The American Heart Association (AHA)’s 2020 goal is to improve the cardiovascular health (CVH) of people living in the United States (US) by 20% and reduce mortality from cardiovascular diseases and stroke by 20%. Given that 155 million adults are in the US workforce, and >60% have employee-based insurance, workplace studies provide an important opportunity to assess and potentially advance CVH through the use of comprehensive workplace wellness programs. Among a cohort of employees of the Baptist Health System, CVH was assessed annually during voluntary health fairs and health risk assessments (HRA) from 2011 to 2014 using the AHA’s 7 CVH metrics: smoking, body mass index (BMI), physical activity, diet, blood pressure, total cholesterol, and blood glucose. Each metric was categorized as ideal, intermediate, or poor according to the AHA criteria. Cochrane-Armitage test was used to detect trends in CVH by year. Ideal CVH, defined as meeting ideal criteria for all 7 metrics, was assessed and compared across years. The overall cohort was 34,746 with 4,895 employees in 2011, 10,724 in 2012, 9,763 in 2013, and 9,364 in 2014. Mean age (SD) was between 43 (±12) and 46 years (±12). Female to male ratio was 3:1. The prevalence of study participants who met the ideal criteria for diet, physical activity, and blood pressure increased significantly from 2011 to 2014 but for BMI, total cholesterol, and blood glucose, a significant decrease was noticed. In addition, the prevalence of study participants in ideal CVH although low, increased significantly over time (0.3% to 0.6%, p <0.0001). In conclusion, this study shows the trends of the AHA’s CVH metrics in a large health care organization. The positive findings noted for the metrics of smoking, physical activity, total cholesterol, and blood glucose should be reinforced. However, the metrics of diet, BMI, and blood pressure need more attention.
In 2010, the American Heart Association (AHA) defined its strategic impact goal as: “By 2020, to improve the cardiovascular health (CVH) of all Americans by 20% while reducing deaths from cardiovascular diseases (CVDs) and stroke by 20%.” To achieve this goal, 7 CVH metrics were introduced: smoking, body mass index (BMI), physical activity, diet, total cholesterol, blood pressure, and blood glucose. Each metric was classified into 3 categories: ideal, intermediate, and poor. According to the AHA, individuals without clinical CVD and who meet the criteria for the ideal category for all 7 metrics are in ideal CVH. Current trends in the United States (US) workforce project an aging employee population that may translate into higher number of employees with chronic conditions including CVD. This scenario creates an opportunity for the workplace to serve as an environment to promote CVD prevention through the use of comprehensive workplace wellness programs. Yet, most studies on ideal CVH are community based. To our knowledge, studies that report the prevalence or trends of the CVH metrics in the workplace are few. For the present study, we examined the trends in the prevalence of the CVH metrics among employees of Baptist Health South Florida (BHSF), a large not-for-profit health care organization. The aim of this study is to show that data collected on the CVH metrics can be used as a tool to assess and monitor the CVH of employees as part of comprehensive workplace wellness programs.
Methods
The BHSF Employee Study is a cross-sectional study that measures the prevalence and trends of the AHA’s CVH metrics among employees. The methods of this study have been previously described. BHSF employees take a voluntary health risk assessment (HRA) annually. The HRA, a part of an incentive driven wellness program, is divided into 2 phases. In the first phase, employees complete an online health questionnaire that uses the WebMD platform. For the second phase, employees attend a health fair where trained healthcare professionals take biometric measures. Employees are eligible for incentives if they are enrolled and contribute toward a BHSF medical plan and are given a $50 reimbursement for each requirement met: nonsmoking, BMI <25 mg/m 2 , blood pressure <140/90 mm Hg, total cholesterol <240 mg/dL, and blood glucose ≤140 mg/dL. Of the ∼15,000 employees, complete health data were obtained from 4,895 employees in 2011, 10,724 in 2012, 9,763 in 2013, and 9,364 in 2014. Participation rate, excluding participants with missing data, was ∼33% in 2011, 71% in 2012, 65% in 2013%, and 62% in 2014. The employee participation rate was much lower in 2011 likely because it was the first time data were collected for the CVH metrics and so many participants did not have complete data on the metrics. Employees who participated in this study consented to the use of their health data for research purposes. This study was approved by the BHSF Institutional Review Board.
Data collected from the online health questionnaire included the following: demographic characteristics (age, gender, race/ethnicity, education); lifestyle habits such as diet, smoking status, physical activity levels, sleep habits, and alcohol intake; self assessment of health status, emotional health, perception of stress levels, and attitudes toward behavioral change. The biometric measures collected included the following: height, weight, BMI, waist circumference, blood pressure, blood glucose, and total cholesterol. Blood pressure, blood glucose, and total cholesterol were measured with electronic devices. Information on the use of medication for high blood pressure, high blood glucose, and high cholesterol were missing from 2011 to 2013; however, the questionnaire was revised in 2014 to include the use of these medications by study participants. All data collected were stored securely in a Health Insurance Portability and Accountability Act Privacy Rule compliant and secure database.
We classified the CVH metrics into ideal, intermediate, and poor categories as defined by the AHA and made modifications where necessary. For smoking, we classified study participants as ideal if they were nonsmokers and poor if they were current smokers. This definition applied for data collected from 2011 to 2013. In 2014, our definition of the smoking metric was similar to the AHA’s definition: ideal: nonsmoker or quit >12 months; intermediate: former smoker or quit ≤12 months; poor: current smoker. The categories for BMI were defined as <25 kg/m 2 as ideal, 25 to 29 kg/m 2 as intermediate, and >30 kg/m 2 as poor. Participants who engaged in ≥75 minutes of vigorous physical activity per week or 150 minutes of moderate physical activity were classified as ideal. Those who engaged in 1 to 75 minutes of vigorous physical activity per week or 1 to 150 minutes of moderate physical activity per week were classified as intermediate, whereas those who engaged in no physical activity were classified as poor. From 2011 to 2013, healthy diet score was defined as ideal if a study participant achieved a score of 4 to 5, intermediate 2 to 3, and poor 0 to 1. In 2014, a healthy diet score of 10 was ideal, 8 to 9 was intermediate, and 0 to 7 was poor. From 2011 to 2013, a total cholesterol level <200 mg/dl was ideal, 200 to 239 mg/dl was intermediate, and ≥240 mg/dl was poor. Blood pressure <120/80 mm Hg was ideal, 120 to 139/80 to 89 mm Hg was intermediate, and ≥140/90 mm Hg was poor. For blood glucose, the cutoff for ideal was <126 mg/dl, 126 to 140 mg/dl was intermediate, and ≥140 mg/dl was poor. In 2014, the use of medication was considered for the definitions of the 3 categories. For total cholesterol and blood glucose levels, we measured nonfasting blood samples.
We calculated the prevalence of each CVH metric categorized as ideal, intermediate, and poor with the 95% confidence intervals, for each study year and the prevalence of each CVH metric by gender. In addition, we calculated the prevalence of the number of ideal metrics met by study participants and summary categories were created for the number of the ideal metrics (0 to 1, 2 to 4, and 5 to 7). The Cochran-Armitage test for trend was performed, and a Bonferroni adjustment of the type I error rate was used to determine statistical significance of tests (α = 0.0016). All data analyses were performed with SAS 9.3 (SAS Institute, Cary, North Carolina).
Results
Study participants included clinical, laboratory, administrative, and other hospital services staff. Female to male ratio of study participants was ∼3:1 for each study year ( Table 1 ). More than half of study participants for each study year identified as Hispanic and more than half had at least a college degree. Other clinical characteristics of study participants are reported in Table 2 .
| Characteristics | HRA 2011 | HRA 2012 | HRA 2013 | HRA 2014 | ||||
|---|---|---|---|---|---|---|---|---|
| N | Prevalence, (95% CI) | N | Prevalence, (95% CI) | N | Prevalence, (95% CI) | N | Prevalence, (95% CI) | |
| Age, mean (95% CI), y | 4895 | 46 (45.6-46.3) | 10724 | 44 (44.1-44.5) | 9763 | 43 (42.8-43.3) | 9364 | 43 (42.3-42.8) |
| Women | 3,772 | 77% (75.9-78.2) | 7,932 | 74% (73.1-74.8) | 7,362 | 75% (74.6-76.3) | 6918 | 74% (73.0-74.8) |
| Men | 1,123 | 23% (21.8-24.1) | 2,792 | 26% (25.2-26.9) | 2,401 | 25% (23.7-25.4) | 2446 | 26% (25.3-27.0) |
| Hispanic | 2602 | 53% (51.8-54.6) | 5683 | 53% (52.0-53.9) | 5286 | 55% (54.4-56.4) | 5188 | 57% (56.3-58.3) |
| White | 998 | 20% (19.3-21.5) | 1958 | 18% (17.5-19.0) | 1806 | 19% (18.1-19.7) | 1560 | 17% (16.4-18.0) |
| Black | 725 | 15 % (13.8-15.8) | 1669 | 16% (14.9-16.2) | 1538 | 16% (15.4-16.9) | 1459 | 16% (15.4-16.9) |
| † Other | 570 | 12 % (10.7-12.5) | 1414 | 13% (12.5-13.8) | 913 | 9.6% (9.00-10.2) | 849 | 9.4% (8.8-10.0) |
| ∗ Post graduate | 820 | 17% (15.8-18.0) | 2027 | 19% (18.3-19.8) | 1900 | 20% (19.1-20.7) | 1925 | 21% (20.4-22.1) |
| College graduate | 1914 | 40% (38.1-40.3) | 4745 | 45% (43.7-45.6) | 4325 | 45% (44.3-46.3) | 4087 | 45% (44.1-46.2) |
| Some college | 1365 | 28% (26.9-29.4) | 2603 | 25% (23.7-25.3) | 2271 | 24% (22.9-24.7) | 2204 | 24% (23.6-25.2) |
| High School or less | 752 | 16% (14.5-16.5) | 1245 | 12% (11.1-12.3) | 1047 | 11% (10.3-11.6) | 840 | 9.3% (8.7-9.9) |
∗ Postgraduate education includes professional degrees; some college includes vocational school; high school or less includes high school graduates, some high school education and grade school education or less.
† Other includes Asian, American or Alaska Native Indian, Native Hawaiian or other Pacific Islander and Multiethnic.
| Characteristics, mean (SD) | HRA 2011 (N=4895) | HRA 2012 (N=10724) | HRA 2013 (N= 9763) | HRA 2014 (N=9364) |
|---|---|---|---|---|
| Body Mass Index (kg/m 2 ) | 28±6 | 28±6 | 29±6 | 29±6 |
| ∗ Healthy Diet Score | 1.3±0.8 | 1.4±0.9 | 1.6±0.9 | 6.1±2.2 |
| † Total Cholesterol (mg/dl) | 180±36 | 182±35 | 185±40 | 175±38 |
| Systolic Blood Pressure (mmHg) | 126±46 | 124±14 | 123±13 | 121±13 |
| Diastolic Blood Pressure (mmHg) | 78±9 | 77±9 | 76±8 | 76±8 |
| † Blood Glucose (mg/dl) | 98±30 | 99±27 | 98±28 | 96±24 |
| Current Smokers | 88 (2%) | 151 (1%) | 209 (2%) | 70 (1%) |
∗ Maximum score for healthy diet score in 2011 to 2013 was 5 and 10 for 2014.
† Non-fasting samples were measured for total cholesterol and blood glucose.
As listed in Table 3 , the prevalence of study participants who were nonsmokers (ideal for smoking) stayed the same from 2011 to 2014. The prevalence of participants who met the ideal criteria for diet, physical activity, and blood pressure levels increased significantly from 2011 to 2014. In contrast, the prevalence of participants with an ideal BMI <25 kg/m 2 , ideal total cholesterol levels <200 mg/dl, and ideal blood glucose levels <126 mg/dl decreased significantly from 2011 to 2014.
| Cardiovascular Health Metrics | HRA 2011 | HRA 2012 | HRA 2013 | HRA 2014 | P value for Trends | ||||
|---|---|---|---|---|---|---|---|---|---|
| No. | Prevalence, 95% CI | No. | Prevalence, 95% CI | No. | Prevalence, 95% CI | No. | Prevalence, 95% CI | ||
| Smoking | |||||||||
| Ideal | 4,807 | 98% (97.8-98.6) | 10,573 | 99% (98.4-98.8) | 9,554 | 98% (97.6-98.1) | 9,190 | 98% (97.9-98.4) | 0.0643 |
| Intermediate | N/A | N/A | N/A | N/A | N/A | N/A | 104 | 1.11% (0.90-1.32) | <.0001 |
| Poor | 88 | 1.80% (1.43-2.17) | 151 | 1.41% (1.19-1.63) | 209 | 2.14% (1.85-2.42) | 70 | 0.75% (0.57-0.92) | <.0001 |
| Body Mass Index | |||||||||
| Ideal | 1,723 | 35% (33.9-36.5) | 3,376 | 32% (30.6-32.4) | 3,005 | 31% (29.9-31.7) | 2,958 | 32%(30.6-32.5) | 0.0004 |
| Intermediate | 1,704 | 35% (33.5-36.1) | 3,952 | 37% (35.9-37.8) | 3,519 | 36% (35.1-37.0) | 3,284 | 35% (34.1-36.0) | 0.3925 |
| Poor | 1,468 | 30% (28.7-31.3) | 3,396 | 32% (30.8-32.5) | 3,239 | 33% (32.1-34.1) | 3,122 | 33%(32.4-34.3) | <.0001 |
| Physical Activity | |||||||||
| Ideal | 2976 | 61% (59.4-62.2) | 7,007 | 65%(64.4-66.2) | 7,368 | 76% (74.6-76.3) | 6931 | 74% (73.1-74.9) | <.0001 |
| Intermediate | 1,315 | 27% (25.6-28.1) | 2,696 | 25% (24.3-26.0) | 1,907 | 20% (18.7-20.3) | 1945 | 21% (19.9-21.6) | <.0001 |
| Poor | 604 | 12% (11.4-62.2) | 1,021 | 9.52% (8.97-10.1) | 488 | 5.00% (4.57-5.43) | 488 | 5.21 (4.80-5.70) | <.0001 |
| Diet | |||||||||
| Ideal | 68 | 1.39% (1.06-1.72) | 172 | 1.60% (1.36-1.84) | 291 | 2.98% (2.64-3.31) | 389 | 4.20% (3.80-4.60) | <.0001 |
| Intermediate | 1,665 | 34% (32.7-35.3) | 3,995 | 37% (36.3-38.2) | 4,543 | 47% (45.5-47.5) | 2276 | 24% (23.4-25.2) | <.0001 |
| Poor | 3,162 | 65% (63.3-65.9) | 6,557 | 61% (60.2-62.1) | 4,929 | 51% (49.5-51.5) | 6699 | 72% (70.6-72.5) | <.0001 |
| Total Cholesterol | |||||||||
| Ideal | 3,543 | 72% (71.1-73.6) | 7,644 | 71% (70.4-72.1) | 6,445 | 66% (65.1-67.1) | 6,457 | 69% (68.0-70.0) | <.0001 |
| Intermediate | 1,110 | 23% (21.5-73.6) | 2,484 | 23% (22.4-24.0) | 2,537 | 26% (25.1-26.9) | 2262 | 24% (23.3-25.0) | 0.0020 |
| Poor | 242 | 4.94% (4.34-5.55) | 596 | 5.56% (5.12-5.99) | 781 | 8.00% (7.46-8.55) | 645 | 6.90% (6.40-7.40) | <.0001 |
| Blood Pressure | |||||||||
| Ideal | 1,701 | 35% (33.4-36.1) | 3,753 | 35% (34.1-35.9) | 3,639 | 37% (36.3-38.3) | 3,697 | 40% (38.5-40.5) | <.0001 |
| Intermediate | 2,222 | 45% (44.0-46.8) | 5,860 | 55% (53.7-55.6) | 5,620 | 58% (56.6-58.5) | 3,972 | 42% (41.4-43.4) | <.0001 |
| Poor | 972 | 20% (18.7-21.0) | 1,111 | 10% (9.78-10.9) | 504 | 5.16% (4.72-5.60) | 1,695 | 18% (17.3-18.9) | 0.8214 |
| Blood Glucose | |||||||||
| Ideal | 4,490 | 92% (91.0-92.5) | 9,841 | 92% (91.2-92.3) | 8,930 | 92% (90.9-92.0) | 7,618 | 81% (80.6-82.1) | <.0001 |
| Intermediate | 164 | 3.35% (2.85-3.85) | 363 | 3.38% (3.04-3.72) | 465 | 4.76% (4.34-5.19) | 1,334 | 14% (13.5-15.0) | <.0001 |
| Poor | 241 | 4.92% (4.32-5.53) | 520 | 4.85% (4.44-5.26) | 368 | 3.77% (3.39-4.15) | 412 | 4.40% (4.00-4.82) | 0.0146 |
| No. of Ideal Cardiovascular Health Metrics | |||||||||
| 0 | 3 | 0.06% (0.00-0.13) | 2 | 0.02% (0.00-0.04) | 3 | 0.03% (0.00-0.65) | 6 | 0.06% (0.01-0.11) | 0.5132 |
| 1 | 46 | 0.94% (0.67-1.21) | 114 | 1.06% (0.87-1.26) | 82 | 0.83% (0.67-1.02) | 200 | 2.14% (1.84-2.43) | <.0001 |
| 2 | 448 | 9.15% (8.34-9.96) | 948 | 8.84% (8.30-9.38) | 725 | 7.43% (6.91-7.95) | 907 | 9.67% (9.09-10.3) | 0.5174 |
| 3 | 1,269 | 26% (24.7-27.2) | 2,742 | 26% (24.7-26.4) | 2,382 | 24% (23.5-25.3) | 2122 | 23% (21.8-23.5) | <.0001 |
| 4 | 1,589 | 33% (31.1-33.8) | 3,540 | 33% (32.1-33.9) | 3,354 | 34% (33.4-35.3) | 2925 | 31% (30.3-32.2) | 0.1385 |
| 5 | 1,051 | 22% (20.3-22.6) | 2,329 | 22% (20.9-22.5) | 2,208 | 23% (21.8-23.4) | 2124 | 23% (21.8-23.5) | 0.0336 |
| 6 | 475 | 9.70% (8.87-10.5) | 1,018 | 9.49% (8.94-10.0) | 965 | 9.88% (9.29-10.5) | 1020 | 11% (10.3-11.5) | 0.0032 |
| 7 | 14 | 0.29% (0.14-0.44) | 31 | 0.29% (0.19-0.39) | 44 | 0.45% (0.32-0.58) | 60 | 0.64% (0.48-0.80) | <.0001 |
| 0-1 | 49 | 1.00% (0.72-1.28) | 116 | 1.08% (0.89-1.28) | 85 | 0.87% (0.69-1.05) | 206 | 2.20% (1.90-2.50) | <.0001 |
| 2-4 | 3,306 | 68% (66.2-68.9) | 7,230 | 67% (66.5-68.3) | 6,461 | 66% (65.2-67.1) | 5954 | 64% (62.6-64.6) | <.0001 |
| 5-7 | 1,540 | 32% (30.2-32.8) | 3,378 | 32% (30.6-32.4) | 3,217 | 33% (32.0-33.9) | 3204 | 34% (33.3-35.2) | <.0001 |
| Total | 4,895 | 10,724 | 9,763 | 9,364 | |||||
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