Good morning, everyone. Thank you so much for joining us this morning. I apologize. I am so short that you probably cannot see me behind this podium here, but you can hear me, right? That's good. That's good. Great. So it's a pleasure to be here today. I am Val Tivnen, Dr. Nathan Jones, and it's not the first time I present with Dr. Nathan Jones. So it's really a pleasure to be here bringing such an important topic, which is physical activity interventions in the workplace. A couple of disclosures, Dr. Jones and I, we don't have any financial disclosures today. And again, it's a pleasure to introduce my co-speaker here, Dr. Captain Nathan Jones. He is a physician board certified in both occupational and environmental medicine, as well as lifestyle medicine. He is a captain in the United States Air Force Medical Corps, and he currently works at an occupational medicine physician at Joint Base Elmendorf-Richardson in Anchorage, Alaska. He serves on the Air Force Wide Lifestyle and Performance Medicine Working Group. He co-leads other working groups, and he also authored multiple peer review articles, delivered lots of academic presentations, and he also provided expert consulting with many different companies. Dr. Jones also earned his bachelor's of science in molecular biology from Brigham Young University. He then attended the State University of New York, where he graduated with his MD, and he also got his MPH at Harvard T.H. Chan School of Public Health. I'm the director of population health strategy and well-being at EBS, Employee Benefit Solutions. We are a consulting company in Boston, Massachusetts, and my role there is to support about 250 clients around the U.S. and also global in bringing a culture of health in the workplace where employees thrive and are also engaged at work. I have about 30 years of experience in wellness, well-being, and lifestyle medicine fields. I am the chair of the Lifestyle Medicine Workplace Group from ACLM, and I'm also involved in other organizations, such as HERO, which is the Health Enhancement Research Organization. I have a master's in education from Boston University and a master's in public health from UCLA. And in my spare time, I am an adjunct professor at Merrimack College in Andover, Massachusetts. I'm going to skip to the agenda. The agenda really actionalized our objectives today. So today we'll talk a little brief history of physical activity in the workplace. We'll talk about the evidence, health risks, and benefits associated with physical activity. We'll go over the guidelines. We'll talk about some effective interventions. And we'll give you some real examples of what many companies out there are doing to bring physical activity into the workplace. And Dr. Jones will end with the framework. So a brief history of physical activity in the workplace. So in 2007, I'm sure many of you know that the ACSM, in collaboration with the American Medical Association, they set forth an initiative to motivate physicians to prescribe physical activity in the workplace. And we all know here the immense benefits of physical activity. Employees are more engaged at work, less healthcare costs. So we all know the benefits. And I remember in my profession, when I got this news from ACSM, I thought it was amazing, right? Exercise is medicine. But how did everything start? How did we get here? Well, we know that one of the earliest documentations of the importance of physical activity for physicians came from Susruta, who was the first physician to prescribe moderate exercise to his patients. He was a physician, a surgeon in India in 600 BCE. So again, it's not something recent, right? Hippocrates also, there are many documentations related to the importance that he put and the value of exercise. And he was one, again, one of the first folks also to have documented that he prescribed physical activity or exercise for people, which they called in that era, with overconsumption. I think nowadays we would call obesity, right? But it seems like it was really in the Industrial Revolution that this movement really picked up. As you probably know, there were many employees in that time that worked 70-hour week in very unsafe, you know, settings. So companies back then started really realizing the importance of bringing wellness and investing in the health of their employees because they knew that healthy employees would work harder, would be more engaged at work. So as you can see, those are real pictures, actually, of that era. I'll call your attention here to the Hershey Chocolate Company here in Pennsylvania, right? They were actually one of the pioneers, and they built a recreational facility for the employees and their families, you know, many, many years ago that they allowed employees and families to exercise, play sports, swim, you know, with that, again, that goal. And here are examples also of some companies that invested in bringing settings in which people, employees could do calisthenics, right? Remember, who remembered the word calisthenics here? Okay, yeah. So as you can see, you know, from that era, things started picking up. The Pullman Boating Company also was another one that they created a boating club for employees in 19th century, I think 1870. And this is a very interesting flyer from the National Cash Register, so really promoting what they do in the workplace, right? So you know, they can attract employees to work there. So as you can see, this is, you know, comes from many years. And how about recently, the 1980s, 90s, we have Johnson & Johnson, who, as you probably know, has published tons of research on their wellness programs. They really bent the healthcare cost with their wellness programs. Texas Instruments was the first company actually worked there in 1990s that had a fitness center inside the company, the first one in the U.S. And I put Boeing here because Boeing was actually the first company that eliminated smoking in the workplace. So it's not much related to physical activity, but I'm sure that it's important also to know that that's an important landmark. So today, what do we see, right? We see that companies are capitalizing on wearables, all employees wear them, right? Or they have a cell phone that they can track their steps. A lot of activity challenges, right, where a company invests some money in some healthy competitions to bring physical activity in the workplace. Due to the hybrid environment that we are now, how many people here work hybrid, in a hybrid environment? Some people, okay. I don't know about you, but I felt that I'm exercising more in a hybrid environment because at 12 noon, I can go in my basement, do a Peloton class, take a shower, and go back at 1 o'clock, right? So the hybrid environment really helped also. And companies are also investing in virtual exercise classes to employees, including meditation, mindfulness, lots of incentives are provided for employees who participate in many physical activity events. And also keeping in mind that all that we do in the workplace has to comply with the EEOC regulations, making sure that it's equitable to everybody and that everyone is, you know, can earn an incentive. And now I will pass to Dr. Nathan Jones. Good morning, everyone. Captain, Dr. Nathan Jones, thanks for being here today. As Val had mentioned, I'm board certified in occupational medicine as well as lifestyle medicine and something I'm really passionate about is using the workplace as a platform to not only prevent injury and to treat injury, prevent illness, and get workers back to work, but also using it as a platform to promote health and wellness and actually try to leave people a little bit better than we found them rather than just avoid breaking them further. So before we launch into more of the meat of our talk, I wanted to review really quickly some of the health benefits associated with physical activity as well as some of the health risks of inadequate physical activity. So a few definitions that come from CDC in terms of what is physical activity, which is separate and distinct from exercise. And kind of a layperson's diagram there, but that holds a lot of value in terms of highlighting some or the wide variety of significant health benefits that can be associated with regular and adequate levels of physical activity. Val had mentioned before the American College of Sports Medicine initiative, exercise is medicine. And some of you may be familiar with Robert Butler, who's most known for some of his work with the National Institute on Aging, and he is quoted to have said, if exercise could be packaged in a pill, it would be the single most widely prescribed and beneficial medicine in the nation. And if you take a look at the numerous health effects there listed on the diagram, I think we can all agree that if we did have a pill that could have that wide reaching of an impact on our patients, that would be one we would use pretty widely. Kind of the holy grail of public health research is the impact on overall mortality. And there are so many papers out there that show this. I liked this one because, you know, there were just some pretty nice graphics to demonstrate that. But what I'm trying to highlight is that you do start to see some of the health benefits in terms of overall mortality almost immediately. So I think sometimes it's a barrier for our patients or our workers to think about initiating physical activity or to increasing their physical activity. Well, I could never get to the gym five days a week. Well, I could never go for a run three days a week. But if you can get them to do anything at all and try to explain that to your patients, there's going to be some benefit. And actually, arguably, they get the most bang for their interventional buck as they're starting out, as they're starting from zero, reaching towards that goal of 150 minutes of moderate to vigorous physical activity per week. And if they reach that goal, you can see from the graphs there that they actually achieve they will achieve about 70% of the overall mortality benefit that they can from physical activity once they reach that 150 minutes per week. And then they start to plateau a little bit in terms of overall mortality benefit. And even if you really overdo it, you can see there at the very end, there can be an actual kind of regression of that overall mortality benefit. But that's coming at levels 10 plus times the recommended physical activity level. Probably not something a lot of us have to worry about. I include myself in that category as well as our patients. This was an interesting paper that I just wanted to at least point you to in terms of translating the health benefits of physical activity into more of an organizational outcome that maybe some of your employers or companies would be interested in. You know, fairly large study that actually tried to look at the impact of various lifestyle factors, including physical activity, on absenteeism in the workplace. And did some interesting calculations, including the proportional attributable fraction, which just as a brief reminder, is the proportional reduction in population-wide disease that you could expect if you were to, you know, either eliminate an exposure or bring an exposure down to a previously determined level. And so in terms of this paper, it was looking at low physical activity. And if you could remove low physical activity, or rather get these individuals in the study to an adequate level of physical activity, you could expect to impact up to 7.8% of the absenteeism related to musculoskeletal disease, and even up to 20% of the absenteeism due to depressive disorders. So pretty impressive numbers that they were calculating here, and to me really highlights the potential large impact that physical activity can have, not only on the health of the individual worker, but also on the health of the organization. I wanted to briefly mention sedentary behavior, which, again, similar to physical activity and exercise, at least in the scientific literature, is considered its own separate entity. And there's a strict definition here of sedentary behavior. It's something that comes up again and again in the research on physical activity in the workplace, especially as, at least the American economy, you'll see a trend towards more of the office-based, service-based workers, which I think we all feel in occupational medicine especially. But sedentary behavior, again, separate and distinct from physical activity, has its own independent effects on our health. And interesting graphic here from the paper that tries to illustrate some of those mechanistic pathways of how sedentary behavior, in and of itself, can actually negatively impact our health and performance. Specifically in the realm of cognitive performance, you know, there are a few different pathways highlighted on this figure here where, you know, for example, one is through low glucose delivery to the brain, where after a meal, you then have a prolonged period of sedentary behavior leading to hyperglycemia, which then triggers hyperinsulinemia, and then tanking your blood glucose, and you're not going to have as much energy for your brain. We all feel that kind of mid-afternoon as we're starting to flag a little bit in our work days. Similarly, though, they've actually done physiological measurements to show that there is reduced blood circulation to the cerebrum as you are going through long periods of sedentary behavior related, obviously, to low rates of skeletal muscle contraction, decreased venous return to the heart, decreased preload, stroke volume, all those physiological measurements that we remember from medical school. But they have been able to measure these specifically in related to prolonged bouts of sedentary behavior. All right, let's look into the guidelines now. So this is probably familiar to you, right? The American College of Sports Medicine and the Center for Disease Control Recommendations is 150 minutes of moderate intensity aerobic activity every week, and also two times a week at least do some weight training. Raise your hand here, who follows this guideline for the most part? Be honest. All right, excellent. So let's expand a little bit, right? First and foremost, any activity counts, right? These are just guidelines. But the goal here is to reduce time spent in sedentary behavior every day, right? So you know, 150 minutes of moderate intensity activity each week, at least two days a week to do some muscle strengthening like exercise with weights or yoga or even body weight exercises, right? And Nathan already mentioned this beautiful quote here. What I also want to stress is that there is a numerous amount of research coming, this is from 2022, that shows that small bouts of exercise throughout the day counts also, right? This one in particular was from the UK, because as you know, UK has socialized medicine and they have tons of data of people's wearables and they did this study, took about seven years, and they looked at folks who did bouts of exercise and they saw that those who engaged in one or two minute bursts of exercise roughly three times a day, like speed walking while commuting to work or rapidly climbing stairs, showed a nearly 50% reduction in cardiovascular mortality risk and roughly 40% reduction in the risk of dying from cancers, as well as causes of mortality compared with those who did no vigorous sports of fitness. I'll take that, absolutely. If you don't have the time to do 30 minutes of continuous exercise, go up and down the stairs of your building once in a while, you know, go outside, do a little bit of speed walking and, you know, you'll be fine. All right, effective interventions. Okay, so now we'll move into, again, some of the things that I hope you can take back to your workplaces, or at least consider implementing in your workplaces, or if you have, you know, leadership within your organization that is asking, hey, doc, do you have any ideas of what we could do in our workplace to promote physical activity? Hopefully these are some of the actual ideas that you can take back with you. This was, you know, I pulled this kind of word cloud from a review paper and if we had more time or it was more of a workshop type scenario, you know, we'd ask for ideas and people could call them out what they're most familiar with. So you can see some of the most common physical activity interventions that, at least in this review article, were associated with trying to make this happen or to implement in the workplace setting. There's a study that's put out by the CDC in 2019, it's actually an update of a study from 2004, where they surveyed workplaces in 2017, a fair number, and found that, lo and behold, you know, I think this isn't a surprise to many of us, but lots of companies are offering some sort of health promotion or wellness component, and you can see there highlighted 41% address physical activity. The things I really wanted to highlight, though, are the two points down at the bottom, which is that only about half of the companies reported using data either to choose which interventions they were going to implement or to evaluate those interventions. So pretty surprising that people and companies are willing to just decide upon something and do it without having the data. And if nothing else, I hope that some of the information in this talk will bridge that gap so that all of you can take back some data to your companies and say, hey, if we're going to do something, let's look at what we first actually want to accomplish, which needle are we trying to push in terms of the outcome of interest for us, and two, what is the actual evidence that's put out in terms of different interventions and its effect on different outcomes? One more graphic table from that CDC study, which is just showing some of the broad stroke categories for physical activity interventions in the workplace. You can see, you know, Val had mentioned some of the first on-site exercise facilities, all the way down to paid time for physical activity. These are some of the things that we're going to talk about and see what the evidence actually is for some of these interventions. But you can also see the rate of how often these companies, according to size, are offering some of these physical activity interventions. The big takeaway being, as the size of your company goes up, it seems like it's more common for the employees to have access to these interventions. If anyone's seen this edition of the Hierarchy of Controls, it's from the NIOSH Total Worker Health Initiative, trying to highlight that, again, the workplace does not have to be just a place where we hopefully don't get hurt or hopefully don't get some terrible occupational illness. It can also be a place of health promotion and health improvement. And specifically within the context of physical activity, these were just some kind of back of the envelope type sketches that I had put together about different ways that we can actually apply the more traditional Hierarchy of Controls to improving physical activity in the workplace. And I wanted to also mention that, similarly to our approach to more routine occupational hazards, we don't have to pick only one of these. There's no rule that we can only have one. This is something that we can pick from each multiple, even, options from each corner of the menu, as we would with, say, loud noise or with, you know, in my current work in the Air Force, you know, we deal with a lot of heavy metal exposure. And we would never rely just on one aspect of this Hierarchy of Controls. And we should have a similar approach to promoting physical activity in the workplace, where we don't have to hang our hat on one hook. We don't have to put all of our eggs in one basket in terms of trying to promote that healthy aspect of our workers' lives. So most of the evidence that we're going to talk about is from the initial results of a systematic review that a colleague from the CDC and myself are working on. We're not done. We've done a lot of the study design, the search strategy, screening, and then full article review. we're still going through the quality assessment. But it's a systematic review of reviews and meta-analyses. There's so much out there in terms of investigating the scientific impact of physical activity interventions in the workplace that we thought that would be kind of the most appropriate approach and least overwhelming at least. And even then, you can see that there is a lot that's been put out there. The main goal of our study being to identify those interventions that have been studied enough to warrant their own systematic review or meta-analysis, and then trying to kind of aggregate a lot of that information into, you know, one approachable place. So that being said, please don't throw spears or come at me if I don't mention a specific intervention that you have in your workplace or that you've developed or that you know to be effective. It's nothing personal. It could just be that that particular intervention has not had enough studies done on it to, you know, to have its own systematic review. So moving into the individual interventions, you know, I won't apologize for my busy slides because that's the way I think. And if nothing else, I want these slides to be a resource to you as you go back. They are available on the SwapCard app. If you don't have access to that, feel free to email myself or Val. We can definitely get them to you. All of the references for the different reviews and meta-analyses that back up some of the information on the slides are on the slides themselves, and there's an extensive list of references at the end so that when you go back to your place of employment, you can bring some of this data with you and actually look at some of it for yourselves. But one of the first places you can start in terms of promoting physical activity in the workplace is actually just telling people about physical activity and telling them it's good for them and telling them it's important. You know, it's tough to lump so many different interventions into one broad category, and so that kind of gives us some mixed results on the actual outcomes. But the long story short is that this can make a difference, you know, and even having as passive a material as a printed intervention informational campaign can actually improve people's physical activity by a small amount. And if we start talking about the aggregation of marginal gains, again, choosing from different levels of that hierarchy of controls, you know, we can actually start to make a significant impact if we start to accumulate some of those marginal gains. I also found it interesting that specifically there in the counseling section, there is a study that shows in particular occupational health professionals, that's us, our counseling of individual workers can increase their physical activity. So it's something we shouldn't be shy about talking to our patients about in the occupational medicine clinic. You know, hey, here's what we should be doing with our physical activity, or, you know, I see that your BMI is creeping up towards the limit, or your lipids, or, you know, hemoglobin A1C, whatever it is, here's some ideas about how to increase physical activity in your life individually. Again, Val had mentioned the on-site gym. It's probably one of the most common things if, you know, an employer is going to think about trying to increase physical activity within, among their workforce, well, let's build a gym for them. You know, if you build it, they will come, right? But I'd say not always, you know, it's very separate to have actually a gym on-site versus having people use that gym. And there are very mixed results in terms of what kind of impact that will actually have, but if you can then start to add in, say, this intervention of having an on-site gym with some of those other levels of controls in the hierarchy of controls, you know, are you giving them paid time to exercise where they can just scoot off during lunch, as Val was saying, into the gym? Are you letting people, are you overworking people to the point where they feel like I'm already having to stay late, by the time I have my work done, I just have to jet home and get my kids? You know, if we start to combine some of these levels of control, we can actually find much more effectiveness within each one of those controls individually. Policy changes. Again, this is such a wide-reaching intervention group that it's hard to make really broad conclusions there, but tried to put on this slide some of the examples of policy changes or administrative controls that were represented in that systematic review and meta-analysis level literature. Interesting that the free and reduced gym memberships shows up there, and there's some thought that instead of giving them something totally for free, if you give workers, you know, discounted or subsidized access, they have a little bit of skin in the game and may be a little bit more likely to actually utilize that resource. So interesting there. You know, walking meetings, walking groups, paid exercise time we mentioned as well. The other thing to think about with policy changes is they have the potential to be a bit longer lasting, you know, than, hey, let's bring in, you know, a spin instructor to our corporate gym for three weeks, and then, yeah, good, people came to the class, and then what? You know, but if we write changes into the policies of our company, we can expect those policies to endure, at least until we change them again. But there's potential, at least, that they can have more staying power compared to some of the other interventions that we'll talk about. Group exercise classes and challenges, again, a very wide intervention group, many different outcomes that have been studied in there as well. And we'll actually pull out a few of the kind of subgroups of group exercise classes that I felt had enough literature out there to warrant their own slide, at least. Again, the discussion here will be, well, how long is this going to be effective? You know, how long are you going to have that group exercise class? And you can see some efficacy for as long as that class is in place, but once the class is over, once you no longer bring in that instructor to the workplace, if you cancel that subscription to the online library of workouts that your employees can access from home, what's going to be the long-term impact on the physical activity of your workers? Yoga was one of the kind of subcategories of exercise classes that there's so much literature out there on yoga. And probably unsurprisingly, for anyone who's actually taken the time to practice yoga on a regular basis, the literature does bear out that there's a positive impact on our psychological functioning, especially anxiety and stress symptoms. Not so much in terms of the physical activity, at least at the systematic review and meta-analysis level, but if mental health outcomes is specifically something that your company wants to improve and wants to work on, yoga could be a very viable option, and there's a lot of good data to suggest that it can be an effective one for that particular outcome. Another group exercise intervention that I thought was rather unique and novel was team sports. I don't know how many of us think about this, if we're trying to promote activity, physical activity among our workers, but team sports, signing up your team for either an extramural league or having an intramural league within your own organization can actually have a positive impact on a number of worker-centric outcomes. One thing that I was hoping to see that I didn't necessarily see represented in the literature was how does playing on a team affect some of the more organizational outcomes, such as team cohesion, or how well are people working together in your workplace. Didn't see that necessarily, but could definitely be true still, just not studied at that higher level. One other thing here, you'll see that actually it was found that team sports can have a positive impact on fitness itself, which is again separate from just physical activity. This is actually measuring your cardiorespiratory fitness and how high a level you can perform. Think about that, depending on the population that you're working with, are you working with firefighters, law enforcement officers, military, where that fitness level is actually an important independent outcome that we need to look at. Team sports can be a way to potentially increase that fitness. Kind of a completely anecdotal caveat, I know that in my unit there in the military, it seems any time we try to do any kind of sport-related physical activity for our physical training, we always have a few injuries, people twisting an ankle or banging into somebody. Keep that in mind too, in terms of getting your workers involved in sports. Val had mentioned wearables already. I don't know how many of us feel like the little dog on this picture sometimes, but if you really get into that step counting, it can become almost demotivating when you're not tracking those steps. But what is measured gets managed and improved. If we're counting our steps, if we're counting our calories, if we're counting almost anything, we can see an improvement in that. That bears out in the literature in terms of workplaces being involved in wearable interventions to improve the physical activity in their workplace. But you can see that the outcomes that have been studied are really focused on those outcomes that the wearable can track. But a modest, modest benefit on BMI as well at the meta-analysis level. There's such a broad range of other technologies that were studied. Most of them center around prompting people to stand up and take a break and go for a walk. You know, it's been 30 minutes since you moved away from this position, you know, it's time to at least stretch your arms or do something. And a lot of very unique and I thought creative ways to get at this. You can see some of them listed there. Interesting to note that a lot of these interventions, you know, could represent potentially the rising generation in the workforce. But a lot of these digital interventions, very, very high level of acceptability to the workers. They love this stuff and they want to get engaged with it. The problem is, as with a lot of digital interventions, not just in physical activity, but across the panorama of digital health interventions, is that there's low retention. You know, and that's not even just digital health. If any of you remember Pokemon Go from how long ago was that, six or seven years ago? I mean, that was a craze where they had 40 to 50 million daily users every day. But by the next year, you know, use had declined 75, 80%. I don't know if people still play Pokemon Go. Maybe they do. Anyway, there was kind of a meteoric rise and fall of that. And we can see similar things within digital interventions to promote physical activity in the workplace. Active commuting. This is another thing that people have studied a lot. They really, really, really want this to work. And it does work for some things and certain interventions work. So you can see a long list of strategies to promote active commuting and that ranges from kind of improving the infrastructure within your workplace to support and promote active commuting to providing educational materials on how to do it, as well as to even just giving your workers access to bicycles so that they can do this or, you know, a safe access to your workplace in terms of pedestrians walking to work. Becomes a little tricky because some of the factors that actually impact people's likelihood to engage in active commuting are outside of the sphere of influence of the workplace. You know, we're talking about how safe is it for people to bike on the road in your community? What kind of bike paths or walking paths are available? Is there a pedestrian bridge across that super busy highway that's blocking access to your workplace? So some of these can get outside of what we can control in the workplace. But there are even some studies showing that at a higher level, companies in an area come together and try to promote some of that change within their community and you think about the positive aspects there, not only for their workers, but for the overall community and the health there can be pretty impressive. Another thing to highlight here, again, one of the few interventions that can actually positively impact the aerobic fitness of your workers. So if you're thinking about that particular population that we mentioned earlier, could be something to think about. Active design, we're getting towards the end of, you know, the interventions that we'll talk about. Definition here provided by New York City who brought together a bunch of their departments to put out a report on active design. This is how they defined it. Again, this is something that a lot of people have studied and they want this to work so badly and for some things it does work. Stairs. How many people have been taking the stairs here at the conference? Many? Many people? Yeah. So what's the problem? You know, this is, I love the venue here. This is no criticism of the venue or of ACOM for choosing this venue. But there are a few problems with the stairs here in terms of actually promoting its use. I mean, one, they're kind of hard to find sometimes. Kind of unmarked, you peek in a door, nope, that's not, yeah, here are the stairs. And then if you get in there, not the most aesthetically pleasing stairs that I've ever been on. I'll just put it that way. You know, but we've got the cement. We've got the very drab colors. You know, there's some cleaning that could be done there. But I'm just saying that in terms of actually promoting your workers to use stairs and to utilize that option for physical activity throughout their day, there are a lot of things that we can do in our workplaces to make that the most desirable approach. You know, in terms of the actual visual appeal and comfort, safety, there is evidence that even just the point of decision prompts, you know, for example, having a sign to say, hey, let's take the stairs today or, you know, anything like that can actually motivate people, at least for a short time, to increase their use of the stairs. You do have to be careful of that, though. I mean, Val had mentioned like ADA and EEOC. There's a very unfortunate picture circulating on the internet of a gentleman in a wheelchair, you know, parked right in front of an elevator that has plastered all over the door, you know, different promotions of like, hey, today we're going to take the stairs or let's use the stairs today. So you do need to be cognizant of that in terms of not only your workforce, but what's the public-facing side of your business and who's going to be utilizing that portion of the business and what kind of messaging are you sending out there. So something to be aware of. Important also to note on the stair interventions that the vast majority of these studies actually show some benefit. So if your goal, at least to get a foot in the door with your leadership, is to actually have some data to come back with and say, hey, this is working. Stair promotion, stair use promotion might be a good place to start because it'll probably work. In terms of active design, it's really a tale of two cities. There's stair use and then there's everything else. And some of the, you can see some of the other ideas that have been studied in terms of active design. You know, is your campus a safe and inviting place for people to work when they have breaks or on their lunch? What's the surrounding community like? You know, are people fearing for their lives if they step off your campus? Is there a walking trail nearby? What about a park? Any kind of green space that they can utilize? But you can also start to look at different organizational strategies within the workplace itself. Well, how are we organizing the seating arrangement? You know, a flexible seating arrangement is actually shown to increase physical activity. Open office design, unimpaired visual access to your colleagues can actually prompt people to get up and move a little bit more. Also the strategic distribution of not only resources that are needed for their work in terms of, you know, the input to whatever process your workers are doing. But then also the waste products or the out product, where are they going to deliver that? And so if you start to strategically place some of those central gathering points, that can also prompt people to get up and move a little bit more. You know, also important to note that similar to policy changes, active design can have a little bit more of a lasting impact because it's not something that comes and goes once you build the building. That's kind of the way it is potentially. And the effect may last longer than, you know, the exercise class that's over in three weeks. I'll breeze through some of this. I mean, there might be the single most literature on the alternative or active workstations. You know, we're talking about sit stand desks. We're talking about bicycle desks and treadmill desks. There's so much research out there. And most of it shows that, yes, in fact, you are going to at least decrease your sedentary behavior in the workplace due to these interventions. There's a lot of research too showing that cycling and treadmill desks can increase your actual energy expenditure throughout the day. Sit stand desks, not so much. But then there's a whole separate body of research on, well, what are the impacts on the cognitive and fine task performance of my workers when they're using some of these? A valid concern, as you can see borne out, that there are some actual decreases that can be seen in terms of the productivity and the performance of your workers if they are using especially some of the higher level physical activity interventions. So something to keep in mind. Just one more time, you know, hey, you don't have to choose just one. We can definitely pick from the menu and pick a few from here. I won't spend much time on these slides. You can take a look at these. Again, if you don't have access to them, feel free to email me. But I also wanted to organize things a little bit by the outcomes that are studied in case your workplace specifically is saying, hey, doc, how can we improve the physical activity or how can we decrease the sedentary behavior among our workers? Here are some of the different interventions that have actually been shown to have an impact. Again, just a plug for the fitness because there were not many interventions that actually showed a positive impact on the cardiorespiratory fitness of workers. You can see some of them listed right there. And we talked about some of these already, the steps and psychological health, think yoga there, wearables for the steps. Kind of the bottom line, return on investment. That's probably what a lot of your leadership might want to hear about. And I'll just be honest and say that there's not really a lot of definitive data out there to show that, hey, 100% across the board, this is all going to be great and you will see a positive return on investment. I just can't say that. It's actually, I mean, the results vary widely, you know, from negative to, you know, plus 2,000 in terms of the actual return on investment. Interesting that a lot of the, there was one review that looked specifically at the type of studies reporting on return on investment and how that, and how that impacted the actual value that was reported for the return on investment. Showed that most of the RCT studies reported either a very modest or no return on investment. And then the non-RCT studies seem to be the ones that more predominantly reported a positive and very large, largely positive return on investment. But so if that's the only thing that your company cares about, I just can't promise you that there's going to be the most compelling data. If you can spin some of these other organizational outcomes, as well as the worker-centric outcomes that we've talked about, I think that could be potentially a good avenue forward. And one slide, again, just for you to look at, there are a lot of reviews and meta-analyses focused specifically on different occupational groups. So if these are any of the groups that you're working with, there are reviews out there that have actually tried to pull together specifically the literature on implementing a physical activity intervention in the workplace for your occupational group. So it could be a good place for you to start to get an idea of what else has been studied in there. All right. So let's put all this theory into practice. What are companies doing in terms of what Dr. Nathan Jones talked about? And I will say, if you want more information about ROI, we have Dr. Ray Fabius here with us today. Raise your hand, Dr. Fabius. He is an expert on that. You can talk to him. He has an amazing company that does that very well. So thanks for being here. So yes, so here are real examples of some of clients that I work with. And as you can see in what Dr. Nathan Jones mentioned, those are some examples, like stand-up desk. Of course, you standing up, it's better than sitting, but you're still not moving, right? So let's do a treadmill then, a treadmill desk. So there are many different workstations that do just like that. So the picture in the middle here is from Mass General Hospital. Actually, they put some prompts in their chair, in the stairs, to motivate people as they are climbing to see, hey, you're doing the right thing. And of course, one of the things a lot of companies are doing also for physical activity and also social connectivity, recreation, is to put areas where people can play ping-pong or do something to take the area of the sympathetic to the parasympathetic nerve system throughout the day. Here's again another example, like people relaxing during workday. So basically, what this picture is saying is this company is giving permission for people to take a break and have fun. This company is DraftKings. I'm sure with sports betting, you probably have heard of it. It's one of our clients, and they have like this just amazing culture. This is a cybersecurity company in Lexington, Massachusetts, in which they have designed, as Nathan mentioned, designed their workplace, again, giving permission for people to, instead of being at their desk, that can do some work in those areas. And also, I don't know if you see in here, those are like swings that people can sit and swing and have meetings outside. This is a fake grass that it has like the cornhole, you know, like so examples again of things that, you know, companies are being creative. You know, decreasing the barriers, right? Look at your company's perks and benefits. Gym membership reimbursement. I mentioned virtual exercise classes before. Lifestyle spending accounts. I'm not sure if you ever heard of this, but a lot of companies are investing in giving employees a certain amount of money per year for them to spend on whatever they want to. Some companies put barriers around it, saying you can spend this money with running shoes, gym membership, things like that, to eliminate the barrier if cost is the barrier. Discounts to active commuting. This is very popular in Boston, Massachusetts, which is a city that is not very bike friendly. I will say I've seen many bike accidents in my commuting. But some companies are really not only providing employees with bikes, but also there was a client of mine that every quarter they pay for a company to bring a van to service employees' bikes once a quarter, make sure the tires are working properly. And the free on-site yoga boot camp, personal training, all those things, again, decreasing barriers because employees can have access to that virtually. Most importantly, create that culture of health and movement. A couple of things that we've been suggesting to companies is stop the one hour, 60 minute meetings. Make your one hour meeting 45 minutes so you have that 15 minutes break in between meetings that you can stand up, go for a walk, go up and down the stairs, do the bouts of exercise throughout the day. Allow employees to schedule multiple breaks in their calendars. Put in your calendar so there's no scheduling around it. Organize company-wide walk runs. Taking advantage of community exercise events. Flexible schedules, right? If you allow or your company allow you to have flexible schedules and you like to exercise in the morning, you can exercise and then go to work or leave work early to exercise or to go to the gym. Make it flexible schedules. Definitely create that culture of health and movement. And here are just some real life examples in the area that I live and work. There is an event that usually starts this time of the year called Seaport Sweat. Here's in downtown Boston that they have fitness instructors that come and teach classes throughout the day and employees get out of their buildings and do a class and go back to the building in a nice area. And I'm not sure if you've heard of the JPMorgan corporate race. They are all over the US. I mean, a lot of companies are doing this to sign up your company to participate. And even employees who don't run, you don't have to run. You can walk. You know, a couple of years ago, we have an employee. We participate every year except during COVID. And she's like, I don't, I'm not fit to do this. Well, we can walk. So we actually, I walked with her and that was really a way to motivate her and also provide her with self-efficacy, right? I can do this. I can do a 5K if I just walk at my pace. I'm sorry to Dr. Jones, but before I just want to mention something quickly. Before this past week, I had a meeting with a leadership team in a company in which their top one long-term disability claim was mental health. And May is mental health month and I said to the CFO and CEO, you know, one idea is to give a mental health day to your employees in May so they, you know, they can go to a park or they can do something for their mental health. And his reply was, well, I have to look at the sales. If sales are good, I will do that. So I had to tell him, you are thinking opposite, right? Every time I leave leadership meetings and drive to work, I'm thinking this is the day I'm going to get fired because I actually had to tell him, you're not thinking correctly. But I'm still here, so it's good. Okay, and we'll. Because we're almost out of time, we want to leave with a few minutes for questions. So just a few real-life examples from the Air Force, what's going on there. Is my mic not on? Okay, there? All right, all right. Yeah, thanks, I thought it sounded weird. So the Air Force has their own acronym for HERO. You can see it up there, Health and Readiness Optimization. So if you're talking to a military commander, you don't talk about bottom line or return on investment or net revenue or income. You talk about readiness. You talk about how many folks do we have who can be boots on the ground, who can be in the airplane dropping bombs, who can fulfill those missions. And that's the language that you need to speak when you're talking to commanders about actually implementing mostly any program. But what's the impact on readiness in terms of the military's availability to actually respond as they're needed to? And so this initiative really came out of trying to optimize readiness and looking at what are the conditions that are decreasing the readiness in the military. And specifically, looking at musculoskeletal conditions, injuries, as well as mental health. You know, those are the things that are keeping soldiers, airmen, sailors out of the fight. And so how are we going to address these? There are some different metrics. The hero report that the Air Force, or military rather, creates internally, as well as these operational support teams that are actually sent out to the individual workplaces, to the units, and embedded there, physical therapists, mental health, dietician, strength and conditioning coaches to actually try to coach up that unit in terms of their overall health and wellness. And you can see at least some initial data, some pretty promising results in terms of decreasing those profiles or work restrictions for different members. And another intervention, we talked about, you know, some of the wearables and tracking some of those things. I help with the oversight, the U.S. Air Force side of oversight of a $1.25 million grant that the Air Force has given to this company called Fit Rankings. I have no, you know, financial interest in the company itself. I just help oversee from the Air Force side. Where they're developing a platform to not only help to collect and track some of this health data, including physical activity, including sleep, including nutrition, to show and kind of reflect back to the airmen. There's also options to have some kind of social networking. Who in my unit is doing what? How are we doing as a unit? But then also to build kind of an aggregated level of data for the commanders to see, well, what is the actual health of our unit? They have their own dashboard that they can go in and see, you know, what am I doing to my unit that they're only getting five hours of sleep on average per night? You know, what's the workload that we're dealing with, and how can we address that? Just really quickly, some things to think about as you start to design your own interventions in the workplace. You know, what are the benchmarks that you're working with? What kind of physical activity are your workers getting? What's the benchmark of the metrics that you're trying to move the needle on? You know, be it mental health, be it healthcare claims, be it workers' compensation injuries. And, you know, with that, you also need to consider the desired outcome. Because even if you come in with, you know, a nice, shiny, sparkling program that doesn't have any data to influence the outcome of interest to your company, you know, the likelihood of that actually getting implemented might be kind of low. And it might seem like a no-brainer, but solicit stakeholder input. You know, some of the companies that I had worked with in the Boston area, you'd be amazed when I was going around and talking to some of the employees about, hey, what would you prefer in terms of an intervention that might help you or remove some of the barriers for you to achieve healthy levels of physical activity? The workers were saying, no one had ever asked me that before. You know, the decision had been made and then just assumed that everyone would buy in. But think about the impact if you ask the workers in the first place and then design your intervention around what the worker actually wants. What's that going to do to your participation rates? There are also reviews of reviews on different theoretical models and frameworks that you can utilize. You know, I'm not as smart on that stuff, but I did include some references here so that you can look at those as may be helpful. Here are just some conserved principles of success that seem to show up again and again across programs that actually had a positive impact. You know, you can review these again. But I found it interesting that people do seem to appreciate when it's kind of some of their own. I know there's a really interesting talk by a fire department earlier in the conference about how they kind of had their own homegrown experts in, you know, healthy lifestyle that the firefighters especially seemed to appreciate and connect to, maybe more so, you know, than an outsider. So with that, I do, we will end the actual presentation. We appreciate you being here. But do want to leave some time for questions and comments if there are any. Thank you very much. Thank you. Thank you. Hi, good morning. Is this on? Okay, great talk. I have to brag about Dr. Jones. He was my resident, and he does, always does a great job. And this is, I'm sorry, I have to embarrass you somehow. But more seriously, thank you for your talk. I work for P&G, and a lot of, I think one of the things that is a struggle is for people who are in manufacturing. Because a lot of these people are, their work is affiliated with a machine. They work shift work. Many times it's not eight hours. It can be as much as 12 hours, plus there's overtime. And by the time they're done with their job, they're exhausted, and they have easily 15,000 steps in one shift. And they think they're healthy. They're like, oh, I'm excellent condition. Yet the values, their values say to the contrary. So I would like to get your input on how we do wellness ideas that you may have for a population like so. I mean, for myself, Nathan knows, I've worked on doing ergonomic programs for them, which they need anyway, like industrial athletes. So kind of incorporating a little wellness, a little dash of wellness with that. But it is challenging for such a population, which is the one that really brings up the numbers of claims. So I'd like your input. Yeah, that's a great question. And I consulted a Gillette company, actually, in Andover, Massachusetts many years ago in my 20s. And I will say that they had the manufacturing the middle and the fitness center very visible. And I know manufacturing workers would go to the fitness center. And I was always like, let's go exercise. And then I started thinking, wait a minute, they exercise all day. So I started doing 10-minute stretching classes. And everybody showed up, right? Or mindfulness meditation, right? So it's really meeting classes. I'm sorry? Where did you do the classes? Did you do it right on the floor? Or did you do it separately? Yeah, during breaks. I would do in the break room. They had break rooms. They actually had the smoking room at that time. You couldn't see anybody. It's like smoke. It's not there anymore. Yes, no, I wouldn't go in there. But after work, in between shifts, I also did some in the gym, quick, quick stretchings. The other thing that is very popular now for manufacturing is to have a vendor that is on the floor with them. There are some companies like Marathon Health or having a wellness coordinator on site or some type of clinical person that can maybe take blood pressures or talk to them. Those are your benefits. Educate them. Talking to them and meeting where they are is important. The other factor is companies also have to be connected to the communities where employees work. New Balance was a client of mine also. And we found out that their employees in Maine were much, much less healthy than the ones in Boston and Lowell. And by doing a focus group, we found out that they were in a food desert. People did not have access to fruits and vegetables. So the company actually invested in bringing a farmer's market on site once a month. So it's really listening to them, I would say, more than other industries. But that's a great question. Yeah, hi. I can't. It's off. It's off. Oh, did I touch? Sorry, sorry. So just one thing I was going to say, in the talk, there are some good references for specifically not only exercise, but specifically strength and resistance training that can have a positive impact on some of those musculoskeletal injuries and claims. So the references are in there. We created one after you left. All right, this is good. I just wanted to get some additional, if you had any additional insights. It's just challenging. Good, good. Yeah, just wanted to make sure that that was at least out there. So it sounds like you're well ahead, though. Trying, trying. Thank you. Thanks. I don't know who's next. Yeah, great work. Thank you for both of you. This is one of the more important topics, as far as well-being goes, I think. Just a really short story. When I was an undergrad, I went to University of Aberdeen in Scotland for one semester. And I remember walking into a lab on Wednesday afternoon. There was nobody. And I was told that Wednesday afternoons is sports day for the entire university. And nobody was working. And it wasn't a mandatory rule, but people actually took part in that break. And I got sucked into the rugby team. And that's a whole other story in itself, one of the biggest disasters of my life. But I feel like that would be a very, very difficult, hard corporate sell. But do you both think that there's some value in that, in creating a massive block of time within the week to ensure that people are actually taking care of themselves? Yeah, I mean, I think you already said both things that I was going to say is, yes, I do think there would be value to that. I think you lived it and experienced it. And two, I think it is going to be a hard sell. But I hope that with some of the data that we have here, and that is out there beyond, obviously, what's in this presentation, that you can still show the benefit to the corporation. And sometimes you do have to spin it to, hey, the return on investment or the bottom line isn't the only thing we have to think about. And there are some other impacts. Maybe they're a little bit more indirect, or we have to talk around a little bit. I see Dr. Fabius coming in. He'll have something to say about that, I know. And again, Dr. Fabius' work, obviously, will show that there are positive impacts to the bottom line and the overall growth of the company. Speaking specifically of the physical activity interventions in and of themselves, there are different ways to get at that. So trying to find out what's important to your company and sell the program in the language of that readiness for the military, bottom line for others. Maybe other people are having a hard time recruiting talent. And so even if the program is a loss on the spreadsheet, having workers that they value and that they can't really replace still being with the company could be another way to spin it. And there is data out there for a lot of those outcomes. Congratulations for the great presentation and the extensive literature review. I'd like to know if there are evidence that sponsored gym membership is effective to improve physical health somehow. In my country, there are lots of options for that currently. And I heard from my senior leadership prove me that we are not only going to offer to those who already are physically active. Is there literature about that, my question? Thank you. Yeah, I'm not sure if there's literature on that. But I will say that the strategy of doing paid gym membership is a strategy that a lot of companies are doing to not only attract new talent, but also keep the talent, because a lot of people are asking for it. But I also would say I agree with you that the people who are really ready to exercise are the ones who are taking advantage of it. But I think if you do a comprehensive wellness program and really move a company culture to a culture of health, you start having people that want to conform to their pack. And you can actually do that healthy contamination in which people are like, oh, I have this as a benefit. Maybe I will try. But I will have to check if there is any literature. Do you know, Dr. Faber, is there any literature on that? Yes. Let me share with you a couple of things. First of all, what you just said was spot on. Really what this is about is this is a cultural iconic opportunity. When you promote physical activity, it positions the culture of the organization in a different way. One of my great mentors was Dee Eddington. How many people know Dee Eddington? So this is a great opportunity for me. Now, sadly, Dee died recently. But he wrote two books. But the big one that I think everybody should read is called Zero Trends. So when there is the argument, which you hear from your leadership, that we put a gym into, and I'm using this as a metaphor, we put a gym into the work site and only the healthy people used it as a criticism. You should be very quick to make it clear that there is literature and research, particularly from Dee Eddington, that shows that you may actually, if you have to invest in a segment of your workforce in regards to physical activity, it may be way better for you to invest in the ones that are ready and the ones that are already healthy than to try to take somebody who's already somewhat debilitated and make them better. I'll use my own family as an example. Diabetes runs rampant in my family. And my father was a classic example of someone who didn't take care of himself at all. And he became diabetic at 35 and died at 49. It may be that that experience of watching my father decay as a young child led me to a commitment to building cultures of health and well-being. My grandfather, who took pretty good care of himself, didn't become diabetic till he was 70. And I myself, I'm happy to tell you who've been trying to take very good care of myself is not yet diabetic. But I do realize if I live long enough, I probably will. So this notion of delaying the progression of chronic disease by helping someone under your employment stay healthy and push back chronic illness is a frontier of return on investment that's just starting to permeate in this space. But it's a very, very big impact. And we should all try to do some studies. I understand that they have to be longitudinal. But we need to do more studies to show that those people who take care of themselves through your efforts to guide them in the right direction and make it easier for those that are ready to do it provide a huge return on investment. One last study that I want to share with you is the Lamplighter study, which is now ancient. How many people know the Lamplighter study? OK, so you have homework to do. The Lamplighter study, which was done in the UK with Unilever, showed something that's, as we say in this country, especially in Philadelphia from Thomas Jefferson, self-evident. And that is that people who are healthier perform better at work. And that study actually gave everybody a health rating and then looked at their rating of performance at work. And the high-performing folks had significantly higher health. And so health is directly correlated to high performance. Thank you. Yes. So the idea that the tendency is for the healthy to become unhealthy. So you better help the healthy too. We can have a last question. Last question. Wonderful presentation and wonderful comments as well. Keeping with the gymnasium on site, in our post-COVID world, have you noticed or seen any fall-off or reluctance for workers to use an on-site gymnasium? And if so, how have you helped them to come to another decision on that? Yes. I have seen that a lot. But I think it's coming back. It's really coming back, especially when you're very clear that you can wear a mask when you exercise if you'd like to, or the equipment is clean, that it's very clear that the company is taking good care in terms of hygiene and keeping the areas clean. People are coming back more and more to the gym. Yes. Thank you. OK. Thanks again, everyone. You have our contact info up here. If there's anything else we can try to do or help or answer. Thanks. Thank you.

workplace physical activity interventions

physical activity programs

wearables

virtual exercise classes

evidence and benefits of physical activity

recommended guidelines

informational campaigns

on-site gyms

active commuting

active design in the workplace