All measurements were executed in the morning after an overnight fast, at the worksite of the participant and performed by the same researcher. Measurements started in September and data collection was completed for all study participants in August Body weight, height, skinfold thickness and waist circumference were measured.

Body weight kg was measured, in underwear, to the nearest 0. Height m was measured to the nearest 1. Skinfold thickness was determined using the sum of four skinfolds measured with the Harpenden skinfold calliper HSK-BI, British Indicators, West Sussex, UK.

Skinfolds included biceps anterior surface of the biceps midway between the anterior auxiliary fold and the antecubital fossa , triceps vertical fold on the posterior midline of the upper arm, halfway between the acromion and olecranon process , subscapular fold on the diagonal line coming from the vertebral border to between 1 and 2 cm from the inferior angle of the scapulae and suprailiac diagonal fold above the iliac crest even with the anterior auxiliary line.

Waist circumference measures were obtained to the nearest 0. It was measured at the abdominal waist horizontal at the umbilicus. The self-report measures were assessed with a self-administered written questionnaire, which participants returned completed during the body composition measurements.

A required sample size of participants from 12 worksites was determined to be large enough to detect a medium effect size Cohen's d 0. The power calculation assumed an intraclass correlation of 0.

The primary outcomes examined in this study are changes in body weight, BMI, sum of skinfolds and waist circumference from baseline to 12 months and 24 months. Prior to the analyses, data of female participants who had been pregnant during the two-year project were excluded.

To assess potential dropout bias, baseline characteristics age, gender, BMI, marital status, education and smoking status were compared between those who dropped-out and those who attended all measurements.

An intention-to-treat analysis was conducted for 12 and 24 months in which dropouts in the intervention and control group were assigned average weight changes that were observed in the control group at both time-points.

The analyses data not presented showed similar results as the 'on treatment analyses' both for the changes after 12 and 24 months, the 'on treatment analysis' are the primary analyses and are presented below. The effect analyses were performed in five steps. First, differences in baseline characteristics of participants in the intervention and control group were explored, using Student's t-test or Chi-square test.

Second, differences between the intervention and control group in changes in body weight, BMI, skinfold thickness and waist circumference at 12 and 24 months were examined using linear regression analyses adjusting for various baseline characteristics age, gender, BMI, marital status, education and smoking status.

The measurements were repeatedly obtained for the same subjects, nested within several worksites, yielding a three level design. To deal with possible dependencies in the measurements across time due to being obtained for the same worksites and persons, the multilevel linear regression analyses were conducted in MlwiN employing a random intercept that varies both at the level of worksites and at the level of persons [ 18 ].

By including the baseline measurement of the outcome variable in the analysis as one of the measurements at the lowest level, combined with a specific coding for the effect of time, differences of outcomes with baseline are analysed, in this way correcting for differences between the intervention groups at baseline.

In this analysis the unstandardized regression coefficient B for the interaction between time and the intervention factor represents the intervention effect on such change scores.

The analysis model is comparable to a repeated measures ANOVA adjusted for baseline for follow-ups at 12 months and at 24 months, however there being no random interaction effects with time.

Adjustments for the baseline value of age, gender, BMI, marital status, education and smoking status were made, by including these variables as covariates in the analysis. Thirdly, Cohen's d effect sizes were calculated in order to calculate the magnitude of the intervention effect; d is defined as the difference between two means divided by the pooled standard deviation in the population.

Fourth, potential interaction effects of the intervention group with gender, age and BMI were explored. If significant interactions occurred analyses were repeated with stratification by gender, age, or BMI. Fifth, two types of intraclass correlation coefficients ICCs were calculated for each of the four outcome measures.

The ICC on worksite-level is the random intercept variance at worksite-level divided by the total variance and thus reflects the degree to which differences on outcome measures can be explained by random effects of the worksites. The ICC on person level is the random intercept variance at worksite level plus the random intercept variance at person level divided by the total variance, thus reflecting to what extent differences on outcome measures can be explained by random effects of worksites and individuals [ 20 ].

The number of participants who were not measured at 12 and 24 months was 71 The most common reasons for discontinuation were change of occupation, conflict with workload and stress-related issues.

The dropout analyses revealed some selective dropout. Baseline characteristics of the control and intervention group are described in table 1. Participants from the intervention group were older and had a higher BMI than participants from the control group Apart from these differences groups did not differ in terms of baseline characteristics.

Changes in skinfold thickness, waist circumference, body weight and BMI for the two groups over 12 and 24 months are depicted in table S1 additional file 1. A greater reduction in sum of skinfolds was observed for participants in the intervention group than for participants in the control group.

Participants from the intervention group reduced their waist circumferences over time in comparison to an increase in the control group. Changes in weight and BMI however did not differ significantly between the two groups neither at 12 nor at 24 months. Although changes in weight and BMI were not statistically significant, they were in favour of the intervention group.

The corresponding Cohen's d 's were all smaller than 0. Significant interaction terms were found for the changes in skinfold thickness table 2. No significant effects were observed among men. Data collected by observation and registration of activities revealed that four of the six worksites implemented environmental interventions.

All four worksites placed posters near the elevators and stairs to stimulate stair use over a 3-week period [ 21 ] and provided general information on the project.

Two hospital, paper-factory of these four worksites formed worksite linkage boards and implemented more environmental interventions, which included making the NHF-NRG In Balance-project visible through articles in the worksite personnel magazine or through intranet.

The hospital organized several special events: a 1-week placement of an 'information wall' containing information on the balance between food intake and physical activity in addition to the presence of a health professional who took waist circumference measurements and gave advice.

This worksite also handed out free apples during National Health Week, together with information booklets and maps and walking routes that were located around the hospital. Moreover, they made their personnel aware of the hospitals physical activity facilities, e.

squash, aerobic classes, bikes to borrow. After the 2-year period the hospital was in negotiation regarding a specific bike-scheme. The paper-factory organized a series of workshops given by a dietician on healthy eating, distributed pamphlets on physical activity and information regarding special offers at local sports facilities.

The present study was designed to test the and month effectiveness of the NHF-NRG In Balance-project, with regard to changes in body weight, BMI, sum of skinfolds and waist circumference. The results indicate that with regard to changes in sum of skinfolds and waist circumference the project was indeed effective at both 12 and 24 months.

Even though changes in weight and BMI between the intervention and control group were not significantly different, they did change in the desired direction.

Overall, the intervention of the NHF-NRG In Balance-project had a positive effect on the body composition measures of the individuals in the intervention group.

The interpretation of effect sizes of Cohen's d imply effects of medium magnitude for the changes in skinfold thickness and waist circumference both after 12 and 24 months Cohen's d between 0. Such changes in body composition indicators may have important health implications, as it has been demonstrated that the health risks associated with obesity derive primarily from fat rather than weight [ 22 ].

Moreover, it is not only the total amount of fat that is important, but also the distribution of fat in the body [ 23 ], with central fatness being most related to health risks [ 24 ]. The reduction in skinfold thickness and waist circumference observed in the present study reflects a reduction in central fatness [ 22 , 25 ].

The decrease in waist circumference is most relevant, as a large waist circumference is independently associated with health risks [ 26 , 27 ] and mortality [ 28 , 29 ]. On a population level it has even been shown that there is a more significant trend of increases in waist circumference over time than BMI [ 30 ].

With regard to changes in waist circumference it has been demonstrated that an increase in fibre intake was associated with a reduction in waist circumference in men [ 31 ].

A strong dose-response relationship has also been observed between the amount of exercise and measures of central obesity [ 32 ]. Interestingly, changes in physical activity can lead to changes in body composition, which may be reflected in changes in waist circumference, while body weight remains stable through increased muscle mass [ 33 , 34 ].

This is in line with the findings of the present study. Stratified outcome analyses were interesting. It appeared that the intervention only had an effect on the changes in skinfold thickness in women and not in men. It would be interesting to see if this is a result of the engagement in different energy balance-related behaviours of men and women.

The process evaluation of the environmental interventions showed that two worksites formed a worksite linkage-board, who implemented several environmental interventions throughout the two year period.

When taking baseline characterises into consideration, the individuals in these two worksites appeared to show better results with regard to changes in waist circumference and sum of skinfolds than individuals in worksites with fewer components to the intervention both after 12 and 24 months data not shown.

Although the study was not powered to significantly detect these between-worksite differences, this finding does underscore the importance of intervening on both the individual and the environmental level. Moreover, it showed that the context of the worksites did not affect the uptake of the intervention, as one of these two worksites had predominantly white-collar workers and the other blue-collar.

This finding as worksite-health promotion programs are often less likely to result in health behaviour change in blue-collar workers [ 35 ]. The NHF-NRG In Balance-project is one of few worksite obesity prevention programmes, which 1 is primarily aimed at weight gain prevention through changes in both food intake and physical activity, 2 contains both individual and environmental components and 3 assesses longer-term follow-up effectiveness.

A recent review of papers on lifestyle interventions aimed at prevention of overweight and obesity, with primary programme objective weight management, prevention of weight gain or moderate weight loss among adults, included four additional studies to the present study, in which workplace interventions were evaluated.

Two of these studies included behavioural goals that were aimed at both diet and physical activity; three included both cognitive and environmental goals and two studies assessed effectiveness after a 12 month follow-up.

Significantly smaller increases in BMI in the intervention conditions were observed in one study; no treatment effect for weight or BMI changes was found in the others. Two of the studies also included measurements on percent body fat, both of which observed significantly positive effects [ 36 ].

These findings are in line with those observed in the present study. To date, there has been an increase in the number of worksite obesity prevention studies that are testing environmental or combined environmental-and individual-level worksite interventions over a longer period of time, e.

However results regarding effectiveness have not yet been published. In the present study, we perceived several benefits of implementing the intervention within a worksite setting. Firstly, the worksites provided access to a large number of adults with different educational backgrounds. Moreover, the employees within the worksites are able to play an important role in diffusing the intervention throughout the worksite by impacting social norms, which in the long-term may influence the behaviours of co-workers who did not change their behaviour initially [ 38 ].

Difficulties were perceived with regard to enhancing facilitators of environmental changes, as only two of the six worksites set up a worksite-linkage board. As the linkage boards play a crucial role in the adoption, implementation and institutionalization of the environmental components, strategies should be developed to mobilize support and commitment for the formation of such boards.

There are a number of limitations of this study, including those concerning the generalizability. An important reason for companies not to participate in the NHF-NRG In Balance-project proved to be the randomized evaluation design of the programme, implying that companies were not willing to take the risk of being excluded from the intervention [ 16 ].

We were therefore forced to drop the original randomization design of the programme and assign worksites to the experimental and control group based on matching. As a result of which it is possible that selection bias occurred, weakening the internal validity of the results. Moreover, external validity was weakened by the fact that participating worksites were most likely not representative of the average worksite, in that the participating worksites probably showed a higher interest in health promotion than worksites in general.

Implementing the project in less interested worksites might not have generated the same results. A second limitation of the present study is the recruitment of participants. Even though the aim of the project was to prevent weight gain in young adults, there was a relatively high response of older and overweight individuals, in line with observations of other studies [ 27 , 28 ].

This may have resulted in a selection bias, in which individuals who were more interested to change the targeted behaviours were oversampled.

Moreover, there was a high response of participants with a tertiary education. The third limitation concerns the statistical analysis, although sophisticated multilevel analyses were executed in this study, the statistical procedures may not fully account for all potential dependencies that were introduced as a result of the research design.

For example, our statistical model contained only one random component for worksite, implying that every worksite is assumed to have exactly the same response to the intervention if in intervention or to the control situation if in the control condition. The fourth limitation pertains to the process evaluation; unfortunately we were unable to perform an in-depth analysis regarding the uptake of interventions by the individuals.

The fifth limitation is related to the absence of a significant difference in weight changes over time between both groups. However, weight changes observed in the control group were smaller than those expected, with smaller weight change differences between the groups 0.

The smaller increase in weight in the control group is most likely a result of measurement effects. However, it could also be a result of a selection bias; the control group might have consisted of more motivated individuals who are susceptible to change.

Moreover, it is possible that those individuals who dropped-out were those with a higher BMI. The findings presented here show the effectiveness of the NHF-NRG In Balance-project and support the value of using workplace settings for maintenance of behavioural changes in the area of weight gain prevention.

Additionally, it underscores the importance of systematically developing an intervention that contains both individual and environmental components and is directed at changing both physical activity and dietary behaviour.

Furthermore, the results support the notion that more attention needs to be given to generating interest in weight management both among worksites and among individuals who are at risk of weight gain.

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Pak J Med Sci 27 1 — Download references. Department of Physiology, Basirhat College, Basirhat, West Bengal, India. Department of Physiology, University of Calcutta, Kolkata, West Bengal, India.

You can also search for this author in PubMed Google Scholar. Correspondence to Tusharkati Ghosh. Clinical Biochemistry, University of Westminster, Westminster, United Kingdom.

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Policies and ethics. Skip to main content. Abstract The skinfold thickness in different locations like tricep, bicep, subscapular, suprailiac, and calf generally measures the subcutaneous fat deposition in the body.

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