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Abstract

Objective

This review summarized the literature on employer-sponsored workplace wellness programs (WWP) to reduce cardiovascular disease (CVD) risk factors in employees at-risk for CVD.

Data Source

Using keywords related to WWP and CVD, a comprehensive search was conducted for articles published between 2000-2024 in PubMed, CINAHL, PsycINFO, ABI/INFORM, and Web of Science.

Study Inclusion and Exclusion Criteria

Original, peer-reviewed quantitative research articles comparing employer-sponsored WWP to a control or comparison group to reduce CVD risk factors in civilian adults that were at-risk for CVD were included.

Data Extraction

Summary tables included program/intervention, occupation/industry category, employer size, participant sample size, participant characteristics, outcomes, and other key information.

Data Synthesis

Intervention results and overall quality of the articles were evaluated to determine the state of the literature and whether WWP yielded statistically significant improvements in CVD-related outcomes.

Results

Eighteen articles met eligibility (including 7 randomized controlled trials). Systolic and diastolic blood pressure were the most commonly studied outcomes. Most studies reported non-statistically significant results, but nearly half found significant improvements in systolic blood pressure.

Conclusion

This systematic review found mixed evidence on the effectiveness of WWP to improve CVD risk factors. By focusing on at-risk employees and objectively measured biometrics, this review provides a more targeted synthesis of the evidence. Future studies should consider longer interventions and a randomized approach to augment the rigor and interpretability of intervention findings.

Keywords

work worksite wellness health promotion heart disease cardiometabolic diabetes workplace interventions medical self-care

Objective

Cardiovascular diseases (CVD) have remained one of the major causes of death in the United States since 1920¹ and are the leading cause of death and disability among workers.^2,3 CVD encompass a range of heart and blood vessel diseases including hypertension, coronary heart disease, congestive heart failure, stroke, and atrial fibrillation, among others.¹ The American Heart Association estimates that 49% of the U.S. population had some form of CVD between 2017-2020.⁴

While health behaviors (e.g., tobacco use, diet, exercise) are often addressed by community-based efforts to reduce CVD, the role of the workplace may be overlooked.² Characteristics of the workplace may both drive CVD and present a unique opportunity to deliver services and support. Work is linked to about 10-20% of all CVD deaths in middle-age populations.^5,6 Various factors specific to employment (e.g., shift work, work-life balance, sedentary labor, heavy physical exertion, environmental hazards) pose concerns for the onset and worsening of CVD.^2,5,7,8 For example, a systematic review found that work-related stress was significantly associated with CVD and CVD-related mortality in 13 out of 20 prospective cohort studies and randomized controlled trials (RCTs).⁸

Furthermore, there are considerable indirect costs of CVD that stem from lost productivity, absenteeism, and presenteeism (i.e., when employees are present but working at reduced capacity due to illness) in the workplace that have economic consequences both for employers and employees.^1,9,10 The American Heart Association estimates that the indirect costs from CVD reached $184.6 billion between 2020-2021. Data from the 2019 Panel Study of Income Dynamics estimated that employees with heart disease received on average $13,463 less in annual income compared to those without heart disease, and employees with stroke received about $18,716 less.¹¹ These figures amounted to approximately $203.3 billion lost in total labor income for heart disease and $63.6 billion for stroke, far greater than labor income losses associated with premature mortality.¹¹ Likewise, a 2012 study found that each short-term disability claim filed because of a heart attack or chest pain resulted in $8,000 in lost productivity, with long-term claims generating over $52,000 in lost revenue to employers.^1,12

On the other hand, employers are in a unique position to promote cardiovascular health and reduce CVD through workplace wellness programs (WWP).¹³ Employers may invest in WWP to increase employee satisfaction and retention and diminish revenue losses associated with disease-driven reductions in work productivity. Additionally, working-age adults spend more than half of their waking lives engaging in work and related activities.¹⁴ The sheer contact that employees have with their workplace suggests that WWP may be an opportunity for employees to enhance their cardiovascular health.¹⁵ Additionally, the goal-oriented, congregate nature of workplace settings may exemplify the core mechanisms of effective group-based interventions (e.g., peer support, team cohesion, group coherence, accountability, shared experiences) that promote healthy behaviors and program participation.^16,17 Finally, as the number of employers offering WWP increases,¹⁸ there is more availability of the infrastructure and resources needed for employers to adopt and expand these health interventions.^5,19,20 For example, the National Institute for Occupational Safety and Health (NIOSH) has disseminated a Total Worker Health framework that guides employers in health promotion efforts.^21,22 Increasing the proportion of worksites that offer a WWP is also one of the Healthy People 2030 objectives.²³

Despite the opportunity for employers to advance cardiovascular health, past research has not systematically examined the characteristics or effectiveness of WWP to promote cardiovascular health in the U.S., particularly among at-risk populations who may benefit from WWP the most.²⁴ Prior reviews have often included non-U.S. populations, broad workforce samples, wide-ranging physical health outcomes, and often self-reported outcomes.²⁵ However, several relevant systematic reviews have considered CVD risk factors.

A systematic review that focused on male-dominated industries found little evidence of intervention effectiveness on systolic or diastolic blood pressure.²⁵ A 2010 review found no evidence for a positive effect of workplace lifestyle interventions on blood pressure, serum lipid profile, blood glucose, or triglycerides.²⁶ On the other hand, a 2021 meta-analysis investigating interventions to improve diet and cardiometabolic risk factors found positive effects on LDL and HDL cholesterol, triglycerides, diastolic blood pressure, and fasting glucose; though the study only included multicomponent interventions targeting the overall workforce rather than at-risk populations or specific cardiometabolic diseases.²⁷ An umbrella review examining the effects of workplace interventions on type 2 diabetes, CVD, mental health, and musculoskeletal disorders identified 5 reviews that included measures of cardiovascular health,²⁸ but focused on non-U.S. populations, were limited to specific sectors (e.g., industrial workers), examined a broad variety of health outcomes, or had limited evidence for biometric measures of hypertension, diabetes, and high cholesterol.^22,26,29-31 Another umbrella review examined workplace interventions for musculoskeletal disorders, psychological and behavioral disorders, and older employees, but did not focus on CVD.³²

In contrast, this review specifically focuses on U.S.-based WWP targeting employees with elevated cardiovascular risk factors, restricts inclusion to studies with pre/post comparative designs (excluding descriptive or educational-only programs), and emphasizes objectively measured biometric outcomes (e.g., blood pressure, HbA1c, cholesterol, glucose). By narrowing our focus to at-risk populations and objectively measured outcomes, this study provides a more rigorous and clinically relevant synthesis of the evidence base and identifies methodological weaknesses that future workplace cardiovascular health research must address. As such, this systematic review aimed to collate and elucidate the research literature on employer-sponsored WWP for employees at risk of CVD in the U.S.

Methods

This study examined health outcomes resulting from employer-sponsored WWP that targeted cardiovascular health for at-risk employees. We registered the systematic review in the International Prospective Register of Systematic Reviews (PROSPERO; ID #1338287). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach to document the identification of eligible articles (Figure 1).^33,34 We used the Rayyan³⁵ systematic review software for article screening, Zotero³⁶ reference management software for article storage and organization, and Microsoft Excel for manual data extraction.

Figure 1.

Flowchart of the identification of articles following the PRISMA approach.^33,34

Data Sources

A health sciences librarian conducted literature searches in PubMed using both a keyword search (Supplemental Table 1) and a Medical Subject Headings (MeSH) search (Supplemental Table 2). Keyword searches were also performed in CINAHL, PsycINFO, ABI/INFORM, and Web of Science. A search algorithm was used to query for peer-reviewed, English-language articles published between January 2000 – June 2024 using keywords related to (1) the workplace, (2) health or wellness, (3) programs or interventions, and (4) cardiovascular or metabolic disease. Titles and abstracts were exported to the Zotero³⁶ reference management software where duplicates were removed and initial eligibility was assessed. Articles that specifically measured CVD biometrics were then identified using an in-depth eligibility screening protocol.

Inclusion and Exclusion Criteria

Inclusion criteria included (1) original, peer-reviewed research articles that (2) addressed programs or interventions related to health promotion, safety, maintenance, screening, or treatment of cardiovascular or metabolic disease (hypertension, hyperlipidemia, hypercholesterolemia, atherosclerosis, atrial fibrillation, heart failure, acute myocardial infarction, stroke, or diabetes).³⁷ Articles had to (3) evaluate an employer or worksite-based program or otherwise target employees of a specified entity, (4) be available in English and describe programs or interventions that were conducted in the U.S., (5) include adult employees (ages 18 or older), and (6) focus on civilian populations. Additionally, articles had to (7) present original research involving primary data collection that (8) reported quantitative findings, and further, (9) compare findings from an intervention group to a control or comparison group and (10) describe research that targeted workers who were identified as “at-risk” for adverse health outcomes. (11) In the event that more than one article described similar findings from the same study, only the article presenting the most up-to-date or comprehensive study results was included. A detailed list of inclusion and exclusion criteria can be found in Supplemental Table 3.

Eligibility Screening

For the first screen, articles were sorted alphabetically by author name and evenly split for review by a health sciences librarian and a health services researcher. Titles/abstracts that clearly did not meet inclusion criteria were flagged for exclusion. Titles/abstracts were then reassigned to the opposite reviewer for further review. Articles that were flagged for exclusion by both reviewers were removed.

Next, articles were imported into the Rayyan³⁵ systematic review software for a second screen that provided an in-depth examination of the remaining titles/abstracts. Both reviewers screened the titles/abstracts to exclude any articles describing workplace interventions that did not address cardiovascular or metabolic disease. Discrepancies were discussed and were resolved between reviewers when possible, while any conflicts or ambiguous titles/abstracts were retained.

Finally, a third screen was conducted using the full texts of the remaining articles. To begin, a subset of ten articles were screened by both reviewers to improve inter-rater reliability. Disagreements were resolved through group-based discussion with the entire study team; clarifying notes were added to the inclusion/exclusion criteria before proceeding with the remainder of the full-text review. Potentially eligible articles were tagged with the specific chronic condition(s) that were targeted, and ineligible articles were tagged with the primary reason for exclusion. Articles that generated conflicting decisions by the two reviewers were flagged for adjudication by one of the two project leads (a medical psychologist and a mixed methods researcher), whose decision was then brought to the larger study team meeting for discussion and a final verdict. The rationale for the final inclusion or exclusion decision was also documented. The reference sections of the remaining eligible articles were scanned for additional articles that were unidentified by the initial literature search. Throughout the review process, the study team met weekly to discuss questions, address inconsistencies, highlight emerging themes, and further refine the details of inclusion/exclusion criteria when additional specificity was needed.

Data Extraction

Data from the final sample of articles was extracted into an Excel spreadsheet by the health sciences librarian and two health services researchers. Elements for data extraction were chosen a priori and grounded in a core set of recommended health metrics for the evaluation of employee health management programs, developed by the Health Enhancement Research Organization (HERO) and Population Health Alliance.²⁰ The following data elements were extracted when available: author name; publication year; article title; number of worksites included in the program/intervention; free-text descriptions of the worksite/occupation type; employer size (under vs over 5000 employees, based on prior classifications used in national datasets and large-employer surveys^38,39); participant sample size (exact number, when reported); free-text descriptions of sociodemographic and clinical characteristics of participants at baseline (when reported); free-text descriptions of the program/intervention; free-text descriptions of the interventions’ goal or target condition; conditions targeted by the intervention (hypertension, cholesterol, diabetes, or other cardiovascular condition, reflecting selected HERO metrics guidelines²⁰); years during which the intervention was administered; duration of the intervention in weeks/months/years; delivery mechanism(s) by which the intervention was administered (in-person, online, and/or telephonic, per the HERO metrics guidelines²⁰); whether monetary incentives were provided (e.g., cash, gift cards, cost-sharing incentives (coded as yes/no)); whether the study was grounded in theory or a conceptual framework (yes/no); whether an RCT design was used (yes/no); whether pre-/post-measures were reported (yes/no); and free-text descriptions of the authors’ key findings and recommendations. All extracted data was cross-checked for accuracy by three team members.

Additionally, we conducted a quality assessment of the articles using criteria established by the National Heart, Lung and Blood Institute (NHLBI) for before-after (pre-post) studies with no control group and case-control studies (NHLBI, 2021).⁴⁰ These quality assessment tools are frequently used for systematic reviews to assist reviewers in examining concepts key to a study’s internal validity.

Data Synthesis

Characteristics of the articles and underlying studies were summarized in line with recommendations by HERO and the Population Health Alliance.²⁰ Article characteristics and their underlying study designs are characterized categorically and descriptively in Table 1. Intervention results are captured in Table 2 and include a categorization of whether the authors reported statistically significant improvements, worsening, or non-significant results for each health outcome. These results were summarized across articles and summed to provide total counts of articles that resulted in significant improvement, worsening, or no effects of each outcome in Table 3. Finally, a mixed methods researcher and a health services researcher conducted an evaluation of study quality using the tailored study quality assessment tools developed by the NHLBI.⁴⁰ A synthesis of overall study quality and article-specific quality ratings are presented in Table 4.

Table 1.

Study Characteristics (N = 18)

Author, year, and title	Numberworksites/employers	Location	Worksite/Occupation	“At-risk” participant characteristics	Sociodemographiccharacteristics of intervention participants	Average clinical metrics of intervention participants at baseline	Yearsadministered	Interventionduration	Analyticsample size	RCT
Barham et al (2011) Diabetes prevention and control in the workplace: A pilot project for county employees	3	NY	County employees (department of probation, department of health, and department of social services)	Overweight or obese employees with diabetes or at risk for diabetes	Age (mean): 51 years Female: 81% White: 81%	SBP: 135 mmHg (±14) DBP: 74 mmHg (±10) Glucose: 107 mg/dL (±36) HbA1c: 6.2% (±1) Total cholesterol: 207 mg/dL (±38) HDL cholesterol: 47 mg/dL (±14) LDL cholesterol: 126 md/dL (±24) Triglycerides: 140 mg/dL (±61)	2008-2010	3 months; followed by monthly maintenance	41	N
Carnie et al (2013) Randomized trial of nutrition education added to internet-based information and exercise at the work place for weight loss in a racially diverse population of overweight women	1	MD	National institutes of health	Overweight or obese female employees without diabetes	Age (mean): 47 years Female: 100% White: 33% Black: 56% Asian: 4% Hispanic: 7%	HOMA insulin resistance: 2.3 (±2) Total cholesterol: 185 mg/dL (±33) HDL cholesterol: 53 md/dL (±13) LDL cholesterol: 114 mg/dL (±28) Triglycerides: 88 mg/dL (±46)	NR	3 months; followed by monthly maintenance for 3 months	158	Y
Cheon et al (2020) When workplace wellness programs work: Lessons learned from a large employer in Texas	Multiple (not specified)	TX	Large state-wide employer	Employees with out-of-range biometric values for BMI, SBP, DBP, blood glucose, or cholesterol	Age (mean): 45 years Female: 63% Race/ethnicity: NR	SBP: NR DBP: NR Glucose: NR Total cholesterol: NR	2012-2016	2-8 weeks	24,117	N
Cohen et al (2020) Impact of primary care worksite health and wellness clinics on HbA(1c) level among prediabetic or diabetic employees	Multiple (not specified)	CA	Agricultural and packaging sites for a private global consumer packaged goods company (The wonderful company)	Employees with prediabetes or diabetes	Age (mean): 48 years Female: 56% Race/ethnicity: NR	HbA1c: 6.1% (±1)	2016-2017	2+ visits	662	N
Deitz et al (2014) Heart Healthy Online: An innovative approach to risk reduction in the workplace	3	OH, VA, WV	Hospitals	Employees with at least one known risk factor for cardiovascular disease	Age (range): 21-72 years Female: 86% White: 92% Black: 4% Indian: 2% Asian: 1% Hispanic: 1%	SBP: 125 mmHg (±13) DBP: 79 mmHg (±9)	NR	6 weeks	188	Y
Faghri and Li (2014) Effectiveness of financial incentives in a worksite diabetes prevention program	4	NR	Long-term care facilities belonging to single corporation	Overweight or obese employees at risk for type 2 diabetes	Age (mean): 45 years Female: 91% White: 40% Black: 54% Hispanic: 3%	SBP: 123 mmHg (±17) DBP: 77 mmHg (±12)	NR	16 weeks	73	Y
Ferdowsian et al (2010) A multicomponent intervention reduces body weight and cardiovascular risk at a GEICO corporate site	2	MD, VA	Insurance company corporate sites (GEICO) employees	Overweight employees with BMI ≥25 or type 2 diabetes	Age (range): 21-65 years Female: 73% Race/ethnicity: NR	SBP: 119 mmHg (±2) DBP: 81 mmHg (±1) HbA1C: 7.4% (±0.3) Total cholesterol: 187 mg/dL (±5) HDL cholesterol: 53 mg/dL (±2) LDL cholesterol: 104 mg/dL (±4) Triglycerides: 154 mg/dL (±12)	NR	22 weeks	113	N
Gamston et al (2019) Description of a pharmacist-led diabetes prevention service within an employer-based wellness program	1	AL	Pharmaceutical care center (Auburn University)	University employees with prediabetes-level A1C	Age (mean): 50 years Female: 52% White: 57% Black: 29% Asian: 10% Hispanic: 0% Other: 4%	Glucose: 108 mg/dL HbA1c: 5.8% HDL cholesterol: 51 mg/dL (±14)	2016-2019	24 weeks	55	N
Kraemer et al (2012) A randomized study to assess the impact of pharmacist counseling of employer-based health plan beneficiaries with diabetes: The EMPOWER study	7	OR	Variety of employers and state-based health insurance carriers	Employees with diabetes or their medical beneficiaries	Age (mean): 56 years Female: 39% White: 90% Black: 3% Asian: 0% Native American: 3% Hawaiian: 3% Hispanic: 6%	SBP: 136 mmHg DBP: 78 mmHg Glucose: 149 mg/dL HbA1c: 7.3% Total cholesterol: 177 mg/dL HDL cholesterol: 46 mg/dL LDL cholesterol: 100 mg/dL Total:HDL ratio: NR Triglycerides: 165 mg/dL	NR	12 months	67	Y
Kramer et al (2015) Improving employee health: Evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease	1	PA	Large international company (Bayer corporation)	Employees who were overweight or had risk factors for prediabetes or metabolic syndrome	Age (mean): 52 years Female: 55% White: 93.3% Non-white: 6.7%	SBP: 121 mmHg (±12) DBP: 81 mmHg (±8) Glucose: 92 mg/dL (±11) Insulin: 6.8 mg/dL (±8) HbA1c: 5.7% (±0.3) Total cholesterol: 195 mg/dL (±38) HDL cholesterol: 52 mg/dL (±14) LDL cholesterol: 114 mg/dL (±31) Triglycerides: 134 mg/dL (median)	2011	12 weeks; followed by bi-weekly then weekly support for 1 year	89	N
Misra-Hebert et al (2016) Financial incentives and diabetes disease control in employees: A retrospective cohort analysis	NR	OH	Employee health program (cleveland clinic)	Employees with diabetes	Age >40 years: 93-95% Female: 71-73% White: 58-62%	SBP: 127.8-128.9 mmHg HbA1c: 7.31-7.52% LDL cholesterol: 97.5-103.6 mg/dL	2008-2012	1 year	1092	N
Salinardi et al (2013) Lifestyle intervention reduces body weight and improves cardiometabolic risk factors in worksites	4	MA	Office-based worksites	Overweight or obese employees with BMI ≥25	Age (mean): 45 years Female: 58% White: 71% Black: 11% Asian: 9% American indian or Alaska Native: 9% More than one race: 4% Unknown: 5% Hispanic: 4%	SBP: 132 mmHg (±2) DBP: 84 mmHg (±1) Glucose: 101 mg/dL (±2) Total cholesterol: 197 mg/dL (±4) HDL cholesterol: 47 mg/dL (±2) LDL cholesterol: 125 mg/dL (±4) Non-HDL chol: 149 mg/dL (±4) Total:HDL ratio: 5 (±0) Triglycerides: 129 mg/dL (±7)	2010-2011	6 months; followed by monthly maintenance for 6 months	84	Y
Schweitzer et al (2023) Short-term intensive lifestyle therapy in a worksite setting improves cardiometabolic health in people with obesity	Multiple (not specified)	TN	Ballad health system	Overweight or obese employees with 2 or more risk factors for metabolic syndrome	Age (mean): 54 years Female: 75% Race/ethnicity: NR	SBP: 142 mmHg (±14) DBP: 82 mmHg (±13) HbA1c: 7.4% (±2) Total cholesterol: 182 mg/dL (±43) HDL cholesterol: 40 mg/dL (±9) LDL cholesterol: 112 mg/dL (±34) Triglycerides: 206 mg/dL (±97)	NR	6 weeks	54	Y
Senecal et al (2018) Digital health intervention as an adjunct to a workplace health program in hypertension	1	TN	CareHere LLC administered program to 81 employers across 42 states	Employees with hypertension	Age (mean): 53 years Female: 51% White: 76% Black: 12% Hispanic: 3% Other: 9%	SBP: 145 mmHg (±12) DBP: 89 mmHg (±8)	2011-2014	1 year	1622	N
Touger-Decker et al (2010) Workplace weight loss program; Comparing live and internet methods	2	NJ	Academic setting with an urban campus and a suburban central campus	Overweight or obese employees with BMI ≥25	Age (mean): 46.5 years Female: 93% White: 46% Non-white: 54%	SBP: 127 mmHg (±19) DBP: 85 mmHg (±12) Glucose: 95 g/dL (±13) Total cholesterol: 194 mg/dL (±34) HDL cholesterol: 49 mg/dL (±17)	2006-2008	12 weeks	95	N
Watson et al (2012) Evaluating a web-based self-management program for employees with hypertension and prehypertension: A randomized clinical trial	6	MA	Computer company (EMC corporation)	Workers with hypertension	Age (mean): 49 years Female: 21% White: 86%	SBP: 134 mmHg (±14) DBP: 81 mmHg (±8)	2007-2008	6 months	392	Y
Weinhold et al (2015) A randomized controlled trial translating the diabetes prevention program to a university worksite, Ohio, 2012-2014	1	Midwest	Major university	Employees with prediabetes who were overweight or obese	Age (mean): 52 years Female: 80% White: 77% Black or Asian: 23% Hispanic: 0%	SBP: 129 mmHg (±2) DBP: 91 mmHg (±2) Glucose: 109 mg/dL (±2) Total cholesterol: 195 mg/dL (±5) HDL cholesterol: 51 mg/dL (±3) LDL cholesterol: 113 mg/dL (±4) Triglycerides: 166 mg/dL (±13)	2012-2014	4 months; with follow-up at 7 months	68	N
Wilson et al (2017) Evaluation of a digital behavioral counseling program for reducing risk factors for chronic disease in a workforce	Multiple (not specified)	MA	Global storage and information management services company (iron mountain)	Employees with prediabetes	Age (median): 46 years Female: 58% White: 68% Black: 14% Hispanic: 9%	SBP: 123 mmHg (±1) DBP: 79 mmHg (±0.4) Glucose: 95 mg/dL (±1) Total cholesterol: 191 mg/dL (±2) HDL cholesterol: 48.2 mg/dL (±1) LDL cholesterol: NR Triglycerides: 146 mg/dL (±4)	2013-2015	16 weeks; followed by weekly maintenance for 36 weeks	634	N

Abbreviations: NR: Not reported; Y: Yes; N: No; RCT: Randomized controlled trial; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HbA1c: Hemoglobin A1C; HDL: High-density lipoprotein; LDL: Low-density lipoprotein.

*The underlying NIH Diabetes Prevention Program model is based on social cognitive theory.

Table 2.

Intervention Outcomes

Author, year, and title	Programdescription	Interventiongoal/target	Between-group differences in outcomes
Author, year, and title	Programdescription	Interventiongoal/target	Stratified (if applicable)	Hypertension	Diabetes	Cholesterol
Barham (2011) Diabetes prevention and control in the workplace: A pilot project for county employees	Lifestyle intervention program incorporating the diabetes prevention program curriculum	Primary (short-term goals): Improve nutrition, physical activity, and weight loss; Secondary (long-term goals): Decrease diabetes and cardiovascular risk		SBP: NSDBP: NS	Glucose: NSHbA1c: NS	Total cholesterol: NSHDL cholesterol: NSLDL cholesterol: NSTriglycerides: NS
Carnie (2013)Randomized trial of nutrition education added to internet-based information and exercise at the work place for weight loss in a racially diverse population of overweight women	Internet wellness information and nutrition education sessions	Whether nutrition education sessions at work added to internet-based wellness information and exercise resources would facilitate weight and fat mass loss in a racially diverse overweight population of female employees			HOMA (insulin resistance): NS	Total cholesterol: NS HDL cholesterol: NSLDL cholesterol: NSTriglycerides: NS
Cheon (2020)When workplace wellness programs work: Lessons learned from a large employer in Texas	Nutrition, diabetes prevention, and hypertension prevention program	Compare the effectiveness of three wellness programs (diabetes prevention, hypertension prevention, and nutrition program) on health outcomes	Diabetes prevention intervention arm:	SBP: NSDBP: NS	Glucose: - Intervention: 39% increase	Total cholesterol: NS
			Hypertension prevention intervention arm:	SBP: - Intervention: 2% increase DBP: - Intervention: % decrease NR	Glucose: - Intervention: 29% increase	Total cholesterol: - Intervention: % decrease NR
			Nutrition program intervention arm:	SBP: +Intervention: 4% decreaseDBP: NS	Glucose: + Intervention: 2% decrease	Total cholesterol: NS
Cohen (2020)Impact of primary care worksite health and wellness clinics on HbA(1c) level among prediabetic or diabetic employees	Health and wellness clinic incorporating multidisciplinary primary medical care with overall wellness programs	Improve hemoglobin A1c (HbA1c) control among diabetic and pre-diabetic employees	Prediabetics+diabetics:		HbA1c: NS
			Prediabetic subgroup:		HbA1c: NS
			Diabetic subgroup:		HbA1c: + >1 percentage point lower among clinic users compared to non-users (7.42 versus 8.5)
Deitz (2014)Heart Healthy Online: An innovative approach to risk reduction in the workplace	Heart healthy online, a web-based cardiovascular health promotion program	Cardiovascular health promotion program using an accessible and flexible format to provide information on disease prevention/behavioral strategies to reduce risk		SBP: NSDBP: NS
Faghri and Li (2014)Effectiveness of financial incentives in a worksite diabetes prevention program	Personalized weight-loss consultation program with weekly and total weight loss goals and monetary incentives and investments	Evaluate the effects of financial incentive structures (simple financial reward and self-imposed penalty) in a 16-week diabetes prevention program for weight loss, including impacts on risk for developing diabetes and cardiovascular complications with follow-up		16-week follow-up
				SBP: NSDBP: NS
				28-week follow-up
				SBP: NSDBP: NS
Ferdowsian (2010)A multicomponent intervention reduces body weight and cardiovascular risk at a GEICO corporate site	Low-fat vegan diet program incorporating vitamin regimen, weight monitoring, educational presentations, cooking demonstrations, and record-keeping	Determine if a multicomponent nutrition intervention program at a corporate site reduces body weight and improves other cardiovascular risk factors in overweight individuals; examine effectiveness of a worksite nutrition program including a low-fat, vegan diet on body weight, plasma lipid concentrations, blood pressure, work absenteeism, and in individuals with diabetes, glycemic control by HbA1C		SBP: + Intervention: 0 mmHg change Control: 5.7 mmHg increase DBP: + Intervention: 0.4 mmHg decrease Control: 5.1 mmHg increase	HbA1c: NS	Total cholesterol: NSHDL cholesterol: +Intervention: 4.3 mg/dL decreaseControl: 0.4 mg/dL decreaseLDL cholesterol: NSTriglycerides: NS
Gamston (2019)Description of a pharmacist-led diabetes prevention service within an employer-based wellness program	Wellness program incorporating the diabetes prevention program curriculum	Article aims to describe the implementation of a pharmacist-led diabetes prevention service that leveraged an existing biometric screening program within an employer-sponsored wellness program. Program provided early identification and intervention for uncontrolled or undiagnosed chronic disease.			Glucose: NSHbA1c: NS	HDL cholesterol: NS
Kraemer (2012)A randomized study to assess the impact of pharmacist counseling of employer-based health plan beneficiaries with diabetes: The EMPOWER study	Waived out-of-pocket expenses for medications and physician visits paired with educational pharmacist appointments or educational materials on diabetes mgmt.	Assess the impact of pharmacist counseling on empowering people w/diabetes to better self-care		SBP: NSDBP: NS	Glucose: NSHbA1c: NS	Total cholesterol: NSHDL cholesterol: NSLDL cholesterol: NSTotal cholesterol:HDL ratio: NSTriglycerides: NS
Kramer (2015)Improving employee health: Evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease	Diabetes prevention program group lifestyle balance, a behavioral lifestyle change intervention focusing on weight loss and physical activity	Decrease risk factors for type II diabetes and cardiovascular disease		SBP: +Intervention: 1.8 mmHg decreaseControl:1.9 mmHg increaseDBP: NS	Glucose: NSInsulin: NSHbA1c: +Intervention: 0.1% decreaseControl: 0.004% decrease	Total cholesterol: NSHDL cholesterol: NSLDL cholesterol: NSTriglycerides: NS
Misra-Hebert (2016)Financial incentives and diabetes disease control in employees: A retrospective cohort analysis	Disease management program for diabetes and cardiovascular risk factors incorporating financial incentives	Change in HbA1c; secondary changes in LDL, SPB, weight		SBP: + Intervention: 0.01 mmHg decrease Control: 0.30 mmHg increase	HbA1c: + Intervention: 0.05% decrease Control: 0.00% change	LDL cholesterol: + Intervention: 3.20 mg/dL decrease Control: 2.35 mg/dL decrease
Salinardi (2013)Lifestyle intervention reduces body weight and improves cardiometabolic risk factors in worksites	Multicomponent lifestyle intervention for weight loss that focused on changing dietary intake and eating-behavior patterns, including recommendations for diet change and education in behavioral change	Change in body weight, and secondary outcomes included changes in cardiometabolic risk factors		SBP: + Intervention: 9 mmHg decrease Control: 6 mmHg increase DBP: + Intervention: 8 mmHg decrease Control: 1 mmHg decrease	Glucose: + Intervention: 6 mg/dL decrease Control: 6 mg/dL increase	Total cholesterol: +Intervention: 13 mg/dL decreaseControl: 1 mg/dL increaseHDL cholesterol: NSLDL cholesterol: NSNon-HDL cholesterol: +Intervention: 14 mg/dL decreaseControl: 1 mg/dL decreaseTotal cholesterol:HDL ratio: NSTriglycerides: NS
Schweitzer (2023)Short-term intensive lifestyle therapy in a worksite setting improves cardiometabolic health in people with obesity	Intensive lifestyle intervention based on the pritkin program, incorporating frozen packed-out meals, group nutrition, behavioral education, cooking classes, and exercise sessions 3 times per week	Change in body weight, and secondary outcomes included changes in cardiometabolic risk factors		SBP: +Intervention: 10 mmHg decreaseControl: 0 mmHg changeDBP: NS	HbA1c: + Intervention: 1.2% decrease Control: 0.1% increase	Total cholesterol: + Intervention: 18 mg/dL decrease Control: 14 mg/dL increase HDL cholesterol: - Intervention: 2 mg/dL decrease Control: 1 mg/dL increase LDL cholesterol: + Intervention: 12 mg/dL decrease Control: 10 mg/dL increase Triglycerides: + Intervention: 45 mg/dL decrease Control: 6 mg/dL increase
Senecal (2018)Digital health intervention as an adjunct to a workplace health program in hypertension	Digital health intervention web portal incorporating individualized plans and compatible with smartphones and electronic health records	Hypothesis was DHI participation and frequency of use would be associated with blood pressure control and secondary outcomes of weight and body mass index (BMI) in a large retrospective observational analysis		SBP: + Intervention: 13.85 mmHg decrease Control: 11.06 mmHg decrease DBP: + Intervention: 7.72 mmHg decrease Control: 5.60 mmHg decrease
Touger-Decker (2010)Workplace weight loss program; Comparing live and internet methods	Intervention to address energy intake, weight, physical activity, and cardiovascular disease risk administered weekly via internet or in-person and incorporating weigh-ins, food and activity diaries, and healthy eating lessons	Changes in weight & waist circumference; secondary outcomes in body fat, FRP, HRQOL, energy & micronutrient intake, BP, physical activity		SBP: NSDBP: NS	Glucose: NS	Total cholesterol: NSHDL cholesterol: NS
Watson (2012)Evaluating a web-based self-management program for employees with hypertension and prehypertension: A randomized clinical trial	Intervention using BP monitors, communication devices, a self-management website, and individualized feedback	Lower blood pressure		SBP: NSDBP: +Intervention: 27.4% attained a decline of ≥5 mmHgControl: 15.9% attained a decline of ≥5 mmHg
Weinhold (2015)A randomized controlled trial translating the diabetes prevention program to a university worksite, Ohio, 2012-2014	Group-based intervention adapted from the diabetes prevention program outcomes study lifestyle balance program	Weight loss		4-month follow-up
				SBP: + Intervention: 8.3 mmHg decrease Control: 0.4 mmHg decrease DBP: + Intervention: 8.5 mmHg decrease Control: 1.8 mmHg decrease	Glucose: + Intervention: 8.6 mm/dL decrease Control: 3.7 mm/dL decrease	Total cholesterol: NSHDL cholesterol: NSLDL cholesterol: NSTriglycerides: NS
				7-month follow-up
				SBP: + Intervention: 6.3 mmHg decrease Control: 0.4 mmHg increase DBP: + Intervention: 7.5 mmHg decrease Control: 0.6 mmHg decrease	Glucose: NS	Total cholesterol: NSHDL cholesterol: +Intervention: 4.1 mg/dL increaseControl: 0.3 mg/dL decreaseLDL cholesterol: NSTriglycerides: NS
Wilson (2017)Evaluation of a digital behavioral counseling program for reducing risk factors for chronic disease in a workforce	The Omada health program, a digital adaptation of the diabetes prevention program incorporating small group support, a behavior change curriculum, and health coaches	Effectiveness of a digital diabetes prevention program in reducing weight and blood glucose measurements		SBP: NSDBP: NS	Glucose: + Intervention: 1.5 mg/dL decrease Control:1.1 mg/dL increase	Total cholesterol: NSHDL cholesterol: NSLDL cholesterol: NSTriglycerides: NS

Notes. Results reflect between-group differences between intervention and comparison/control groups. Significant differences are noted in bold.

(+) Significant improvement

(-) Significant worsening

(NS) Non-significant results.

Abbreviations. SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HbA1c: Hemoglobin A1C; HDL: High-density lipoprotein; LDL: Low-density lipoprotein.

Table 3.

Summarized Intervention Outcomes

Outcome	Total	Significant improvements		Significant worsening		Non-significant results
Systolic blood pressure^{41,43,45-47,49-58}	17	8	47.1%	1	5.9%	8	47.1%
Diastolic blood pressure^{41,43,45-47,49,50,52-58}	16	5	31.3%	1	6.3%	10	62.5%
Total cholesterol^{41-43,47,49,50,52,53,55,57,58}	13	2	15.4%	1	7.7%	10	76.9%
HDL cholesterol^{41,42,47-50,52,53,55,57,58}	11	1	9.1%	1	9.1%	9	81.8%
LDL cholesterol^{41,42,47,49-53,57,58}	10	2	20.0%	0	0.0%	8	80.0%
Triglyceridesl^{41,42,47,49,50,52,53,57,58}	9	1	11.1%	0	0.0%	8	88.9%
Glucose^{41,43,48-50,52,55,57,58}	11	4	36.4%	2	18.2%	5	45.5%
Hemoglobin A1C^{41,44,47-51,53}	8	3	37.5%	0	0.0%	5	62.5%
Insulin or insulin resistance^42,50	2	0	0.0%	0	0.0%	2	100.0%

Notes. If results were reported for multiple follow-up time points (e.g., Faghri and Li, 2014 and Weinhold et al, 2015), only results for the follow-up point closest to the intervention is reported. However, this distinction only affected our reporting of HDL cholesterol and glucose by Weinhold (2015), who observed non-significant effects for HDL cholesterol and significant improvements for glucode at the 4-month follow-up (reflected in this table), but then saw significant improvements in HDL cholesterol and non-significant effects for glucose by the 7-month follow-up (not reflected in this table). For Cohen, only the pooled estimates from the combined sample of pre-diabetics and diabetics) were reported. Pooled estimates were also used for Misra-Hebert (2016). Results from the three intervention arms reported in the single article by Cheon et al (2020) are each included here and thus treated as three separate study populations.

Abbreviations. HDL: High-density lipoprotein; LDL: Low-density lipoprotein.

Table 4.

Quality of the Articles and Their Interventions

Article	NHLBI quality rating questions for case-control studies
Article	Question clearly stated and appropriate	Population clearly specified	Sample size justified	Controls and cases from similar populations	Criteria used to select cases and controls valid, reliable, and implemented consistently	Cases clearly defined and differentiated from controls	If <100% eligible cases/controls selected, they were randomly selected	Used concurrent controls	Exposure was clearly defined, valid, reliable, and implemented consistently	Assessors of exposure blinded to case/control participant status	Confounders measured and adjusted	Used both pre/post and case/control methods
Barham	Yes	Yes	No	Yes	Yes	Yes	NA	No	NA	Yes	NR	Yes
Carnie	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	NA	Yes	NR	Yes
Cheon	Yes	Yes	No	NR	NR	Yes	Yes	NR	Yes	Yes	NR	Yes
Cohen	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	Yes	Yes	NR	Yes
Deitz	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	Yes	Yes	NR	Yes
Faghri & Li	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	NA	Yes	NR	Yes
Ferdowsian	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	NA	Yes	NR	Yes
Gamston	No	Yes	No	Yes	Yes	Yes	NA	No	No	No	NA	Yes
Kraemer	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	NA	Yes	NR	Yes
Kramer	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	Yes	Yes	NR	Yes
Salinardi	Yes	Yes	Yes	Yes	Yes	No	No	Yes	No	No	No	Yes
Schweitzer	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
Senecal	Yes	No	No	No	Yes	No	NA	No	No	Yes	Yes	Yes
Touger-Decker	Yes	Yes	Yes	No	Yes	Yes	NA	Yes	Yes	No	Yes	Yes
Watson	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes	Yes	Yes	No	Yes
Weinhold	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	Yes	Yes	Yes	Yes
Wilson	Yes	Yes	Yes	Yes	Yes	No	No	No	Yes	Yes	No	Yes
	NHLBI quality rating questions for before-after (pre-post) studies with no control group
	Question clearly stated and appropriate	Eligibility criteria prespecified and clear	Participants representative of population eligible for intervention	All eligible participants enrolled	Sample size sufficient to provide confidence in the findings	Intervention clearly described and delivered consistently	Outcomes prespecified, clear, valid, reliable, and assessed consistently	People assessing outcomes blinded to intervention assignment	Loss to follow-up after baseline ≤20% and accounted for in analysis	Reported changes in outcomes pre/post intervention (and pre/post P-values)	Outcomes measured multiple times before and after intervention	If group-level intervention, accounted for individual-level data to determine group-level effects
Misra-Hebert	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes

Notes. The NHLBI quality rating questions for before-after (pre-post) studies with no control group were used to extract quality indicators for the article by Misra-Hebert et a. (2016), which instead of a traditional control group used a propensity-matched non-employee comparison group cared for by the same physicians as those in the intervention.

Abbreviations. NA: Not applicable; NR: Not reported; NHLBI: National Heart, Lung, and Blood Institute.

Results

Sample

Our keyword and MeSH searches (Supplemental Tables 1 and 2) yielded a total of 2513 records (Figure 1). Of these, 862 were identified as duplicates. Among the remaining 1651 unique articles, 1227 were determined as irrelevant and thus excluded during the initial title/abstract screen. After a second screening of the remaining potentially relevant titles/abstracts, an additional 330 articles were excluded. This left 94 articles for a full-text review, including a review of their reference sections. Of those, 14 articles met eligibility criteria whereas 80 were excluded because they did not meet inclusion criteria. The most common reason for exclusion was that the study did not include or compare results from an intervention group to a control/comparison group. We also conducted a reference review of the 94 articles that were eligible for a full-text review. The reference review identified four additional articles that met inclusion criteria. Our final analytic sample included 18 articles.^41-58 A PRISMA flowchart detailing the progression of article identification, screening, and inclusion is depicted in Figure 1.^33,34

Study Characteristics

The design and study characteristics of each intervention are characterized in Table 1. The final sample of eligible articles were published between 2010⁴⁷ to 2023.⁵³ Most studies included multiple worksites, and occasionally multiple employers, across a diverse sample of occupations and industries including health care delivery organizations, universities, government agencies, insurance providers, IT/computer companies, pharmaceutical and medical suppliers, consumer goods businesses, office worksites, and retail. The number of worksites per intervention ranged from 1-7 among the 13 articles that quantified this information.^{41,42,45-50,52,54-57} Participant sample sizes ranged from 41^{41 to}24,117⁴³; the average sample size was 1645 and the median was 104 participants. Examples of populations characterized as “at-risk” for negative health outcomes included individuals with prediabetes or type 2 diabetes, who were overweight (BMI ≥25), had hypertension, out-of-range biometric values of systolic BP or diastolic BP, high cholesterol, metabolic syndrome, or other known risk factors for CVD. Participant demographics and their clinical metrics at baseline are also summarized in Table 1.

Across studies, the interventions were administered between 2006⁵⁵ to 2019,⁴⁸ though the intervention period was not specified in 6 articles.^{42,45-47,49,53} The duration of the interventions varied from 2-24 weeks in a few studies to 1-2 years in others. The articles captured a range of health interventions across 18 states that included intensive lifestyle interventions, nutrition interventions, diabetes prevention programs, and digital health interventions, among others. All except one of the interventions included an in-person component (17/18).^41-55,57,58 Eight studies included web-based components^{42,45,48,52,54-56,58} and three included telephonic components.^47,50,56 Monetary incentives were provided in 11 studies.^{42,43,45-51,54,56} There were 9 study designs that were theory-driven^{41-43,46,48,50,52,57,58} and 7 RCTs.^{42,45,46,49,52,53,56} All studies conducted traditional pre/post analyses among the intervention group with the exception of Cohen et al,⁴⁴ who used propensity scores to match clinic users in 2016 to a group of non-users with similar characteristics from 2015 to 2016. Attrition rates ranged from 3% to 31% (Supplemental Table 4).

Intervention Outcomes

Table 2 presents the goals and target conditions of each intervention and indicates whether the intervention yielded between-group differences that were significantly positive (i.e., clinical improvement), significantly negative (i.e., clinical worsening), or non-significant, comparing results for the intervention group to the control/comparison group. Table 3 collapses the condition-specific findings across interventions to summarize the total number of interventions that found significant vs non-significant results by each condition type. Of note, the study by Cheon et al⁴³ incorporated three distinct intervention arms (i.e., one focused on diabetes prevention, another on hypertension prevention, and the third was a nutrition program). Each of these three arms is counted as a separate intervention for the purpose of Table 3, which in turn summarizes results from 20 interventions across the 18 included articles. Additionally, Table 3 only reports results from the first follow-up time point for the two studies that reported results at multiple follow-up time points.^46,57

There were 16 interventions across 14 studies that targeted both SBP and DBP as clinical outcomes of interest,^{41,43,45-47,49,50,52-58} with one additional study targeting SBP but not DBP.⁵¹ Across the 17 SBP-focused interventions, about half (47.1%) found non-significant results^{41,43,45,46,49,55,56,58} while the other half (47.1%) found significant improvements for the intervention group compared to the comparison/control group.^{43,47,50-54,57} In contrast, only 5 of the 16 interventions (31.3%) targeting DBP observed significant improvements.^{47,52,54,56,57} Significant worsening in both SBP and DBP was observed for the hypertension prevention arm in the multi-armed intervention study by Cheon et al.⁴³

There were also 16 interventions across the 14 studies that targeted diabetes as a clinical outcome of interest. Blood glucose levels were used as a biomarker for diabetes in 11 interventions,^{41,43,48-50,52,55,57,58} HbA1C was used in 8 interventions,^{41,44,47-51,53} and 2 interventions measured effects on insulin resistance (e.g., HOMA: Homeostasis Model Assessment for Insulin Resistance).^42,50 Taken together, results across the various interventions tended to err toward non-significance. For example, 45.5% of the interventions targeting blood glucose levels and 62.5% of the interventions targeting HbA1C were non-significant, respectively. However, four of the 11 interventions (36.4%) targeting blood glucose levels^43,52,57,58 yielded significant improvements for the intervention group, as did 3 of the 8 interventions (37.5%) targeting HbA1c.^50,51,53 Of note, Weinhold et al⁵⁷ observed mixed results when examining outcomes at stratified time points, including significant improvements in glucose levels for the intervention group at their 4-month follow-up which were no longer significantly different from trends in the control group by the time of the 7-month follow-up. Likewise, findings differed by clinical subgroups in the study designed by Cohen et al,⁴⁴ wherein there were significant improvements in HbA1C levels for the diabetic group, but not for the prediabetic group or the combined group of diabetics plus pre-diabetics.

There were 15 interventions across 13 studies that targeted cholesterol as a clinical outcome and measured participants’ lipid profiles.^{41-43,47-53,55,57,58} Thirteen of the interventions measured changes in total cholesterol,^{41-43,47,49,50,52,53,55,57,58} 11 measured HDL cholesterol,^{41,42,47-50,52,53,55,57,58} 10 measured LDL cholesterol,^{41,42,47,49-53,57,58} and 9 measured triglycerides.^{41,42,47,49,50,52,53,57,58} The majority of interventions examining total cholesterol (10/13; 76.9%), HDL cholesterol (9/11; 81.8%), LDL cholesterol (8/10; 80%), and triglycerides (8/9; 88.9%) reported non-significant changes in the intervention group compared to the control/comparison group. Significant between-group improvement was reported in HDL cholesterol in one intervention.⁴⁷ A third study by Weinhold also observed significant improvements in HDL cholesterol at a final (7-month) follow-up, but not in an earlier 4-month follow-up.⁵⁷ Two interventions reported significant improvements in LDL cholesterol^51,53 and one found significant improvements in triglycerides.⁵³ The hypertension intervention arm of the study by Cheon observed significant worsening in total cholesterol for the intervention group compared to comparison groups,⁴³ and Schweitzer observed significant worsening for HDL cholesterol.⁵³

Quality of Evidence

Table 4 assesses the quality of evidence in each article, guided by the NHLBI quality rating tools.⁴⁰ Only one article was a before-after (pre-post) study with no control group. Instead, the study used a propensity-matched non-employee comparison group cared for by the same physicians as the intervention participants.⁵¹ All other studies were based on a conventional case-control research design.

Most articles clearly described their objectives and study populations; however, many did not report or clearly describe key methodological elements. Most articles did not provide a power estimate or sample size justification or clarify the approach used to measure and statistically adjust for potential confounders. The research question or objective and study population were clearly stated and appropriate in 17 of the 18 articles. Of the 17 articles reporting case control studies, only four provided a sample size justification. There was also a high dropout rate among participants in many studies. The attrition rate varied between 3% and 31% across the included studies. However, a high number of articles (n = 5) did not report attrition rates or discuss participant withdrawal from the study. Also, a number of studies reported that some participants (considered completers) did not complete all parts of the intervention or measurement (n = 5) (Supplemental Table 4).

Sixteen articles reporting case control studies included sufficient definitions, inclusion and exclusion criteria, and algorithms or processes used to identify or select cases and controls and 14 articles clearly defined and differentiated the cases from controls. The measures of exposure/risk were clearly defined, valid, reliable, and implemented consistently across all study participants in nine of the case-control articles. Other articles did not clearly describe an approach for consistent intervention exposure or fidelity. There were 14 articles reporting case control studies that selected individuals for the control group from the same or similar population as the case group and there were 12 articles that used concurrent controls. Most articles (13/17; 76%) described a study methodology in which data analysts of the exposure/risk were blinded to the case or control status of participants. Only four articles clearly reported whether key potential confounding variables were measured and adjusted statistically in the analyses.

Discussion

This systematic review assessed the effectiveness of WWP targeting CVD risk factors among at-risk populations. The quality and consistency of results varied considerably across studies, which included a wide range of industries and interventions.

Interventions targeting hypertension, diabetes, and cholesterol showed mixed results. This variability might reflect the heterogeneity in the design of WWP targeting CVD. Furthermore, blood pressure, glucose, and lipid outcomes may be influenced by many factors in addition to individual health behaviors, such as job demands, environmental stressors, workplace culture, and organizational supports. The variety of types of interventions was wide and interventions that focused on individuals’ behavior change (i.e., diet or exercise counseling) may have overlooked structural or psychosocial factors that impede sustained improvement. For example, past research has shown that WWP with favorable outcomes are often embedded within organizations where the corporate culture encourages wellness to improve employees’ lives (not only to reduce costs), where employees and leadership are invested in supporting the WWP, and where corporate policy and the physical environment encourages WWP participation.⁵⁹ The inconsistency across studies may signal missed opportunities to address broader organizational determinants of health that WWP should be designed to address. Rather than “just” enacting individually-focused interventions in the workplace, WWP should be designed to take advantage of the workplace environment, leadership, and culture to enhance the intervention. It is not clear that the included studies were designed to take advantage of these opportunities.

Evidence Quality Summary

The quality of research designs varied widely, reflecting findings from other systematic reviews of workplace health interventions.^{9,15,32,60,61} Major quality issues included a lack of sample size justification, high participant dropout, and inconsistent intervention exposure.

The quality review of the studies highlighted limitations around methodological rigor. From a broader perspective, these methodological gaps also limit our understanding of how and why certain interventions were successful. For instance, few studies reported on implementation fidelity or contextual factors such as management support, incentives, or workload adjustments. These factors are all central to the Total Worker Health²¹ framework’s call for organization-level integration. Strengthening study designs to include mixed-method or effectiveness and implementation approaches could capture these critical contextual variables and help to inform scalable program interventions.

Study Implications

This review suggests that, while workplace interventions targeting cardiometabolic outcomes can be beneficial, their effectiveness is variable. This conclusion is consistent with prior meta-analytic evidence extending beyond the U.S., which has found modest improvements but substantial heterogeneity in WWP, particularly among multicomponent interventions targeting dietary behaviors across the general workforce.²⁷ Our study, which restricted inclusion to studies with objectively measured biomarkers and comparative designs, may reveal more tempered program effects. Additionally, several factors including intervention duration, mode of delivery, and specific health conditions targeted, likely contribute to variability in outcomes. Interventions with longer follow-up periods (e.g., 1-2 years) may provide more sustainable health improvements compared to shorter interventions (e.g., 2-24 weeks). Additionally, interventions combining in-person and digital components may be more effective than those using a single delivery mode, particularly as businesses increasingly incorporate hybrid or fully-remote working environments. As post-pandemic workplace structures continue to evolve, digital and hybrid WWP may become increasingly central to reaching dispersed workforces and sustaining engagement over time.

Limitations

The current systematic review has limitations. Generalizability of the findings is limited since the search was restricted to English-language articles and U.S.-based studies. The search also focused on peer-reviewed articles, which may introduce publication bias, however many studies reported non-significant or negative findings. Since the studies did not provide sample size justifications or power analyses, our review may underestimate potentially clinically important but statistically non-significant results. The heterogeneity of interventions, ranging from in-person to web-based or telephonic, with different durations and delivery mechanisms, made it difficult to directly compare results or draw firm conclusions about intervention effectiveness. There was also variability in outcome measures (e.g., blood pressure, HbA1C) and assessment methods, making it difficult to synthesize findings. Also, body-mass index was not included as an outcome in this review. The research on employer-sponsored weight management interventions is robust and the current review focused on other, less studied CVD risk factors.

Despite these limitations, this review contributes to the literature by systematically synthesizing evidence on WWP focused on CVD risk factors, an area often overshadowed by studies of workplace weight management. The current investigation also had various strengths, particularly the comprehensive and systematic approach informed by the PRISMA framework and the use of an established quality appraisal tool.⁴⁰ Additionally, the involvement of a health science librarian and queries across multiple databases ensured a broad and reproducible search strategy. Taken together, these approaches allowed a thorough analysis of the current literature that identifies shared weaknesses that can guide future research.

Conclusions

This review highlights both the promise and the limitations of WWP for improving CVD risk factors among at-risk employees. The mixed evidence reflects not only differences in program design and rigor, but also the broader challenge of achieving sustained health improvements in complex work environments. In conclusion, the following key findings were derived from this systematic review:

1. Employee-sponsored WWP targeting at-risk populations show potential but are not uniformly effective. The review demonstrated that WWP targeting cardiovascular and metabolic health in at-risk employees can lead to significant improvements in specific outcomes (e.g., blood pressure, cholesterol, HbA1C), but the results were inconsistent across studies. This suggests that while WWP hold promise, they may need to be better tailored or refined to achieve consistent, significant health improvements. WWP effectiveness might also benefit from taking a more wrap-around or team-based approach, such as working in combination with a case manager or provider to offer medication management and individualized health services in combination with behavior modification.

2. There is a need for stronger study designs and reporting greater detail of the intervention components. The review highlights gaps in study quality, particularly in areas such as sample size justification, controlling for confounders, and clearly defining control groups. More rigorous study designs, including RCTs, are needed to provide clearer evidence of intervention effectiveness.

3. Significant improvements were observed in certain health outcomes (e.g., HDL cholesterol, systolic blood pressure) more often than others (e.g., total cholesterol and glucose levels). This variability suggests that specific types of interventions may be more effective for certain conditions, again underscoring the importance of tailoring interventions to the specific health needs of at-risk employee populations.

4. Longer-term follow-up and sustained engagement in WWP models are needed. Many interventions had relatively short durations, and the long-term sustainability of the health benefits remains uncertain.

Future research should focus on addressing the methodological limitations identified in this review, particularly regarding sample size determination, control of confounding variables, and consistent implementation of interventions. Furthermore, interventions should be tailored to the specific health risks of different subpopulations to maximize their effectiveness. Multi-component WWP that target at-risk groups might also consider more comprehensive and holistic approaches,^10,62 such as complementing the core WWP with access to primary care physicians, nutritionists, or other clinicians that can individualize care and offer wrap-around services. Research is also needed to examine the impact of WWP on organizational financial or economic outcomes to extend sustainability and scalability or to promote upfront investment and employer buy-in. Finally, future analyses should focus on the long-term clinical effectiveness of WWP and the impact that sustained participant engagement may have on ongoing health outcomes.

Ultimately, WWP represent an underused but potentially useful mechanism for positively impacting cardiometabolic outcomes. To fulfill this potential, WWP should be clear and well-designed, consider integrating wrap-around services, and should leverage the unique contextual attributes of the workplace at the organizational level rather than only focusing on individual behavior change. By integrating organizational support into intervention design, WWP will better align with principles of organizational change and support (i.e., Total Worker Health framework²¹) and effectiveness of these interventions may foster sustained improvement in CVD risk factors.

So What?

What is Already Known on This Topic?

Workplace wellness programs (WWP) are widely promoted as a strategy to reduce cardiovascular disease (CVD) risk, yet prior evidence on their effectiveness, especially among at-risk employees, has been inconsistent and limited in scope.

What Does This Article Add?

This systematic review synthesizes evidence from 18 U.S.-based studies evaluating WWP targeting at-risk employees. It reveals mixed results across key outcomes (e.g., blood pressure, cholesterol, HbA1C), identifies gaps in methodological rigor, and highlights the need for longer interventions and tailored approaches.

What are the Implications for Health Promotion Practice or Research?

Health promotion practitioners should design WWP with greater attention to duration, population-specific tailoring, and implementation fidelity. Researchers must strengthen study designs through randomized controlled trials, longer-term follow-up, and improved reporting. Without methodological rigor and sustained engagement, the potential of workplace interventions to reduce CVD risk will remain unrealized.

Supplemental Material

Supplemental Material - Workplace Wellness Programs for Employees at Risk for Cardiovascular Disease: A Systematic Review

Supplemental Material for Workplace Wellness Programs for Employees at Risk for Cardiovascular Disease: A Systematic Review by Mary Louise Pomeroy, Carolyn Hoffman, Sravya Vunnam, Axucillia Moyo, Kathleen Butler, Ali A. Weinstein, Debora Goetz Goldberg in American Journal of Health Promotion.

Footnotes

Mary Louise Pomeroy

Carolyn Faith Hoffman

Ali A. Weinstein

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Health Services and Outcomes Research for Aging Populations training program funded by the National Institute on Aging (grant #T32AG066576) and the Epidemiology and Biostatistics of Aging training program funded by the National Institute on Aging (grant #T32AG000247.

Declaration of Conflicting Interests

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

Supplemental Material

Supplemental material for this article is available online.

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