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Exploring the impact of physical activity- and nutrition-focused workplace wellness programs on employee… Lienhard, Katherine Elizabeth 2020

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  EXPLORING THE IMPACT OF PHYSICAL ACTIVITY- AND NUTRITION-FOCUSED WORKPLACE WELLNESS PROGRAMS ON EMPLOYEE QUALITY OF LIFE  by Katherine Elizabeth Lienhard B.Sc., The University of Massachusetts Amherst, 2017  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in The Faculty of Graduate and Postdoctoral Studies (Kinesiology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  June 2020    © Katherine Elizabeth Lienhard, 2020   ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: Exploring the Impact of Physical Activity- and Nutrition-Focused Workplace Wellness Programs on Employee Quality of Life  submitted by Katherine Elizabeth Lienhard in partial fulfillment of the requirements for the degree of Master of Science in Kinesiology  Examining Committee: Dr. Darren Warburton, Professor, School of Kinesiology, UBC Supervisor Dr. Tamara Cohen, Director of Dietetics and Assistant Professor, Faculty of Land and Food Systems, UBC Supervisory Committee Member Dr. Michael Koehle, Professor, School of Kinesiology, UBC Supervisory Committee Member  Additional Supervisory Committee Members: Dr. Tanis Mihalynuk, Senior Dietitian, Vancouver Coastal Health Supervisory Committee Member        iii Abstract  Background: The majority of employed Canadians work forty hours per week, spending approximately seven hours per day at the workplace. Promoting and/or offering physical activity and proper nutrition at the workplace has been shown to increase activity and improve dietary choices both during and outside of work hours. Further, diet quality and activity levels together play major roles in a person's overall quality of life. Measuring quality of life, which includes physical, emotional, mental, and financial factors, is often conducted via survey, where results can be averaged to create an overall wellness score for each individual.  Purpose: The aim of this study was to determine if nutrition and physical activity workplace wellness programs improve employee quality of life with the hypothesis that participants who participate will have higher overall wellness scores than those who do not. A systematic review with the same aim was also conducted.  Methods: Twenty-eight employees at four Vancouver, BC companies with wellness programs were recruited to complete a survey. Data collection included the WellSuite® IV Health Risk Assessment for the Workforce (Non-U.S.) survey which contains 44 wellness-related questions. Employees who participated in their wellness program 25% or less of the time served as the control group. Data were described using descriptive statistics, contingency and frequency tables, ordinal logistic regression, one-way ANOVA, and independent samples T-tests.  Results: The data suggests that those in the experimental group were more likely to have a higher Overall Wellness Score (p = 0.025), Fitness Score (p = 0.013), and to self-report higher life   iv satisfaction and happiness than those in the control group. Nutrition Score increased with participation in the workplace wellness programs (p=0.035). Though limited by sample size and selection bias, this study supports the existing literature in the field and adds to the discussion on measuring quality of life outcomes of workplace wellness programs.  Conclusion: The consistent and optimistic findings of this study are promising but inconclusive regarding the positive quality of life and overall health impact of workplace wellness programs that incorporate both PA and nutrition components. Future studies may benefit from aiming to limit confounding variables.                           v Lay Summary  Four companies in Vancouver, British Columbia with workplace wellness programs with physical activity and nutrition components were recruited to participate in this study. Employees at each company completed a survey asking questions about their health and participation in the program at their company. The findings suggest that participation in workplace wellness programs with physical activity and nutrition components may improve self-reported quality of life, diet quality, and physical activity levels. Due to small participant counts and the healthy nature of Vancouver, BC and of those who choose to participate in wellness programs and in research, the results are inconclusive but positive overall.                            vi Preface  This thesis is original, unpublished work by the author, Katherine Lienhard, who was responsible for all major areas of study concept formation, data analysis, and preparation of this manuscript. The identification and design of this research project and finalization of this manuscript was completed with assistance from the Supervisory Author, Dr. Darren Warburton, and committee members, Drs. Tamara Cohen, Michael Koehle, and Tanis Mihalynuk. Dr. Brittany Carter also provided guidance and advice. The systematic review was conducted, edited, and revised with assistance from Drs. Shannon Bredin and Erin Shellington. The data presented in this thesis came from a survey conducted by Katherine Lienhard at companies of her recruiting in Vancouver, BC, with permission from Wellsource for use of the survey. Data were analyzed and interpreted by the author. No publications have been submitted to date based on this thesis. Ethical approval for this research was obtained from The University of British Columbia’s Behavioural Research Ethics Board (#H19-01728).                  vii Table of Contents Abstract .......................................................................................................................................... iii Lay Summary .................................................................................................................................. v Preface ........................................................................................................................................... vi Table of Contents ......................................................................................................................... vii List of Tables ................................................................................................................................. ix List of Figures ................................................................................................................................ x List of Abbreviations ..................................................................................................................... xi Acknowledgements ...................................................................................................................... xiii Dedication.................................................................................................................................... xiv Chapter 1: Introduction ................................................................................................................. 1 1.1 Background and Significance ............................................................................................ 1 1.2 Supporting Literature ........................................................................................................ 7 1.2.1 Participation in and Barriers Regarding Workplace Wellness Programs ...................... 7 1.2.2 Supporting Theories ....................................................................................................... 8 1.2.3 Measuring Nutritional/Diet Impact of Workplace Wellness Programs on Participants............................................................................................................................................... 10 1.2.4 Measuring Impact of Workplace Wellness Programs on Physical Activity Behaviors of Participants ....................................................................................................................... 14 1.2.5 Observing the Office Environment .............................................................................. 17 1.2.6 Measuring Quality of Life and Overall Wellness Scores ............................................ 19 1.2.7 Summary of Introduction and Supporting Literature................................................... 20 Chapter 2: Systematic Review...................................................................................................... 21 2.1 Introduction ....................................................................................................................... 21 2.2 Material and methods ....................................................................................................... 26 2.2.1 Search strategy ............................................................................................................. 26 2.2.2 Study Selection ............................................................................................................ 26 2.3 Results ................................................................................................................................ 29 2.3.1. Study Characteristics .................................................................................................. 29 2.3.2 Study Participants ........................................................................................................ 29 2.3.3 Interventions ................................................................................................................ 31 2.3.4 Survey Details .............................................................................................................. 33 2.3.5 Outcome Measures....................................................................................................... 38 2.4 Discussion........................................................................................................................... 41 2.4.1 Quality of Life Outcomes ............................................................................................ 41 2.4.2 Nutrition Outcomes ...................................................................................................... 43 2.4.3 Physical Activity Outcomes ......................................................................................... 44 2.4.4 Strengths and Limitations ............................................................................................ 45 2.4.5 Future Research ........................................................................................................... 47   viii Chapter 3: Exploring the Impact of Physical Activity- and Nutrition-Focused Workplace Wellness Programs on Employee Quality of Life ....................................................................... 49 3.1 Study Aims ......................................................................................................................... 49 3.1.1 Specific Aim 1 ............................................................................................................. 49 3.1.2 Specific Aim 2 ............................................................................................................. 49 3.2 Hypotheses ......................................................................................................................... 51 3.3 Methodology and Procedures .......................................................................................... 52 3.3.1 Study Design ................................................................................................................ 52 3.3.2 Participants ................................................................................................................... 52 3.3.3 Methods........................................................................................................................ 54 3.3.4 Data Collection ............................................................................................................ 56 3.4 Data Analysis ..................................................................................................................... 60 3.5 Results ................................................................................................................................ 61 3.5.1 Office Environment Observations ............................................................................... 61 3.5.2 Demographics, Descriptions of Programs, and Response Rates ................................. 63 3.5.3 Quality of Life Outcomes ............................................................................................ 66 3.5.4 Nutrition Outcomes ...................................................................................................... 69 3.5.5 Physical Activity Outcomes ......................................................................................... 71 3.6 Study Limitations and Biases ........................................................................................... 74 Chapter 4: Discussion and Conclusion ....................................................................................... 78 4.1 Project Reflections ............................................................................................................ 78 4.2 Future Directions .............................................................................................................. 80 4.3 Discussion........................................................................................................................... 82 4.4 Conclusion ......................................................................................................................... 88 References .................................................................................................................................... 89 Appendices .................................................................................................................................. 107 A. Overall Data...................................................................................................................... 107 B. QoL Measures ................................................................................................................... 110 C. Nutrition Measures .......................................................................................................... 112 D. Physical Activity Measures ............................................................................................. 116         ix List of Tables  Table 1 Systematic Review Participant Information .....................................................................29 Table 2 Systematic Review Survey Information ...........................................................................33 Table 3 Systematic Review Outcomes and Results .......................................................................38 Table 4 WellSuite® IV Health Risk Assessment (HRA) for the Workforce (Non U.S.) Questions........................................................................................................................................................57 Table 5 Modified CHEW Results ..................................................................................................61 Table 6 Participating Company and WWP Descriptions ...............................................................64 Table 7 Company Response Rates .................................................................................................65 Table 8 Experimental vs. Control Group Statistical Comparison..................................................67                  x List of Figures  Figure 1 Prisma Flow Diagram ......................................................................................................28 Figure 2 Overall Wellness Score Plot ............................................................................................68 Figure 3 Overall Wellness Score Chart .........................................................................................68 Figure 4 Nutrition Score Plot .........................................................................................................70 Figure 5 Nutrition Score Chart ......................................................................................................71 Figure 6 Fitness Score Plot ............................................................................................................72 Figure 7 Fitness Score Chart ..........................................................................................................73                  xi List of Abbreviations  BHS  Brief Health Survey BMI  Body Mass Index CAPS  Cross-Cultural Activity Participation Study CDSMP Chronic Disease Self-Management Program CESD  Center for Epidemiologic Studies Questionnaire for Depression CG  Control Group CHART Carolina Health Assessment and Research Tool CHEW Checklist of Health Promotion Environments at Worksites EG  Experimental Group FFQ  Food Frequency Questionnaire FS  Fitness Score GQLI  The Göteborg Quality of Life Instrument HB  Health Behavior HWE  Healthy Worker Effect IG  Intervention Group MET  Metabolic Equivalent of Task MH  Mental Health MHS  Mental Health Score MVPA  Moderate and Vigorous Physical Activity NS  Nutrition Score NHANES National Health and Nutrition Examination Survey 1999-2004 OWS  Overall Wellness Score   xii PANWWP Physical Activity and Nutrition Workplace Wellness Program PA  Physical Activity PHA  Personal Health Assessment PICOS  Population-Intervention-Comparator-Outcomes-Study PiL  Purpose in Life POMS  Profile of Mood States Questionnaire RCT  Randomized Controlled Trial ROI  Return on Investment SES  Socioeconomic Status TLQ  Tailoring/Lifestyle Questionnaire WB  Wellbeing wCDSMP Worksite-tailored version of the CDSMP WFH  Work From Home WHSA Workplace Health and Safety Assessment WWP  Workplace Wellness Program WLP  Weight Loss Program         xiii Acknowledgements  I would first like to thank Dr. Darren Warburton, who has been incredibly supportive of my academic and career goals throughout my time at UBC. I truly appreciate the high-caliber laboratory you’ve created with Dr. Bredin and the other members of the lab. The family-first lifestyle you promote has been so ideal for me during this time. I would also like to thank my other committee members, Drs. Tamara Cohen, Michael Koehle, and Tanis Mihalynuk, for your guidance and support along the way. I feel honored to have worked with and learned from you. I would like to thank Drs. Shannon Bredin and Erin Shellington for helping me take on the (at first daunting) task of completing a systematic review. Many thanks to Kai Kaufman for answering so many of my questions, too. I’m so grateful for my colleagues and coworkers at the many jobs I’ve worked while pursuing this degree, as well as my fellow grad students and the professors who’ve helped me immensely along the way, at UBC and at UMass. Finally, I’d like to thank my family and friends for the endless support. I couldn’t have done it without you. Thanks especially to db, Peggy, Liv, Mel, and Elise.          xiv Dedication   To my mom.  1 Chapter 1: Introduction  The first chapter introduces the background of the study and its significance in the field. It then becomes a literature review of supporting studies and theories.   1.1 Background and Significance 1.1.1 Introduction and Rationale Workplace wellness can be defined as, “any biopsychosocially driven modality applied within an organized setting that promotes the health and wellbeing of employees”.1   Contemporary workplace wellness programs may offer free or subsidized healthy food, on-site group exercise classes, nutrition and health education, and/or incentivized health programs.2 Mindfulness meditation, nap spaces, and other similar programs are also becoming popular, especially at larger companies.3 Workplace wellness started in the U.S. in the 1800s when some industries began shortening their workdays from twelve hours to ten or eight hours per day with protecting employees health in mind. In the 1950s, Employee Assistance Programs (EAPs) were created, and focused largely on addressing alcohol use and mental health.1  Workplace wellness programs (WWPs) as we know them today began in the 1970s and were linked with the occupational safety and health movement (OSH) and the worksite health promotion movement (WHP) in America.1 Research on WWPs began in the 1980s, and predominantly addressed the effects of physical fitness efforts on workers’ health and performance and how such programs may attract fresh talent to companies.1 In the 1990s, the Canadian federal government launched an initiative called Healthy People 2000 that proposed that 75% of employers with fifty or more workers should offer health promotion services as a benefit.1 Today we see varied, often complex and expensive WWPs at companies around the world.   2 The North American workforce today is younger and more health-conscious than previous generations. Millennials in particular (but not solely) value lifestyle support from their employer4; fitness discounts, access to healthy food, and activities that align with their own personal health goals. Programs that contain these principles have become a popular means to attract top talent and to lower attrition.4  With 77% of millennials believing that a flexible work schedule makes them more productive4, benefits that allow offer these lifestyle supports will suit a large percentage of the young workforce. Between health incentives, food perks, and mental health support, it is estimated that workplace wellness is an $8 billion industry in the US alone, with 82% of large organizations and 53% of small organizations offering programs in 2018.5   Over the last three decades in the US, workplace absenteeism rates have increased by over 30%.6 Larger companies tend to have higher absenteeism than smaller companies, and the median employee cost of absenteeism is $468 (USD) per year6. Causes of absenteeism typically fall into one of the categories of personal illness, family issues, personal needs, and stress. It is known that chronically absent employees have modifiable health risks: a sedentary lifestyle, hypertension, obesity, smoking, substance abuse, and a poor diet.6 This means that with proper intervention, they can make changes in their lives that will decrease sick days while also lowering their risk of chronic disease. The more recent research in this field has shown that participation in an organized fitness or exercise program is associated with a reduction in absenteeism.6  To date, the bulk of the research in workplace wellness has focused on reducing insurance and medical costs for companies and increasing presenteeism, i.e., strict return on investment (ROI) and concern for profit margins.5  This makes sense, as in America alone there has been a 35% increase in obesity-related healthcare costs between 2000 and 2014 - equaling   3 over $73 billion in medical costs, productivity losses, and associated absenteeism.1  Living with obesity can be seen as a risk factor for decreased productivity.1 Frequent visits to the doctor for obesity-related conditions might have a negative financial impact, as well as a negative emotional and cognitive impact on wellbeing, which in turn impacts productivity at work.1 In addition to focusing on specific costs and savings, research and companies may benefit by looking at which types of programs improve employee quality of life most effectively. By shifting the spotlight to people instead of dollars, companies have the opportunity to implement programs that are more likely to have a positive health impact on their employees in addition to cost savings.7   While programs are a central tenet of workplace wellness, the workspace itself also presents opportunities for health initiatives. Layout, design, and furnishings of office spaces, otherwise known as the built environment, can promote wellness or hinder it. Height-adjustable desks, walking desks (treadmill desks), defined walking paths inside or outside the building, centralized amenities, exposed stairwells that are more likely to be used than enclosed ones, usage of laptops so employees can choose where they want to work and move around throughout the day, multipurpose open space, and access to daylight are all implementations that increase the wellness potential of an office space.8 The WELL Building Standard conceptualizes these ideas and divides them into seven concepts: Air, Water, Nourishment, Light, Fitness, Comfort, and Mind.9 In this standard, Air regards having clean air, through filtration or purification, in the office. Water refers to having accessible clean water on-site. Nourishment reflects providing healthy food choices at the office and promoting nutrition knowledge and awareness. Light refers to optimizing circadian rhythm through windows and smart lighting solutions. Fitness regards providing opportunities for activity and exertion on-site. Comfort reflects that the office   4 environment should be distraction-free, productive, and soothing. Mind refers to supporting mental and emotional health through health professionals, feedback, and relaxation spaces.9 These standards were designed to help builders create WELL spaces from scratch, but existing companies can utilize them to promote wellness through redesigning or rethinking their spaces. In these workspaces, the majority of employed Canadians work 40 hours per week10, spending about 8 hours at the workplace each workday. A study by Onufrak et al. determined that 23.4% of working American adults consume food purchased at the workplace, and that much of it is of low nutritional value.11 Further, promoting and/or offering physical activity at the workplace has been shown to increase activity during work and outside of it.12 Over two thirds of chronic diseases are attributable to sedentary lifestyles, poor nutrition, and cigarette smoking.1  But health status is not just the absence of diseases. Health is a state of complete physical, mental, and social well-being.2 In measuring different health factors through surveys, we can quantify overall health and therefore quality of life (QoL). This defines the human condition more than just a clinical measure. Studies that utilize this comprehensive, holistic definition of wellness have shown that wellness is significantly correlated with health and productivity outcomes.2 Nutrition programs in the workplace can take many forms. Nutrition education may comprise part of or the entirety of the program, in the form of classes or seminars.13 Nutrition counseling may also be a part of these programs, or be offered separately through in-house or outsourced nutrition professionals.13 Wellness programs may also include simply offering healthy snacks or meals to employees14 for free or at a subsidized rate. The goal of these programs is to improve diet quality of participants. Diet quality refers to how well someone’s diet aligns with their countries recommended daily allowances.2    5 Physical activity (PA) programs in the workplace may include an on-site gym with free access for employees, walking programs, fitness incentives, or on-site group fitness classes. Walking initiatives often utilize pedometer programs, or activity monitors like the FitBit™, which are provided at no cost to employees.15 Fitness incentives may take the form of rebates for joining a gym or a monetary value or prize for completing fitness challenges at the workplace. On-site group fitness classes, led by personal trainers or certified group fitness instructors, can be offered for free or at a subsidized rate to staff. There is a wide variety of nutrition and PA program types, allowing for customization to a company’s existing space, workforce, and budget. It is important to break down the different factors encompassing wellness. Wellness (used interchangeably with wellbeing in this study) is comprised of eight dimensions: physical, intellectual, emotional, social, spiritual, vocational, financial, and environmental.16 The physical dimension refers to the body and physical health. Intellectual refers to stimulating the brain and engaging in life-long learning. Emotional wellness is sympathy, empathy, and being in touch with one’s emotions. Social wellbeing means meaningful relationships with family, friends, and other loved ones. Spiritual wellness refers to finding meaning and value in life. Work satisfaction is the main factor in vocational wellness. Financial wellness means the ability to balance budgets and not comparing one’s financial situation to others. Environmental wellness involves the reciprocal relationship between self and world.16  Quality of life (QoL) – whose meaning is closely related to the meanings of wellness and wellbeing – is more than just a physical health measure. The World Health Organization defines Quality of Life as,  An individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and   6 concerns. It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment.17    Research in this field is becoming more popular because of both the size of the industry and because, “worksite-based health promotion strategies have the unique ability to nurture social norms around healthy lifestyle choices, influence shared health behavior environments (e.g., food purchasing settings), and reach individuals across demographic strata.”18 The workplace provides a unique opportunity to contact a diverse and sometimes very large population and promote positive health change.19 There is a recent shift towards looking at value-based benefits of workplace wellness programs like employee morale, job satisfaction, and quality of life18, physiological benefits like reduced risk of chronic disease, and psychological benefits. All of these factors contribute to a person’s overall wellness. Further, even fewer studies have shown the impact of a program that includes both nutrition and physical activity (PA) components on wellbeing. Yet we know that the combination of these lifestyle components has the potential to improve quality of life and prevent chronic disease.20 For example, participants in WWPs have been shown to have increased physical QoL21 and increased mental/psychological QoL22. Improving body composition, musculoskeletal health, physical and cognitive performance, and preventing metabolic diseases including obesity, diabetes mellitus, and cardiovascular disease20, one can achieve a higher quality of life. Studying and conducting programs focused on both nutrition and PA has the potential to produce greater benefits than focusing on just one modality alone.20      7 1.2 Supporting Literature The following section breaks down the literature supporting different components of this study. It reviews statistics on participation in workplace wellness programs. It then covers cognitive and psychological theories related to the topic as background knowledge for the reader. It then reviews how nutrition, physical activity, and the office environment separately impact participants of workplace wellness programs. Finally, it examines the use of overall wellness scores as a way to measure quality of life.  1.2.1 Participation in and Barriers Regarding Workplace Wellness Programs  In US workplaces, around 50% of eligible employees participated in the wellness program provided by their employer.23 A workplace wellness study at a large US warehouse retail company found participation rates in their intervention to be between 34.4 and 44.6%.5 Participation rates alone may be markers of overall success or failure of a program, respectively. A more accessible and comprehensive program may encourage more participation - through actual benefits received, word-of-mouth in the office, or other factors. A program that is not as well designed may not have as high participation rates. This represents one of the major barriers to success of these programs. It has also been shown that WWPs have greater success when there is actual or perceived support from the leaders in the company.24 Providing incentives for good health behaviors and/or gamifying wellness through between-employee competition may also help to increase participation.25,26 Perhaps the largest barrier to implementing and success of a WWP is the budget. WWPs are costly up front27 – meaning that they require monetary investment initially and may take months or years to see any ROI. Costs may include materials/devices, paying an outside contractor or company to implement the program, paying   8 existing staff to create the program, and incentives. This high initial cost may be therefore be prohibitive in smaller companies or companies with lower revenue than the large multinational corporations we see with the largest WWPs today. 1.2.2 Supporting Theories   Social theory surrounding workplace wellness is a triadic model of social cognitive theories. Those being: social comparison theory1 , need theory1 , and self-actualization theory.1  Social comparison theory describes how much individuals are driven by interpersonal evaluation (comparing themselves to others), and how this self-analysis impacts their motivation, performance, and how they validate their behavioral choices.1 In open offices, social comparison may play a large role in health behavior choices. For instance, if one can constantly see their coworkers participating in the program – either virtually or in-person, they may feel pressured to compete with them. Competition and social influence extend to eating behaviors as well.28-30 For example, in a study assessing eating behavior, when a model ate a small versus a large amount, participants (female) reported that a smaller amount of food was appropriate to eat in that situation.30,31 Those participants then ate a smaller portion, and the study authors determined that those original perceptions accounted for the choice to eat the smaller amount.30,31 People model the eating behaviors that they witness. Using this knowledge to design a workplace wellness program may use competition or social influence as a means to motivate employees to stay as healthy as or make healthier decisions than their peers.32  Need theory addresses the roles of affiliation, power, and achievement as drivers and motivators of in-group behavior, and the extent to which these behaviors result in actual adherence to health behaviors.1 Assessing the needs of employees and current areas of their lives that they are looking to improve can help companies design better workplace wellness programs.   9 Finally, self-actualization theory relates to how WWP participation is motivated first by a need to optimize one’s self and how this drive towards bettering oneself could inspire individuals to effect change at the community level.1 This theory is vitally important to workplace wellness program success, as changing first the individual and then the organization and wider society as a whole can be viewed as the ultimate goal of creating healthier spaces. The health belief model (HBM) aims to help explain why people do not adopt disease prevention strategies/habits or undergo screening tests to help detect early signs of chronic disease.22 It suggests that, “...a person's belief in a personal threat of an illness or disease together with a person's belief in the effectiveness of the recommended health behavior or action will predict the likelihood the person will adopt the behavior.”22 Understanding this model can help researchers and designers of workplace wellness program predict how employees will interact and respond to their programs. It can also assist health professionals plan educational and knowledge translation tools aimed at helping employees overcome hurdles to improving their health. Self-efficacy theory is the belief that one has in their own abilities, specifically the ability to complete a task and/or meet the challenges ahead.33 It is related to self-esteem and self-regulation.33 For the definition and that reason, it is an important theory when studying health goals. If someone has high self-efficacy, they are more likely to be able to make routines out of new health goals and have success when making, for example, changes in their diet or exercise routine. Self-efficacy is sometimes broken down into categories (e.g. diet self-efficacy, physical activity self-efficacy) in research.33     10 1.2.3 Measuring Nutritional/Diet Impact of Workplace Wellness Programs on Participants  A 2013 systematic review on the effectiveness of workplace dietary modification interventions found six studies conducted in Brazil, the USA, Netherlands, and Belgium that met the inclusion criteria.34 Four studies reported small increases in fruit and vegetable consumption (less than or equal to a half serving of each per day).34 All of the studies utilized workplace dietary modifications (meaning healthy food was available at the workplace) and three also included nutrition education programming.34 The authors of the review concluded that all of the studies had methodological limitations, such as selection bias or inadequate testing or follow up time.34 The results of this systematic review suggest that workplace dietary modification interventions by themselves and when combined with nutrition education programming increase the fruit and vegetable intake of participants.34 Another systematic review of sixteen studies addressed the effects of worksite health promotion interventions on employee diets.35 Eight of the WWPs included a focus on nutrition education, while the remainder targeted workplace dietary modifications, alone or in combination with the education programming.35 The authors reported that participation in the WWPs led to positive changes in fruit, vegetable, and total fat intake.35 They noted the risk of bias due to self-reported dietary assessment used by the studies.35 They also stated that the quality of studies in this field (up to the April 2009 date of their review) had often been sub-optimal for various reasons.35 The authors suggest that future WWPs should move beyond one-on-one education and instead intervene at multiple levels in the workplace.35 Overall, there is a moderate positive benefit on diet quality from participating in WWPs with nutrition-focused components. In the Leedo et al. study,36 sixty workers at a hospital in Denmark were recruited to participate in an eight-week randomized crossover design study. They received a healthy lunch,   11 snack, and a bottle of water during each shift. Reaction time, mood, and dietary intake were assessed at the beginning and end of both the intervention and control time periods. Mood was assessed with the Profile of Mood States (POMS) questionnaire, which asks the participants their experience over the past week using scales in the areas of: tension-anxiety, confusion-bewilderment, anger-hostility, depression-dejection, fatigue-inertia and vigour-activity.36 Diet was assessed using a four-day self-reported recall, and reaction time was calculated using the Go/No-Go test.36 During the intervention period, intake of total dietary fat was lower (p=0.030), and the intake of carbohydrates (p=0.008), fibre (p=0.031), and water (p<0.001) were greater than in the control period.36 This study, although relatively small (fifty-nine participants) and involving only one workplace, shows that nutrition interventions at work may influence dietary choices to be healthier overall.  A large randomized controlled trial of workers at BJ’s Wholesale Club (n=32,974 employees) found that employees at worksites who attended wellness program sessions had significantly higher positive health behaviors compared to employees at worksites with no programs.5 The intervention consisted of eight modules and was delivered to employees in a group setting by Registered Dietitians over the course of eighteen months. There were no differences in clinical measures of health (such as improved cholesterol and blood pressure), healthcare spending and utilization, and employment outcomes by the end of the study – despite similar research in this field showing positive results in those measures.5 The positive health behaviors results included engaging in regular exercise (p=0.03) and active weight management (p=0.02).5 Therefore employees who participated in the wellness program were more likely to engage in regular exercise and active weight management. Active weight management refers to paying attention to what one eats and how much physical activity one partakes in, either through   12 calorie counting or meal tracking or general awareness. Though this trial was large and surveyed worksites across the United States, it involved employees from only one company. This limits the applicability of the findings for employees in other industries.  A study conducted at Massachusetts General Hospital between September 2016 and February 2018 analyzed worksite food purchases, dietary quality (24-hour dietary recall on two separate occasions), and cardiometabolic risk factors (obesity, prediabetes/diabetes, hypertension, and hyperlipidemia) of 602 employees.18 Mean age was 43.6 years (SD=12.2), 79% were female, and 81% were white. Mean BMI was 28.3 kg/m2 (SD=6.5); 21% had hypertension, and 27% had prediabetes/diabetes.18 They found that healthfulness of workplace food purchases was correlated with employees’ diet quality (determined by self-reported dietary intake, including quality of the diet outside of the workplace) (p<0.001) and lowered cardiometabolic risk factors (p<0.001) after the three-month study period.18 The study authors determined healthfulness of food purchases by utilizing the hospital’s pre-existing rating program which gives food a green label=healthy, yellow label=less healthy, or red label=unhealthy. Employees who purchased healthier food at the workplace (analyzed from looking at actual purchase data from the cafeteria) had healthier overall diet quality (analyzed from two separate 24-hour dietary recalls) and less risk for cardiometabolic disease than those who did not. This was also the first study to evaluate the association of employees’ workplace food purchases with their diet quality outside of work, suggesting that looking at how food at work impacts life outside the office is a direction this field is heading and is one that warrants additional research. One major issue with simply tracking food purchases is that there is no way to know if, or how much of the food the participant actually ate. For this reason, using solely dietary recall may be a more thorough approach to recording diet patterns in a population. This   13 would also help to determine if the healthier dietary choices at work carried through to after work or if participants used healthy eating at work as an excuse to eat less healthily afterwards. A conclusion from these findings is that healthy food promotion and availability in the workplace may positively impact the overall health of the employees who work there.18 This promising study - one that looked at an existing nutrition intervention and observed employee behaviors rather than creating and running a new intervention - may be an effective way to conduct research in this field. It allows for larger participant numbers and, with the right surveying questions and format, can result in significant data. The Food Choice at Work Study (FCW) was a complex workplace dietary intervention cluster-controlled trial that assessed the comparative effectiveness of an environmental dietary modification intervention and a nutrition education intervention both alone and in combination versus a control workplace.37 It took place in Ireland. The nutrition education component included group presentations, individual consultations, and detailed nutrition information/guidelines.37 Environmental dietary modification included workplace cafeteria/lunchroom menu modification, fruit price discounts, strategic positioning of healthier alternatives, and portion size control.37 Measures of dietary intakes, nutrition knowledge and health status were collected at baseline and at a seven to nine month follow-up date.37 The follow-up data were collected for a total of 541 participants (aged 18-64 years).37 The authors reported significant positive changes in intakes of saturated fat (p=0.013), salt (p=0.010), and nutrition knowledge (p=0.034) between baseline and follow-up in the combined intervention versus the control.37 Small but significant changes in BMI (-1.2kg/m(2) (95% CI -2.385, -0.018, p=0.047) were observed in the combined intervention.37 While it is known that elevated intakes of salt and saturated fat can be harmful for people with certain pre-existing conditions, they are   14 of less concern in the diets of healthy populations. It may have been more effective for the authors to address more divisive factors like fiber, water, protein, or fruit and vegetable servings. Effects in the education- and environment-alone workplaces were smaller and usually non-significant.37 The stated conclusion was that combining nutrition education and environmental diet modification in the workplace could be a good approach for eliciting positive dietary changes and weight loss.37 Additionally, though not found in the literature, focusing nutrition education on healthy meal preparation and planning at home might help to promote healthy habits such as bringing in leftovers for lunch. This might help participants avoid unhealthy lunch options in the cafeteria and also benefit long-term behavior change both inside and outside of the workplace. This type of nutrition education would also take some pressure off of the workplace to provide healthy meals all of the time. 1.2.4 Measuring Impact of Workplace Wellness Programs on Physical Activity Behaviors of Participants  A 2008 systematic review addressing workplace physical activity (PA) interventions found fourteen studies that met their inclusion criteria.38 The authors found three public sector studies that provided evidence that WWPs including walking interventions that gave pedometers to participants increased daily step counts in the participants.38 They also found one study that reported a positive intervention effect on walking to work (active commute) in economically advantaged female employees.38 They reported strong evidence that workplace counselling/motivational interviewing increased physical activity in participants.38 A limitation of this review is that it only included studies that took place in UK, Australia, Canada, New Zealand, and the rest of Europe.38 A 2013 systematic review on the same topic found twenty studies that matched their inclusion criteria.39 Twelve (60%) of the studies reported an   15 improvement in physical activity level, steps, or BMI due to participation in a WWP.39 Out of those twelve, ten were less than six months in duration, nine used pedometers, six utilized Internet-based approaches, and five included activities targeting social and environmental (PA offerings at the workplace, such as an in-house gym, group fitness classes, accessible stairwells, walking paths, etc.) levels of the workplace.39 Seven of the eight interventions with pre-post test and quasi-experimental controlled design showed improvement on at least one of the previously stated outcomes.39 But the authors also found that seven of the twelve randomized controlled trials (RCTs) did not prove effective in any outcome.39 The authors concluded that WWPs that utilized pedometers, Internet-based approaches for delivery of programming and/or education, and included programming activities (educational or actual, like group fitness classes) at social and environmental levels were more effective in resulting in positive health change than those who did not follow those characteristics.39 The reviews on this topic show that PA WWP components that utilize pedometer programs, motivational interviewing in person or through the computer, and targeting both social and environmental levels of the workplace may be most effective at promoting positive health change in participants. Jacobson and Aldana’s 2001 study addressed the relationship between the frequency of aerobic activity and absenteeism. 79,070 subjects from 250 related U.S. worksites completed a health profile questionnaire.6 This 30-minute questionnaire included questions pertaining to nutrition, exercise, self-care, medical history, alcohol use, well-being/stress, and biometrics. Exercise was categorized by type, frequency, and duration. Regardless of those categories, a significant relationship was found between exercise and absenteeism, reaching the conclusion that employees who exercise are less likely to have illness-related absences from work.6 Interestingly, they found that while two days of exercise per week (not necessarily while at   16 work) is better than one, no difference in absent days was seen when comparing three days to two, or greater than four days to two. This is a hopeful finding, as encouraging and getting employees to exercise two days a week is more realistic than aiming for four or more, and with those two days they may still see positive benefits. A limitation of this study is that using self-reported data, especially self-reported physical activity amounts, is flawed. Participants tend to overestimate the amount of physical activity that they complete.40-42 Additionally, only aerobic exercise was considered. This serves as a major limitation of this study, as it ends up excluding strength training and activities like yoga, which might also impact absenteeism and overall health. This study relates to the larger workplace wellness program (WWP) theme because it shows that people who exercise are less likely to take days off, so if WWPs can increase physical activity levels in participants, they are therefore likely to reduce absenteeism. There are many studies addressing workplace wellness and physical activity.22 Fewer studies have looked at cardiorespiratory fitness of participants specifically. A prospective cohort study conducted at Washington University (St. Louis, Missouri) included 121 university employees. The participants took part in a workplace wellness program based on the health belief model.43 It included cardiovascular health assessments, questionnaires, personal health reports, eight weeks of pedometer-based walking and tracking (tracking twenty-seven different physical activities), consultation with researchers, weekly wellness education sessions (led by health professionals), and participation rewards.15 They measured exercise self-efficacy using the Barriers Specific Self-Efficacy Scale (BARSE) and the Multidimensional Outcome Expectations for Exercise Scale (MOEES). BARSE is used to quantify a person’s perceived capability to perform regular exercise amid common barriers to exercise.15 The MOEES scale assesses the physical, social, and self-evaluative domains of exercise. Higher scores typically mean that the   17 person has higher exercise outcome expectations.15 The researchers concluded that their multifaceted, pedometer-based workplace wellness program successfully increased physical activity rates and cardiorespiratory fitness of participants within the eight-week intervention. Over the eight weeks, there were increases in daily step count (the number of participants achieving 10,000 steps/day increased from 6% at baseline to 25% at week four and 36% at week eight) and modest improvement in multiple cardiovascular disease risk factors (modest improvements observed in adiposity, blood pressure, resting pulse, recovery pulse rate after exercise, total cholesterol, triglycerides, and fasting blood glucose). Workplace wellness programs aiming to increase physical activity have the potential to improve the health of those who participate in meaningful ways.15  1.2.5 Observing the Office Environment  Modifying the built environment of an office space can impact health without requiring active participation. This eliminates common hurdles and barriers like having to drive far distances and pay fees to access exercise. Because of this, it has become increasingly popular for organizations to put resources into aligning their space with best practices developed by research in this field. Making healthy choices more visible, accessible, and convenient is the goal of designing spaces to promote health.44 From the layout of the space itself to furniture like standing desks, the built environment can impact health directly and indirectly, through social or psychological factors. In the United Kingdom, it is estimated that 570,000 hours per year are lost because of workplace absenteeism related to poor office design.45 Employees’ responses to their workplaces are both psychological and physiological. Open offices - ones without separate offices or cubicles for each employee, once thought of as the best office layout - are now criticized for   18 limiting productivity because employees are constantly exposed to distractions.46 This office type can good for collaboration, though, as employees have easy access to one another. They may also be good for increasing exposure to daylight, views of green areas, and fresh air, both critical components of healthy workspaces because they may help to lower stress levels.46  The WELL Building Standard is a certification that focuses on environmental conditions (air quality, temperature, physical comfort, light, and access to the natural environment), promotion of community, nourishment and fitness accessibility, and the impact of the space on mental health/the mind).9 It can be used when constructing a new building or when redesigning an office space. The Checklist of Health Promotion Environments at Worksites (CHEW) is a direct observation tool addressing characteristics of worksite environments that are known to influence health-related behaviors.23 It is a 112-item checklist of workplace environmental features associated with physical activity, healthy eating, alcohol consumption, and smoking. CHEW assesses three domains: the physical characteristics of the worksite, features of the information environment, and characteristics of the immediate neighborhood around the workplace.23 The first domain addresses staircases and elevators, the number and contents of vending machines, food options in cafeterias and lunchrooms, the presence of bike racks and storage areas, and access to fitness facilities, changing rooms, and showers.23,47 The second domain looks at the bulletin boards and messaging systems, the number of posters, signs, or flyers containing PA or nutrition-related messages or opportunities and the presence of no-smoking signs.23,47 The third domain looks at the neighborhood surrounding the workplace, including access to restaurants or food stores, gyms or recreation facilities, and establishments to purchase cigarettes and alcohol.23,47 It is recommended that two observers complete the checklist for each workplace in   19 order to increase interrater reliability.23,47 The CHEW was modified and used in this study as the way to assess the physical environment of the participating workplaces. The Environmental Assessment Tool (EAT) is a validated physical and social environment assessment tool for worksite obesity prevention.32 It can look at the relationships between environmental interventions, absenteeism, and medical expenditures. EAT is designed to assess organizational and environmental programs and supports related to healthy eating and weight management, and not to be used to evaluate more general support for health promotion.32   1.2.6 Measuring Quality of Life and Overall Wellness Scores  Calculating an overall wellness score has been used in this field to summarize the many aspects of wellbeing and quality of life quantified in research.48 Surveys and tools such as the Gallup-Healthways Well-Being Index49, the The Göteborg Quality of Life Instrument (GQLI)50 , Quality of Well-Being Scale51, and others have been used in the past and in specific populations to measure of QoL. During analysis, these surveys produce individualized wellness scores for each participant through simple mathematics. The issue with such surveys is that they are either outdated, not widely available for use, or designed for a specific population.51 But the advantages of using them center around the existing evidence that correlates higher wellness scores with positive health and productivity outcomes.49,51,52 Other studies have pieced together a variety of different surveys to create an overall wellness score.53-60  This is problematic because combining multiple tools is often not a validated way of using each one, and can be difficult to replicate if the individual surveys become outdated or no longer available. Utilizing one complete survey is more streamlined and will provide additional evidence for the validity and future improvements of the survey.   20 The 36-Item Short Form Health Survey questionnaire (SF-36) is a very popular tool for evaluating health-related Quality of Life.61 It measures eight scales (using thirty-six questions): physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health.61 There are two different dimensions measured by it, a physical dimension, represented by the Physical Component Summary, and a mental dimension, represented by the Mental Component Summary.61 The correct calculation of SF-36 summary/overall scores requires the use of special algorithms, which are owned and controlled by a private company.61 According to its developers, you cannot combine the two SF-36 summary dimensions to produce an overall score of health-related QoL.61 But researchers often do this anyway.61  1.2.7 Summary of Introduction and Supporting Literature  Workplace wellness programs have evolved greatly in recent years. They may include fitness perks like in-house gyms or free group fitness classes, nutrition benefits like healthy food and snacks, nutrition education, or group weight loss programs, and/or involve a workplace design that benefits health through modalities such as standing desks or office design. When evaluating these programs, studies have looked at various wellness and health outcomes. The literature shows promising but moderate evidence supporting that nutrition and PA-focused WWPs improve diet quality, physical activity levels, and therefore may also improve QoL. This study addressed quality of life (QoL) as its main outcome. QoL includes all aspects of wellness including physical, psychological, social, and financial wellbeing. One promising way to quantify QoL is to use a calculated overall wellness score from results of a single survey.     21 Chapter 2: Systematic Review  This chapter is a systematic review of the literature surrounding the research question of this thesis. It supports the previous literature review and also acts as a standalone paper. It addresses the question, “How do workplace wellness programs with physical activity and nutrition components effect employee quality of life?” It moves beyond the categorized focus of the previous literature review and delves into the evidence supporting the main research question of this thesis.  2.1 Introduction Workplaces around the world provide wellness programs to their employees. These programs often promote healthy eating, physical activity, and mental health. The workplace proves to be a uniquely suitable place to implement these programs because of the community nature of the workplace itself, and because Canadian employees often spend around seven hours per weekday there.62 At the workplace, more people can be reached at one time for health promotion and education – proving cost effective (less labor hours for one educator or professional per person). As most people consume food at the workplace18, changing the food offerings or promoting healthy choices there may be received well as those positive changes can be taken up immediately by participants.18 Relatedly, workplace Wellness Programs (WWPs) have the potential to improve employee quality of life (QoL)63,64, decrease risk of chronic disease48, and improve productivity65. Chronic diseases account for five out of the top six leading causes of the death in the US, and many chronic diseases are preventable.44 In creating a healthier workplace through nutrition and physical activity programs, chronic disease may be prevented, QoL improved, and productivity may be increased.   22 It is important to establish a working definition of QoL. QoL – whose meaning is closely related to the meanings of wellness and wellbeing – is more than just a physical health measure. It goes beyond a healthy body to include a healthy social and financial life as well as emotional, social, and psychological health.17 It is also important to define another important term. Wellness (used interchangeably with wellbeing in this study) is comprised of 8 dimensions: physical, intellectual, emotional, social, spiritual, vocational, financial, and environmental.16 The physical dimension refers to the body and physical health. Intellectual refers to stimulating the brain and engaging in life-long learning. Emotional wellness is sympathy, empathy, and being in touch with one’s emotions. Social wellbeing means meaningful relationships with family, friends, and other loved ones. Spiritual wellness refers to finding meaning and value in life. Work satisfaction is the main factor in vocational wellness. Financial wellness means the ability to balance budgets and not comparing one’s financial situation to others. Environmental wellness involves the reciprocal relationship between self and world.16 All of these factors go into the measurement of a person’s QoL, and there is no consensus or gold standard when quantifying it in all populations. A 2013 systematic review on the effectiveness of workplace dietary modification interventions found six studies conducted in Brazil, the USA, Netherlands and Belgium that met the inclusion criteria.34 Four studies reported small increases in fruit and vegetable consumption (less than or equal to a half serving of each per day).34 All of the studies utilized workplace dietary modifications (meaning healthy food was available at the workplace) and three also included nutrition education programming.34 The authors of the review concluded that all of the studies had methodological limitations.34 The results of this systematic review suggest that workplace dietary modification interventions by themselves and when combined with nutrition   23 education programming increase the fruit and vegetable intake of participants.34 Another systematic review of sixteen studies addressed the effects of worksite health promotion interventions on employee diets.35 Eight of the WWPs included a focus on nutrition education, while the remainder targeted workplace dietary modifications, alone or in combination with the education programming.35 The authors reported that participation in the WWPs led to positive changes in fruit, vegetable and total fat intake.35 They noted the risk of bias due to self-reported dietary assessment used by the studies.35 They also stated that the quality of studies in this field up to the April 2009 date of their review had often been sub-optimal.35 The authors suggest that future WWPs should move beyond one-on-one education and instead intervene at multiple levels in the workplace.35 Overall, there is a moderate positive benefit on diet quality from participating in WWPs with nutrition-focused components. A 2008 systematic review addressing workplace physical activity (PA) interventions found fourteen studies that met their inclusion criteria.38 The authors found three public sector studies that provided evidence that WWPs including walking interventions that also gave pedometers to participants increased daily step counts in the participants.38 They also found one study that reported a positive intervention effect on walking to work (active commute) in economically advantaged female employees.38 They also reported strong evidence that workplace counselling/motivational interviewing increased physical activity in participants.38 A limitation of this review is that it only included studies that took place in UK, Australia, Canada, New Zealand, and the rest of Europe.38 A 2013 systematic review on the same topic found twenty studies that matched their inclusion criteria.39 Twelve (60%) of the studies reported an improvement in physical activity level, steps, or BMI due to participation in a WWP.39 Out of those twelve, ten were less than six months in duration, nine used pedometers, six utilized   24 Internet-based approaches, and five included activities targeting social and environmental (PA offerings at the workplace, such as an in-house gym, group fitness classes, accessible stairwells, walking paths, etc.) levels of the workplace.39 Seven of the eight interventions with pre-post-test and quasi-experimental controlled design showed improvement on at least one of the previously stated outcomes.39 But the authors also found that seven of the twelve randomized controlled trials (RCTs) did not prove effective in any outcome.39 The authors concluded that the WWPs that utilized pedometers, Internet-based approaches for delivery of programming and/or education, and included programming activities (educational or actual, like group fitness classes) at social and environmental levels were more effective in resulting in positive health change than those who did not follow those characteristics.39 The reviews on this topic show that PA WWP components that utilize pedometer programs, motivational interviewing in person or through the computer, and targeting both social and environmental levels of the workplace may be most effective at promoting positive health change in participants. Further, fewer studies have addressed the impact of WWPs that contain both nutrition and physical activity components and their impact on QoL of those who participate. It is known that the combined effects of achieving healthy or suggested levels of physical activity with following nutrition guidelines leads to greater health benefits than either one alone.20,66 One systematic review examined the impact of said program type and its impact on employee overweight and obesity.66 That review found that found that workplace physical activity (PA) and nutrition programs achieve modest improvements in employee weight status at the six to twelve-month follow-up.66 Specifically, a pooled effect estimate of −2.8 pounds (95% CI=−4.6, −1.0) was found based on nine Randomized Controlled Trials (RCTs), and a decrease in Body Mass Index (BMI) of −0.5 (95% CI=−0.8, −0.2) was found based on six RCTs.66 The findings   25 were applicable to male and female employees, and across a range of workplace settings.66 Having overweight or obese weight status has been well proven to negatively impact QoL.67-69 Addressing QoL in this systematic review takes that narrow lens of filtering by effects on overweight and obesity and broadens it to look at a participants life as a whole. With positive effects on health seen on that narrow scale we can hypothesize positive effects on a larger scale. A similar systematic review by Dale et al. focused more specifically on mental/psychological wellbeing and QoL, addressed the impact of healthy lifestyle interventions on mental health and wellbeing. The authors found that health behavior change interventions targeting physical outcomes appear to have benefits for mental health and wellbeing, with the strongest evidence for interventions that targeted both exercise and diet.52 The aim of the present review is to conduct a systematic review of studies measuring QoL in relation to participation in nutrition and physical activity workplace wellness programs. This systematic review tightens the scope of the Dale et al. review and furthers the evidence for WWPs with PA and nutrition components based on Dale et al. and other systematic reviews that have addressed nutrition or PA WWPs as standalone outcomes.34,35,38,39,52                26 2.2 Material and methods 2.2.1 Search strategy  Relevant studies were identified by searching three different electronic databases: PubMed, PsycINFO, and Web of Science. There were no time restrictions. Date of search was 04 February 2020. 2.2.2 Study Selection  Criteria for study inclusion were developed using the PICOS design format.70 The “population” is employed adults, “intervention” is a workplace wellness program with nutrition and physical activity components. The “comparison” group are employed adults with no participation in the workplace wellness program with nutrition and physical activity components and the “outcome” of interest is improved quality of life. In all databases searched, search terms included: (intervention OR program OR initiative OR class OR event) OR workshop) AND (physical activity OR exercise OR fitness OR workouts) AND (nutrition OR food OR diet OR eating behavior OR meals OR snacks) AND (wellness OR wellbeing OR quality of life OR happiness OR satisfaction OR health) AND (employee OR staff OR employees OR workplace OR worksite).  The following studies were excluded: studies including adolescents and children; studies on sick or clinical populations; literature reviews, commentaries, editorials, opinion pieces, policy documents, consensus statements, study protocols, newspaper articles, theses, book chapters; interventions addressing solely physical activity or nutrition; outcome measures that   27 did not include factors pertaining to quality of life; and interventions that were reported in a language other than English. The primary outcome measures in this review all related to quality of life. Additional important outcomes were measures relating to nutrition and physical activity. This included measures related to stress, depression, self-perceived QoL, life satisfaction, nutritional/diet quality, physical health, and mental/psychological health. During screening of abstracts and full-texts, articles that included one facet of the desired measures (i.e., physical activity measures but no nutrition measures) were excluded. Articles must have included some mental health, nutritional health, and physical health measures to be included. The nature and specificity of the research question leads itself to restrictive search criteria. This study aims to address the combined impact of nutrition and PA interventions rather than just one or the other. The titles of the studies generated from the searches were reviewed for inclusion by two authors (K.L. and E.S.). Abstracts from potentially relevant titles were then reviewed against the inclusion criteria. The full texts of articles were obtained for all abstracts deemed to be potentially relevant and were reviewed by the authors. Systematic reviews identified by the search were scanned by one author for additional studies. Any disagreements were resolved by discussion and consensus reached before final inclusion. The study selection process from identification to exclusion was documented using the PRISMA flow chart, shown in Figure 1.      28 Figure 1 PRISMA Flow Diagram   29 2.3 Results 2.3.1. Study Characteristics  The initial searches resulted in 3,687 titles. Forty-two full-text articles were reviewed. Seven studies fulfilled the inclusion criteria for the present review. The studies had been performed in different parts of the world, including the United States and Europe. The sectors/industries in which the study took place include engineering, science, operations, health care/medical facilities, government agencies, manufacturing, professional groups, colleges, call centers, childcare, retail, and agribusiness. 2.3.2 Study Participants  The number of participants within each study differed greatly, and the total number of participants across all studies was 5,449 (Table 1). The average age of participants was between 39.5 and 65 years (Table 1). Most of the studies had predominantly female participants (Table 1).  Table 1 Systematic Review Participant Information Author, Year, Country of Origin Participants Participation Rate Demographic Data Sector/Industry Block et al. 2008, United States 787 10% (estimated based off of total number of recruitment emails sent out) 44 (+/- 10.6) years old; 74.3% female Non-medical employees in Kaiser Permanente health care system Clark et al. 2013, United States 1151 Percentage not reported. Classified into wellness center use quartiles by visits per week 39.5 (+/- 11.5) years old; 69.7% female; 43.5% overweight    30 Merrill et al. 2011, United States 3033 81.2% in wellness program 40-49 years old average age group; 29.1% female Agribusiness Low 2015, United States 57 91.94% (5 individuals dropped out) 51 (+/- 6.5) years old; 100% female; 41% non-Hispanic white Health Care Smith 2018, United States 181 56.5% based on number in baseline data collection vs. final analysis 47.9 (+/- 10.1) years old; 87% female, 62% non-Hispanic white, Southern US Health Care, Education, Government, Banking, Processing Das 2019, United States 240 84% based on enrolled vs. completed outcome assessment 46.7 (+/- 11.1) years old; 58% female; 78% non-Hispanic white Broad Range     31 2.3.3 Interventions  The length of the interventions varied from 30 days to 3 years. One was emailed-based63  and utilized participant-chosen health goals. Another mainly utilized access to a wellness center.6  In-person programs led by health professionals or trained coaches were popular6,21,44,48,71,72 Within these in-person programs (including the wellness center), small group settings were used, and topics centered around risk reduction through improving nutrition knowledge and behaviors and increasing physical activity. Further explanations of each program are below. Block et al.: Email and online-based four-month education program, designed to reduce intake of saturated and trans fats and added sugars, increase fruit and vegetable consumption. After randomization, participants chose one topic to focus on for the intervention (increasing PA, increasing fruit and vegetable intake, or decreasing saturated and trans fat and added sugars). The intervention involved individualized feedback, weekly goal setting, individually tailored goals and tips, reminders, and promotion of social support for their chosen health goal.  Clark et al.: Participants were members of an onsite wellness center at a single workplace. Wellness center access included options to participate in exercise classes, water aerobics, access to an indoor track, strength training equipment, aerobic conditioning equipment, nutrition classes, a wellness cafe, personal wellness coaching, and a stress-reduction group program. Participants completed a baseline QoL survey and the same survey one year later. Their wellness center use was tracked over the year using an electronic entry system and class/group attendance.   32 Low et al.: This six-month intervention involved participating in either a weekly motivational counseling or the control group. All participants were offered risk reduction classes (weight/diet, stress, exercise, and smoking cessation) and on-site gym access. IG received weekly communication on goal setting and suggestions for overcoming obstacles based on the goals of the risk reduction class they were enrolled in. They survey was given again for a one-year follow-up. Merrill et al.: The Reaping Rewards wellness program was an ongoing program at the workplaces and included monetary incentives for "good-health behaviors" like periodic physical exams, nutrition and fitness activities, screenings, fitness classes. The program consists solely of these rewards/incentives. Employees completed an HRA with height and weight, physical pain, health limitations, PA, diet, stress and coping, sick days, and biometrics information each year. Smith et al.: The Chronic Disease Self-Management Program (CDSMP) involved small group workshops once per week for six weeks. They were led by trained facilitators on the topics of coping with health problems and negative emotions, nutrition, PA, how to assess new treatments given to them by their healthcare providers, and communication with healthcare providers.     33 Das et al.:  This program was an intensive 2.5-day group-based intervention developed by Johnson & Johnson's Human Performance Institute and delivered by trained coaches. The controls were those in a waitlist control group. The short intervention focused on educating participants on performance psychology, exercise physiology, and nutrition. Participants received educational materials, a sample workout booklet, and online support. 2.3.4 Survey Details  Table 2 describes the surveys used in each study.  Table 2 Systematic Review Survey Information Author, Year Details Regarding Surveys Used in Study Block et al. 2008 ● Established* Survey/Questionnaire Used ○ SF-8 ○ CAPS questionnaire ● Unique Questionnaire Created? ○ Yes ● Number of Questions ○ Not available ● Average Time to Complete ○ 15 minutes ● Method and Timing of Administration ○ Email ○ Pre-post 4-month intervention ● QoL-related Measures ○ SF-8 ■ 8 questions on QoL measures representing 8 domains of physical and mental health. ● PA-related Measures ○ Adapted CAPs questionnaire ■ 34 specific exercise/activity types divided into domains ■ Days/week and minutes/day of participation in each activity in a typical week in the past 4 months. ● Nutrition-related Measures ○ Block questionnaire ■ 35 items regarding "usual" intake in frequency and portion size   34 ● Foods identified for inclusion based on NHANES analysis to ensure inclusion of foods appropriate for different ethnic groups, and if the foods were important contributors of sat and trans fats, fruits and vegetables, or added sugars. ● Other Measures ○ TLQ's tailoring info includes presence of children at home, habits related to cooking and eating out, PA preferences, stage of readiness for change for PA. ○ Presenteeism in the workplace assessed with three questions. ○ Self-efficacy assessed with two questions. Clark et al. 2013 ● Established Survey/Questionnaire Used ○ None ○ Questions gathered from studies that used similar questions in a variety of populations ● Unique Questionnaire Created? ○ Yes ● Number of Questions ○ 13 ● Average Time to Complete ○ Not specified ● Method and Timing of Administration ○ Method not specified ○ Pre-post 12-month intervention ● QoL-related Measures ○ How would you rate your current stress level from 0 (as bad as it can be) to 10 (as good as it can be)? ○ How often do you interact with close friends from 0 (rarely) to 10 (frequently)? ○ During the past week, including today, how would you rate your overall quality of life from 0 (as bad as it can be) to 10 (as good as it can be)? ○ How would you rate your overall health from 0 (poor) to 10 (excellent)? ○ How would you rate your support for maintaining healthy living from 0 (as bad as it can be) to 10 (as good as it can be)? ○ How would you rate your overall spiritual wellbeing from 0 (poor) to 10 (excellent)? ● PA-related Measures ○ How would you rate your current level of physical activity from 0 (not active at all) to 10 (extremely active)? ○ If you walked up two flights of stairs, how would you rate your overall level of fatigue and shortness of breath from 0 (could not do it) to 10 (could do it easily)?   35 ○ How confident are you that you can have a physically active lifestyle (30 minutes of physical activity on most days of the week) from 0 (not at all confident) to 10 (extremely confident)? ○ How would you rate your overall muscular strength and flexibility from 0 (poor) to 10 (excellent)? ● Nutrition-related Measures ○ How would you rate your nutritional habits from 0 (terrible) to 10 (very healthy)? ○ How confident are you that you can follow a healthy diet from 0 (not at all confident) to 10 (extremely confident)?  ● Other Measures ○ After a typical night’s sleep, rate how tired or fatigued you feel from 0 (always) to 10 (never). ○ Participants were also asked (yes or no) to indicate whether they used tobacco, were overweight, or had high blood pressure, high cholesterol, or high blood sugar. ○ Self-reported height and weight. Merrill et al. 2011 ● Established Survey/Questionnaire Used ○ None ● Unique Questionnaire Created? ○ Yes ● Number of Questions ○ Not specified ● Average Time to Complete ○ Not specified ● Method and Timing of Administration ○ Electronic ○ Yearly for 3-year study duration ● QoL-related Measures ○ Physical pain (none to very severe), health limitations (none to cannot work), stress and coping (coping well to cannot cope), job satisfaction (not satisfied to very satisfied), happiness levels (happy none of the time to all of the time), feeling calm and peaceful (none of the time to all of the time) ● PA-related Measures ○ Physical activity ■ Aerobic exercise at least 20-30 minutes/week ● Nutrition-related Measures ○ Diet ■ Fruit and vegetable consumption (servings/day), fat intake (high-fat foods nearly always to low-fat foods only), alcohol consumption (drinks/week) ● Other Measures ○ Demographics, sick days (per year), sleep (frequency of sleep 7-8 hours/night), cigarette smoking, biometrics (BP, cholesterol, triglycerides, glucose) ○ Self-reported height and weight   36 Low 2015 ● Established Survey/Questionnaire Used ○ Cohen Perceived Stress Scale ● Unique Questionnaire Created? ○ Yes ● Number of Questions ○ Not specified ● Average Time to Complete ○ Not specified ● Method and Timing of Administration ○ Pre-post 6-month intervention and 1-year follow-up ● QoL-related Measures ○ Cohen Perceived Stress Scale ○ Ranked risks (weight, stress, PA, smoking) based off of participants level of concern and desire to lower risk ● PA-related Measures ○ Exercise (days/week, minutes/session, intensity) ● Nutrition-related Measures ○ Weight management behaviors (days/week recording caloric intake, days/week weighing themselves) ● Other Measures ○ Age, race/ethnicity, marital/partner status, education, the number of dependents, years, hours and position worked at the hospital, commuting distance, participation in other health promotion activities ○ Readiness to change ○ Physical measures (weight, height, BP, HR, cholesterol, triglycerides, non-fasting blood glucose) ○ Current smoking Smith 2018 ● Established Survey/Questionnaire Used ○ CDC Healthy Days Scale ○ PHQ-8 ○ Work Limitations Questionnaire ○ Work Ability Index ● Unique Questionnaire Created? ○ Yes ● Number of Questions ○ Not specified ● Average Time to Complete ○ Not specified ● Method and Timing of Administration ○ Online or paper survey ○ Baseline and 6-month follow-up ● QoL-related Measures ○ Depression (patient health questionnaire (PHQ-8) ○ Unhealthy Days (CDC Healthy Days Scale) ○ Single-Item Health Indicators (stress, pain, fatigue, sleep problems) ○ Work-Related Limitations (Work Limitations Questionnaire)   37 ○ Work Ability (Work Ability Index) ○ Work-Related Stress ● PA-related Measures ○ PA and Sedentary Behavior ■ Days/week physically active for at least 30 min., total hours sitting during a typical work day ● Nutrition-related Measures ○ Eating Behavior ■ Fast food consumption, servings of fruit/vegetables per day, soda or sweetened beverage consumption ● Other Measures ○ Self-Efficacy (confidence in ability to manage chronic conditions) ○ Medication Adherence ○ Patient-Provider Communication Das 2019 ● Established Survey/Questionnaire Used ○ Rand Medical Outcomes Survey (MOS) 36-item Short-Form (SF-36) ○ Ryff Purpose in Life Scale ○ Center for Epidemiologic Studies Questionnaire for Depression (CESD) ○ International Physical Activity Questionnaire ○ Profile of Mood States Questionnaire (POMS) ● Unique Questionnaire Created? ○ Yes ● Number of Questions ○ Not specified ● Average Time to Complete ● Method and Timing of Administration ○ Electronic ○ Baseline and 6-months ● QoL-related Measures ○ SF-36 ■ Vitality, general health, bodily pain, physical functioning, mental health, role limitations due to physical problems and emotional problems, social functioning ○ Ryff Purpose in Life Scale ○ CESD ○ POMS ● PA-related Measures ○ International Physical Activity Questionnaire ● Nutrition-related Measures ○ Diet quality ● Other Measures ○ MOS sleep, height, body weight, waist and hip circumference, blood measures for glucose and lipids CAPS = Cross-Cultural Activity Participation Study, PA = Physical Activity, NHANES = National Health and   38 Nutrition Examination Survey 1999-2004,TLQ = Tailoring/Lifestyle Questionnaire, QoL = Quality of Life, HRA = Health Risk Assessment, BP = Blood Pressure, CDC = Center for Disease Control, Center for Epidemiologic Studies Questionnaire for Depression = CESD, Profile of Mood States Questionnaire = POMS  *Established = validated or used frequently in the literature  2.3.5 Outcome Measures   Table 3 describes the outcome measures of each study and the results reported for each.  Table 3 Systematic Review Outcomes and Results Author, Year Outcome Measures Results (significant unless noted otherwise) Block et al. 2008 ● Health-related QOL (SF-8), presenteeism, self-efficacy, stage of change. ● PA: total activity, MET-minutes/week, moderate intensity and vigorous intensity PA, walking, sedentary behavior - all in min/wk.). ● Nutrition: fruit, vegetable, saturated and trans fat intake ● TLQ: demographic data, tailoring information, info related to assessing secondary outcomes ● Barriers Questionnaire: participants identify barriers that may get in the way of achieving their health behavior goals ● QoL-related Results ○ Mean SF-8 physical QOL ↑ significantly (p=0.02) ○ SF-8 mental score ↑ significantly (p=0.02) ○ IG was more likely to have improvement in self-assessed health status (p<0.001) ○ IG was more likely to have reduced difficulty accomplishing work tasks because of physical or emotional problems (p<0.001) ● PA-related Results ○ ↑ minutes/week of moderate intensity activity, vigorous intensity activity, and walking ● Nutrition-related results ○ ↑ fruit and vegetable intake ○ ↓ saturated and trans fat intake   39 Clark et al. 2013 ● Overall wellness score (calculated from survey and broken into categories: physical, mental, nutritional, health)) ● High wellness program users (2-3 wellness center visits per week) ○ ↑ health QoL (+7.5, p=0.006) ○ ↓ mental QoL (-5.6, p=0.06) ○ ↑ physical QoL (+21.0, p<0.0001) ○ ↓ average BMI (-0.8, p<0.0001) ● Low wellness program users (less than one wellness center visit every two weeks) ○ ↑ health QoL (+1.4, p=0.65) ○ ↓ mental QoL (-16.9, p<0.0001) ○ ↓ physical QoL (-5.4, p=0.07) ○ ↑ average BMI (+0.2, p=0.21) ● No significant changes in nutrition QOL ● In general, the percentage of participants with high in each QoL category point increased with wellness center use. Merrill et al. 2011 ● HRA: demographics, height, weight, physical pain, health limitations, physical activity, diet, stress and coping, sick days, biometrics (BP, cholesterol, triglycerides, glucose) ● Among participants living with obesity ○ ↑ mental health [feeling calm and peaceful (p=0.001), feeling happy (p<0.001), ability to cope with stress (p=0.003), feeling energy (p<0.001)] ○ ↑ healthy diet [fruit and vegetable consumption (p<0.001), alcoholic drinks per week (p<0.001) ● Among participants who decreased their BMI ○ ↓ fat intake (p=0.004) ○ ↑ weekly aerobic exercise (p=0.472) ○ ↑ feelings of calmness and peace (p=0.001), ↑ happiness (p<0.001), ↑ ability to cope with stress (p=0.003), ↑ physical energy (p<0.001) Low 2015 • Physical and perceptual measures recorded before and after 6-month program. 1-year follow-up. • QoL-related Results o ↑ weight loss (-7.2 vs -3.8 lbs) o ↑ stress reduction (6.5 vs 4.7 on Cohen’s stress scale) • PA-related Results o ↑ exercise days/week (1.4 vs 1.2) • Nutrition-related Results o None • No statistically significant results for any of the data. • One-year follow-up survey had only 16 participants - 94% reported their health the same or better, more in the IG than CG reported they were continuing to make progress on their goals.   40 Smith 2018 • Baseline and 6-month follow-up: health status, perceptions of work performance, healthcare utilization, sociodemographic info, fasting blood draw, height, weight, blood pressure • QoL-related Results o ↓ physically unhealthy days (= -2.07, p=0.018) o ↓ fatigue (= -2.88, p=0.002) o ↓ mental work limitations (= -8.89, p=0.010) • PA-related Results o ↓ sedentary behavior (= -4.49, p=0.018) • Nutrition-related Results o ↓ soda/sugar beverage consumption (= -0.78, p=0.028) o ↓ fast food intake (= -0.76, p=0.009) • Other Results o ↑ patient-provider communication (=0.46, p=0.031) Das 2019 • Baseline and 6 months follow-up QoL and health-related behaviors • QoL-related Results o ↑ SF-36 vitality scale score (p=0.003) o ↑ PiL (p<0.001) o ↑ self-reported general health (p=0.14), mental health (p=0.027), social functioning (p=0.007), absence of emotional and physical role limitations (p=0.026) o ↑ sleep quality (index I p=0.024, index II p=0.021) • PA-related Results o No statistically significant changes • Nutrition-related Results o No statistically significant changes  IG = Intervention Group, CG = Control Group, PiL = Purpose in Life, QoL = Quality of Life, TLQ = Tailoring/Lifestyle Questionnaire, BMI = Body Mass Index,  = change, MET = Metabolic Equivalent of Task               41 2.4 Discussion This section will discuss the outcomes of interest in the reviewed studies (QoL, nutrition, and PA). It will compare the findings to similar studies in the literature and discuss the strength of the findings as the result of the review. It then discusses limitations of both this review and the studies in this review. 2.4.1 Quality of Life Outcomes  QoL as a descriptor is multifaceted. When surveying populations with the goal of quantifying QoL, questions asked may pertain to a variety of topics, including mental, physical, and social wellness. In the literature, there is some interchangeability of the concept of wellness, wellbeing, and QoL. Combined with the fact that there are many surveys and questionnaires designed to look at one factor of QoL (such as depression scales), it can be difficult to find just one survey to utilize when the study aim is to address nutrition, PA, and mental health measures completely. For example, a survey may include questions regarding aerobic exercise while leaving out nutrition exercise. Or it may address social wellbeing but not financial. Various single questions, surveys, and methods can be combined to create a profile of each participant as it aligns to a study’s unique aims. Studies address quantifying QoL through questions regarding a combination of mental and emotional health, life satisfaction, and physical health measures. Some infer being in the normal status for biometrics such as blood pressure, resting heart rate, and BMI to having a higher quality of life than those who are in the unhealthy range of those measures. To expand on limitations in these studies and in the field as a whole, it is important to address the differing definitions of QoL. Some measures and surveys are similar to each other, such as stress reduction and ability to cope with stress, but the lack of total cohesiveness and overlap makes it difficult to draw powerful conclusions from the compiled data.   42 In this review, the following measures were found to be related to QoL: life satisfaction44, perceived health44,63, job satisfaction44, SF-8 physical and mental QoL scores47, physical QoL6, overall QoL6,21, decreased stress21,44,73 increased general health72, increased vitality and purpose in life72, decreased unhealthy days48 (when employees are physically present at work but not working at full performance), and mental health44,72. Participation in the intervention group was related to improvements in each measure. The lack of cohesion in these measures is the primary limitation found in this review. Each of the individual measures relates to QoL and, especially when taken with nutrition and physical activity outcomes, helps to quantify QoL. But while each study certainly addresses and measures QoL, the questions and surveys that make up those measures are not the same.  The results of this review mirror Dale et al.’s review on a similar topic. They found positive effects on mental health, wellbeing, and QoL as results of a variety of intervention types.52 That review was not limited to WWPs, but rather had a broader scope and included interventions in research and practice in a variety of populations. It can be postulated that participating in an intervention or program itself may be therapeutic, and therefore cause increases in QoL, or that by improving other health behaviors one improves their mental health, self-efficacy, and wellbeing, as the majority of studies in this and Dale et al.’s review showed.52 Finally, Dale et al. concluded that interventions targeting diet and exercise appeared to be particularly effective in improving mental health and wellbeing outcomes.52 This finding directly supports the findings from this review and the idea that targeting nutrition and PA together may be more effective than targeting one or the other.    43 2.4.2 Nutrition Outcomes  Nutrition measures typically take the form of Food Frequency Questionnaires (FFQs) or questions regarding regular intake as part of a larger questionnaire/survey. Usage of long, comprehensive FFQs is more commonly seen in nutrition-focused research11, and less in research including both physical activity, nutrition, and QoL components. This is likely because completion of these questionnaires by participants is time consuming and therefore participants are less likely to complete them.74 Studies in this review used specific questions about diet rather than assessing individual intake through 24-hour recalls or a similar modality. Saturated and trans fat were grouped together63, as well as vegetables and fruits44,63. This represents a limitation and criticism of the studies. The nutrition questions were neither comprehensive nor thorough. While nutrition/diet quality was not the primary outcome of this review, it is part of overall health and QoL. Creating a best-practice method for assessing nutrition and diet quality in how they relate to QoL is important for the future of this field. Other methods of assessing solely diet quality include the Diet Quality Index (DQI), Healthy Diet Indicator (HDI), and Mediterranean Diet Score (MDS).75  For this review, the included studies found positive correlations between participation in the wellness program and increased consumption of whole grains44, increased consumption of vegetables and fruits44,63, decreased saturated and trans fat intake63, decreased soda and sugar consumption48, decreased fat intake44, decreased fast food intake48, weight loss21, and positive overall diet change44,63. Increased consumption of fruits and vegetables and decreased fat intake aligns with findings from systematic reviews on WWPs with nutrition components and their impact on participant diet.34,35    44 2.4.3 Physical Activity Outcomes  Measurement of PA depends on the population, the budget and scope of the project, and how the PA measures may interact with the other measures in the study. It can be either self-reported or measured using tangible information like key-card entry into a fitness center. Similar to nutrition outcomes, some studies were not comprehensive in their assessment of PA. Merrill et al. asked only about aerobic exercise44 while Block et al. did not collect activity frequency data and only asked participants to rate different aspects of their physical activity and health63. Like nutrition, a complete breakdown of daily habits is not necessary to add to the QoL quantification, but the field would benefit from a best-practice method of assessing physical activity and fitness of employees.  The studies in this review that  assessed overall frequency of exercise21,44, moderate intensity activity63, vigorous intensity activity63, decreased fatigue48,72, and decreased sedentary behavior48, found significant increases in those areas in participants in the intervention group versus the control group. In a systematic review addressing workplace PA interventions, the authors found (60%) of their included studies reported an improvement in physical activity level, steps, or BMI. These findings support the findings from this review. Two systematic reviews on the topic suggest that programs that target both the social and environmental levels of the workplace are likely to have more positive health outcomes than ones that address just one level.38,39 Only two studies in this review6,21 addressed the social and environmental levels of the workplace. Clark et al. reported that increased participation in their program (usage of an on-site wellness center and nutrition and PA educational classes at the wellness center) led to increased QoL.6 Low et al. reported no statistically significant results.21 Usage of the wellness center and the classes there did not necessarily take place during working hours.    45 2.4.4 Strengths and Limitations  A major strength of many of the included studies is their high sample size. Four had samples greater than one thousand participants.6,44 The average was 5,574 participants. Higher participant numbers add validity to the findings and provide a more diverse population sample. An additional strength is that, with the exception of the Das et al. 2.5-day intervention, each intervention in this review was at least four months long. It is known that achieving recommended weekly energy expenditure rates has greater health benefits than inconsistent exercise.76 Enacting new habits also takes time (exact number of days reported varies), but it can be stated that a longer intervention would provide more opportunities for support from interventions leaders, practice with new ways of eating and exercising and therefore longer lasting change. There is potential to further categorize each intervention, but it would be difficult based on the limited descriptions in the included publications. In regard to biases in the included studies, selection and reporting bias are of particular note. Those who chose to participate in WWPs may be healthier than those who do not.77 Further, those who agree to participate in a research project may be healthier than those who do not.77 Combined, that creates a large selection bias towards healthier participants in studies on WWPs. An addition type of selection bias seen particularly in occupational research is the Healthy Worker Effect (HWE).78 The HWE is the phenomenon that the employed workforce is healthier than the general population.78 This is due to a variety of factors, including but not limited to the fact that chronically ill people are generally not employed, the fact that the elderly are typically retired and no longer in the active workforce, and that some occupations require physical fitness testing or drug testing.78 These reasons are also why socioeconomic status is important to record and reflect on in workplace wellness studies. Studies can evade this bias in   46 their results by choosing to utilize a control group made up of employees at the company being studied (or a similar methodology like employees at a similar company), rather than comparing to the general population.77 All of the studies in this review used an in-house control group. But to some degree, the HWE is unavoidable and does create a bias in any study involving the workforce. Reporting bias is a concern when conducting research on QoL. As discussed, QoL is a complex metric and therefore involves collecting a variety of measures. Outcome reporting bias can then take place, meaning that in the results and discussion of some studies, some of those measures and outcomes are left out.79  This can be due to non-significant results, lack of space, forgetfulness, or even malicious reasons such as attempting to skew results to appease funding or sponsorship sources.79 In this review, Das et al. reported no significant results for weight, diet, PA, or cardiometabolic factors.72 They did include PA, weight, and cardiometabolic factors in tables in their report. Low et al. stated that they collected diet-related data but did not report or discuss it.21 The reasons for this were not stated in their report. Similar to reporting bias, studies in the wellbeing field sometimes suffer from lack of detail in reporting outcome measures.52  A notable weakness of the studies is the lack of use of a single survey. Most created their own bespoke survey, or utilized one made up of questions from other surveys. Only six studies were included in the analysis of this review. This reflects a lack of studies on PA and nutrition WWPs and their potential impact on employee QoL. This resulted in a wide variety of measurement tools and outcomes, and therefore only a qualitative extraction of outcomes and reporting of significance was able to be conducted. In other words, not enough overlapping measures were reported to compile a combined statistical significance for this review.   47 An important observation of the included studies is that in the case of Smith et al. and Das et al., the companies included were in different industries.48,72 To remove confounding variables in a study, it would be helpful to recruit one company or one industry per study. Multiple companies in multiple industries, to expand the sample size even more, would also have a beneficial effect to alleviate the limitation of a smaller sample size and multiple industries. Including just one industry may lead to decreased participation numbers but would improve validity in regard to utilization of the studied WWP in a specific population. Finally, this review utilized a comprehensive search strategy to observe the effects of WWPs with nutrition and PA components on employee QoL. To our knowledge, no review looking at these specific metrics has been conducted. 2.4.5 Future Research  Future research should use the surveys created in these studies to measure identical outcomes in varied and diverse populations, ideally with similar or identical WWPs. This would serve the dual purpose of validating both the survey and the WWP/intervention. Surveys should be validated for work sectors separately to increase validity and replicability. Future research should also pinpoint and account for variables such as socioeconomic status and demographics to help limit confounding variables in the research. Additionally, research on WWP topics such as promoting active transport to work, education on nutrition and PA choices both inside and outside of the workplace, and allowing employees to use working hours to pursue wellness endeavors would all be interesting and beneficial to the field.    48 2.5 Conclusions The findings from this review support the conclusion that WWPs containing physical activity and nutrition modalities positively impact many factors of wellness and health, including QoL, diet quality, and participation in physical activity. Further usage of the surveys developed in these studies is necessary to validate them and continue to create best practices in measuring QoL. Additionally, the creation of a single, comprehensive survey to measure QoL including PA and nutrition factors is warranted by the research and evidence. An ideal survey would include a comprehensive nutrition section (including servings per day or week of all major food and beverage groups) an activity section (including aerobic, resistance, and other training per day or week as well as hours sitting per day), a mental health section (addressing feelings and coping in social, financial, emotional, and vocational topics), as well as questions on sleep, smoking, socioeconomic status, and other basic demographic questions. Validation of the survey could begin in a large study (similar to the larger studies in this field, between 10,000 and 30,000 participants) with many different industries, then narrow down to studies in specific industries. Relating back to this review in particular, the lack of cohesivity in measurement tools and in program designs means it is not possible to say which type of program results in the most positive health outcomes. But the positive trends connected with WWP participation calls for further research in this field.      49 Chapter 3: Exploring the Impact of Physical Activity- and Nutrition-Focused Workplace Wellness Programs on Employee Quality of Life  This chapter describes the methodology used for the main research project. It begins by stating study aims and hypotheses. It then describes methodology and procedures of the project. The second half of the chapter describes data analysis, results, and study limitations and biases.  3.1 Study Aims The aim of the research study was to observe the overall wellbeing of employees at companies in Vancouver, British Columbia with workplace wellness programs who include both a nutrition and physical activity program.   3.1.1 Specific Aim 1  The primary aim of this study was to determine if nutrition and physical activity workplace wellness programming improves employee quality of life. This study utilized a questionnaire including questions addressing each of those facets of quality of life. Due to the fact that wellness and QoL contain nearly the same measures, the wellness score calculated for each participant in this study were used as a tool to quantify their QoL. 3.1.2 Specific Aim 2  The secondary aim of this study was to determine if nutrition and physical activity workplace wellness programming improves diet quality and/or increases physical activity specifically, as opposed to QoL as a whole. While the main purpose of this study was to determine the overall reported nutrition, physical activity, and other wellness effects of   50 workplace wellness interventions, it was important to distinguish between specifically the nutrition and physical activity-related survey responses.                          51 3.2 Hypotheses 1. Employees who participate in a workplace wellness program with nutrition and physical activity components will have significantly higher wellness scores compared to employees at their company who do not participate. 2. Employees who participate in a workplace wellness program with nutrition and physical activity components will have higher overall diet quality than those who do not participate in the program, as evidenced by higher intakes of fruits, vegetables, whole grains, lean protein, plant-based protein, nuts & seeds, and leafy greens. 3. Employees who participate in a workplace wellness program with nutrition and physical activity components will report more time spent being physically active per week than employees who do not participate in the program.               52 3.3 Methodology and Procedures 3.3.1 Study Design   A single survey, completed by participants at companies in Vancouver, BC with nutrition and physical activity workplace wellness programming, was the data collection tool in this quasi-experimental study. The study followed non-equivalent groups between-subjects design where participants were not randomly assigned to conditions. It utilized a single test in the form of a survey. 3.3.2 Participants  Recruitment:  Recruitment started with snowball sampling, beginning with professional connections to office managers, supervisors, and wellness directors at eight different companies in Vancouver, British Columbia. An email was sent to all employees (N=135) through the primary contact at the company (investigators in this study will never have access to employee email addresses) in order to distribute the information about the survey. One follow-up reminder email was sent one week after the initial email.  Inclusion:   Between all participating companies, we aimed to recruit 10-35% of employees at each company to be participants to complete the survey in January 2020. This percentage was based on the participation rates noted in this project’s literature and systematic review.5,6,15,21,22,36,37,44,63,72,80 It is also based on other health survey data in British Columbia,   53 where response rates ranged from 17.1–43.4%.81 Employees were eligible to participate so long as they are employed in any position at their company.  Exclusion:  Those who are not employed by one of the participating companies.  Sample Size Calculation: Originally, it was proposed that a sample size calculation would be used to determine ideal participant counts. This sample size calculation utilized data from the 2016 Canadian Census of Population (most recent census). The population used was the people living in Vancouver, in the employed labour force aged 15 years and over in private households who worked at their usual place (i.e. not at home, outside Canada, or with no fixed workplace address). This population most closely reflected the characteristics of the ideal of participants in this study; not in one single industry, not necessarily all full-time, not working from home, living in Vancouver. This population totals 276,290 people.45 Taking this population number, with an 80% confidence interval and a 5% margin of error, the sample size for this study would be 165 participants. The confidence interval and margin of error come from the CARE cluster randomized controlled trial, where health behaviors and outcomes were monitored after workplace wellness interventions. They had achieved these numbers from their own calculations and from meta-analyses on physical activity interventions.19  After the first round of recruitment, two companies had dropped out for unknown reasons. The contacts at the drop-out companies were contacted once every other week for a total of three different emails, all with no response. The authors hypothesize that drop out was due   54 either to the survey taking place shortly after the December-January holiday break, new projects arising in the company, or predicted lack of interest in the study by the employees at the companies. This coupled with the fact that this sample size calculation was ambitious, it was decided to reduce the sample size to better suit the scope of this master’s project - as multiple years of recruitment were not practicable. After the literature review was conducted, it was decided that this study should aim to achieve completion rates aligned with similar studies in the field. Similar studies were found to report average participation rates between 10-35% of the total employee population.22,48,49,52,63,71,82-85 With the total workplace population of 135 employees at the recruited workplaces and with an 80% confidence interval and 5% margin of error, the sample size would be 75. An 11% margin of error was calculated with the sample size found in this study of twenty-eight participants. 3.3.3 Methods  Data collection included a single, online, survey that asked about different markers of wellness and quality of life. The consent waiver was an electronic cover letter at the start of the survey. The survey is called the WellSuite® IV Health Risk Assessment (HRA) for the Workforce (Non U.S.). It was created by Wellsource, a company that has created evidence-based assessments since 1979. Wellsource has been NCQA certified for Health Appraisals and Self-Management Tools since 2008. Their HRA is compliant with the latest privacy requirements of the Health Insurance Portability & Accountability Act (HIPAA), including the HITECH amendments, and the Genetic Information Non-discrimination Act (GINA). They also adhere to country-specific certifications and requirements as needed. It can be completed online with a computer, tablet, or smartphone. It takes about 10-15 minutes to complete. Nutrition standards and benchmarks are based on data from the Harvard T.H. Chan School of Public Health’s   55 nutrition recommendations and research and the 2015–2020 Dietary Guidelines for Americans. Activity measures include time spent sitting per day, average activity time (in minutes, per day), casual exercise time (walking, yard work, etc.), and strength training. Activity goals are based on data from the Harvard T.H. Chan School of Public Health’s fitness recommendations and the Department of Health and Human Services’ November 2018 Physical Activity Guidelines for Americans. This survey is available for use commercially and academically through Wellsource. It has been used in case studies with the companies Engine 2 (a plant-based nutrition company)86, Nebraska Medicine (which runs two hospitals and 40+ primary and specialty medical clinics)87, and SimplyWell (a full-service wellness provider)88. It was also utilized as the sole survey in the cross-sectional study by Carter & Pitt, which addressed lifestyle and behavioral influences on obesity in female employees.89 Since 2008, Wellsource’s surveys have been certified each year by the National Committee for Quality Assurance (NCQA) in the Wellness and Health Promotion (WHP) category.90 It is an independent certification that is considered the “gold standard”90 for health promotion and wellness products. By looking at modifiable risk factors such as diet, BMI, waist circumference, physical activity levels, and smoking and alcohol habits, we can begin to quantify overall wellness.91 When mental health question results are added, a clearer picture of a participant’s quality of life can be assessed. To access the survey, participants were given a generic username and password (each of which can only be used once) through an internally sent spreadsheet. The username and password were blinded to the researchers, and only known to the participant. To track which survey answers came from which company for analysis, usernames were grouped by company. For example, one company’s employees were assigned numbers from 001-500. Only those directly involved in the study knew which usernames corresponded to which company.   56 The sensitive information in the Wellsource suite was only accessed on secure servers, from secure devices in the Indigenous Studies in Kinesiology laboratory (Lower Mall Research Station, University of British Columbia). Only those directly involved in the study had access to the data during collection, analysis and publication. All involved in data management and storage were made aware of the importance of maintaining the privacy and confidentiality of this information. Data were only identifiable by subject code and will be published in a pooled format so that data are not personally identifiable. 3.3.4 Data Collection  WellSuite® IV Health Risk Assessment (HRA) for the Workforce (Non U.S.) The questions included duration of employment at each company, the percentage of time participating in the wellness program at the company, participant’s self-reported height, weight, and waist circumference, as well as diet, social wellness, work satisfaction, and mental health. Health measures included happiness, stress, energy levels, outlook on the future, life satisfaction, and work satisfaction. Diet questions included average, self-reported intakes of fruit, vegetables, whole grains, dairy, sweets, saturated fats, water, red/processed meat, poultry, fish, plant-based protein, leafy greens, nuts & seeds, sweetened beverages, and salt (per day or per week, depending on the question). There are also questions regarding smoking, alcohol consumption, and sleep. The survey is estimated to take between ten to fifteen minutes to complete. Details regarding the questions in the survey can be seen in Table 4.       57 Table 4 WellSuite® IV Health Risk Assessment (HRA) for the Workforce (Non U.S.) Questions Section Question Topic Section Question Topic Sub Questions Basic Information DOB, sex, race, education level, self-perceived health status, life and work satisfaction  Nutrition Breakfast habits, dairy/milk alternatives, fats, and salt consumption  Stress Work home, and financial stress, coping, social support  Servings daily Fruit, vegetables, whole grains, dairy, sweets, saturated fat, water Health Height, weight, waist circumference  Servings weekly Red or processed meat, poultry, fish, plant-based protein, leafy green vegetables, nuts and seeds, sweetened beverages   Activity Hours sitting per day     Time working out Per day, per week    Time spent doing non-workout activities Per day, per week    Strength-building exercise Time per week   Other Cigarette/tobacco and alcohol use, average hours sleep/night, rating of employer’s interest in employee wellness, time spent working at company, participation in company’s wellness program   Table 4 breaks down the questions contained in the WellSuite® IV Health Risk Assessment (HRA) for the Workforce (Non U.S.).   58 Observing the Office Environment The built environment, including office layout, dining spaces, and accessibility to the outdoors, fresh air, and natural light was observed by the researcher. Leaving out this observational data would mean missing an opportunity to fully define and characterize the wellbeing environment of the workplaces. As a way to further categorize companies and wellness programs, the built environment of the workplace will be observed and recorded. Based on a review of measures of worksite environmental support for PA and nutrition92, the Checklist of Health Promotion Environments at Worksites (CHEW) was chosen. It was not only included in that review, but also used in a study in the systematic review conducted as a part of this graduate project.47 Almeida et al. also modified the checklist for usage in their study.47 As mentioned before, the CHEW is a 112-item checklist used to assess the characteristics of worksite environments that are known to influence health behaviors and outcomes.23 It is comprehensive and time-consuming to conduct. It works best when analyzing just one type of workplace23 and not a variety, as that may result in missing data. For those reasons it was decided to use a modified CHEW checklist for this study. This keeps the organization and ideas of CHEW, while ensuring a higher level of relatability between the checklist outcomes and the workplaces in this study.  The CHEW categories chosen in this study are: 1. Is office freestanding or connected to other buildings? 2. Are there changing rooms and showers? 3. Staircases a. Open or enclosed, centrally located? 4. Office Layout   59 a. Open office or traditional (cubicle or enclosed desks) 5. Fitness Centre a. In-house or on grounds/campus 6. Vending machines a. Healthy offerings, unhealthy offerings, none at all 7. Healthy eating choices/environment/education a. Description of food and nutrition environment 8. Lunchroom/eating space a. Communal or private 9. Walking paths (not sidewalks) a. Paved or unpaved designated walking paths 10. Grassy areas/access 11. Sidewalks 12. Bike lanes 13. Restaurants/cafes/bars (within 5 blocks) a. Access to restaurants/cafes/bars in a variety of price ranges, healthful options, etc. 14. Food shops (within 5 blocks) a. Access to large grocery stores, convenience stores, etc.       60 3.4 Data Analysis Data are described using descriptive statistics, contingency and frequency tables, ordinal logistic regression, non-parametric one-way ANOVA, independent samples T-tests, and one-way ANOVA. Means of overall wellness scores (OWS), mental health scores (MHS), nutrition scores (NS), and fitness scores (FS) were calculated. Contingency tables were used to visualize work and life satisfaction, future outlook, self-assessed health, and happiness compared between the control group (CG) and experimental group (EG). Ordinal logistic regression between the EG and CG was used to assess OWS, NS, and FS. Models were run comparing OWS, MHS, NS, and FS; with each of the variables individually; comparing MHS, NS, and FS; and finally comparing OWS, NS, and FS to determine best Akaike information criterion (AIC). Non-parametric one-way ANOVA with dependent variables OWS, MHS, FS, and NS was used with the Kruskal Wallis test to compare the EG to the CG. The independent samples T-test with Levene’s test was used with the hypothesis that the EG > CG in OWS, NS, FS, MHS, and exercise frequency. Finally, contingency tables addressed many specific questions in the nutrition and fitness sections of the survey, such as intakes of different food groups.           61 3.5 Results This section of the chapter describes the results of the present study. It begins with the results of observing the office environment, continues into the results regarding overall wellness scores and QoL. It then describes results observed in nutrition and physical activity outcome domains.  3.5.1 Office Environment Observations   The results of the modified CHEW checklist are displayed in Table 5.   Table 5 Modified CHEW Results Category Company 1  Company 2  Company 3  Company 4  Freestanding or connected to other buildings?* Freestanding Freestanding Part of office building Part of office building Changing rooms and showers? Yes Yes No Not directly in-office Staircases Open Closed n/a Closed Office Layout* Combination Traditional Combination Traditional Fitness Centre In-house In-house None On grounds Vending machines* Healthy None None Healthy and unhealthy Healthy eating choices/environment/education Variety of food options Variety of food options, nutrition education, nutrition promotion Healthy lunches Variety of food options, nutrition education, nutrition promotion Lunchroom/eating space* Communal Communal Communal Communal Walking paths (not Good access Good access Good access Good access   62 sidewalks) Grassy areas/access Direct access Direct access Good access Direct Access Sidewalks Direct access Direct access Direct access Direct access Bike lanes Direct access Direct access Direct access Direct access Restaurants/cafes/bars (within 5 blocks) High variety High variety High variety Medium variety Food shops (within 5 blocks) High variety High variety High variety Medium variety  Direct access = within 1 block Good access = within 5 blocks                                                                                      *= not included in CHEW score Green shading = optimal responses Yellow shading = intermediate responses Red shading = less optimal responses  Observations from the CHEW checklist can be assigned values for scoring. After the checklist was completed it was observed that four categories - freestanding building, office layout, vending machines, and lunchrooms/eating space - did not contain enough evidence to assign a positive or negative value to the potential responses. For example, we do not know if having a healthy vending machine is better than having no vending machine. A freestanding office may indicate a larger/more profitable company (more funds to put towards rental space/more space needed) and therefore a company with greater resources to dedicate to wellness programs. So, these four categories were excluded from the score. The rest of the items were scored in a binary fashion. If the highest possible ranking was achieved, that category received one point. If not, it received zero. In this manner, eleven total points were possible. Companies 1 and 2 each achieved ten total points, and companies three and four each achieved   63 six total points. All companies had good access to walking paths (accessible within five blocks of the office) and direct access to sidewalks and bike lanes.  Companies 1 and 2, each with ten points, shared many similarities in regard to the CHEW categories. But Company 1 had a combination/hybrid office layout and healthy vending machines, compared to traditional and none in Company 2. Company 1 had the highest survey response rate, at 32%. 3.5.2 Demographics, Descriptions of Programs, and Response Rates  Demographics The majority of the participants were female (68%, N=19) and the remaining nine participants were male (32%). Of the twenty-eight respondents, 46% (N=13) earned a bachelor’s degree and 43% earned a graduate degree (N=12). The majority (82%, N=23) were employed at their company as a full time, in-office worker. Three participants had been working for 6 months or less, four for 6 months-1 year, nine for 1 year-3 years, seven for 3 years-5 years, four for 5 years-10 years, and one for over 10 years. Seven percent of the participants classified their race as Asian, seven percent as Hispanic, Latino, or Spanish, fourteen percent other, sixty eight percent white, and four percent Pacific Islander.   Descriptions of Programs  Table 6 describes each company’s industry and how their mission statement may relate to wellness. It then describes the nutrition, PA, and other programming that make up the WWP. It also shows participant distribution between the CG and IG at each company.     64 Table 6 Participating Company and WWP Descriptions Company Company Description Nutrition Programming Physical Activity Programming Other Programming Participant Distribution Company 1 An athletic and lifestyle apparel company. Its messaging and products promote health and wellness to their customers, and those values are reflected in the workplace environment. Employee health is a central tenet of its mission statement and workplace design. • Healthy vending machines • Occasional local restaurant lunch delivery • Free fitness and meditation classes at in-house studio every day • Monthly fitness stipend for each employee • Informal fitness/sports groups created and run by employees  • Control Group (CG)=6 • Intervention Group (IG)=10 Company 2 Company 2 is in the financial and banking technology industry.  • Healthy lunch option in cafeteria every day • On-site gym/fitness center • On-site yoga classes 2x/week • Informal fitness/sports groups created and run by employees • Lifestyle Incentive Program: Employees can accumulate points by exercising, losing weight, smoking cessation, etc. & can exchange points for up to $400/year • CG=0 • IG=2 Company 3 An athletic and lifestyle apparel company. Its messaging and products promote health and wellness to their customers, and employees are encouraged to live healthfully and promote • Chef at office who focuses on healthy cooking • Family dining atmosphere • Free lunch • Weekly fitness classes • Local fitness discounts  • CG=4 • IG=2   65 wellness through their own lives. • Able to eat lunch outdoors Company 4 Company 4 is an office-based department of an academic institution. It manages wellbeing initiatives on campus and some human resources topics for staff and faculty. • Food and dining discounts • Extended benefits that cover wellness and nutrition services • Nutrition education • Discounts to fitness centers • Fitness and activity initiatives and education  • CG=0 • IG=4  Response Rates  The average response rate (the percentage of the total employed population who completed the survey) for this study was 18.25%. Below is a table detailing the response rates by company. One participant who began the survey did not complete it for unknown reasons.  Table 7 Company Response Rates Company Responses Total Employees Percent Response Rate Company 1 16 50 32.00% Company 2 2 20 10.00% Company 3 6 40 15.00% Company 4 4 25 16.00%   Average Response Rate 18.25%    Only Company 1 and Company 3 had participants in both experimental (participating in the wellness program at their company 25-100% of the time) and control (participating in the wellness program at their company 0-25% of the time). This fact means that whenever EG and   66 CGs are compared in the results and discussion of this study, it is predominantly a comparison of Company 1 and Company 3. The EG includes participants from both Company 2 and Company 4 as well, but the more meaningful comparison when looking at EG vs CG is between Company 1 and Company 3. With all 28 participants, 10 make up the control group and 18 make up the experiment group.  3.5.3 Quality of Life Outcomes   Hypothesis one states that employees who participate in a workplace wellness program with nutrition and physical activity components will have significantly higher wellness scores compared to employees at their company who do not participate. As previously stated, in this study, QoL is measured mainly by the overall wellness score (OWS), calculated by averaging then combining the totals of each section of the survey. This score quantifies the participants mental, physical, nutritional, emotional, and preventative health. Mental Health Score (MHS), future outlook, happiness, work satisfaction, and life satisfaction were also measures of interest in this section.   All participants completed the waist circumference self-measurement question, with all but one participant falling within the healthy range for their gender, as defined by the Heart and Stroke Foundation of Canada.93  In Company 1 and Company 3 (companies with a control and experimental group), the average OWS was higher in the experimental (Company 1=73.8, Company 3=81.5) than in the control group (Company 1=69.5, Company 3=65.8). According to the Independent Samples T-Test, the experimental group had significantly higher chance of having a higher average OWS (p = 0.025) and Fitness Score (FS) (p = 0.013) than those in the control group (Table 8). Figure 2 displays OWS score distribution and Figure 6 displays FS distribution. The differences between   67 the average Mental Health Score (MHS) between groups was not significant, but in the EG it was observed that the average MHS trended slightly higher (74.2) than the control groups (73.5). When asked to rate their work satisfaction, fourteen participants in the experimental group (78%) stated they were mostly or very satisfied with their job, and eight participants in the control group (80%) stated the same. The life satisfaction question found eight in the experimental group (44%) very satisfied compared to two in the control group (20%). When assessing their own overall health, seventeen participants in the intervention group (94%) rated themselves to have good or excellent health, compared to only seven in the control group (70%). One participant in the experimental group rated their health as fair (5%), the lowest ranked response to that question (potential responses include fair, good, and excellent) compared to three participants in the control group (30%). Overall happiness differed between groups, with six in the experimental group (33%) rating themselves as very happy compared to three in the control group (30%). Eleven in the experimental group rated themselves pretty happy (61%), where question responses ranged from unhappy to very happy, compared to seven in the control group (70%). Tables with this data can be found in the appendices in the QoL measures section.  Table 8 Experimental vs. Control Group of all Companies Statistical Comparison           Score Statistic df p Cohen's d Overall Wellness Score 2.049 26 0.025 0.8083 Nutrition Score 1.208 26 0.119 0.4763 Fitness Score 2.367 26 0.013 0.9334 Mental Health Score 0.164 26 0.435 0.0648 *Independent Samples T-Test, Student's T-Test   68 Figure 2 Overall Wellness Score Plot                       *The Shapiro-Wilk Test of Normality for these variables (p=0.109) determines that the data is normally distributed.  Figure 3 Overall Wellness Score Chart    69 3.5.4 Nutrition Outcomes   Hypothesis 2 relates to the nutrition measures of this project and states that employees who participate in a workplace wellness program with nutrition and physical activity components will have higher overall diet quality than those who do not participate in the program, as evidenced by higher intakes of fruits, vegetables, whole grains, lean protein, plant-based protein, nuts & seeds, and leafy greens. The average Nutrition Score (NS) trended slightly higher in the experimental (71.1) than in the control group (65.9), though the relation was not significant. The highest Nutrition Score was seen at Company 4 (82.3), which proved significantly higher than the mean NS at the other companies with Ordinal Logistic Regression (p=0.039). This p-value was seen in a model with an AIC of 67.2 where NS was run with OWS and FS. An even lower p-value for NS (p=0.011) was seen when the model included MHS, NS, and FS (AIC=65.6); MHS replaces OWS. Figures showing nutrition scores can be found in Figures 4 and 5. It was determined that increased participation in the wellness program (by percent of time) led to increased Nutrition Score (p=0.035). Fruit, vegetable, whole grain, sweets, water, saturated fat, and dairy intakes were all similar (within one serving per day) between the experimental and control groups. Ten participants in the experimental group (56%) had zero servings of red meat per week, while only two in the control group (20%) had zero servings per week. In the experimental group, seven participants (39%) recorded two or more servings per week of fish, while only two in the control group (20%) recorded the same intake. When asked about intake of plant proteins, ten in the experimental group (56%) and three in the control group (30%) reported consuming four or more servings per week. Twelve participants in the experimental group (67%) consume four or more   70 servings of leafy green vegetables per week, compared to 9 (90%) in the control group. Six in the experimental group (33%) consumed six or more servings of nuts and seeds per week, compared to two participants (20%) in the control group. Twelve participants (67%) in the experimental group consumed no sweetened beverages each week, compared to seven participants (70%) in the control group. Detailed intake tables with this data can be found in the appendices under the nutrition measures section.  Figure 4 Nutrition Score Plot   Nutrition Score is the weighted total of the nutrition questions in the survey. The Nutrition Score can therefore be used to quantify a participant’s average diet quality.   *The Shapiro-Wilk Test of Normality for these variables (p=0.328) determines that the data is normally distributed.      71 Figure 5 Nutrition Score Chart  3.5.5 Physical Activity Outcomes   Hypothesis 3 refers to physical activity and states that employees who participate in a workplace wellness program with nutrition and physical activity components will report more time spent being physically active per week than employees who do not participate in the program.  When asked to estimate their exercise minutes per day (on days that they exercise), participants in the experimental group logged 61.94 minutes compared to the control group, who logged 50.50 minutes. In terms of active minutes per day (in the survey, this question is phrased as, “Other than when you’re working out, how much time do you spend being physically active? Examples: Walking briskly, casual biking, yard work.”, the experimental group reported 64.17   72 minutes compared to 46.50 minutes in the control group. This time does not include exercise minutes. When asked about how many days per week the participant exercised, the experimental group averaged 4.83 days compared to 3.10 days in the control group. This measure was statistically significant according to the independent samples T-test (p=0.009). Finally, the experimental group spent an average of 5.44 days a week being active, compared to 4.40 days in the control group. Figures showing distribution of Fitness Scores can be found in Figures 6 and 7.  Figure 6 Fitness Score Plot  Fitness Score is the weighted total of the physical activity and cardiorespiratory and physical fitness-related questions in the survey. The Fitness Score can therefore be used to quantify a participant’s average engagement in physical activity and overall fitness.  *The Shapiro-Wilk Test of Normality for these variables (p<0.001) determines that the data is not normally distributed.   73 Figure 7 Fitness Score Chart               74 3.6 Study Limitations and Biases Study Limitations Several limitations exist in this study. In order to increase participation in the survey, it took only ten-fifteen minutes to complete. A longer survey would have been more comprehensive, but likely have lower completion rates.81  This survey was completed by the participants themselves. Self-reported numbers may not be as accurate as data independently collected by researchers; participants have been shown to underestimate their body mass and waist circumference and overestimate their height.94 Participants may also overestimate their active minutes per day and servings sizes of foods consumed.74 These data can be considered representative but not exact.94  In order to access the survey, participants needed a unique username and password. The usernames and passwords were distributed electronically. This extra step likely resulted in fewer participants than would have resulted if the survey could have been accessed through a simple URL link. Alternatively, the companies who agreed to participate anecdotally reported that the extra security provided by this step was appreciated and was a reason they agreed to participate.  A major limitation to what can be interpreted from the results of this study is the small participant numbers. While some statistical significance was found, more would have been able to be attained had the participation numbers been higher. Many statistical comparisons were done by lumping together the control and EGs from all companies. While meaningful when interpreted correctly, the outcomes from those comparisons would have been more meaningful if participant count had been high enough to compare EG and CG at each company individually. Additionally, securing the participation of entire workplaces rather than specific teams would   75 have helped to eliminate some selection bias. Those teams who agreed to participate may have been healthier than those who opted out.  A limitation of the current study worth discussing is the health-centric culture of three out of four of the companies surveyed. Only Company 2 is neither in the wellness industry nor managing wellness in some way or focused on employee wellness as a central tenet of their mission statement. Companies who are involved in the health space were likely more apt to respond to recruitment to be in a study about health in the first place. Similarly, the participants surveyed may represent a healthier-than-average population. For more representative data, a more diverse selection of companies should be surveyed. That was the goal of recruitment in this study, but time, resources, and uncontrollable factors (i.e. companies dropping out and not responding) did not allow for the ideal distribution of industry diversity. Finally, Vancouver is a relatively healthy city and British Columbia is a relatively healthy province. The average life expectancy of all ages is higher in Vancouver than the British Columbia (BC) average.45 Additionally, Vancouver reports lower prevalence of asthma, COPD, diabetes, heart failure, and high blood pressure than the BC average.45 Anecdotally, Vancouver has a reputation of being a highly physically active city, and the access to the outdoors that the geographic location of Vancouver provides attracts a healthy and activity-loving community. On a larger scale, Conference Board Canada reports that BC is the top placing province in its provincial health report card.95 The provincial health report card evaluates Canada and fifteen peer countries on the following indicators: life expectancy, premature mortality, infant mortality, self-reported health status, mortality due to cancer, mortality due to heart disease and stroke, mortality due to respiratory disease, mortality due to diabetes, mortality due to diseases of the nervous system, suicides, and self-reported mental health.95 Vancouver is home to many health-  76 related companies, which attract employees who are interested in the manifestos they represent. The companies who agree to complete a health-related survey are likely filled with healthier employees than those who may decline to participate. This selection bias also impacts the employees at those companies who participate vs those who do not. These factors may skew the sample, making it healthier than the general population of British Columbia, Canada, North America, etc. This limits the applicability of the results to a small sample rather than to a larger demographic. Interestingly, the demographic population of Vancouver differs greatly from the demographics of this study sample. The largest differences lie between the Asian ethic groups (46.5% of the Vancouver population45, 7.14% of the study population) and the European/White ethnic groups (49.3% of the Vancouver population45, 68% of the study population). In addition, of the twenty-eight respondents, 46% (N=13) earned a bachelor’s degree and 43% earned a graduate degree (N=12). Two participants had completed some college and one did not respond to that question. In 2016, 73% of Vancouverites between the ages of 25 and 64 had some form of postsecondary credential, including 5% with apprenticeship or trades certificates, 21% with college/university diplomas, 30% with undergraduate degrees and 17% with post-graduate degrees.45 The sample in this study is not representative of the population of Vancouver in terms of education, an important measure related to socioeconomic status (SES). Socioeconomic status is a vitally important concept to consider when addressing public health and wellness. The companies in this study may have hired employees with a higher SES to begin with, as they are more technical, and their jobs require certain degrees to attain. Then once participants have those jobs and pay levels their SES may increase even more. Having low SES is a risk factor for many health problems, chronic stress, and higher morbidity and mortality.96 The health of this survey population is further evidenced by the fact that 96% of participants reported a healthy waist   77 circumference according to the Hearth and Stroke Foundation of Canada’s guidelines.93 A larger sample size more representative of the demographics of the city would be more effective for making connections between the health and impact of WWPs on Vancouver citizens. In conclusion, there are several limitations in this study. In regard to the survey itself, the limitations include the shorter, more limited nature of the survey, the fact that the survey was self-reported, and the requirement of a unique username and password to access it, likely leading to decreased participation numbers. On a larger scale, the small sample size of the study and selection bias of surveying employees at “healthy” companies located in a relatively healthy city are additional limitations to the validity of the findings.                         78 Chapter 4: Discussion and Conclusion  Chapter 4 begins with reflections on this project. It then goes into future directions for research in this field. The discussion of the results from this study follows. Finally, it ends with the conclusion statement of this study.  4.1 Project Reflections  Recruitment was a major issue in this study. In order to recruit more companies and therefore more participants, more time should be devoted to the task, i.e. recruitment should start earlier than the planned survey date. Employees and decision-makers at companies are very busy, and often take longer than expected to respond to messages – this time could have been better accounted for. An email or flyer campaign may also be advisable for the first stage of recruitment. Companies from a wider variety of industries should have been recruited in order to decrease bias. “Healthy” companies (those in the fitness or health industries) proved more likely to agree to participate than more general offices or business companies. Four out of the six initial companies recruited were related to the health and wellness industry in some way. This represents a major bias of this study. Completion rates were not a large problem, as only one participant who started the survey did not complete it. Missing data were not an issue and participants filled out all pertinent questions. This adds validity to the various scores calculated. It also suggests that the survey used was completable and intuitive. The user interface is highly designed and includes help buttons that, for example, explain to participants what a serving size of a particular food is. When compared to a survey that is just black and white, no explanation of questions or help available, one would guess that the more user-friendly survey would have higher response rates   79 and would be more well received. This would be an interesting avenue for future research. In regard to participation rates at the companies recruited, a researcher should go to the office to instruct or promote the survey to employees if at all possible, to help increase awareness of and participation in the survey. Finally, if budgets allow, it would likely increase participation if completion of the survey could be incentivized. Even a small “raffle prize” has been proven to increase completion rates of surveys and is widely used in research and industry, as well as reduce selection bias.97,98  This or a similar project may have been better suited to a multi-year, team project rather than an independent master’s thesis. This would have allowed more time, funding, and resources to generate higher participant numbers and more detailed analysis over multiple years. Despite this, this project served as an excellent learning opportunity and effective masters project. Some statistically significant results were found, and many trends were reported.              80 4.2 Future Directions As evidenced by the systematic review, there are a plethora of similar surveys available in this field. Instead of cutting-and-pasting separate surveys, or coming up with new one, it is time that researchers begin to pursue true validation for the existing surveys. This study’s utilization of a single survey is one of its strengths.  It may also be beneficial to develop more standardized language when talking about and describing wellness programs. This would allow for more consequential reviews and add cohesiveness to a field with a lot of differentiated data. For example, there could be clearer definitions for “nutrition education in the workplace”, and “fitness discounts”. Nutrition education in the workplace may be posters, classes, pop-up info sessions, etc. Fitness discounts may be rebates for gym memberships or discounts at local gyms or fitness classes. Each study typically defines these things on its own but coming up with widely accepted definitions would add a level of formality to a rather informal topic and help to push forward nation and world-wide efforts to implement programs.  Single-industry research projects may be more effective means of learning about workplace wellness. Choosing to recruit companies from a single industry per study would help to eliminate some confounding variables and be able to make more conclusive statements regarding results. Alternatively, it may be interesting to conduct further analyses of how and if industry alone impacts QoL measures and impact of WWPs.  This program of study is being completed in the spring of 2020, as the COVID-19 pandemic is impacting society. Around the world, many employees are working from home and facing the unique challenges that go along with that. Anecdotally, I think that this pandemic will change the way many companies and people work - shifting out of the workplace and into the   81 home. Some workplaces will certainly go back to in-office work once it is safe to do so, but I predict many will offer more flexibility in this area. Though not scientific, I feel that this idea is important to include in this paper as recognition that I am not blind to current issues and because the industry that this paper is written about has undergone such a drastic change in such a short amount of time. Work from home (WFH) presents challenges regarding motivation and productivity, as well as establishing routine without being in the presence of coworkers and often without a designated workspace. I suspect that there will be an increase in research and media (scientific and public) around how to work from home, and that guiding clients in how to succeed in WFH will become a new specialization for fitness, nutrition, and mental health professionals. Many principles of workplace wellness programming could also be adapted for the home. The challenge for workplaces in this increased WFH future will be to find ways to support their employee’s well-being while they’re in the home. Perhaps this will take the form of rebates and stipends for health and fitness expenses, as we have seen in some companies already. It is positive that WFH often gives greater flexibility of time for personal and family endeavors for employees, as well as monetary and environmental savings on commuting and the need to rent large office spaces. This is a new frontier for work and hopefully will create new opportunities for better health in the post-COVID-19 world.         82 4.3 Discussion  The WellSuite® IV Health Risk Assessment (HRA) for the Workforce (Non U.S.) was simple to use and to extract raw data from. Only one participant did not complete the survey once they started it, which is a positive sign for future use. After the literature and systematic review as part of this study, one may observe that the questions in the HRA are similar or equivalent to the questions that make up the patchwork of surveys used in similar studies.5,6,15,21,22,36,37,44,63,72,80 With further, more rigorous testing, the HRA could be validated for use in companies in British Columbia. This fact may also make it a competitive choice for companies looking to conduct their own internal review of WWP or overall employee wellness. Despite the small sample size, there are a number of measures in this study that achieved statistical significance or approached it. OWSs and Fitness Scores were statistically more likely to be higher in the experimental group compared to the control group (p=0.025 and p=0.013, respectively, according to the Independent Samples T-Test). The difference in Nutrition Scores between groups approached statistical significance, with a p value of 0.119. A similar finding, had it been significant and in a study with larger sample size and a more rigorous study design, would mean that participating in a workplace wellness program (at a company in Vancouver, BC) with nutrition and physical activity components may lead to increases in your overall wellness and physical fitness. These consistent and positive findings are promising but inconclusive for the positive quality of life and overall health impact of workplace wellness programs that incorporate both PA and nutrition components.  There were many trends observed in the data. Although not statistically significant, they are worth noting. Work satisfaction, self-assessed health, life satisfaction, and happiness were all higher in the experimental group than in the control group. These measures are particularly   83 important for the QoL definition. Work and life satisfaction are more obviously related to QoL. If you are satisfied with your work and life overall, you likely have a higher QoL than someone who does not.52 The same reasoning pertains to self-assessed health. If you rate yourself as a healthy person you would also likely think that your QoL is relatively high. In Company 1 and Company 3 (companies with a control and experimental group), the average OWS was higher in the experimental than in the control group. Those in the experimental group had a significantly higher chance of having a higher OWS (p = 0.025) than those in the control group (Table 8). The highest overall average OWS was seen at Company 4 (75.5), but this difference was not statistically significant. The differences between the average Mental Health Score between groups was not significant, but the experimental groups mean was slightly higher (74.2) than the control groups (73.5). These data may show that even at different companies, increased participation in the WWP leads to endorsement and self-reporting of higher QoL. Interestingly, Company 2 and Company 4 had the highest Fitness Scores and Nutrition Scores, respectively. Companies 2 and 4 also had the heaviest focus on PA programming (Company 2) and nutrition education programming (Company 4). While not statistically significant, Company 4 had the highest average OWS (75.5) followed by Company 2 with an average OWS of 73.5. If this statistic were significant in a larger sample and more rigorous study design, it may mean that focusing on a balance between PA and nutrition programming and avoiding heavy specialization in just one may have the greatest positive impact on employee QoL. A systematic review addressing the impact of healthy lifestyle interventions on mental health and wellbeing found that health behavior-change interventions targeting physical outcomes appear to have benefits to mental health and wellbeing, with the strongest evidence for interventions that targeted exercise and diet.52 Mental wellbeing is a large part of overall QoL.   84 Between all companies, the EG group reported higher work satisfaction, life satisfaction, overall health, and happiness than those in the CG (those who participated 25% or less of the time in the WWP at their workplace). The aforementioned systematic review supports the central tenet and findings of this study that addressing the physical, modifiable outcomes of diet quality and physical activity levels can improve mental wellbeing and therefore overall QoL.52  Company 2, with the on-site gym/fitness center, on-site yoga classes two times per week, and informal fitness/sports groups also had the highest average Fitness Scores out of the four companies. Their programming was the most in-depth physical activity programming of all of the participating companies, only slightly more offerings than Company 1. But Company 2 only had two survey responses, making this strictly observation. This result warrants further research into that type of PA programming and its impact on employee health. A systematic review of workplace PA interventions found that WWPs that used pedometers, applied Internet-based approaches, and included activities at social and environmental levels were more likely to report being effective than those without these characteristics.39 That review supports the findings of this study, where an on-site fitness center (environmental-level intervention) and a social fitness environment produced the greatest PA positive effect. Another review reported similar findings, with additional support for active commutes (walking, biking, or running to work), which all four companies in this study have the potential for according to the results of the CHEW survey.38 Promoting active commuting as part of the WWP and being physically located in a place where active commuting is possible may increase fitness level and physical health.38 That fact also supports the rationale that Vancouver, BC is a healthy place to work, as much of the city is walkable and bikeable. In order to see even greater physical activity and fitness positive   85 effects, usage of a pedometer program may be advisable, as it has been widely reported that pedometer programs are effective at producing these positive health outcomes.38,39   Company 4’s participants had the highest average Nutrition Score (not statistically significant). Observationally, they also had the most comprehensive nutrition education programming and promotion of the four companies. Workplace nutrition education has been shown to improve diet quality by other studies.99 Specifically, there is some evidence that nutrition education programs in the workplace can have modest positive effects (increase of less than or equal to a half-serving per day of each) in diet in terms of fruit and vegetable intake.34,80 But there is also uncertainty in regards to the effectiveness of workplace nutrition and dietary interventions, with some studies on the topic reporting little to no positive effects of interventions on overall diet.34,80 Two systematic reviews suggest that a combination of nutrition education and workplace dietary modifications (i.e. healthy food availability at the workplace) shows the greatest potential for positive dietary outcomes in participants.34,35 Company 4 focused the most on nutrition education, but other companies in the study surpassed it in healthy food offerings in the workplace. Companies 2 and 3 both offered healthy lunch options in the workplace each day. There is literature to support WWPs with nutrition components, but this study does not provide conclusive evidence for or against any modality of it.  When conducting the statistical analysis, multiple models were run for the ordinal logistic regression test comparing the overall scores to company. The lowest AIC (65.3) was seen when the NS and FS’s were combined. The second highest (65.6) when MHS, NS, and FSs were combined. Combining all four (OWS, NS, FS, and MHS) resulted in an AIC of 67.5. When individual models were run, only NSs AIC was lower than when they were all combined (66.4). This suggests a relationship between nutrition and fitness measures that is greater and more   86 related than when looking at either alone. The model containing MHSs is less high quality. Perhaps the mental health questions were less clearly worded or other confounding variables impact the MHS outside of the score, like time worked at job or weight. This would be an interesting avenue for future testing of the survey.   Vancouver is reported as a healthy place to work and live, and the results of this study defend that fact. After looking at maps while compiling CHEW data it became apparent that much of the city has excellent access to bike and walking paths, healthy food options, and nature. The locations of the companies add insight into the demographics of the employees who work there. The companies are located in more affluent areas of the city, and their employee base likely is from similar areas. Further, Vancouver’s average annual household income is also about $93,00011, higher than BC’s average and Canada’s average. Higher income means more discretionary income, and therefore more funds for individuals to spend on luxury or hobby pursuits. For Vancouverites this may be for health and fitness related services. All of these factors combine to first make Vancouver a healthy city and therefore bias the sample. This can be taken two ways. Either that Vancouver attracts healthy citizens because of the environment (natural and built) or that citizens become healthy once they live here because of the work and life environment. Likely the truth is a combination of these ideas. Office layout is a topic that has fluctuated greatly over time. From the 1960s when office cubicles were invented, to the more modern “open concept” office, each layout has pros and cons. Cubicles and closed desk spaces/separate offices do not promote as much collaboration as open-concept offices do. But open concept offices sometimes make employees feel watched, and employees find more distractions if they are so closely connected to the rest of their coworkers and office happenings. Today a consensus is that a hybrid office space - one with collaborative   87 and private workspaces - is the top option for productivity and health.100 Company 1 and Company 3 both have this type of hybrid/combined office space (Table 5). Company 2 and Company 4 have the traditional cubicle/closed office space (Table 5).  Many consistencies were found between the findings of this project and the findings of similar research. Overlaps in the findings included that participants showed increased happiness22,44, increased minutes of physical activity per week44,63, and better overall perceived health22,44 and physical QoL6,22,44. Studies with larger sample sizes were more likely to show statistical differences in increased intake of “healthy” foods (i.e. whole grains, fruits, vegetables, lean protein).44,47 Based on the healthy-leaning trends seen in the results of this study, if more participants had been recruited there may have been similar results to those larger studies.                  88 4.4 Conclusion This study showed that workplace wellness programming incorporating PA and nutrition components may be associated with higher self-reported QoL, diet quality, and physical activity levels. In terms of limitations, the selection bias of measuring QoL in a relatively healthy city like Vancouver, BC and the small sample size cannot be overlooked. The EG had significantly higher OWSs than the CG (p=0.025), and reported higher work satisfaction, life satisfaction, overall health, and happiness. Additionally, the EG had significantly higher FSs than those in the control group (p=0.013). A systematic review supports the findings of this study, where an on-site fitness center (environmental-level intervention) and a social fitness environment produced the greatest PA positive effect.39 Not addressed in the survey but supported by the CHEW checklist and the literature, promoting active commuting as part of the WWP and being physically located in a place where active commuting is possible, like the Vancouver, BC location of all four companies, may increase fitness level and physical health in participants.38 NS was also significantly positively correlated with the amount of time participating in the WWP across all companies (p=0.035). Two systematic reviews suggest that a combination of nutrition education and workplace dietary modifications (i.e. healthy food availability at the workplace) shows the greatest potential for positive dietary outcomes in participants.34,35 For future research, higher participation numbers, more strategic methodology around industries included, and diving further into the nuances of QoL are suggested. Overall, this study supports the existing literature around WWPs and adds to the field of quantifying QoL and the complex factors that it includes.     89 References 1. Garrin JM. The power of workplace wellness: A theoretical model for social change agency. Journal of Social Change. 2014;6(1):109-117. https://pdfs.semanticscholar.org/8434/e560a2da22fb7a0e5f6862d140008979b3de.pdf. 2. Ho S. The future of workplace wellness programs. Strategic HR Review. 2017;16(1):2-6. https://www-emerald-com.ezproxy.library.ubc.ca/insight/content/doi/10.1108/SHR-11-2016-0101/full/pdf. 3. 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