Systematic review: What works to address obesity in nurses?

Systematic review: What works to address obesity in nurses? Abstract Background There is evidence that the prevalence of overweight and obesity among nurses is increasing. As well as the impact on health, the costs associated with obesity include workplace injury, lost productivity and sickness absence. Finding ways to address obesity in nurses may be a challenge because of the barriers they face in leading a healthy lifestyle. Aims To identify the available evidence for interventions to address obesity in nurses. Methods Databases searched included CINAHL, SCOPUS (which encompasses the Cochrane Database of Systematic Reviews), PsycINFO, MEDLINE and British Nursing Index. Ancillary searching of the grey literature was conducted for case studies of weight management interventions in National Health Service (NHS) settings. Inclusion criteria were studies involving nurses that reported on interventions addressing health behaviours that contribute to obesity and included at least one obesity-related outcome measure. Results Eleven primary studies were found concerning lifestyle interventions for nurses. There was no strong evidence for any particular intervention to address obesity, although integrating interventions into nurses’ daily working lives may be important. Case studies from the grey literature showcased a range of interventions, but very few studies reported outcomes. Conclusions The review demonstrates that there is insufficient good-quality evidence about successful interventions to address obesity in nurses. Evidence does indicate that interventions should be designed around the specific barriers nurses may face in leading a healthy lifestyle. Health promotion, literature review, NHS workforce, nurse, obesity Introduction Overweight and obesity contribute significantly to a range of chronic diseases including diabetes, cardiovascular disease and arthritis [1]. Obesity-related morbidity is recognized as having indirect costs owing to lost productivity such as sickness absence [2,3]. This is of particular importance for nursing, given its ageing workforce and the increasing prevalence of overweight and obesity among nurses [4–7]. A prevalence study of nurses in Scotland found that 69% were overweight or obese, and obesity was significantly higher among nurses than other healthcare professionals and those working in non-health-related occupations [8]. Nurses report low levels of physical activity, and diets low in fruit and vegetable consumption but high in sugar [7,9–11]. Finding ways to improve nurses’ health is an important challenge not only because nurses comprise the largest healthcare occupational group both in the UK and globally but also because many nurses have poor health profiles [12–14]. Existing reviews of workplace health interventions to address obesity suggest that the most effective interventions to improve employees’ health behaviours combine individual and environmental strategies, such as pairing personalized messages with environmental support and reinforcement [15,16]. The evidence is inconclusive as to whether targeting a specific behaviour such as physical activity is more effective than a healthy lifestyle approach. In a systematic review, Power et al. concluded that interventions combining diet and physical activity had greatest success [17]; however, two other reviews reported that interventions targeting a single behaviour were more effective than mixed interventions [18,19]. The National Institute for Health and Care Excellence (NICE) guideline on obesity prevention (CG43) suggests that workplaces providing health checks for staff should ensure that they address weight, diet and activity, and provide ongoing support to maintain adherence [20]. The guideline recommends that workplaces support action to improve food and drink provision in the workplace (including restaurants, hospitality and vending machines) and offer tailored educational and promotional programmes, such as behavioural interventions or environmental changes (e.g. changes to food labelling or provision of healthy alternatives). NICE also highlights the need for commitment from senior management, enthusiastic catering management, a strong occupational health lead, links to other on-site health interventions, supportive pricing policies and heavy promotion or advertisement at point-of-purchase (Table 1). Table 1. Typology of the most common interventions used to address obesity in health services workforces in England Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  View Large Table 1. Typology of the most common interventions used to address obesity in health services workforces in England Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  View Large Evidence from National Health Service (NHS) audit data suggests that NHS Trusts found it more difficult to address obesity than any other health behaviour, with only 28% of trusts having an obesity strategy or policy in place [21]. Thirty-eight per cent of trusts did not offer similar healthy food options in the evening compared with the daytime, and 73% did not offer such choices overnight. Only 38% of trusts offered staff multicomponent interventions to tackle obesity, despite the evidence for such interventions being recommended by NICE as both effective and cost-effective [21]. There are additional factors that make addressing obesity in nurses a challenge. The nursing workforce is predominantly female and includes shift workers and a large number of low-paid employees, which are factors associated with higher obesity prevalence [22]. Several cross-sectional studies report significant associations between shift work and increased body mass index (BMI) in nurses [23–25]. Night shift workers are less likely to engage in leisure-time physical activity, which may lead to weight gain [25]. A literature review by Lowden et al. found that night shift work was also associated with meal irregularity, higher carbohydrate, animal fat and protein intake coupled with low dietary fibre consumption and frequent snacking [26]. Sleep deprivation and disruption to circadian rhythms are other potential causes, and short-term sleep restriction is associated with impaired metabolism, increased blood pressure and appetite dysregulation [27]. In the absence of choice, readily available vending machines and the common sharing of snacks may also contribute to weight gain in nurses [28,29]. The aim of this study was to review effective interventions to address obesity in nurses. It aimed to describe the types of interventions and strategies used to address obesity in nurses and to identify those factors that contribute to successful approaches. Methods This review took a systematic approach to searching for, reviewing, extracting and analysing literature in appraising the evidence on workplace-based interventions to address obesity in nurses. This scoping review (as described by Booth et al. [30]) sought to answer a relatively broad question about what works to address obesity in nurses through considerations of relatedness and practicality. The review thus considered in what circumstances and for whom interventions may be effective. Evidence was drawn from both academic and ‘practice-based’ evidence: Published peer-reviewed primary research of obesity interventions in any country Published literature reviews on NHS workplace interventions to address obesity Grey literature regarding NHS workplace interventions to address obesity Ancillary searching for projects, evaluations and case studies of interventions to address obesity in NHS settings The inclusion and exclusion criteria were defined prior to commencing the search (Table 2). Table 2. Inclusion and exclusion criteria for the review Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    View Large Table 2. Inclusion and exclusion criteria for the review Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    View Large A list of keywords was drawn up. Terms related to nurses (e.g. ‘nursing workforce’, ‘nurses’) were combined with ‘obesity’, ‘overweight’ and terms associated with health behaviours related to obesity (e.g. ‘exercise’, ‘physical activity’, ‘diet’, ‘nutrition’), terms associated with interventions (e.g. ‘initiative’, ‘project’, ‘programme’) and terms associated with the workplace (e.g. ‘workforce’, ‘staff’, ‘worker’, ‘employee’). Outcomes of interventions were either changes in risk factors or related morbidity; reduction in weight, BMI, waist or other anthropometric indices; changes in dietary intake; or changes in physical activity levels. Truncation and synonyms were used to retrieve the greatest possible number of studies. The following databases were searched for relevant literature: Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS (which encompasses the Cochrane Database of Systematic Reviews), PsycINFO, MEDLINE and British Nursing Index. Further hand searching was conducted by reviewing the references of all retrieved studies. No geographical limits were placed on the search to include all potentially relevant contexts. Google was used to search for grey literature. To focus the results, the phrase ‘NHS workplace interventions to address obesity’ was used to search and the search was limited to pages from the UK only. Results were searched until there were no further references to NHS interventions that included nurses. The online database of NHS Employers, which compiles case studies of good practice in workplace interventions, was also searched. One reviewer screened titles and abstracts of identified studies in the academic literature. A data extraction form tailored to the review questions was created in Microsoft Excel and piloted with two studies. Information extracted included setting, participants, study design, outcome measures, results and any notes the reviewer had about the study. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) checklists for quality appraisal [31]. Results Types of interventions and strategies used to address obesity in nurses are summarized in Table 3. Seven studies focused on both physical activity and dietary interventions [32–38], whereas the remaining three studies were focused on physical activity only. All but two studies [39,40] used multicomponent intervention strategies. One study was an ecological intervention tackling individual, organizational and environmental factors [35]. Five studies involved changes to nurses’ workplace activity (e.g. walking meetings) or involved exercise routines incorporated into their working day [37,38,40–42]. Four studies used incentives or challenges [34,38,40,41] to motivate nurses to increase their physical activity or fruit and vegetable consumption, and four studies used motivational strategies such as goal setting [36], personalized health coaching [37,42] or motivational emails [40]. The majority of interventions were conducted for between 2 and 6 months, with the shortest being an 8-h self-care programme [36] and the longest a 5-year ecological intervention including health campaigns, provision of facilities and health promotion activities [35]. The follow-up periods in several of the included studies were less than 6 months [36–38,40]. Table 3. Primary research of interventions to address obesity in nurses Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  HPLP II, Health Promoting Lifestyle Profile-II; NS, non-significant; PA, physical activity; RFWT, Rockport Fitness Walking Test; RN, registered nurse. View Large Table 3. Primary research of interventions to address obesity in nurses Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  HPLP II, Health Promoting Lifestyle Profile-II; NS, non-significant; PA, physical activity; RFWT, Rockport Fitness Walking Test; RN, registered nurse. View Large An ancillary search of the grey literature found 11 examples of NHS interventions for obesity reduction and weight management (Table 4). These interventions used a variety of activities, including financial incentives, on-site exercise classes, team-based challenges or subsidized schemes. Two interventions took a staged approach, with participants matched to interventions based on their BMI or the amount of weight they needed to lose. Some interventions used external providers, and some were developed with health care professionals working within the NHS Trusts. Several interventions were developed based on the evidence from staff surveys or health risk assessments, as in Cambridge, Northumbria, and Sandwell and West Birmingham trusts. Table 4. Case studies of weight management interventions in NHS settings Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    aDate of the case study as published on the NHS Employers website unless otherwise stated. View Large Table 4. Case studies of weight management interventions in NHS settings Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    aDate of the case study as published on the NHS Employers website unless otherwise stated. View Large In terms of the type of study design used to investigate effectiveness of interventions to address obesity in nurses, 11 studies from the academic literature reported on 10 interventions with nurses (Table 3). Two studies reported on the same intervention, but both were included as they added different information [32,33]. Six of the studies were conducted in the USA [32,33,36–38], and there was one study each from Brazil [39], Canada [34], Denmark [42], England [35] and Taiwan [40]. Six studies recruited only nurses as participants [33,34,36–38,40], whereas the remaining studies included other health care professionals and health service employees. Sample sizes ranged between 37 and 1134 participants [35,39]. Most studies were quasi-experimental pre- and post-intervention studies with follow-up [32–36,38,40,41]. There was one descriptive exploratory study [39], one single-blinded randomized controlled trial [42] and one repeated-measures feasibility study [37]. Although only one study purposefully recruited obese participants [39], almost all of the studies recorded a mean BMI at baseline that was overweight or obese [32,33,35,37,38,40,41]. Apart from one 5-year follow-up of 1452 employees [35], sample sizes were generally small, which may have compromised studies’ ability to find effectiveness. It also illustrates the challenges of getting adequate take-up and making interventions acceptable to nurses. Three studies used power calculations to determine their sample sizes prior to recruitment [36,39,42]. All studies but one [39] used convenience sampling, which may have introduced self-selection bias or ceiling effects. For example, the nurses in one study volunteered through recruitment adverts and thus may have been motivated to increase their physical activity regardless [38]. Control groups were included in six studies [33,36,37,40–42]. Attrition of more than 60% was noted in three studies [36,41,42]. Speroni et al. reported that only 51% of the nurses in their study attended at least 50% of the exercise sessions offered [33]. All of the studies used self-report measures to assess change, although seven studies included objective measures of body composition or physical fitness also [33,34,37,38,40–42]. Six studies included validated measures [35–37,39,40,42], and three studies reported that they piloted their measures prior to use [38,39,42]. All of the studies reported positive changes in participants’ health behaviours, albeit small in some cases. Four studies noted significant reductions in BMI [33,38,39,42], although Speroni et al. [33,33] noted that changes in BMI were not sustained at follow-up. Three of these studies had only female participants [37,38,40] apart from Speroni et al. [33] whose sample was 98% female. Most studies did not report the theoretical underpinning for the intervention development and their understanding of the mechanisms by which behaviour change may occur. Tucker et al. [38] reported that their intervention was based on the principles of cognitive-behavioural and social learning theories and McElligott et al. [36] used Pender’s Health Promotion Model [43]. The case studies from grey literature noted positive effects in the examples of NHS interventions that reported their outcomes, although the detail of reporting varied. This makes it hard to draw conclusions on the success of interventions. The level of take-up was not always recorded. Clinically significant weight loss (of more than 5% of body weight) was noted in two interventions in Cambridge and Kent [44]. The Cambridge intervention encompassed fortnightly dietician-led workshops on health and weight management, and the trial in Kent used a financial incentive where participants received a bonus if they achieved their final target weight [44]. Positive changes to dietary behaviours and physical activity were also noted in both studies. In terms of the factors that contributed to successful outcomes, most interventions appeared to be acceptable to nurses, although Tucker et al. recommended that more time was needed to integrate the intervention into participants’ workflow [38]. Five of the intervention studies had attempted integration into nurses’ daily lives by being conducted during the working day or near the workplace [33,37,38,40,41]. Participants noted that the workplace was often not conducive to supporting healthy interventions [38,40]. Four studies involved alterations to the workplace, either by incorporating group exercise sessions into nurses’ working days [33] or by installing equipment in workplaces to help nurses be more active over the course of the working day [37,38,40,41]. Of these five studies, four noted significant reductions in nurses’ BMI post-intervention [33,37,40,41]. Discussion Eleven peer-reviewed studies and 11 case studies of NHS interventions for obesity reduction and weight management were included in this review. The included interventions provide limited evidence on what works to address obesity in nurses. Only four of the included studies from the academic literature and two of the NHS case studies found significant reductions in nurses’ BMI. Most of the intervention studies sought to address individual behaviour change through diet or physical activity. It was noted that few of the included studies addressed organizational factors such as stress or work life that might be a factor in the inability to maintain a healthy weight [7]. Five interventions focused on system-level interventions such as releasing staff to participate in exercise sessions during the working day. Of these studies, four reported significant reductions in nurses’ BMI post-intervention. System-level interventions may represent a promising approach to encouraging greater physical activity during the working day and could be expanded to focus on healthier food intake also. This is the first review of what works to address obesity in nurses. The main strength of this in-depth review is its scope, in that the review sought to integrate primary research with NHS case studies taken from the grey literature. This novel approach allowed us to comprehensively draw together the best available evidence to gain insight into plausible interventions to address obesity in nurses. The studies identified are as a result of careful and extensive searches of the peer-reviewed and grey literature. By including grey literature alongside peer-reviewed research, it was possible to gain insight from real-life settings, including issues of design and delivery, and the factors that were considered important for the success or failure of workplace interventions to address obesity. That said, the review can rely only on what was reported in the grey literature. As the detail of reporting varied, it is hard to draw definite conclusions on the outcomes of interventions. This type of real-life public health evaluation is complex, and descriptions of interventions in grey literature are often poor. This means that the research identified may not be replicable and offers limited options for evidence synthesis. There are methodological weaknesses in the primary studies. Only one of the included studies was a ran domized trial [42], sample sizes in the included studies were generally small and several of the interventions had low take-up. High attrition in several of the evaluated interventions had low take-up. High attrition in several of the evaluated interventions may have caused a systematic bias, where those who completed the intervention study were more motivated to lose weight. Most of the intervention studies were limited to short-term evaluations (6 months or less), which may lead to an over-estimation of impact when maintenance of any behavioural change is known to be difficult. In common with reviews of interventions for obese adults [45], there is considerable heterogeneity of interventions and designs in the included studies, which makes it difficult to draw conclusions about the characteristics of successful interventions. The review does highlight that if progress is to be made in designing interventions to address obesity in nurses, the complexity of nurses’ working lives must be addressed. Nurses face potential barriers to leading healthy lifestyles both inside and outside the workplace, including shift work, lack of breaks, the fast-paced nature of the job, and the emotional labour of nursing. This makes them less likely to participate in workplace health promotion programmes than other healthcare staff. The review found a surprising dearth of workplace-based health promotion programmes to address weight in nurses, despite evidence that nurses are as, if not more, likely than the general population to be obese [8,46]. Previous research has noted that the fast-paced nature of nursing work may impede intervention delivery [47]. Finding workplace health promotion strategies that can fit around work rotas and support nurses’ working lives is warranted. Nurses’ acceptance and satisfaction are crucial to the success and sustainability of any workplace health promotion programme [37]. Previous research with obese nurses found that understanding the norms, needs and structures of their working environment was crucial to take-up [48]. Interventions that build social support and increase self-efficacy have been identified as important predictors of adopting healthier behaviours specifically among health care staff [35]. Co-production of interventions with nurses and participatory approaches to intervention design are desirable. The review findings suggest that targeting populations with obesity or risk factors for obesity was more effective than interventions that were open to all. But this may be difficult to implement if staff feel singled out or personally blamed [49]. Previous reports of an NHS weight loss programme that used a targeted approach noted that some staff took offence to being asked to join the programme [50]. Many of the case studies from NHS settings have noted that support and buy-in from board members and senior management was essential to programme success, and two studies in this review noted that the support of colleagues and nurse managers was identified as important [35,38]. Further research is recommended to investigate the willingness of managers and senior stakeholders to address obesity in the workplace. 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For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Occupational Medicine Oxford University Press

Systematic review: What works to address obesity in nurses?

Occupational Medicine , Volume Advance Article (4) – Mar 22, 2018

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Abstract

Abstract Background There is evidence that the prevalence of overweight and obesity among nurses is increasing. As well as the impact on health, the costs associated with obesity include workplace injury, lost productivity and sickness absence. Finding ways to address obesity in nurses may be a challenge because of the barriers they face in leading a healthy lifestyle. Aims To identify the available evidence for interventions to address obesity in nurses. Methods Databases searched included CINAHL, SCOPUS (which encompasses the Cochrane Database of Systematic Reviews), PsycINFO, MEDLINE and British Nursing Index. Ancillary searching of the grey literature was conducted for case studies of weight management interventions in National Health Service (NHS) settings. Inclusion criteria were studies involving nurses that reported on interventions addressing health behaviours that contribute to obesity and included at least one obesity-related outcome measure. Results Eleven primary studies were found concerning lifestyle interventions for nurses. There was no strong evidence for any particular intervention to address obesity, although integrating interventions into nurses’ daily working lives may be important. Case studies from the grey literature showcased a range of interventions, but very few studies reported outcomes. Conclusions The review demonstrates that there is insufficient good-quality evidence about successful interventions to address obesity in nurses. Evidence does indicate that interventions should be designed around the specific barriers nurses may face in leading a healthy lifestyle. Health promotion, literature review, NHS workforce, nurse, obesity Introduction Overweight and obesity contribute significantly to a range of chronic diseases including diabetes, cardiovascular disease and arthritis [1]. Obesity-related morbidity is recognized as having indirect costs owing to lost productivity such as sickness absence [2,3]. This is of particular importance for nursing, given its ageing workforce and the increasing prevalence of overweight and obesity among nurses [4–7]. A prevalence study of nurses in Scotland found that 69% were overweight or obese, and obesity was significantly higher among nurses than other healthcare professionals and those working in non-health-related occupations [8]. Nurses report low levels of physical activity, and diets low in fruit and vegetable consumption but high in sugar [7,9–11]. Finding ways to improve nurses’ health is an important challenge not only because nurses comprise the largest healthcare occupational group both in the UK and globally but also because many nurses have poor health profiles [12–14]. Existing reviews of workplace health interventions to address obesity suggest that the most effective interventions to improve employees’ health behaviours combine individual and environmental strategies, such as pairing personalized messages with environmental support and reinforcement [15,16]. The evidence is inconclusive as to whether targeting a specific behaviour such as physical activity is more effective than a healthy lifestyle approach. In a systematic review, Power et al. concluded that interventions combining diet and physical activity had greatest success [17]; however, two other reviews reported that interventions targeting a single behaviour were more effective than mixed interventions [18,19]. The National Institute for Health and Care Excellence (NICE) guideline on obesity prevention (CG43) suggests that workplaces providing health checks for staff should ensure that they address weight, diet and activity, and provide ongoing support to maintain adherence [20]. The guideline recommends that workplaces support action to improve food and drink provision in the workplace (including restaurants, hospitality and vending machines) and offer tailored educational and promotional programmes, such as behavioural interventions or environmental changes (e.g. changes to food labelling or provision of healthy alternatives). NICE also highlights the need for commitment from senior management, enthusiastic catering management, a strong occupational health lead, links to other on-site health interventions, supportive pricing policies and heavy promotion or advertisement at point-of-purchase (Table 1). Table 1. Typology of the most common interventions used to address obesity in health services workforces in England Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  View Large Table 1. Typology of the most common interventions used to address obesity in health services workforces in England Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  Level/approach  Intervention  Example  Individual  On-site weight management  Imperial College Healthcare NHS Trust pilot programme  Weight management vouchers  Royal Liverpool and Broadgreen NHS Trust  Motivational interviewing or coaching  Guys and St Thomas’ NHS Foundation Trust  Pedometers  Camden and Islington NHS Foundation Trust  Wellness programme including healthy eating and physical activity  Nottingham University Hospitals NHS Trust  Financial incentives scheme  NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial  Community  Team-based challenges (e.g. Global Corporate Challenge)  York Teaching Hospitals NHS Foundation Trust  Wellness champions or advocates  Camden and Islington NHS Foundation Trust  Motivational ‘buddies’  Northumbria Healthcare NHS Foundation Trust  Organizational  Healthy canteens  South Warwickshire NHS Foundation Trust with the Food for Life partnership  Walking meetings  NHS Grampian  Active travel  NHS Bristol  Healthier catered food at meetings or events  Northumberland, Tyne and Wear NHS Foundation Trust  Obesity targets  Northumbria Healthcare NHS Foundation Trust  Healthy workplace awards  The Walton Centre NHS Foundation Trust  Staff sports days  NHS North West  Professional  Public health advice for nurses  RCN ‘Healthy Workplace, Healthy You’ campaign  Professional pledges  Nursing Standard ‘Eat Well, Nurse Well’ campaign  View Large Evidence from National Health Service (NHS) audit data suggests that NHS Trusts found it more difficult to address obesity than any other health behaviour, with only 28% of trusts having an obesity strategy or policy in place [21]. Thirty-eight per cent of trusts did not offer similar healthy food options in the evening compared with the daytime, and 73% did not offer such choices overnight. Only 38% of trusts offered staff multicomponent interventions to tackle obesity, despite the evidence for such interventions being recommended by NICE as both effective and cost-effective [21]. There are additional factors that make addressing obesity in nurses a challenge. The nursing workforce is predominantly female and includes shift workers and a large number of low-paid employees, which are factors associated with higher obesity prevalence [22]. Several cross-sectional studies report significant associations between shift work and increased body mass index (BMI) in nurses [23–25]. Night shift workers are less likely to engage in leisure-time physical activity, which may lead to weight gain [25]. A literature review by Lowden et al. found that night shift work was also associated with meal irregularity, higher carbohydrate, animal fat and protein intake coupled with low dietary fibre consumption and frequent snacking [26]. Sleep deprivation and disruption to circadian rhythms are other potential causes, and short-term sleep restriction is associated with impaired metabolism, increased blood pressure and appetite dysregulation [27]. In the absence of choice, readily available vending machines and the common sharing of snacks may also contribute to weight gain in nurses [28,29]. The aim of this study was to review effective interventions to address obesity in nurses. It aimed to describe the types of interventions and strategies used to address obesity in nurses and to identify those factors that contribute to successful approaches. Methods This review took a systematic approach to searching for, reviewing, extracting and analysing literature in appraising the evidence on workplace-based interventions to address obesity in nurses. This scoping review (as described by Booth et al. [30]) sought to answer a relatively broad question about what works to address obesity in nurses through considerations of relatedness and practicality. The review thus considered in what circumstances and for whom interventions may be effective. Evidence was drawn from both academic and ‘practice-based’ evidence: Published peer-reviewed primary research of obesity interventions in any country Published literature reviews on NHS workplace interventions to address obesity Grey literature regarding NHS workplace interventions to address obesity Ancillary searching for projects, evaluations and case studies of interventions to address obesity in NHS settings The inclusion and exclusion criteria were defined prior to commencing the search (Table 2). Table 2. Inclusion and exclusion criteria for the review Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    View Large Table 2. Inclusion and exclusion criteria for the review Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    Inclusion criteria  Exclusion criteria  • Literature on interventions addressing health behaviours that contribute to obesity:  • Editorials, discussion or concept papers, book reviews, commentaries or other non-peer-reviewed articles in academic journals   ◦ Obesity (including overweight)     ◦ Diet     ◦ Physical activity    • Includes description and measurement or analysis of an intervention to change at least one of obesity, diet or physical activity  • Protocols for intervention studies  • Includes an outcome measure related to obesity, diet or physical activity  • Studies that examined only prevalence, knowledge or attitudes towards obesity, diet or physical activity, cost-effectiveness or sickness absence, for example  • Studies involving nurses (defined as professionals employed by virtue of a recognized nursing qualification)  • Studies involving student nurses  • Focuses on interventions conducted in the workplace or where participation is restricted to individuals on the basis of their employment  • Studies of community-based interventions  • Published in English    • Published between 2000 and 2016    View Large A list of keywords was drawn up. Terms related to nurses (e.g. ‘nursing workforce’, ‘nurses’) were combined with ‘obesity’, ‘overweight’ and terms associated with health behaviours related to obesity (e.g. ‘exercise’, ‘physical activity’, ‘diet’, ‘nutrition’), terms associated with interventions (e.g. ‘initiative’, ‘project’, ‘programme’) and terms associated with the workplace (e.g. ‘workforce’, ‘staff’, ‘worker’, ‘employee’). Outcomes of interventions were either changes in risk factors or related morbidity; reduction in weight, BMI, waist or other anthropometric indices; changes in dietary intake; or changes in physical activity levels. Truncation and synonyms were used to retrieve the greatest possible number of studies. The following databases were searched for relevant literature: Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS (which encompasses the Cochrane Database of Systematic Reviews), PsycINFO, MEDLINE and British Nursing Index. Further hand searching was conducted by reviewing the references of all retrieved studies. No geographical limits were placed on the search to include all potentially relevant contexts. Google was used to search for grey literature. To focus the results, the phrase ‘NHS workplace interventions to address obesity’ was used to search and the search was limited to pages from the UK only. Results were searched until there were no further references to NHS interventions that included nurses. The online database of NHS Employers, which compiles case studies of good practice in workplace interventions, was also searched. One reviewer screened titles and abstracts of identified studies in the academic literature. A data extraction form tailored to the review questions was created in Microsoft Excel and piloted with two studies. Information extracted included setting, participants, study design, outcome measures, results and any notes the reviewer had about the study. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) checklists for quality appraisal [31]. Results Types of interventions and strategies used to address obesity in nurses are summarized in Table 3. Seven studies focused on both physical activity and dietary interventions [32–38], whereas the remaining three studies were focused on physical activity only. All but two studies [39,40] used multicomponent intervention strategies. One study was an ecological intervention tackling individual, organizational and environmental factors [35]. Five studies involved changes to nurses’ workplace activity (e.g. walking meetings) or involved exercise routines incorporated into their working day [37,38,40–42]. Four studies used incentives or challenges [34,38,40,41] to motivate nurses to increase their physical activity or fruit and vegetable consumption, and four studies used motivational strategies such as goal setting [36], personalized health coaching [37,42] or motivational emails [40]. The majority of interventions were conducted for between 2 and 6 months, with the shortest being an 8-h self-care programme [36] and the longest a 5-year ecological intervention including health campaigns, provision of facilities and health promotion activities [35]. The follow-up periods in several of the included studies were less than 6 months [36–38,40]. Table 3. Primary research of interventions to address obesity in nurses Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  HPLP II, Health Promoting Lifestyle Profile-II; NS, non-significant; PA, physical activity; RFWT, Rockport Fitness Walking Test; RN, registered nurse. View Large Table 3. Primary research of interventions to address obesity in nurses Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  Study and setting  Participants  Design  Outcome measures  Results  1. Andersen et al. (2015) [42]; Denmark  Convenience sample of 54 nurses and nurses’ aides working in municipal health care  • Randomized controlled trial  • Self-reported BMI• Aerobic capacity• Hand-grip strength  • No significant difference in BMI (P = NS)  • Two-pronged approach: ◦ 1.5-h expert health advice based on participants’ lifestyle, motivation, resources and power to act  • Aerobic capacity showed a strong trend towards a significant improvement compared to baseline     ◦ 10 weeks of team-based aerobic fitness and strength training for 50 min 3 times per week during work hours    • Control group received health advice only    2. Blake et al. (2013) [36]; England  Convenience sample of 1452 employees in a large NHS workplace  • Before and after evaluation (5-year follow-up)• Multilevel ecological intervention including health campaigns, provision of PA facilities, dietary interventions, community interventions (e.g. staff cycles schemes) and health screening  • Self-reported BMI• International Physical Activity Questionnaire• Dietary habits• Self-efficacy for PA and diet  • No significant differences in BMI between baseline (M = 25.2, SD = 4.9) and follow-up (M = 25.4, SD = 5.9)  • Significant improvement in the proportion of participants who reported meeting PA guidelines from baseline to follow-up (56 and 61%; P < 0.001)  • The number of respondents who reported that they did not consume 5 servings of fruit/vegetables daily increased from baseline to follow-up, although the difference did not reach statistical significance (57% at baseline, 61% at follow-up)  3. Chyou et al. (2006) [43]; USA  Convenience sample of 191 female physicians, nurses and other staff at one medical clinic  • Prospective observational follow-up study• 20-week walking programme 3 days/week with incentive (1 point for every 1 min spent doing moderate-intensity PA) to reach minimum PA recommendations• Web programme with healthy living advice and motivational tips  • Self-reported activity levels• Self-reported BMI• RFWT  • Significant decrease in BMI from baseline to follow-up (P < 0. 05)  • There was a significant (P < 0.001) increase in PA levels compared to baseline levels• 88 (47%) maintained the same activity level, 7 (4%) decreased their level of activity, while 91 (49%) increased their level of activity  4. Haddad and Marco (2011) [40]; Brazil  Random sample of 37 obese employees at 1 hospital (2 nurses, 10 nurse technicians, remainder admin or maintenance)  • Descriptive exploratory study• 8 weeks of weekly ear and electro acupuncture sessions  • BMI measured by researchers• Waist-to-hip measurement• Appetite behaviour before, during and after the intervention  • No significant difference in BMI or weight after the acupuncture  • A significant difference (P < 0.05) was found between waist-hip ratios before and after the acupuncture  • There were significant changes in appetite regarding satiety, fullness and desire for sweet and tasty foods  5. Lavoie-Tremblay et al. (2014) [35]; Canada  Convenience sample of 60 nurses working at a multisite healthcare centre  • Longitudinal study with pre-intervention-post- intervention at 8 weeks and follow-up at 6 months• 1-h on-site lunchtime lecture by a kinesiologist• 30-min one-to-one health evaluation• 8-week challenge tracking daily PA and fruit and vegetable consumption  • Self-reported BMI• Daily step count• International Physical Activity Questionnaire• Blood cholesterol level  • No significant differences were noted in participants’ BMI, waist circumference or weight  • Participants’ cholesterol scores decreased from baseline to post- intervention, although this decrease was not significant  • No significant difference was found in PA scores between baseline and post- intervention or between post-intervention and follow-up  • 79% of participants had maintained their PA at 6 months  6. McElligott et al. (2010) [37]; USA  Convenience sample of 103 hospital nurses  • Quasi-experimental, repeated-measures design• 8-h programme based on principles of holistic nursing• Intervention group formulated a goals-based Self-Care Plan used to improve health and describe self-change commitments• Control group received no intervention  • Self-reported nutrition and PA as measured by the HPLP II  • There was a significant increase in nutrition score (P < 0.05) compared with the control group over time  • No significant change in PA was noted  7. Speroni et al. (2012, 2013) [33,34]; USA  Convenience sample of 217 nurses drawn from 7 hospitals in 3 states  • Before and after study• 1-h weekly exercise sessions with an exercise trainer for 12 weeks• Four 1-h yoga sessions• Four 1-h sessions with a dietician• Diary completion addressing healthy lifestyle principles (exercise/yoga, food/water consumption and sleep)• Control group received no intervention  • BMI measured by researchers• Waist circumference  • Participants experienced a greater mean reduction from baseline to week 12 in BMI than contrast group participants (−0.494 kg/ m2, control = −0.18 kg/ m2). This reduction was significant (P < 0.05)  • Participants experienced a greater mean reduction in waist circumference (−0.895 in, control = −0.091 in) from baseline to week 12, but this difference was not significant  8. Tucker et al. (2011) [38]; USA  Convenience sample of 58 nurses who were mothers of young children and worked in adult medical wards  • Quasi-experimental pilot study• 10-week worksite PA intervention integrated into work flow including through workstation treadmills, standing work desks, and walking meetings, Wii Fit in staff room; 3-min exercise breaks  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Intervention participants lost significantly more body fat mass than control participants (mean fat mass decrease of 0.68 and 0.07 kg for intervention and control participants, respectively) over time      • Toolkit with home exercise equipment relaxation CD, fitness DVD, nutrition and PA tips brochure, nutritious snack, walking meeting tag, Frisbee and a wellness journal• Pedometer challenge to increase overall daily hours of PA by 1 h/daily over 10 weeks    • Both groups increased steps from baseline to post- intervention, with control participants averaging an increase of 1358 daily steps (SD = 3089) and intervention participants averaging 1424 daily steps (SD = 2985), but these differences were not significant after controlling for baseline BMI  9. Tucker et al. (2016) [39]; USA  Convenience sample of 22 RNs and 18 medical assistants working in a medicine speciality clinic and an outpatient chemotherapy clinic  • Repeated-measures feasibility study• 6-month worksite PA intervention completed in brief periods within nurses’ workflow during work hours• Participants were randomized to (i) early texting group who received personalized health coaching via text messaging during months 1–3 or (ii) delayed texting group who received personalized health coaching via text messaging during months 4–6  • Change in fat mass• PA measured by wearable device• BMI measured by researchers  • Fat mass and percentage fat were lower but not statistically significant for either the early or delayed texting group  • Changes from baseline to 6 months were significant for both intervention groups for BMI (P < 0.01), weight (P < 0.01), total lean mass (P < 0.01), percentage time in moderate PA (P < 0.05), percentage time in sedentary PA (P < 0.01), active energy expenditure (P < 0.01) and steps (P < 0.05)  10. Yuan et al. (2009) [41]; Taiwan  Convenience sample of 90 nurses from 5 different hospital units  • Two-group pre- and post- quasi-experimental design• Intervention group were given a stair-stepper which was to be used daily for 20–30 min after work for 3 months• Control maintained usual habits  • Self-reported BMI• Aerobic capacity• Hand-grip strength• Flexibility  • The experimental group had a small, significant reduction in BMI (P < 0.05)• After adjusting for baseline exercise habits, the experimental group performed significantly better than the control group on measures of physical fitness post-intervention  HPLP II, Health Promoting Lifestyle Profile-II; NS, non-significant; PA, physical activity; RFWT, Rockport Fitness Walking Test; RN, registered nurse. View Large An ancillary search of the grey literature found 11 examples of NHS interventions for obesity reduction and weight management (Table 4). These interventions used a variety of activities, including financial incentives, on-site exercise classes, team-based challenges or subsidized schemes. Two interventions took a staged approach, with participants matched to interventions based on their BMI or the amount of weight they needed to lose. Some interventions used external providers, and some were developed with health care professionals working within the NHS Trusts. Several interventions were developed based on the evidence from staff surveys or health risk assessments, as in Cambridge, Northumbria, and Sandwell and West Birmingham trusts. Table 4. Case studies of weight management interventions in NHS settings Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    aDate of the case study as published on the NHS Employers website unless otherwise stated. View Large Table 4. Case studies of weight management interventions in NHS settings Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    Setting  Intervention  Results  1. Barking, Havering, and Redbridge University Hospitals NHS Trust  • 12-week healthy eating and weight loss challenge  • No published evidence found  • Exercise classes offered on and off-site with a personal trainer dedicated to staff    • Motivational and healthy events including Work out at Work Day, Fruity Fridays (providing free fruit for staff), The Big Dance and the Global Corporate Challenge    • Park benches, fruit stalls and outdoor exercise equipment installed to encourage staff to take breaks outdoors    2. Bradford District Care NHS Foundation Trust (June 2015)  • In response to a new Commissioning for Quality and Innovation (CQUIN) included:  • No published evidence found   ◦ Introduction of health and well-being initiatives     ◦ Healthier food for staff    • Use of a well-being zone portal and app which is free for staff and their families    • A programme of health and fitness activities for staff including pilates, Zumba, weight loss challenges and a pedometer challenge    3. Cambridge University Hospitals NHS Foundation Trust (January 2016)a  • Seven health and weight management workshops held fortnightly over 4 months, based on successful community programme run by local dietician  • Almost 95% lost weight• 72% completed• 39% lost 5% or more (5% weight loss is clinically significant)  4. Royal Liverpool Hospital NHS Trust (unpublished)  • 12-week course of on-site exercise classes run by the local Territorial Army regiment and monitored by a cardiac rehab facilitator and a physiotherapist  • Anecdotal evidence of impact but no published evidence found  • Chocolate ‘amnesty’ scheme in place where staff can swap chocolates for healthier options    5. Northumbria Healthcare NHS Foundation Trust (April 2015)  • Three-tiered approach: ◦ Tier 1 included walking sessions, gym discounts and resources (CouchTo5k), weekly peer-led weight management sessions, pedometer or individual activity challenges, 3-week challenge to change one habit  • Small uptake for weight management but those who did take part lost weight  • 55% of participants in the healthy eating challenge (N = 300) lost weight• 75% of those completing the pedometer challenge (N = 240) increased their PA   ◦ Tier 2 was a 12-week Healthy Foundations programme for staff with BMI of 25–35   ◦ Tier 3 had specialist intervention including dietician referral and weight management programmes    • Staff completed ‘portion size training’    • Rewording of large portions to ‘double’ to raise awareness    • Healthy vending machines audited monthly to ensure 30% of total products are an approved healthier option as identified by dietician    6. Healthworks Homerton (unpublished)  • Gym membership scheme with free membership if staff attended 6+ times in a 6-week period and reduced subscription regardless of attendance• Exercise classes at varied days and times• Increased healthy options in canteens and vending machines  • Intervention showed benefits in terms of decreased stress levels and BMI, but recorded negative impact in terms of snacking and eating ‘5 a day’      7. York Teaching Hospitals NHS Foundation Trust (June 2015)  • Subsidized staff to participate in the Global Corporate Challenge (pedometer challenge)  • 94% participants achieved a 20% increase in weekly PA    • 32% decrease in sickness absence  8. Imperial College Healthcare NHS Trust pilot programme (unpublished)  • Pilot scheme to help 200 workers from the six hospitals within the Trust• Three-tiered approach: ◦ Level 1 includes a 12-week group Slimming World sessions delivered in the community. Sessions focus on the need to be more active, healthy eating and personal eating plans.  • No published evidence found     ◦ Level 2 is a 12-week group weight management programme delivered within the hospital trust using cognitive-behavioural therapy and focusing on an individual’s relationship with food and activity. Weight management practitioners deliver sessions with input from a specialist psychologist and dietician. ◦ Level 3 offers a series of one-to-one consultations by clinicians at the trust, as well as a series of group sessions. Individuals will be encouraged to lose five to ten per cent of their body weight through a holistic, patient-centred, multidisciplinary approach. A consultant endocrinologist, a clinical psychologist and specialist dietician jointly deliver the service.    9. NHS Eastern and Coastal Kent Primary Care Trust ‘Pounds for Pounds’ trial [45]  • Financial incentive weight loss programme advertised to NHS staff and the general public  • 45% of participants achieved clinically significant weight loss   ◦ Rewards were tied directly to weight loss results. Participants chose plans based on how much weight they wanted to lose over a defined time period, with optional additional weight ‘maintenance’ periods.  • 24% lost more than 10% of their baseline weight• The mean number of months actively weighing in was 6.4• The number of participants completing the programme was less than those for commercial weight loss programmes or other referral schemes   ◦ Participants were credited monthly for cumulative weight loss up to a maximum target weight loss rate of 7.1 lb (3.2 kg) monthly and for weight loss maintenance. Participants received their accumulated financial rewards, plus a bonus equal to 50% of the total maximum reward if they achieved their final target weight at plan completion.   ◦ Participants were provided with a booklet of weight loss tips  10. Sandwell and West Birmingham Hospitals NHS Trust (August 2015)  • 6-week weight loss classes and healthy cooking classes  • No published evidence found  • Weekly health checks and healthy living advice from health trainers    • Free exercise classes (Tai Chi and aqua aerobics) were held at a local leisure centre for older workforce and disabled staff    aDate of the case study as published on the NHS Employers website unless otherwise stated. View Large In terms of the type of study design used to investigate effectiveness of interventions to address obesity in nurses, 11 studies from the academic literature reported on 10 interventions with nurses (Table 3). Two studies reported on the same intervention, but both were included as they added different information [32,33]. Six of the studies were conducted in the USA [32,33,36–38], and there was one study each from Brazil [39], Canada [34], Denmark [42], England [35] and Taiwan [40]. Six studies recruited only nurses as participants [33,34,36–38,40], whereas the remaining studies included other health care professionals and health service employees. Sample sizes ranged between 37 and 1134 participants [35,39]. Most studies were quasi-experimental pre- and post-intervention studies with follow-up [32–36,38,40,41]. There was one descriptive exploratory study [39], one single-blinded randomized controlled trial [42] and one repeated-measures feasibility study [37]. Although only one study purposefully recruited obese participants [39], almost all of the studies recorded a mean BMI at baseline that was overweight or obese [32,33,35,37,38,40,41]. Apart from one 5-year follow-up of 1452 employees [35], sample sizes were generally small, which may have compromised studies’ ability to find effectiveness. It also illustrates the challenges of getting adequate take-up and making interventions acceptable to nurses. Three studies used power calculations to determine their sample sizes prior to recruitment [36,39,42]. All studies but one [39] used convenience sampling, which may have introduced self-selection bias or ceiling effects. For example, the nurses in one study volunteered through recruitment adverts and thus may have been motivated to increase their physical activity regardless [38]. Control groups were included in six studies [33,36,37,40–42]. Attrition of more than 60% was noted in three studies [36,41,42]. Speroni et al. reported that only 51% of the nurses in their study attended at least 50% of the exercise sessions offered [33]. All of the studies used self-report measures to assess change, although seven studies included objective measures of body composition or physical fitness also [33,34,37,38,40–42]. Six studies included validated measures [35–37,39,40,42], and three studies reported that they piloted their measures prior to use [38,39,42]. All of the studies reported positive changes in participants’ health behaviours, albeit small in some cases. Four studies noted significant reductions in BMI [33,38,39,42], although Speroni et al. [33,33] noted that changes in BMI were not sustained at follow-up. Three of these studies had only female participants [37,38,40] apart from Speroni et al. [33] whose sample was 98% female. Most studies did not report the theoretical underpinning for the intervention development and their understanding of the mechanisms by which behaviour change may occur. Tucker et al. [38] reported that their intervention was based on the principles of cognitive-behavioural and social learning theories and McElligott et al. [36] used Pender’s Health Promotion Model [43]. The case studies from grey literature noted positive effects in the examples of NHS interventions that reported their outcomes, although the detail of reporting varied. This makes it hard to draw conclusions on the success of interventions. The level of take-up was not always recorded. Clinically significant weight loss (of more than 5% of body weight) was noted in two interventions in Cambridge and Kent [44]. The Cambridge intervention encompassed fortnightly dietician-led workshops on health and weight management, and the trial in Kent used a financial incentive where participants received a bonus if they achieved their final target weight [44]. Positive changes to dietary behaviours and physical activity were also noted in both studies. In terms of the factors that contributed to successful outcomes, most interventions appeared to be acceptable to nurses, although Tucker et al. recommended that more time was needed to integrate the intervention into participants’ workflow [38]. Five of the intervention studies had attempted integration into nurses’ daily lives by being conducted during the working day or near the workplace [33,37,38,40,41]. Participants noted that the workplace was often not conducive to supporting healthy interventions [38,40]. Four studies involved alterations to the workplace, either by incorporating group exercise sessions into nurses’ working days [33] or by installing equipment in workplaces to help nurses be more active over the course of the working day [37,38,40,41]. Of these five studies, four noted significant reductions in nurses’ BMI post-intervention [33,37,40,41]. Discussion Eleven peer-reviewed studies and 11 case studies of NHS interventions for obesity reduction and weight management were included in this review. The included interventions provide limited evidence on what works to address obesity in nurses. Only four of the included studies from the academic literature and two of the NHS case studies found significant reductions in nurses’ BMI. Most of the intervention studies sought to address individual behaviour change through diet or physical activity. It was noted that few of the included studies addressed organizational factors such as stress or work life that might be a factor in the inability to maintain a healthy weight [7]. Five interventions focused on system-level interventions such as releasing staff to participate in exercise sessions during the working day. Of these studies, four reported significant reductions in nurses’ BMI post-intervention. System-level interventions may represent a promising approach to encouraging greater physical activity during the working day and could be expanded to focus on healthier food intake also. This is the first review of what works to address obesity in nurses. The main strength of this in-depth review is its scope, in that the review sought to integrate primary research with NHS case studies taken from the grey literature. This novel approach allowed us to comprehensively draw together the best available evidence to gain insight into plausible interventions to address obesity in nurses. The studies identified are as a result of careful and extensive searches of the peer-reviewed and grey literature. By including grey literature alongside peer-reviewed research, it was possible to gain insight from real-life settings, including issues of design and delivery, and the factors that were considered important for the success or failure of workplace interventions to address obesity. That said, the review can rely only on what was reported in the grey literature. As the detail of reporting varied, it is hard to draw definite conclusions on the outcomes of interventions. This type of real-life public health evaluation is complex, and descriptions of interventions in grey literature are often poor. This means that the research identified may not be replicable and offers limited options for evidence synthesis. There are methodological weaknesses in the primary studies. Only one of the included studies was a ran domized trial [42], sample sizes in the included studies were generally small and several of the interventions had low take-up. High attrition in several of the evaluated interventions had low take-up. High attrition in several of the evaluated interventions may have caused a systematic bias, where those who completed the intervention study were more motivated to lose weight. Most of the intervention studies were limited to short-term evaluations (6 months or less), which may lead to an over-estimation of impact when maintenance of any behavioural change is known to be difficult. In common with reviews of interventions for obese adults [45], there is considerable heterogeneity of interventions and designs in the included studies, which makes it difficult to draw conclusions about the characteristics of successful interventions. The review does highlight that if progress is to be made in designing interventions to address obesity in nurses, the complexity of nurses’ working lives must be addressed. Nurses face potential barriers to leading healthy lifestyles both inside and outside the workplace, including shift work, lack of breaks, the fast-paced nature of the job, and the emotional labour of nursing. This makes them less likely to participate in workplace health promotion programmes than other healthcare staff. The review found a surprising dearth of workplace-based health promotion programmes to address weight in nurses, despite evidence that nurses are as, if not more, likely than the general population to be obese [8,46]. Previous research has noted that the fast-paced nature of nursing work may impede intervention delivery [47]. Finding workplace health promotion strategies that can fit around work rotas and support nurses’ working lives is warranted. Nurses’ acceptance and satisfaction are crucial to the success and sustainability of any workplace health promotion programme [37]. Previous research with obese nurses found that understanding the norms, needs and structures of their working environment was crucial to take-up [48]. Interventions that build social support and increase self-efficacy have been identified as important predictors of adopting healthier behaviours specifically among health care staff [35]. Co-production of interventions with nurses and participatory approaches to intervention design are desirable. The review findings suggest that targeting populations with obesity or risk factors for obesity was more effective than interventions that were open to all. But this may be difficult to implement if staff feel singled out or personally blamed [49]. Previous reports of an NHS weight loss programme that used a targeted approach noted that some staff took offence to being asked to join the programme [50]. Many of the case studies from NHS settings have noted that support and buy-in from board members and senior management was essential to programme success, and two studies in this review noted that the support of colleagues and nurse managers was identified as important [35,38]. Further research is recommended to investigate the willingness of managers and senior stakeholders to address obesity in the workplace. 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Occupational MedicineOxford University Press

Published: Mar 22, 2018

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