Question #1:
“About 610,000 people die of heart disease in the United States every year–that’s 1 in every 4 deaths. Heart disease is the leading cause of death for both men and women. … Of these, 525,000 are a first heart attack and 210,000 happen in people who have already had a heart attack.”
What are the modifiable and unmodifiable risk factors for heart disease?
In your opinion, why is heart disease still the leading cause of death in the U.S.?
Would you say that you follow a heart healthy diet? Why or why not?
Question #2:
After reading the article: “Impact of a four-year wellness programme on coronary artery disease risk in male employees”, why do you think changes in BMI and HDL cholesterol were not significant?
Do you feel that the program was successful? Why or why not?
Have you ever participated in an employer based wellness program and if so, what was your experience?
African
Journal for Physical, Health Education, Recreation and Dance (AJPHERD)
Vol. 17, No. 3 (September) 2011, pp. 489-501.
Impact of a four-year wellness programme on coronary artery
disease risk in male employees
L. LATEGAN, D.C. LOURENS AND A.J.J. LOMBARD
Department of Sport and Movement Studies, University of Johannesburg, South Africa; E-mail:
leonl@uj.ac.za
(Received: 21 February 2011; Revision Accepted: 12 May 2011).
Abstract
During the last few decades employers have realised that the health of an employee can have a
positive influence on productivity.Thus, some corporate employers started implementing
wellness programmes as part of their employee assistance programmes. In order to evaluate the
impact of such programmes, the present study used a sample of 91 male employees. Baseline
medical screening was performed after which a wellness programme was introduced. Employees
were monitored every year for progress and the post-test was performed at the end of the four-
year period. Employees were monitored for changes in total cholesterol (TC), high-density
lipoprotein cholesterol (HDL), low- density lipoprotein cholesterol (LDL), triglycerides (TG),
TC/HDL ratio, LDL/HDL ratio, fasting blood glucose (BG), systolic blood pressure (SBP),
diastolic blood pressure (DBP), body mass index (BMI) and total coronary artery disease (CAD)
risk.The Repeated Measures General Linear Model Test was used to determine significant
changes (p≤0.05) from pre-test to post-test. The results indicated that the wellness programme
significantly decreased CAD risk by 25.6%. The TC, LDL-C, LDL/HDL-C ratio, TC/HDL-C
ratio, BG, resting SBP and resting DBP also improved significantly, while TG showed a non-
significant improvement. Two CAD risk factors however, deteriorated significantly namely,HDL
and BMI.The major finding of this investigation suggests that a corporate wellness programme
has long-term beneficial effects on CAD risk in men and that the reduction in CAD risk is mainly
attributed to the beneficial effects of regular exercise and lifestyle modifications.
Key words: Coronary artery disease, wellness, exercise, employee.
How to cite this article: Lategan, L., Lourens, D.C. & Lombard, A.J.J. (2011). Impact of a four-
year wellness programme on coronary artery disease risk in male employees. African Journal for
Physical, Health Education, Recreation and Dance, 17(3), 489-501.
Introduction
Chronic diseases of lifestyle are responsible for 60% to 70% of all natural deaths
in industrialised, westernised communities (Chapman, 1991; AHA, 2003;
ACSM, 2006). Coronary artery disease (CAD) accounted for nearly 41% of
natural deaths in the year 2000 in the United States of America. Furthermore,
approximately 20% of Americans suffer from disorders like hypertension and
angina, related to CAD (AHA, 2003).
mailto:leonl@uj.ac.za
490 Lategan, Lourens and Lombard
The mortality rate from CAD in South Africa (SA) shows similar trends. In SA,
16.3% of all deaths between 1995 and 2005 were as result of CAD (Norman et
al., 2007) and between 1997 and 2004 on average,195 people died daily because
of some form of CAD.About 33 people die daily because of myocardial
infarction, while about 60 die daily because of stroke. For every woman who
dies of a heart attack, two men die (Bradshaw, n.d.). More than half of the deaths
caused by chronic diseases, including CAD, occur before the age of 65 years.
These are premature deaths which negatively affect the work force and have a
major impact on the economy of the country (Pestana et al., 1996; Bradshaw et
al., 2003). Preventing CAD by actively reducing its main risk factors like
smoking, hypertension, hyperlipidemia and physical inactivity, thus warrants the
urgent attention of all role players in the field of health.
Strydom, Dreyer and Wilders (1998) reported that South African men showed
four main coronary artery disease (CAD) risk factors: elevated total cholesterol
(TC), smoking, hypertension and physical inactivity. Dreyer (1996) reported
elevated levels of TC, low-density lipoprotein cholesterol (LDL), triglycerides
(TG) and total cholesterol/high-density lipoprotein cholesterol ratio (TC/HDL) in
South African men. A study by Van Zyl (1995), found that 62% of employees in
middle management positions had elevated TC levels (>5.2 mmol/l).These
findings are not surprising, especially when considering the low levels of
physical activity typical of this population. In support of this, Uys and Coetzee
(1989) found that only 12% of male managers in South Africa considered
physical activity a priority in their schedule, while Dreyer (1991) reported that
only 14.3% of male managers participated in regular and adequate physical
activity to render any significant health benefits.
During the last few decades, employers have realised that the health status of
employees can have a direct influence on their company‟s productivity. The
physiological advantages of regular physical exercise, such as an improvement in
cardio-respiratory fitness and improved energy levels, also have some
psychological advantages. These include improved morale and a positive feeling
towards employers, as well as lower levels of anxiety, higher mood state and
lower depression. Not only does physical conditioning have a positive effect on
productivity, it also has a direct influence on employee absenteeism (Pretorius et
al., 1989). A comparative study between two life insurance companies in
Toronto, Canada, revealed a 20% lower absenteeism level in employees from the
experimental company who took part in at least two physical workouts per week
over a ten-month period, compared to their more sedentary counterparts (Cox,
1982). The results of a classical study by Anderson and Jose (1987) showed that
sedentary employees spent 30% more days in hospital per year than their active
counterparts.
Impact of a four-year wellness programme on coronary artery disease risk 491
In an attempt to lower health-related costs of employees and improve
productivity, some employers have started implementing wellness and worker-
support programmes as part of their employee assistance programmes (Seaward,
1988; Schwartz, 1989; Uys & Coetzee, 1989). This practice began taking shape
in South Africa in the 1980‟s, when the first wellness programmes were
implemented in local companies (Strydom et al., 1985). However, recently, some
companies have started to question the economic viability of running expensive
wellness programmes. Very few published studies have measured the long-term
impact of corporate wellness programmes and thus, little evidence exists to
support the economic value of corporate wellness programmes. The aim of this
study thus, was to determine the long-term effectsof a corporate wellness
programme on the CAD risk of middle and top-level male managers.
Materials and Methods
The research design used followed an experimental, quantitative, pre-test post-
test design (Figure 1). The present study utilised a sample of 91 managers at
middle and top levels in one specific company. They were all informed of the
risks and benefits involved and they voluntarily participated in the study that
spanned over four years. Seventy six (83.5%) of the initial 91 managers who
started the research, successfully completed the four-year study. Fifteen
managers did not complete the four-year experiment, as some resigned and
others were transferred or retrenched. Baseline testing was performed before
each manager entered the wellness programme, and they were tested at yearly
intervals for four years.
The pre-test consisted of a thorough medical examination that included a resting
systolic blood pressure (SBP) and diastolic blood pressure (DBP) assessment,
followed by an anthropometrical assessment that included height, weight and
body mass index (BMI) and a fasting blood lipid profile pathology test that
evaluated TC, HDL, LDL, TG, TC/HDL and LDL/HDL, as well as blood
glucose (BG). After a fasting period of at least nine hours, a qualified nurse took
a sample of arterial blood which was used for the analysis. Blood analysis was
conducted by a commercial pathological laboratory. This assessment was
repeated each year for four years. A classification system (Table 1), based on
previously published research, was used to determine the participants‟ CAD
risk
at pre-test and again at post-test. The present article focuses on the changes that
occurred between the pre-test and the post-test, i.e. over the four-year period.
492 Lategan, Lourens and Lombard
Figure 1: Research design.
Pre-test (1)
Test
2
Test 3
Post- test (4)
Intervention
Intervention
Intervention
Statistical Analysis
SAMPLING
Impact of a four-year wellness programme on coronary artery disease risk 493
Table 1: Classification of CAD risk for selected risk factors.
Variable Risk Norm Risk Score Source
1. TC
(mmol/l)
Desirable <5.2 0
JAMA (1993)
ACSM
(2006)
Borderline High >5.2-6.2 1
High >6.2 2
2. LDL- Cholesterol
(mmol/l)
Desirable <3.4 0 JAMA (1993)
ACSM (2006)
Borderline High 3.4-4.1 1
High >4.0 2
3. HDL-cholesterol
(mmol/l)
Low risk >1.55 0
JAMA (1993)
ACSM (2006) Average risk 0.91-1.55 1
High risk <0.9 2
4. LDL/HDL-cholesterol
ratio
Normal risk <3.5 0
Holford
(1997)
Williams (2002)
High risk >3.5 1
5. TC/HDL-cholesterol
ratio
Normal risk <3:1 0
Bornow (1992)
Powers & Dodd
(1983)
Borderline High
risk
3:1-5:1 1
High risk 5:1-9:1 2
Very High risk >9:1 3
6. Triglycerides
(mmol/l)
Normal risk <2.0 0
JAMA (1993) Boderline High risk 2.01-4.51 1
High risk 4.52-11.28 2
Very High risk >11.28 3
7. Fasting Blood Glucose
(mmol/l)
Normal risk 3.3-6.1 0
Powers &Howley
(1997)
AACVPR (1999)
Pre-diabetes 6.1-6.9 1
Diabetes >6.9 2
8. Resting SBP
(mm Hg)
Normal risk <120 0
Robbins et al.
(2005) ACSM
(2006)
Prehypertention 120-139 1
Stage 1
Hypertension
140-159 mm
Hg
2
Stage 2
Hypertension
160-180 3
Robbins et al.
(2005) ACSM
(2006)
Stage 3
Hypertension
>180 4
9. Resting DBP
(mm Hg)
Normal risk <80 0
Robbins et al.
(2005) ACSM
(2006)
Pre-hypertension 80-89 1
Stage 1
Hypertension
90-99 2
Stage 2
Hypertension
100-110 3
Stage 3
Hypertension
>110 4
10. BMI (kg/m²) Normal risk 18.5-24.9 0
ACSM (2006) Overweight 25-29.9 1
Obesity Class 1 30-34.9 2
Obesity Class 2 35-39.9 3
Obesity Class 3 >40 4
494 Lategan, Lourens and Lombard
The corporate wellness programme included free access to a medical doctor, the
corporate gymnasium and supervised training programmes, access to recreational
clubs (e.g. cycling and running club) and regular health-related workshops on a
variety of wellness topics, like healthy nutrition and smoking cessation. In
addition, group tours were organised for individuals who participated in sporting
events like the Comrades Marathon, Two Oceans Marathon and Cape Argus
Cycling Tour. Less competitive managers were also catered for by offering
spinning and aerobics exercise classes four days per week, and organising
recreational activities in the form of river rafting and hiking expeditions once a
year. Efforts were also made to persuade the company caterers to offer healthy
food and beverage choices at the in-house cafeteria. Participation was voluntary
and no-one was forced to participate at any stage. However, the goal was to
create a supportive culture for making healthy lifestyle choices. As an example,
managers were allowed to attend exercise classes during working hours and
travel arrangements were coordinated to facilitate group participation in sporting
events over weekends. The company also established a fully-equipped
gymnasium and appointed a qualified exercise scientist to coordinate the
corporate wellness programme. Issues of medical confidentiality prevented the
researchers from having access to the information regarding which staff
members received chronic medication or specialised diets.
Data analysis
The collected data were analysed by the University of Johannesburg‟s Statistical
Consultation Services (STATCON). Descriptive statistics and the Repeated
Measures General Linear Model Test (Pohlmann & McShane, 1974) were
performed. This was done to determine the significance of the changes observed
between the pre-test and the subsequent post-test. A confidence level of 95% was
used to determine statistical significance (p≤0.05).
Results
The 76 male middle and top-level managers who participated in this four-year
study were middle-aged with a mean age of 45 years at the start of the study. The
results of the study are summarised in Table 2.
Total cholesterol was significantly (p<0.05) reduced by 13.98% from 5.51
mmol/l (±0.923) to 4.74 mmol/l (±0.92). At the start of the study, the
participants‟ TC level was “borderline-high” (5.2–6.2 mmol/l) (JAMA, 1993;
ACSM, 2006), but after the four-year corporate wellness programme the mean
TC level was in the normal range. In addition, of the 19 (25%) participants who
had “high” TC levels (>6.2 mmol/l), only five (6.6%) recorded values of above
6.2 mmol/l at the end of the four-year study period. This reduction in TC was
Impact of a four-year wellness programme on coronary artery disease risk 495
supported by a significant (p<0.05) reduction of 17.85% in LDL levels from 3.64
mmol/l (±0.837) to 2.99 mmol/l (±0.817). The group‟s mean LDL level at pre-
test placed them in the “borderline high” category (3.4–4.0 mmol/l), but at post-
test their mean LDL level was reduced to a “desirable” level. Twenty (26.3%)
participants reported high LDL levels (>4.0 mmol/l) at pre-test, compared to
only six participants (7.9%) at post-test.
However, the participants did not improve their TG or HDL levels. The
participants‟ TG decreased non-significantly (p>0.05) by 8.82% from 1.45
mmol/l (±0.732) to 1.33 mmol/l (±0.812), while their HDL reduced significantly
(p<0.05) by 4.2% from 1.22 mmol/l (±0.261) to 1.17 mmol/l (±0.247).
Table 2: Changes in CAD risk factors over the four-year period.
Pre/Post
Mean
(mmol/l)
SD Min Max
Diff.
Diff.
(%)
p-value
TC Pre 5.51 0.923 3.57 8.07
Post 4.74 0.920 2.60 7.43 -0.77 13.98 0.000
*
LDL Pre 3.64 0.837 1.92 5.75
Post 2.99 0.817 1.05 5.03 -0.65 17.85 0.000*
TG Pre 1.45 0.732 0.42 3.43
Post 1.33 0.812 0.34 3.59 -0.12 8.82 0.563
HDL Pre 1.22 0.261 0.73 2.09
Post 1.17 0.247 0.66 1.74 -0.05 4.20 0.018*
LDL/HDL Pre 3.12 1.00 1.02 6.52
Post 2.68 0.98 0.93 5.94 -0.44 14.03 0.000*
TC/HDL Pre 4.70 1.253 2.11 8.70
Post 4.22 1.249 2.30 9.41 -0.48 10.13 0.000*
BG Pre 5.01 0.472 3.90 6.50
Post 4.64 0.591 3.40 7.10 -0.37 7.43 0.000*
SBP Pre 130.64 11.69 109.0 170.0
Post 124.30 10.89 100.0 144.0 -6.34 4.84 0.022*
DBP Pre 77.82 9.12 58.00 100.00
Post 75.00 6.64 62.00 91.00 -2.82 3.63 0.020*
BMI Pre 27.58 4.80 19.00 44.70
Post 28.08 4.85 18.80 45.40 +0.50 1.81 0.012*
Total CAD risk Pre 8.08 3.067 1 15
Post 6.01 2.490 1 12 -2.07 25.57 0.000*
* Statistically significant difference (p<0.05); mmol/l = milli-mole per litre; SD = standard
deviation
Notwithstanding the fact that HDL did not increase as expected after exercise
training, the LDL/HDL and TC/HDL ratios respectively, improved significantly
(p<0.05) as a result of the magnitude of the reductions seen in LDL and TC,
respectively. LDL/HDL reduced significantly by 14.03% from 3.12 (±1.0) to
2.68 (±0.98), while TC/HDL reduced significantly by 10.13% from 4.7 (±1.253)
to 4.22 (±1.249).
496 Lategan, Lourens and Lombard
The fasting BG level of the participants also reduced significantly (p<0.05) by
7.43% from 5.01 mmol/l (±0.472) to 4.64 mmol/l (±0.591).The group‟s resting
SBP decreased significantly (p<0.05) by 4.84% from 130.64 mm Hg (±11.69) to
124.3 mm Hg (±10.89). Resting DBP also showed a small, but significant
(p<0.05) reduction of 3.63% from 77.82 mm Hg (±9.12) to 75.0 mm Hg
(±6.64).BMI showed a small, but significant increase (p<0.05) from 27.58 kg/m 2
(±4.80) to 28.08 kg/m
2
(±4.85). Finally, the group‟s total CAD risk showed a
significant reduction (p<0.05) of 25.57% from 8.08 (±3.067) to 6.01 (±2.49).
Discussion
Companies expect a return on investment and thus, a study investigating the
long-term effects of a corporate wellness programme was long overdue. The
present authors monitored middle and top-level managers yearly over a four-year
period, while providing them with support (Wellness Programme) in managing
their CAD risk.
From Table 2 and Figure 2, it is clear that the participants in the Wellness
Programme managed to make statistically significant improvements, in their TC,
LDL, LDL/HDL and TC/HDL levels, but failed to significantly improve their
TG and HDL levels. Shaw (2004) demonstrated decreases in TC (6.9%), LDL
(20.1%) and TG (29.4%) and an increase in HDL (22.4%) in healthy, sedentary
males (20 – 35 years) following 16 weeks of aerobic exercise training, while
Coopoo and co-workers (2000) reported reductions in TC (13.8%), LDL (2.8%)
and TG (47%) and an increase in HDL (16.4%) in people with hyperlipidaemia,
following 6 months of exercise training. The present group‟s significant decrease
in HDL (4.2%) and non-significant increase in TG (8.82%) after the intervention
period is in contrast to the other studies quoted above. One possible explanation
could relate to the absence of weight-loss demonstrated by the present study‟s
participants. Their BMI increased significantly over the four-year period and
thus, the participants remained “overweight” and although BMI is not a sensitive
method for determining body composition, particularly for determining
percentage body fat, regular aerobic exercise training has been effective in
reducing BMI (DiPietro et al., 1998; Shaw, 2004). At present, the precise
mechanism(s) responsible for alterations in lipoproteins and lipids following
exercise are unknown (Boyden et al., 1993). Exercise is thought to impact on
lipoprotein-lipid profiles by increasing lipoprotein lipase (LPL), which removes
cholesterol and free fatty acids from the blood (Stefanick & Wood, 1994). Many
researchers reiterate this finding by stating that regular AER results in a two- to
fourfold increase in LPL, effectively increasing the ability of a muscle fibre to
oxidize fatty acids originating from plasma TG (Holloszy et al., 1986). Another
possible reason for the present group not showing an improvement/reduction in
BMI over the four years, could be that they primarily engaged in resistance
Impact of a four-year wellness programme on coronary artery disease risk 497
versus aerobic exercise training which could explain an increase in BMI as a
result of increasing their lean muscle mass. However, since the authors did not
record the precise exercise mode, lipid-lowering drugs used, smoking, or dietary
intake for each participant, we cannot attribute these findings on TG, HDL and
BMI to exercise mode alone. Previous work done by Shaw (2004) and Goldberg
and co-workers (1984) indicated that resistance training did not lead to
significant increases in HDL. Notwithstanding the present study‟s findings on
HDL and TG, it is clear from Figure 2 that the intervention did have an overall
positive effect on blood lipids.
Figure 2: Percentage improvements in blood lipids after four years of interventions.
* Statistically significant change (p<0.05).
In terms of the other CAD risk factors monitored (BG, SBP, DBP& BMI), all of
them except for BMI showed a significant improvement (Figure 3).Both SBP
and DBP showed significant improvements following the four years, despite the
fact that the group‟s BMI increased (an increase in body weight is often
associated with higher blood pressures). The significant decrease in blood
*
*
*
*
*
498 Lategan, Lourens and Lombard
pressure that was observed shows the effectiveness of this programme in
addressing an important CAD risk factor. However, the programme was not
effective in combatting creeping obesity (commonly found in this population)
(Kroll, 2001). The authors would recommend that future studies pay more
attention to possible solutions for halting or reversing this trend among middle-
aged men.
Figure 3: Percentage improvements in other CAD risk factors after four years of interventions.
*Statistically significant change (p<0.05).
Conclusion
The four-year corporate wellness programme resulted in a meaningful and
statistically significant reduction of more than 25% in total CAD risk. Although
no attempt was made to make exercise compulsory, the mere availability of
medical practitioners, exercise facilities and training options and the fact that the
corporate culture in the company became supportive of healthy lifestyle choices,
promoted a healthier lifestyle which resulted in significant health improvements
by reducing CAD risk in this population. Future studies could possibly focus on
halting the phenomenon of creeping obesity in this population, as well as to find
effective long-term strategies to increase HDL levels and to decrease TG levels
by using non-pharmacological strategies.
Impact of a four-year wellness programme on coronary artery disease risk 499
Acknowledgement
Our sincere thanks to STATKON from theUniversity of Johannesburg for
analysing the data and to Kumba Resources for making this study possible.
Results of this study were presented at the 2008 SASRECON held in Port
Elizabeth.
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