not just competent but also have a high level of autonomy about reaching them, their efforts are more likely to result in long-lasting behavior change131. This finding is promising and suggests that autonomous motives are important to encourage among those who are hoping to lose weight and keep it off over time. The results of Paper 2 deepen our understanding of Teixeira’s findings and suggest that the autonomous motives can explain the effects of WAY interventions on the total calorie intake and body weight.

Although WAY weight loss interventions (WEB and WPI) were not successful in changing physical activity self-efficacy, empirical evidence shows that increased self- efficacy may lead to desirable changes in nutrition, physical activity and weight42, 86, 119,

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. While testing and developing theory is a worthwhile activity in its own right, the real significance of understanding important constructs from SCT and SDT are most useful if

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we can integrate these constructs in meaningful ways as part of interventions to help employees lose weight or maintain a healthy weight. In this regard, the growing

evidence for the utility of SCT-based and SDT-based interventions for obesity prevention and control is a significant advance191. Prevention and interventions directed toward overweight and obese employees at workplaces should target autonomous motives and self-efficacy to promote healthy lifestyle and to help them lose weight, which are both theory- and evidence-based. These dissertation results suggest that helping employee build their self-efficacy and increase their autonomous motives may be efficient ways in delivering weight loss interventions to reduce obesity in workplaces.