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The educational program must include approaches to stress awareness/reduction at the environmental level and at the individual level.

Social, physical, and company stressors must be explained and methods to ease or elevate stressors must be presented. At the individual level how changes in attitudes and behaviors help one to cope with stressors; learning techniques to minimize stress response, such as meditation, relaxation response, and exercise.

Content of the program must support the following:
• Identifying sources of stress
• Relationship of stress to health
• How the individual experiences stress, personal, family, work
• Solutions for coping and managing stress
• Techniques for decreasing stress
• Value of stress, both negative and beneficial
• Practical steps of incorporating stress reduction into lifestyle

Personnel delivering stress management programs ought to have training in psychology, behavioral sciences, or related disciplines such as mental health professionals, counselors, health educators, psychologists, and psychiatrists. Training in a reputable program on how to instruct the stress management course including group process skills is a must.

A diet education program ought to include a nutritional needs assessment, education counseling, and referral as significant.

Educational sessions and materials should include the following information:

• The relationship of nutrition and chronic diseases
• Improving eating patterns
• Relationship of nutrition and proper weight maintenance
• Exercise
• Stress
• Blood Pressure (BP)
• Cholesterol
• Diabetes and other chronic diseases.
• Nutritionally accurate information regarding the relationship of health to diet, including cholesterol, fats, fiber, alcohol, carbohydrates, salt, sugar, and vitamin/mineral supplementation.

Methods for identifying healthier foods and incorporating low-calorie, high nutrient foods into eating habits. Guidelines for bettering eating habits ought to be based on or consistent with national recommendations such as The Food Guide Pyramid.

Instructor ought to be a registered dietitian, registered nurse, or have a baccalaureate degree or higher in health education with training in diet. If an allied health professional instructs the program, a consultation and review of the program design by a registered dietitian is recommended.

It is recommended that smoking cessation programs subscribe to the Code Of Practice for Tobacco Cessation Programs.

Smoking cessation programs must be multi-component with a focus on skills to build beneficial voluntary behavior change practices. Useful techniques include starting reasons for quitting, understanding the smoking habit, various techniques for stopping and remaining a non-smoker, overcoming the problems of quitting, short-term objective setting, weight management, stress management, importance of exercise, relationship of alcohol consumption to urges to use tobacco. Use no aversive or scare tactics.

In programs that use aids such as the “patch” or medications such as “Zyban” appropriate consultation ought to be available on the usage of these aids.

The instructor should have formal training in smoking cessation from a nationally recognized organization such as American Heart Association, American Cancer Society, American Lung Association, or a nationally recognized commercial program such as Smoke Enders.

Evaluation of success is occasionally very dubious in smoking cessation programs. Measurement of success should include participation rate, including the number implementing the program, the number completing the program, and the average number per session. Also included, number and percent who stopped smoking at the end of the program, and the number and percent who had not resumed smoking by the end of one year.

Participatory exercise programs must include education on benefits of regular exercise and risks of a sedentary lifestyle, its impact on cardiovascular health and diseases, its relationship with weight management and stress management, and aerobic exercise options. Discussion and practice of safe principles of exercise – warm up, cool down, frequency, intensity, duration, flexibility and strength components. The program follows ground rules by the American College Of Sports Medicine.

Safety precautions should include the following:

• Informed consent prior to beginning exercise with clear and complete written and verbal guidelines of possible risk, purpose of exercise, exercise format to be followed, opportunity for questions, and a signed informed consent with date.
• A screening/evaluation of participants to determine if medical evaluation is essential for exercise such as the Physical Activity Readiness Questionnaire (PAR-Q, see forms).
• Measurements of Blood Pressure and resting heart rate are useful evaluation information to determine exercise readiness.
• Participants who fail screening are medically referred and must obtain a written clearance from their physician to exercise.
• The basic content of an aerobic fitness program should include:

Warm up   5 – 10 minutes
Aerobic exercise   20 – 40 minutes
Cool down   5 – 10 minutes

Exercise instructors ought to have education and training in exercise physiology, physical education, physical therapy or comparable discipline, or possess a current certification by a nationally recognized sports medicine or exercise association, and be CPR certified.

Program offered is consistent with scientific and medical recommendations for weight loss, reflects a multi-disciplinary approach which offers four components: behavioral, exercise, diet, and maintenance, and is in accordance with the document Guidance For Treatment Of Adult Obesity. It includes:

• Screening to verify that the colleague has no medical or psychological conditions which would make weight loss inappropriate, and to identify the colleague’s level of health risk, classifying participants not only on excess body weight, but also on the basis of associated medical conditions and central heath risk.
• Referral for participants who are morbidly obese who would require medical guidance for weight loss.
• Informed consent, explanation of potential physical and psychological risk from weight loss and regain, likely long-term success of program, full cost of the program, credentials of the employee.
• Identification of contributing factors to colleague’s weight status, serving as the basis for an individualized weight loss plan which includes the weight goal and plans for nutrition, exercise, and behavioral components.
• Weight objective of attendant is reasonable based on personal and family weight history not solely on height and weight charts; initial weight loss objective does not exceed loss of 10% of body weight, 1-2 pounds per week.
• Explanation of unsafe weight loss methods.
• Daily calorie level is adjusted to meet each colleague’s recommended rate of weight loss.
• Daily caloric intake is not less than 1,000 calories; if less, physician monitoring is necessitated.
• Food plan designed so participants can choose foods which meet 100 percent of all the Recommended Daily Allowance (RDA) except for calories. Nutritional supplementation can be used to achieve RDAs, however must not greatly exceed RDAs.
• Nutrition education encouraging permanent healthful eating habits based on The Food Guide Pyramid.
• Participant involved in meal planning and food selection.

The protein, fat, carbohydrate, and fluid content of the food plan meet safety recommendations:

Protein   Between 0.8 and 1.5 grams of protein per kilogram of objective body weight, but no more than 100 grams of protein a day.
Fat   10 – 30 percent calories as fat.
Carbohydrate   At least 100 grams per day.
Fluid   At least one liter of water daily.

• Exercise component ought to be a significant portion of the program and be both didactic and experiential.
• Participant is appropriately screened for exercise using a screening questionnaire such as the Par-Q Readiness Assessment (see forms). Instruction on recognizing untoward responses to exercise.
• Participants work towards 30-60 minutes of exercise 5-7 days per week.
• No appetite suppressant prescriptions.
• Maintenance plan available for continued support.
• Weight control programs should be conducted by a registered dietitian or by degreed health professionals with training in nutrition with consultation by a registered dietitian.
• Trained lay leaders may support  if supervised by nutrition professional.

Note: There’s an interactive version of Guidance for the Treatment of Adult Obesity at e-Guidance for the Treatment of Adult Obesity.

A program is required to offer appropriate interpretation of blood lipid screening results, including a caution that a single measurement neither excludes nor establishes a diagnosis of their blood cholesterol.

Follow national ground rules:

Total Cholesterol
Desirable cholesterol   < 200 mg/dl
Borderline cholesterol   200 – 239 mg/dl
Hypercholesterolemia   > 240 mg/dl

HDL
Desirable HDL    > 35 mg/dl
Low HDL    < 35 mg/dl

Refer blood lipid screening participants to medical as follows:

Total Cholesterol
< 200 mg/dl    Recheck blood lipid in five years, if history of coronary heart disease or if two or more CHD risk factors are detected refers to risk reduction program or health professionals, as appropriate.
200 - 239 mg/dl    If history of CHD or if two or more other risk factors are detected, refer to healthcare or risk reduction service within two months; if no published history of CVD or less than two other risk factors, reassess blood lipid status within 1-2 years.
> 240mg/dl    Refer to medical care within two months.

HDL
> 35 mg/dl   If fewer than 2 risk factors and borderline total cholesterol, refer to risk reduction service, as appropriate. Reassess HDL in 1-2 years.

Provide the following:
• The relationship of blood cholesterol, elevated Blood Pressure (BP), and other risk factors.
   o Risk factors include: elevated Blood Pressure 140/90 or higher or on hypertension medication; current cigarette smoking; family history of premature CHD; diabetes mellitus; age – male > 45 years, female > 55 years or premature menopause without estrogen replacement therapy.
   o Negative risk factor: high HDL 60 mg/dl or greater (subtract one risk factor).
   o Risk factors such as family history, smoking, high fat or other unhealthy diet, and lack of exercise lead to the development of cardiovascular disease (CVD).
• Definitions and causes of high blood lipids and HDL, desirable levels, the meaning and limitations of a single measurement, the cause of variability, and the need for multiple measurements prior to diagnosis.
• Wide range of treatment options, including diet (e.g., effect of controlling fat intake less than 30 percent of total calories from fat, less 10 percent saturated fats), less than 300 mg. of cholesterol per day, well-balanced diet, weight maintenance or reduction, exercise, and medication.
• Importance of following prescribed treatment and professional advice.

Appropriate healthcare or allied health professional trained in measurement of Blood Pressure (BP), referral protocols, and delivering educational messages to attendant conducting Blood Pressure (BP) programs. These programs are necessitated to follow national standard procedures.

• National ground rules for Blood Pressure protocols:
   o Calibration of Blood Pressure calculating equipment
   be done at least each year.
   o Two or more measurements of colleague’s Blood Pressure should be taken.
   o Referral of participants with elevated Blood Pressure (BP) readings to personal physician for further evaluation.

• Systolic/Diastolic Follow-Up:
   o Normal:   <130 / <85
      Action: Recheck in 2 years
   o High Normal:   130-139 / 85-90
      Action: Recheck in 1 year

• Hypertension:
   o Stage 1 (Mild):   140-159 / 90-99
      Action: Confirm within 2 Months.
   o Stage 2 (Moderate):   160-179 / 100-109
      Action: Refer to source of care within 1 month.
   o Stage 3 (Severe):   180-209 / 110-119
      Action: Refer to source of care within 1 week.
   o Stage 4 (Very Severe):   >210 / >120
      Action: Refer to source of care immediately.

• Appropriate educational messages:
   o Normal:   <130 systolic and <85 diastolic
      Action: No referral. If on treatment, then inform attendant that Blood Pressure (BP) is under good control today and should continue seeing and following treatment program.
   o High Normal:   130-139 systolic and/or 85-89 diastolic
      Action: Recommend that participant have Blood Pressure (BP) rechecked within 1 year unless under treatment. Advise participant that the readings are in a high normal range that needs rechecking. In the interim, suggest that one of the most effective means to decrease Blood Pressure (BP) is to bring weight into normal range and to exercise.
   o High:   >140 systolic and/or >90 diastolic
      Action: Refer to physician for further evaluation within 2 months unless the level is within urgent, emergency, or isolated systolic hypertension levels. If already on treatment, advise attendant of readings and need to get Blood Pressure to a intention of 140/90 or less.
   o Isolated Systolic Hypertension:   140-159 systolic and < 90 diastolic in a attendant 65 years of age or older.
      Action: Advise colleague to inform physician of readings at next visit and consider advice regarding weight loss and exercise if appropriate.
   o Urgent:   180-209 systolic and/or 110-119 diastolic
      Action: Recommend obtaining health care evaluation within 1 week.
   o Emergency:   >210 systolic and/or >120 diastolic
      Action: Obtain immediate medical attention.

• Provides the following:
   o Written results, referral ground rules, and an explanation of Blood Pressure levels given to each colleague with individualized counseling, including advice about the interval of time recommended when the colleague must be checked again.
   o Utilizes the recommendations in The Fifth Report Of The Joint National Committee on Detection, Assessment and Treatment of High Blood Pressure (BP), March 1994.
   o Written and audiovisual materials that are informative, easy to understand, and useful while containing scientifically accurate information.
   o Relationship of elevated Blood Pressure and other risk factors, such as family history, smoking, high fat and unhealthy diet, lack of exercise, in the development of cardiovascular disease, including stroke, kidney disease, heart attack, and other diseases.
   o Definition and causes of elevated Blood Pressure (BP).
   o Importance of following prescribed treatment.

Health risk screening programs should be carried out on a one-on-one basis by trained healthcare professionals. Health risk measures should include the following:

• Blood Pressure measurements – at least two Blood Pressure measurements taken during the assessment episode, using a mercury sphygmomanometers or regularly calibrated aneroids.
• Blood Pressure treatment status – determine whether the colleague is under a doctor’s care, on any medication, on a prescribed diet, or any other type of treatment for hypertension.
• Blood cholesterol measurement – total cholesterol and HDL-cholesterol taken either using a properly tested and maintained table top blood analyzer offering immediate feedback to the client, or sending blood to a laboratory offering feedback using a method that is as effective as immediate feedback.
• Cholesterol treatment status – evaluate whether the client is under a doctor’s care, on any medication, on a prescribed diet, or any other sort of treatment for elevated blood lipids.
• Obesity – utilize an accepted method for estimating obesity. By way of example assess participants height and weight and use the 1959 Metropolitan Life Height/Weight charts or use Body Mass Index.
   o Identify people 20% or more above their ideal weight.
• Smoking status – assess whether the participant currently smokes cigarettes, whether the client has quit or never smoked, and the number of cigarettes smoked/day.
• Exercise habits – assessment questions may be limited to frequency and duration exercise. Do participants exercise in a moderately vigorous fashion at least three times per week for 30 minutes or more.
• Diabetes – whether the client has diabetes, and whether or not it is currently under control. A blood glucose may be also done via finger stick and desk top analyzer. Several manufactures make available cassettes which include blood lipid and glucose measurements.
• Cerebrovascular disease or occlusive PVD – ascertain if the client has had a stroke or other kind of blood vessel disease.
• Family history of cardiovascular disease – ascertain whether any of the participants’ parents or siblings had a heart attack or sudden death due to heart disease before age 55.
• Coronary heart disease – evaluate if the client has had a heart attack or other type of coronary heart disease.
• Stress – attendant’s assessment of stress in work and/or personal life. A series of well-tested and validated questions assessing levels of stress are available from the Worker Health Program.
• Participant release form (see forms) – A release form is necessitated in which the participant authorizes the program to draw blood for testing to send information to the participant’s medical care provider if medical care risks are identified, and to obtain information from the provider about diagnosis and prescribed treatment.
• Participant interest survey – if an assessment of interest has not been collected previously, the assessment exercise must evaluate levels of interest in programs such as: weight management, tobacco cessation, fitness or exercise, stress management, nutrition, self-care, blood lipid control.
• Health education messages – the screener must review with the participant his/her identified health risks and what they mean to the participant’s overriding health, and give the participant a written record of the Blood Pressure, total cholesterol, and any other physiological measures taken.
• Referral of participants for treatment – participants with elevated risks must be referred to appropriate sources of diagnosis and possible treatment following nationally or locally recognized guidelines for such referral.

Demographic information must include location of the assessment, workplace, client’s name, address, social security number, home and work phone number, sex, race, birthdate, relevant work information (e.g., hourly or salaried), department number, and work shift.

Program directors or providers ought to have a background in wellness programming and a professional health-related degree or certification. They ought to have expertise in content areas, planning, promotion, administration, assessment, and ability to grow a program and tailor the program to the worksite.

Program providers ought to have a quality assurance program for evaluating the performance of service personnel, to evaluate satisfaction of participants, and for personnel training and continuing education.

An overall policy statement should be available from directors and program vendors addressing the following concerns: assurance of confidentiality of health data, referral to healthcare for at-risk participants, follow-up with referred participants and those at-risk, program evaluation on process and outcomes, business of the workplace for promotion of wellness and changes in corporate culture. A clear contract or letter of agreement for services should be provided.

Stay away from being the “best” or doing the “most.” Encouraging staff members to be the best or doing the most promotes excessive behavior, discourages others, and creates elitism. The best designed incentive programs are ones which are based on achieving objectives and goals that are attainable by most people. Recognition, acknowledgment by top management, or special privileges are examples of excellent intangible incentives and rewards.

Incentive ideas:

• Free or Low-Cost:
   o Certificates
   o Movie passes
   o Recognition in employee newsletter
   o Mugs
   o Water bottles
   o Commendation from management
   o T-shirts
   o Hats

• Moderate Cost:
   o Entertainment tickets
   o Sweatshirts
   o Waist packs
   o Subscriptions to health magazines
   o Health and fitness books
   o Videos

• High Cost:
   o Week-end getaways
   o Dinner for two
   o Clocks
   o Watches

• Others:
   o Cash
   o Gift certificates