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Workplace energy expenditure devices (WEEDs), such as bicycle desks and treadmill desks, can contribute to weight gain prevention and disease risk-reduction. Little is known about the extent to which adults with diverse health risk factors are interested in using WEEDs.
Primary care patients aged 18-65 years at two outpatient clinics in Central Pennsylvania completed a cross-sectional survey in April, 2014 to assess interest in using “a small pedaling device under the desk” and “walking on a treadmill with a desk attached” if these options were provided at no-cost. Demographic and health risk factors were also assessed. Multiple logistic regression analyses were used to examine the associations of demographic and health risk factors with interest in using WEEDs.
Among 240 patients, 106 (44.2%) reported interest in using WEEDs. Of these 106 patients, interest in using a bicycle desk (91.5%) was higher than interest in using a treadmill desk (65.1%), p < 0.001. Females were more likely than males to be interested in using a bicycle desk, and patients aged 18-44 years were more likely than those aged 45-65 years to be interested in using a treadmill desk.
Results suggest that diverse patient populations may have interest in using WEEDs. Promoting use of WEEDs in primary care practices could help meet national standards for providing comprehensive, patient-centered care.
The prevalence of obesity in the US has more than doubled, from 15% to 36%, since the 1970s.1,2 Independent of dietary factors, a critical factor contributing to rising obesity rates has been the progressive decline in work-related energy expenditure associated with increased computer automation.3,4 Since 1960, the average energy expenditure due to work-related physical activity has dropped by more than 100 calories per day.4
Workplace energy expenditure devices (WEEDs) such as bicycle desks and treadmill desks have been shown to increase energy expenditure,5-7 reduce overweight/obesity,7,8 and improve blood glucose and lipid profiles.8 Because evidence suggests that it is possible to use WEEDs while simultaneously engaged in other work activities (e.g., typing), WEEDs may also reduce the time-related opportunity costs of physical activity.6,7 Statements by the American Heart Association recommend further evaluation of environmental strategies for activity promotion,9,10 such as WEEDs, and a recent NIH-sponsored working group was established to advance efforts to use WEEDs and other strategies to reduce sedentary behavior.11 Despite the documented benefits of WEEDs, no study, to our knowledge, has assessed public interest in using these devices, or the degree to which interest is influenced by demographic and health-related characteristics. Understanding the extent to which diverse community members are interested in using WEEDs could help identify if, and to whom, these devices should be recommended.
Primary care settings represent a viable context for reaching diverse populations to promote physical activity interventions such as WEEDs.12 The Patient-Centered Medical Home standards from the National Committee for Quality Assurance (NCQA) include key (“must pass”) elements for medical practices to “support self-care,” in part by providing educational materials, self-management tools, and counseling to adopt healthy behaviors for at least 50% of patients.13 Presenting educational brochures about WEEDs, providing opportunities to try out these devices in medical offices, and counseling patients on how to use them to increase physical activity, could help meet the NCQA standards. Promoting use of WEEDs may also be a viable strategy for meeting the requirements of the Affordable Care Act (ACA), which mandates that non-profit academic health centers must document efforts to promote community health to maintain their tax exempt status and avoid a $50,000 excise tax.14,15 However, prior to implementing WEEDs promotion efforts, it is important to understand which primary care populations might be receptive to using these devices.
Therefore, this exploratory study aimed to assess interest in using WEEDs, and demographic and health-related predictors of interest in use, among a medically-diverse sample of primary care patients. We focused this initial assessment on the two WEEDs that have demonstrated the greatest potential to increase daily energy expenditure among working-aged adults: bicycle desks and treadmill desks.16 We expected that this study would facilitate future hypothesis-generation about the extent to which different patient subgroups would be receptive to interventions to promote use of WEEDs in primary care practice.
Data for this cross-sectional study were obtained from a larger 2-page quality improvement survey that was administered to outpatients at two general internal medicine outpatient clinics at the Penn State Hershey Medical Center (Hershey, PA) in April, 2014. Survey items asked about patients' health-related characteristics, and interest in participating in future preventive health programs being considered by our clinical team to meet national guidelines for providing comprehensive patient care.13,14 Consecutive patients were handed the survey during the clinic check-in process. Administrative staff used the following script to describe the survey to patients: “For the next several weeks, we're asking all of our patients to fill out this short questionnaire before seeing your doctor. When you're done, please drop it in this box. Thank you very much.” No financial incentive was provided, and staff did not review surveys for completeness.
The Institutional Review Board of Penn State College of Medicine determined this study to be consistent with a quality improvement initiative, based on the Code of Federal Regulations (45 CFR part 46). It was therefore exempt from formal review, given that the survey was anonymous and performed to identify programs that could benefit patients.
Two questions were designed to assess interest in using WEEDs: “Would you consider any of the following, if they were provided to you for FREE: (A) Using a small pedaling device under your desk to increase your activity while working?; (B) Walking on a treadmill with a desk attached to increase your activity while working?” Response options were “yes” or “no.” These questions were designed to have face validity for quality improvement purposes, and were not formally tested for reliability or validity.
Age, gender, and education were assessed using self-reported questions from the 2013 Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System (BRFSS).17
Hypertension, hypercholesterolemia, diabetes, overweight/obesity, and smoking were assessed using self-reported questions from the 2013 CDC BRFSS.17 Moderate-to-vigorous physical activity was assessed with a single-item measure: “How many days during a typical week do you perform physical activity where your heart beats faster and your breathing is harder than normal for 30 minutes or more?”18
Of 500 consecutive patients given a survey, 441 surveys were returned for a response rate of 88.2%. As we aimed to assess interest in using WEEDs among working-aged adults, surveys with missing data on interest in using bicycle- or treadmill desks (n=53), missing age data (n=7), or adults >65 years (n=141), were excluded, leaving a final sample size of 240.
Descriptive statistics and the McNemar test were computed to characterize the sample. Associations between explanatory variables (i.e., demographic and health-related characteristics) and interest in using the bicycle desk and treadmill desk were assessed using both unadjusted logistic regression models and multiple logistic regression models (all variables were mutually adjusted for in these models). Multicollinearity among the explanatory variables was assessed. Variance inflation factors were less than 10 (mean=1.19) and tolerance statistics were above 0.2 (mean=0.84), suggesting that the shared variance between the explanatory variables was sufficiently small that each variable could contribute to the multiple logistic regression analyses.19
Missing data for the explanatory demographic and health-related variables ranged from 0 to 5% for all variables, except for gender, where 21% of data were missing. Multiple imputation was applied to handle missing data, and was conducted using all study variables.20 Five imputed datasets were created using a fully conditional specified model, thus taking into account the uncertainty of the implied values.21 Pooled estimates from these 5 imputed datasets were used to report all results and p-values. All analyses used two-tailed tests, with alpha set at 0.05, and were conducted using SPSS version 22.0 (IBM, Inc., Armonk, New York).
Most participants were middle-aged, female, and college-educated. The most common health-related comorbidities were overweight/obesity, hypercholesterolemia, and hypertension (Table 1).
Of the 240 participants, 106 (44.2%) reported interest in using WEEDs. Among these 106 participants, 34.9% reported interest in using a bicycle desk only, 8.5% reported interest in using a treadmill desk only, and 56.6% reported interest in using both devices. Overall interest in using a bicycle desk (91.5%) was higher than interest in using a treadmill desk (65.1%), (McNemar's test, p < 0.001).
Both unadjusted and adjusted analyses indicated that females were about twice as likely as males to be interested in using a bicycle desk (p's < 0.05). In unadjusted analyses, current smokers and those with hypercholesterolemia were less likely to be interested in using a bicycle desk than those without these health risk factors (p's < 0.05). Although smoking status and hypercholesterolemia were no longer significantly related to interest in using a bicycle desk in adjusted analyses, the magnitude and direction of results were similar to results from the unadjusted analyses (Table 2).
The only sample characteristic that was significantly associated with interest in using a treadmill desk was patients' ages (Table 2). In both the unadjusted and adjusted analyses, patients aged 18-44 years were about twice as likely as patients aged 45-65 years to be interested in using a treadmill desk (p's < 0.05).
To promote comprehensive patient care, the NCQA and ACA guidelines now encourage primary care providers to connect patients to environmental resources that could help sustain preventive health behaviors.12-15, 22 Environmental resources such as WEEDs hold potential for helping medical providers to meet the NCQA and ACA guidelines as they are available in both rural and urban communities, and are typically used at low physical intensity levels—making them accessible to patients with lower physical fitness. Evidence suggests that low intensity physical activity, when performed regularly, can be as effective as some medications for preventing chronic disease.23,24 However, as the effects of potential treatments/resources can be moderated by individual characteristics,25 it is important to understand which patients are interested in using WEEDs. To our knowledge, this is the first study to assess interest in using WEEDs among primary care patients.
Overall, 44.2% of working-aged outpatients seen at a medical center in Central Pennsylvania reported interest in using WEEDs. Among those interested in using WEEDs, about 92% were receptive to using a bicycle desk, compared to about 65% for a treadmill desk. As the cost for a compact, desk-based pedaling device is approximately $100-$150, relative to over $1,000 for a treadmill workstation, compact pedaling devices may be a more cost-efficient option for health organizations or employers aiming to achieve wider dissemination of WEEDs.
When analyses were adjusted for patients' demographic and health characteristics, few patient characteristics significantly predicted interest in using WEEDs. Women were about twice as likely as men to be interested in using a bicycle desk, consistent with results from prior studies evaluating desk-based pedaling devices.5,6 Patients aged 18-44 years were about twice as likely as patients aged 45-65 years to be interested in using a treadmill desk, consistent with findings suggesting that physical activity and agility declines with age.26,27 No other patient characteristics significantly predicted interest in WEEDs, after adjusting for other demographic and health covariates. Regardless of statistical significance, the magnitude of the odds ratios for the relationship between patient characteristics and interest in using WEEDs were in the small to medium range.28 These findings suggest that diverse patients may be receptive to efforts to promote use of WEEDs, with interest highest among younger, working-aged women.
Strengths of this study included a high response rate, and the inclusion of participants with diverse health comorbidities. Among study limitations, responses were based on self-report, and preferences for different WEEDs might have changed had patients had the opportunity to use each device. The study was also performed with a convenience sample that was overrepresented by women, and to maintain high response rates, few covariates (e.g., income, ethnicity/race) were measured. Therefore, study findings might not generalize across other populations. Furthermore, although analyses were limited to working-aged adults, patients were not asked if they were employed in sedentary- or active jobs. Interest in WEEDs may have been greater had we limited analyses to those employed in sedentary occupations. Finally, while assessing interest in using health programs/resources is a recommended step in program planning,29 and while such interest has predicted future participation,30 more research is needed to clarify the extent to which interest in using WEEDs predicts actual use.
Despite these limitations, this study adds to the limited data available about patients' interest in using WEEDs. Overall, patients with diverse clinical characteristics expressed modest to moderate interest in using WEEDs, and reported most interest in using a bicycle desk. Medical providers could capitalize on patients' interest in using WEEDs to increase the likelihood of using these devices by referring patients to related informational resources or programs. Future research may benefit from evaluating if physician referrals to programs that provide ongoing accountability or financial incentives to use WEEDs can increase and sustain patients' physical activity, and reduce risk of chronic disease. By encouraging diverse patients to use WEEDs, medical providers could increase environmental support for patients' daily physical activity, and contribute to meeting the NCQA and ACA standards for providing comprehensive, patient-centered care.
Preparation of this article was supported, in part, by developmental research funds from the Division of General Internal Medicine, Penn State College of Medicine, and in part, by grant R21 HL118453, awarded to Dr. Rovniak from the National Heart, Lung, and Blood Institute, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. We thank Jay Cho, BS, and Andris Freivalds, PhD, for their helpful comments and edits to the manuscript.