Healthy living for healthcare workers: It is time to set an example

Over the past 30 years, there have been significant advances in the ability to diagnose, evaluate and treat patients with coronary artery disease.¹ As a result, developed countries have seen an overall decline in the absolute numbers of deaths directly attributable to cardiovascular disease (CVD).² For example, the United Kingdom has observed a 68% decrease in CVD-related deaths from 1980 to 2013, with similar rates of decrease seen in the United States.^3,4 At the same time in which these advances have occurred, the incidence of metabolic diseases such as obesity, hyperlipidemia, and diabetes have been rising, considerably increasing the overall risk profile of the population and driving increases in the global rates of death from CVD.^5–8 Thus it remains important to continue to define and understand health habits of the population, including unique groups such as healthcare workers, in order better to design interventions which can promote healthy lifestyle habits.

In this issue of European Journal of Preventive Cardiology, Mittal and colleagues report the results of a survey performed to evaluate the lifestyle choices and cardiovascular health of hospital staff in the UK.⁹ The survey was offered to all National Health Service (NHS) workers in four centers located near London in 2015. Participation in the survey was voluntary and included questions in which workers self-reported data on profession/job, cardiovascular risk factors, health habits, and previous atherothrombotic events.

In total, the survey was sent to approximately 9000 staff, of whom 1289 staff completed the demographics and risk factor portion of the survey and 1158 staff completed the entire survey (corresponding to an overall response rate of approximately 13%). Respondents were equally split between workers with clinical (51%) and non-clinical (49%) responsibilities. Data on specific clinical duties or profession (nurse, physician, etc.) were not obtained. Compared to benchmark data from the general population in the UK, ascertained from Health Surveys of England, healthcare workers had lower reported rates of obesity, hypertension, diabetes, hyperlipidemia and tobacco abuse.

Overall, healthcare workers had poor dietary habits. While marginally better than the general population, only one out of six healthcare workers reported that they ate five portions of fruit or vegetable per day, while five out of six respondents reported eating more than the daily recommended amount of fat or sugar. In addition, one out of five healthcare workers consumed more than the recommended amount of alcohol per week, with clinical personnel consuming higher amounts than non-clinical personnel (P = 0.02). Physical activity was also suboptimal for healthcare workers, with only about half of respondents reporting moderate or vigorous physical activity. The rates of physical activity were numerically lower in healthcare workers than the rates reported in the overall population in the UK.

Reducing cardiovascular risk is important for public health. In order to obtain this, adopting healthy lifestyle choices is imperative because obesity is a major contributor to the development of other cardiovascular risk factors including hypertension, metabolic syndrome/diabetes and hyperlipidemia. There have been several studies suggesting that food intake is largely responsible for the obesity epidemic,¹⁰ although the lack of exercise also contributes. According to the European Society of Cardiology guidelines, exercise plays an important role in the promotion of a healthy lifestyle in all individuals.¹¹ These data reported by Mittal and colleagues⁹ suggest that a considerable amount of work remains to be done in order to improve the lifestyle choices and cardiovascular risk factors of those who work in our healthcare systems. While the overall health appears to be somewhat better than those rates reported for the general population, it remains unknown whether these potential differences would even persist after adjusting for differences in the populations. Thus we must work to find ways in which our healthcare workers can model the type of behaviors and choices that we hope to encourage in our patients.

While the promotion of healthy behaviors is important for all, it is particularly important for healthcare workers. Face-to-face counseling between a healthcare provider and patient is an important element in effecting change in healthcare behaviors given that unhealthy providers are less likely to be effective than healthy counterparts.¹² Providers with better personal health habits and more positive attitudes toward counseling have been shown to provide guidance to a broader range of patients and to do so more aggressively.¹² Cornuz and colleauges found that four characteristics of physicians predicted negative attitudes toward alcohol and smoking counseling: consumption of three alcoholic drinks per day (odds ratio (OR) 8.4), sedentary lifestyle (OR 3.4), lack of national certification (OR 2.2), and lack of awareness of their own blood pressure (OR 2.0).¹³ Clearly, the health of a provider impacts not only the wellbeing of the providers, but also the patients.

In addition to the need for healthcare workers to set an example of healthy living, these lifestyle choices are also important for both the personal health of our colleagues and the overall success of our healthcare organizations. The NHS has estimated that more than 10 million working days are lost every year due to health events, costing the health system £1.7 billion.¹⁴ In the USA, one study identified five conditions (smoking, physical inactivity, obesity, hypertension, and diabetes) that were each associated with 1 to 2 days of missed work per year¹⁵ and has considerable economic consequences. Healthy employees have been shown to have overall a better quality of life and greater workplace satisfaction.¹⁶ These effects have consequences on the overall rates of personal and job satisfaction, which could lead to better interpersonal relationships between providers, patients, and families.^17,18 In addition, previous studies have shown that healthy workforces have lower rates of workplace injuries, less time away from work due to sickness or illness, and lower health costs. These are particularly important benefits for the government in countries like the UK and for employers in countries such as the USA, as these entities have historically supported a significant proportion of healthcare costs.^16,19

The differences in health habits between healthcare workers and the general population are present despite the fact that healthcare workers observe the ramifications of poor health choices on a daily basis. Why are healthcare behaviors not better? Mittal and colleagues⁹ found that healthcare workers lacked the motivation for healthy behaviors and cited their overall fatigue and lack of facilities at work as frequent reasons for which they did not participate in more physical activity. In a similar manner, lack of motivation seemed to be a significant contributor to the poor dietary choices of healthcare workers although respondents also noted that that healthy food choices were not available in the cafeterias on campus. While healthcare systems exist to improve the lives of the populations they serve, we cannot lose focus on the wellbeing of those who work in this setting. Thus promoting healthy lifestyle choices in healthcare workers is important.²⁰

How can health systems improve the health of their workers? Given the significant influence of the workplace over the lifestyles of employees, the workplace environment can be used in a positive way to promote healthier living (Table 1).⁸ Physical activity programs in the workplace offer employees some level of convenience, can promote positive lifestyle choices, and allow for the acceptance of healthy behaviors as a cultural norm. Earlier studies have shown that workplace interventions can improve the health of employees including increasing fitness levels, lowering the risk of diabetes, and decreasing levels of cardiovascular risk factors.²¹ Furthermore, higher levels of physical activity were associated with a lower risk of overall mortality and cardiovascular events among all income strata.²² As such, healthcare systems should promote healthy lifestyle choices in their workers by increasing access to facilities that promote physical activity. Exercise facilities co-localized with the workplace increases utilization by employees.²³

Secondly, healthcare employees spend long hours working in the healthcare environment and often will eat one, if not more, meals while at work. As such, making a conscious effort to provide a variety of fresh fruits and vegetables and other healthy meal options is important. As fresh fruits and vegetables are often more expensive than less healthy alternatives, subsidizing the costs or incentivizing purchase of these healthier alternatives have been shown to increase utilization.^8,24 Some workplaces have utilized additional financial incentives to improve the lifestyle choices of their employees. One large healthcare system that self-insured the healthcare costs of its employees recently instituted a program in which workers who were non-smokers paid lower health insurance premiums than those who smoked.^25,26 Utilization of these types of financial incentives may play a role in the promotion of healthy behaviors.²⁴ While a healthy lifestyle cannot be forced on any one individual, an incentive program could be considered in which normal body mass index, avoidance of smoking, exercise, and regular visits to a primary care physician are rewarded.

Overall, this survey provides important, contemporary evidence regarding how we and our other healthcare workers make lifestyle choices and behave. While these data suggest our overall health may be slightly better as compared to the general population, there is still significant room for improvement. Despite being promotors of public health, we, as healthcare workers, possess many of the same cardiovascular risk factors we are advising our patients to eliminate. It is possible, if not likely, that our work environment and stresses associated with healthcare delivery facilitate some of these unhealthy behaviors. Thus workplace interventions such as access to exercise facilities, behavioral and dietary counseling, and affordable food options at work could help offset some of the unhealthy consequences of working in healthcare. Further work is needed to help understand how and which workplace interventions can promote healthy lifestyle choices to ensure a healthy, well-functioning healthcare workplace.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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