prevalence and risk factors of metabolic syndrome … · prevalence and risk factors of metabolic...

PREVALENCE AND RISK FACTORS OF METABOLIC

SYNDROME AMONG YOUNG BPO EMPLOYEES IN NCR:

DEVELOPMENT OF A LIFESTYLE MANAGEMENT PROGRAM

FOCUSING ON MODIFIABLE RISK FACTORS OF METABOLIC

SYNDROME

FINAL REPORT

UGC MAJOR RESEARCH PROJECT

2013-2016

Principal investigator: Dr. Ravinder Chadha

Co-investigator: Dr. Renuka Pathak

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Table of Contents

Topic Page Number

x List of tables i x List of figures vi x List of abbreviations vii x List of annexures ix x Executive Summary x x Introduction 1 x Methodology 25 x Results and discussion 60 x Development and implementation of lifestyle management

program 160

x References 220 x Annexures 242

i

List of tables

Table number Title

1 Differential criteria proposed by various expert groups to define Metabolic Syndrome

2 Risk factors for Metabolic Syndrome 3 Role of lifestyle interventions (RCTs) in MetS and its components 4 Growth of India's outsourcing industry 5 Reference values for technical error of measurement 6 Technical Error of Measurement for various anthropometric

measurements 7 Contemporary ecological models developed in the field of health

promotion 8 Health promotion programs and the ecological approach 9 Socio-demographic profile of calling level BPO employees

10 Socio-demographic profile of managerial level BPO employees 11 Gender differences in the components of Metabolic Syndrome

among calling level BPO employees 12 Gender differences in the components of Metabolic Syndrome

among managerial level BPO employees 13 Anthropometric and Biochemical profile of calling level BPO

employees 14 Anthropometric and Biochemical profile of managerial level

employees 15 BMI of calling level BPO employees classified according to the IOTF

(2000) criteria 16 BMI of managerial level BPO employees classified according to the

IOTF (2000) criteria 17 Comparison of anthropometric measurements between calling and

managerial level employees 18 Body fat percent among calling and managerial level BPO

employees 19a Correlation matrix between anthropometric, biochemical and

physiological measures among calling level BPO employees (n=415) 19b Correlation matrix between anthropometric, biochemical and

physiological measures among managerial level BPO employees (n=61)

20 Hemoglobin levels of calling and managerial level BPO employees 21 Comparison of hsCRP levels among calling and managerial level BPO

employees 22 Distribution of calling level BPO employees according to hsCRP risk

categories 23 Distribution of managerial level BPO employees according to hsCRP

risk categories 24 Distribution of calling level BPO employees according to hsCRP risk

levels and Metabolic Syndrome (ATPIII and IDF criteria)

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25 Distribution of managerial level BPO employees according to hsCRP risk levels and Metabolic Syndrome (ATPIII and IDF criteria)

26 Comparison between hsCRP levels of calling level employees according to Metabolic Syndrome diagnosis

27 Comparison between hsCRP levels of managerial level employees according to Metabolic Syndrome diagnosis

28a Comparison between hsCRP levels of calling level employees categorized according to number of Metabolic Syndrome (ATPIII) components in abnormal range

28b Comparison between hsCRP levels of calling level employees categorized according to number of Metabolic Syndrome (IDF) components in abnormal range

29a Comparison between hsCRP levels of managerial level employees categorized according to number of Metabolic Syndrome (ATPIII) components in abnormal range

29b Comparison between hsCRP levels of managerial level employees categorized according to number of Metabolic Syndrome (IDF) components in abnormal range

30 Comparison of hs-CRP levels between employees working at the calling level with and without various components of metabolic syndrome

31 Comparison of hs-CRP levels between employees working at the managerial level with and without various components of metabolic syndrome

32 Association of socio-demographic, anthropometric and biochemical measures with Metabolic Syndrome among calling and managerial level employees

33 Family medical history of calling level BPO employees 34 Family medical history of managerial level BPO employees 35 Relatives of calling level BPO employees with medical history of

diabetes and/or heart disease and/or high blood pressure and/or thyroid disorder

36 Relatives of managerial level BPO employees with medical history of diabetes and/or heart disease and/or high blood pressure and/or thyroid disorder

37 Association of family medical history with Metabolic Syndrome among calling and managerial level employees

38 Frequency of alcohol consumption in calling level BPO employees 39 Frequency of alcohol consumption in managerial level BPO

employees 40 Alcohol consumption with meals during past 30 days in calling level

BPO employees 41 Alcohol consumption with meals during past 30 days in managerial

level BPO employees 42 Association of alcohol consumption with Metabolic Syndrome 43 Tobacco use (Current and past) among calling level BPO employees

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44 Tobacco use (Current and past) among managerial level BPO employees

45 Tobacco use among calling level BPO employees 46 Tobacco use among managerial level BPO employees 47 Association of tobacco usage with Metabolic Syndrome among

calling and managerial level employees 48 Distribution of various perceived stress related parameters among

calling level BPO employees 49 Distribution of various perceived stress related parameters among

managerial level employees 50 Association of perceived stress with Metabolic Syndrome at the

calling and managerial level 51 Time spent on work related moderate intensity activities among

calling and managerial level BPO employees 52 Leisure time related vigorous physical activities among BPO

employees 53 Leisure time moderate intensity activities among calling and

managerial level BPO employees 54 Time spent on activities of moderate intensity during leisure by

calling and managerial level BPO employees 55 Office sitting time of calling and managerial level BPO employees 56 Total traveling time of calling level BPO employees 57 Total traveling time of managerial level BPO employees 58 Sitting time for recreational activities of calling level BPO employees 59 Sitting time for recreational activities of managerial level BPO

employees 60 Daily walking for at least 10 minutes continuously by the calling

level BPO employees 61 Daily walking for at least 10 minutes continuously by the managerial

level BPO employees 62 Association of physical activity with Metabolic Syndrome among

calling and managerial level employees 63 Meals usually skipped by calling and managerial level BPO

employees 64 Frequency of eating in between meals among calling and

managerial level BPO employees 65a Cooking medium preferred by calling level BPO employees

65b Cooking medium preferred by managerial level BPO employees

66 Consumption of supplements and health foods among calling and managerial level BPO employees

67 Frequency of office canteen food consumption among calling and managerial level BPO employees

68 Frequency of eating out among BPO employees 69 Frequency of ordering food from outside among calling and

managerial level BPO employees 70a Mean food group intake for of calling level BPO employees working

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in the BPO industry (n=105) 70b Mean food group intake of managerial level BPO employees

working in the BPO industry (n=16) 71a Mean percent adequacy of food groups with respect to

recommended daily intakes or calling level BPO employees (n=105) 71b Mean percent adequacy of food groups with respect to

recommended daily intakes for managerial level BPO employees (n=16)

72 Percent calories derived from macronutrients in the diet of calling and managerial level BPO employees

73a Mean nutrient intake of calling level employees working in the BPO industry (n=105)

73b Mean nutrient intake of managerial level employees working in the BPO industry (n=16)

74a Mean percent adequacy of nutrients with respect to Recommended Dietary Allowances (n=105) for calling level BPO employees

74b Mean percent adequacy of nutrients with respect to Recommended Dietary Allowances (n=16) for managerial level BPO employees

75 Association of dietary habits and nutrient intake with Metabolic Syndrome and its components at the calling and managerial level

76 Association of triglyceride levels with type of oil consumed among calling level employees

77 Association of triglyceride levels with type of oil consumed among managerial level employees

78 Comparison of triglyceride levels w.r.t oil consumption among calling level employees

79 Comparison of triglyceride levels w.r.t oil consumption among managerial level employees

80 Association of eating outside in restaurants/dhabas/eating joints with Metabolic Syndrome among calling level employees

81 Association of ordering food from outside with Metabolic Syndrome among calling level employees

82 Association of eating outside in restaurants/dhabas/eating joints with Metabolic Syndrome among managerial level employees

83 Association of ordering food from outside with Metabolic Syndrome among managerial level employees

84 Association of eating outside in restaurants/dhabas/eating joints with components of Metabolic Syndrome among calling level employees

85 Association of ordering food from outside with components of Metabolic Syndrome among calling level employees

86 Association of eating outside in restaurants/dhabas/eating joints with components of Metabolic Syndrome among managerial level employees

87 Association of ordering food from outside with components of Metabolic Syndrome among managerial level employees

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88 Percent adequacy of food group and nutrient intake among male calling level BPO employees in relation with Metabolic Syndrome

89 Percent adequacy of food group and nutrient intake among female calling level BPO employees in relation with Metabolic Syndrome

90 Comparison between the mean daily intake of food groups and nutrients among calling level BPO employees with and without Metabolic Syndrome

91 Individual goals and targets for BPO employees 92 Specific targets for BPO employees with Metabolic Syndrome 93 Communication matrix of the sessions conducted with the BPO

employees 94 Feasibility of general targets for all the BPO employees (n=20) 95 Feasibility of specific targets for those with Metabolic Syndrome

(n=9) 96 Dietary and lifestyle practices of BPO employees (n=41) before

program implementation 97 Gradual change in practices of BPO employees over a 6 week time

period (n=41) 98 Queries posed and solutions suggested 99 Dietary and lifestyle practices of BPO employees (n=41) after

program implementation 100 Change in practices of BPO employees before and after 6 weeks of

follow up 101 Change in self–efficacy of BPO employees before and after program

implementation 6 weeks of follow up (n=41)

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List of figures

Figure number Title

1 Relationship between disease and economic growth 2 Indian BPO Exports and Employment 3 Phase-wise depiction of study plan 4 Research Design 5 Map of National Capital Region of Delhi – Location of BPO companies

included in the present study 6 STEPS framework 7 Digital weighing scale 8 Microtoise fixed on the wall using a double sided tape 9 BC 420 MA High Capacity Body composition Analyzer

10 Omron HEM – 7201 automatic blood pressure monitor 11 Factors affecting health behavior 12 Ecological approach 13 Type of information collected from various Key Informants 14 Sex-wise distribution of calling level employees (n=415) 15 Prevalence of Metabolic Syndrome among calling level BPO employees

according to ATPIII and IDF criteria (n=415) 16 Prevalence of Metabolic Syndrome among managerial level BPO

employees according to ATPIII and IDF criteria (n=61) 17a Type of alcoholic beverage consumption gender-wise in calling level

BPO employees (n=214) 17b Type of alcoholic beverage consumption gender-wise in managerial

level BPO employees (n=37) 18 Calling level BPO employees engaged in work related moderate

intensity activities 19 Percent distribution of calling level BPO employees according to the

number of days in a week they were engaged in work related moderate intensity activities

20 Managerial level BPO employees engaged in work related moderate intensity activities

21 Percent distribution of calling BPO employees according to the number of days in a week they were engaged in LTPA of vigorous intensity

22 Percent distribution of calling level BPO employees according to the number of days in a week they were engaged in activities of moderate intensity during leisure time

23 Means of transportation used by calling level BPO employees for travel to and from work

24 Means of transportation used by managerial level BPO employees for travel to and from work

25a Food preferences of calling level BPO employees 25b Food preferences of managerial level BPO employees 26a Meals usually consumed by calling level BPO employees 26b Meals usually consumed by managerial level BPO employees

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27a Types of food items consumed usually by calling level BPO employees in between the meals

27b Meals usually consumed by managerial level BPO employees 28a Reasons for eating out by calling level BPO employees 28b Reasons for eating out by managerial level BPO employees 29a Mean daily percent adequacy of food intake (Food group wise) for

calling level employees 29b Mean daily percent adequacy of food intake (Food group wise) for

managerial level employees 30a Mean percent adequacy of daily nutrient intake among calling level

BPO employees 30b Mean percent adequacy of daily nutrient intake among managerial

level BPO employees 31 Development of the lifestyle management program 32 Agreement to the knowledge statements by the BPO employees before

and after education session 33 BPO employees' responses to the education sessions (n=20) 34 Employees' responses regarding session quality 35 Model of stakeholder engagement 36 Knowledge level of BPO employees before program implementation

(n=41) 37 Dietary Self-efficacy before program implementation (n=41) 38 Exercise related self-efficacy before program implementation (n=41) 39 Self-efficacy related to alcohol consumption before program

implementation (n=34) 40 Self-efficacy related to tobacco usage before program implementation

(n=30) 41 Change in practices of maximum number of employees week wise 42 Knowledge level of BPO employees after 6 weeks follow up (n=41) 43 Diet related Self-efficacy after 6 weeks follow up (n=41) 44 Exercise related self-efficacy after 6 weeks follow up (n=41) 45 Self-efficacy related to alcohol consumption after 6 weeks follow up

(n=41) 46 Self-efficacy related to tobacco use after 6 weeks follow up (n=41)

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List of abbreviations

Abbreviation Full form

NCDs Non-communicable diseases CVDs Cardiovascular diseases DM Diabetes mellitus WHO World health organization MetS Metabolic syndrome IGT Impaired glucose tolerance EGIR The European group for the study of insulin resistance NECP-ATPIII National cholesterol education program adult treatment panel iii AACE American association of clinical endocrinology IDF International diabetes federation AHA/NHLBI American heart association/national heart, lung, and blood institute T2DM Type 2 Diabetes mellitus HsCRP High sensitivity C reactive protein HDL High density lipoprotein IL-1 Interleukin-1 IL-6 Interleukin-6 TNF α Tumor necrosis factor-α BMI Body mass index WC Waist circumference LDL Low density lipoprotein TLM Therapeutic lifestyle management program LISM10! Life style modification program for physical activity and nutrition program BPO Business process outsourcing LTPA Leisure time physical activity FY Financial year IT Information technology GDP Gross domestic product NCR National capital region NCT National Capital Territory FGDs Focus group discussions KIIs Key informant interviews HR Human resource TIPs Trials for Improved Practices FFQ Food frequency questionnaire TEM Technical Error of Measurement IOTF International obesity task force NFI Nutrition Foundation of India VLDL Very low density lipoprotein GOD Glucose oxidase POD Peroxidase ESH-IP European Society of Hypertension International Protocol

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List of Annexures

Annexure 1 Consent form and information sheet Annexure 2 Background information questionnaire Annexure 3 WHO STEPS Instrument Annexure 4 INTERHEART stress questionnaire Annexure 5 Food Frequency Questionnaire Annexure 6 24 hour Diet Recall Performa Annexure 7 Standardization of utensils Annexure 8 Focus Group Discussion probes Annexure 9 Key Informant interview schedules

Annexure 10 Resource Kit Annexure 11 Knowledge statements form (pre and post-trial) Annexure 12 Sessions’ feedback form Annexure 13 Self-efficacy form (pre and post-trial) Annexure 14 Practices form Annexure 15 Self-tracking booklet – My Healthy Diet Book Annexure 16 List of healthy messages designed for the program Annexure 17 Overall program feedback form

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EXECUTIVE SUMMARY

The aim of the present study was to map the occurrence of Metabolic Syndrome (MetS) and

its risk factors among business process outsourcing (BPO) industry employees in the

National Capital Region and to develop and implement a lifestyle management program for

them. Metabolic Syndrome, which is an important risk factor for non-communicable

diseases, is characterized by presence of 3 or more of the 5 components viz. abdominal

obesity, high blood pressure, high triglyceride levels, low HDL levels and high fasting blood

glucose. This cross-sectional analytical study was carried out in seven BPO companies among

415 calling level employees (21-30 years; 274 males; 141 females) and 61 managerial level

employees (25-40 years; 54 males; 7 females) of those companies. Phase I comprised

assessment of anthropometric status (weight, height and waist circumference [WC]), body

composition, biochemical measures (fasting blood glucose, total triglycerides, HDL

cholesterol, high sensitivity C reactive protein [hsCRP] and hemoglobin), blood pressure,

dietary habits and diet intake pattern (24 hour diet recall, food frequency questionnaire and

dietary habits questionnaire), perceived stress (INTERHEART study questionnaire, 2004),

physical activity and tobacco usage and alcohol consumption (WHO STEPS questionnaire,

2008) among BPO employees. Metabolic Syndrome was present among 11.8% employees

according to the Adult Treatment Pattern III (ATPIII, 2001) criteria and 18.3% according to

International Diabetes Federation (IDF, 2005) criteria (specific for South Asians). At the

managerial level, prevalence of MetS was 21.3% according to ATPIII criteria and 31.1%

according to IDF criteria. The prevalence was significantly higher in the male employees

(p<0.05) both at calling as well as managerial levels. The hsCRP levels were above 3mg/dl in

more than one fourth (27.7%) of the calling level and more than one third (37.7%) of the

managerial level employees, thus categorizing them under high (3-10 mg/dl) and highest risk

(>10mg/dl) categories for persistent inflammation. The hsCRP levels were significantly

associated with Metabolic Syndrome according the IDF criteria (p=0.001). As the number of

diagnostic components of MetS in the abnormal range increased, there was a progressive

derangement of the metabolic profile as reflected by increase in the level of WC,

triglycerides, hsCRP and decrease in the levels of HDL of both calling and managerial level

employees. Presence of positive family medical history of DM/thyroid

disorders/hypertension/heart disease or paternal family history (grandfather) of any of

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these disorders were significantly associated with MetS among calling level employees

(p=0.039). However, these associations were not significant among managerial level

employees (p=0.562). Occasional drinking was significantly higher in individuals with MetS at

the calling level (ATPIII p=0.042; IDF p= 0.011) while no association was observed between

occasional drinking and MetS at the managerial level (p=0.930). Current smoking was

significantly associated with MetS among managerial level employees (p=0.038). Depression

during past 1 year (p=0.029) and past 2 weeks (p=0.012) was reported by significantly higher

number of employees with MetS at the calling level. No such association was observed

among the managerial level employees. Engaging in 4 or more days of physical activity for at

least 10 minutes continuously had lower odds for developing the syndrome among the

calling level employees (Odds ratio [OR] 0.334). Among them, skipping breakfast (OR 1.94)

or lunch (OR 2.42) was associated with twice the likelihood of having the syndrome. Among

food groups, mean intakes of pulses (males ATPIII p=0.012; females IDF p=0.036) in both

males and females, fruits (ATPIII p=0.046) in males, and green leafy vegetables (IDF p=0.001)

and milk and milk products (IDF p=0.040) in females were significantly lower in those with

MetS. On the other hand, intakes of roots and tubers in both males (IDF p=0.048) and

females (ATPIII p=0.027), and meat and poultry (ATPIII p=0.030) in males were significantly

higher among those having MetS. Intake of nutrients including riboflavin (males ATPIII

p=0.028; females ATPIII p=0.001; IDF p=0.000) in both males and females, protein (IDF

p=0.002), thiamine (ATPIII p=0.000; IDF p=0.001), vitamin A (ATPIII p=0.016; IDF p=0.002)

and niacin (IDF p=0.043) in males and vitamin C (ATPIII p=0.003; IDF p=0.008) in females

were significantly lower while intakes of energy (ATPIII p=0.001; IDF p=0.016), fat (ATPIII

p=0.029; IDF p=0.041) and carbohydrate (ATPIII p=0.042) were significantly higher in those

with MetS.

The second phase of the present study involved the development and implementation of a

lifestyle management program at workplace using the Ecological model for behavior change

among BPO employees with focus on promotion of healthy eating habits and physical

activity along with efforts to discourage harmful use of alcohol and tobacco products. The

program acted on three levels of the ecosystem viz. intrapersonal, social and cultural, and

physical environment. It was assessed for its acceptability and feasibility before

implementation. Results of phase I, focus group discussions with BPO employees and key

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informant interviews with HR managers, administrative managers and canteen operators

formed the basis of program development. A total of 20 employees from one company

participated in the feasibility trial of the program. The program development involved three

steps – (i) designing of specific key messages, and goals and targets for the employees, (ii)

Development of sessions, communication material and activities to facilitate achievement of

goals and targets by improving awareness, skill and self-efficacy, and (iii) Program trial to

assess acceptability and feasibility. The messages focused on diet quality, regularity of meals,

choosing healthy options while eating out, healthy beverages, salt intake, intake of

processed foods, tobacco usage, alcohol consumption, physical activity and stress

management. The goals and targets were acceptable to all the employees. Various ways

were suggested to the employees to overcome barriers faced in order to achieve their

targets. Based on the feasibility and acceptability trial, it was decided to implement the

program after refining some of the communication material and making certain

modifications in the program activities. A total of 41 employees of the BPO selected for

program implementation consented to participate and thus were included. The program

followed the same strategy as the trial. Before program implementation, knowledge,

practices and self-efficacy levels of the employees were assessed. This was followed by

conducting interactive educational sessions on nutrition and health promotion and

prevention as well as reversal of Metabolic Syndrome. At the socio-cultural level, formation

of peer groups of employees working in the same work process at the company to assist in

achievement of goals and targets was done. At the physical-environment level changes

introduced were introduction of curd and fresh fruits in the cafeteria, increase in aisle space

on work floors for walking while taking calls, provision of foot exerciser at the desk, creation

of badminton court in company compound. A follow up period of 6 weeks post the sessions

involved setting of goals and targets for employees and self-tracking by them using a

tracking booklet over that period. Reinforcement during this period was done by sending

daily health messages on Whatsapp, creation of a Facebook page and an email portal to

answer any employee queries. After the 6 weeks follow up, the employees were again

assessed on their knowledge, practices and self-efficacy. The lifestyle management program

led to a significant improvement in the knowledge level of the BPO employees participating

in the program trial (Z = -2.261; p = 0.02). Significant improvement in the number of

employees’ daily intake of fruit (p=0.000), salad (p=0.005), two servings of pulses (p=0.007),

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and regular physical activity for ≥30 minutes (p=0.005) were observed. Also, a decline in

preference of refined cereals over whole cereals (p=0.000), daily eating out (p=0.000),

breakfast skipping (p=0.002), and reduction in tobacco (p=0.000) and alcohol use (p=0.000)

were observed. However, certain practices such as daily consumption of at least two

servings of cooked vegetables and increase in intake of milk and milk products (other than in

tea and coffee), use of full cream milk, preference of mutton over chicken and fish and

addition of extra sugar to beverages did not show significant improvement after 6 weeks.

The program contributed to significant improvements in the self-efficacy levels pertaining to

diet, exercise, alcohol consumption and tobacco use (p for all <0.05). Program feedback

obtained from employees participating in the program using a questionnaire revealed that

all the employees were of the opinion that the program was very useful and had instilled in

them the importance of healthy diet and physical activity. To facilitate increase in physical

activity and regular eating and sleep pattern, the employees suggested that same shift

timings be allotted to each employee for at least one month instead of the present bi-weekly

rotation. This was not agreed by the company administration as work policies of the

company did not permit it. Radical changes in cafeteria menu were also not accepted as

canteen was running on a contractual basis with a pre-designed menu. Since Metabolic

Syndrome is reversible, there is an urgent need to initiate appropriate screening and

intervention strategies for BPO employees including worksite nutrition and health education

programs to promote healthy lifestyle so that these young adults do not fall prey to chronic

diseases in the near future.

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CHAPTER 1: INTRODUCTION

Non-communicable diseases (NCDs) are defined as “those diseases that are not passed from

person to person, are of long duration and generally slow progression” (WHO, 2015).

Cardiovascular diseases (CVDs), cancer, chronic respiratory disease and diabetes mellitus

(DM) are four major NCDs affecting the world. The prevalence of non-communicable

diseases (NCDs) is on the rise in the developing countries and is disproportionately higher to

the developed countries (Islam et al., 2014; Terzic and Waldman, 2011). According to World

Health Organization (WHO) estimates, NCDs will account for 80% death burden in the world

by 2020. This would include 7 out of 10 deaths due to NCDs in the developing countries,

with 60% of them being premature i.e. under 70 years of age (WHO, 2013; Geneau et al.,

2010; Abegunde et al., 2007; Mathers and Loncar, 2006). India will continue to hold its

position in having the highest diabetic patients in the world (Sicree et al., 2006). There is a

rise in obesity in the country, which leads to increased blood pressure, insulin resistance and

dyslipidemia eventually leading to Metabolic Syndrome (MetS). It increases the risk for

developing diabetes mellitus (DM) and cardiovascular diseases (CVDs) (Popkin, Adair and

Ng, 2012; Misra et al., 2011). The increase in the prevalence of NCDs currently as well as the

high projected prevalence in the future is a matter of concern. Though pharmacological

approach is one way of treating MetS, modifications in the diet and lifestyle is the most

sustainable approach that should be followed (Pritchett et al., 2005). Strategizing public

health policies and intervention programs is the need of the hour and deserves urgent

attention, since MetS is reversible at a younger age.

1.1 Metabolic Syndrome

Metabolic Syndrome (MetS) or syndrome X is associated with any combination of

metabolic/non-metabolic disturbances including increased level of fasting blood sugar, and

triglyceride, elevated blood pressure, low HDL level, and abdominal obesity. Individuals

meeting at least three of the above mentioned abnormalities are labeled as having the

disease [Shiwaku et al, 2005; McNeill et al, 2005]. These individuals are at increased risk of

cardiovascular diseases, diabetes, dyslipidemia, stroke, osteoarthritis, some kinds of

cancers, and their subsequent morbidity and mortality. The final result of these events is

impairment of quality of life and a heavy burden of expenses to the health care system

[Shiwaku et al, 2005; McNeill et al, 2005; Jaber et al, 2004]. A healthy society reflects the

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well-being of a nation and the quality of human capital is an important contributor to

economic growth. Figure 1 depicts the simple linkage between disease and economic

growth [Chadha et al, 2008].

Figure 1: Relationship between disease and economic growth

Source: Adapted from Chadha et al, 2008; www.who.int In most countries, about 20–30% of the adult population is predisposed to MetS [Grundy,

2008]. It is not a discrete entity known to be caused by a single factor. Moreover, it shows

considerable variation in the components among different individuals. This variation is even

greater among different racial and ethnic groups [Grundy et al, 2005]. Thus, MetS is not

restricted to the adults only, the predisposition of MetS however, starts much early in life

especially during the adolescence and young age [Budak et al, 2010; Tailor et al, 2010;

Nelson and Bremer, 2010; Cizmecioglu et al, 2009; Smith and Essop, 2009]. Although the

underlying cause of MetS is unknown, however, insulin resistance and visceral fat

accumulation have been proposed as the initial drivers. Lack of congruent diagnostic criteria

has resulted in report of variable prevalence of the diseases in different studies [Ford et al,

2002; Rantala et al, 1999; Bonora et al, 1998; Marette JP, 1994].

DISEASE

Absenteeism, morbidity, mortality,

shorter lifespan

Low productivity High dependency

Lower income, less GDP, low Human Development

index

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There is a significant prevalence of MetS among western as well as Indian adults. However,

insulin resistance may have been present for years before the development of these

conditions, conferring increased risk for development of other components of this

syndrome including raised blood pressure and coronary heart disease. Asian Indians have

been reported to be particularly predisposed to insulin resistance because of abdominal

obesity [Misra and Vikram, 2004]. Conditions of dyslipidemia, hypertension, insulin

resistance, hyperinsulinemia, and obesity, especially in constellation, have been shown as

potent risk factors for coronary heart disease in adults (25-37 years) in the Bogalusa study in

USA [Sathanur et al, 1998]. Sinha et al [2002] documented impaired glucose tolerance (IGT)

in 25% of pre pubertal and 21% of post pubertal overweight youth of multiethnic cohort of

167 children and adolescents in USA. Although they found that 4% of their cohort had silent

diabetes, reports from other pediatric diabetes centers indicate that type 2 diabetes

accounted for between 8% and 45% of new onset cases of diabetes in youth. Monzavi et al

[2006] reported that 49.5% of youth had multiple risk factors associated with the MetS in

California, based on modified definition of the National Cholesterol Education Program, and

10% had impaired fasting glucose and/or impaired glucose tolerance. Measures of insulin

resistance correlated significantly with the risk factors of the MetS. In the Jackson heart

study [2015] among 4416 adults in USA with one or more subclinical conditions viz.

peripheral arterial disease, left ventricular hypertrophy, microalbuminuria, high coronary

artery calcium (CAC) score, and low left ventricular ejection fraction, it was observed that

those with MetS or DM had higher odds of these subclinical conditions. At the clinical level,

treating the metabolic risk factors is the way to treat MetS [Grundy, 2012].

Type 2 diabetes and hypertension are the major associates of MetS. Both are generally

present several years before diagnosis and at the time of diagnosis patients generally have

some sort of end organ damage. Timely diagnosis and treatment can prevent morbidity and

mortality of patients and can save productive years of their lives. However, data on young

adults is especially meager in India. Lack of awareness, unhealthy habits, physical inactivity,

obesity, and faulty food habits are responsible for the increase in incidence of the MetS in

young adults. A worksite intervention program can help employees adopt healthier lifestyles

and achieve modest weight loss [Kalleen et al, 2011].There is thus an important and urgent

need to develop a lifestyle management program.

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1.2 Diagnostic criteria

The commencement of defining MetS began in 1998, by a consultation group on the

definition of diabetes for the World Health Organization (WHO) (Alberti and Zimmet, 1998).

This was followed by the European Group for the study of Insulin Resistance (EGIR) in 1999,

the National Cholesterol Education Program Adult Treatment Panel III (NCEP: ATPIII) in

2001, the American Association of Clinical Endocrinology (AACE) in 2003, the International

Diabetes Federation (IDF), and the American Heart Association/National Heart, Lung, and

Blood Institute (AHA/NHLBI) in 2005. The criteria for defining MetS vary among all these

definitions (Table 1). However, the major characteristics of MetS include insulin resistance,

abdominal obesity, elevated blood pressure, and lipid abnormalities (such as elevated levels

of triglycerides and low levels of HDL cholesterol) as defined by the expert panel of the

World Health Organization in 1998.

1.3 Prevalence: Worldwide

Twenty five per cent of the adults in U.S are affected by MetS [Tan et al, 2004]. The

incidence of MetS among the Asian ethnic groups is not well defined whereas Asia is

probably prone to the highest prevalence of diabetes and cardiovascular diseases in near

future [Kim et al, 2004]. Prevalence of this syndrome was observed to be 11.9% in Brazil

[Martins et al, 2015], 7.1% in Israel [Pinhas-Hamiel et al, 2015] 19% in Mongolia [Shiwaku et

al, 2005], 21% in Jordan, 17% in Palestine [Jaber et al,2004], 24.2% in Malaysia, 21.17% in

Taiwan [Kim et al, 2004], 12.2% in Singapore, 12% in Japan, 14.8% in China, and 28.6% and

27.8%, respectively, in male and female Koreans [Tan et al, 2004; Grundy et al, 2004].

1.4 Prevalence: India

Prevalence of MetS is on the rise in the developing countries (affecting nearly ¼ th of the

populations), including India (Grundy et al, 2005). The earliest study (Indian Council of

Medical Research [ICMR], 1995) on prevalence of MetS in India was done in the urban areas

of Delhi and rural Haryana and the prevalence was 30% and 11% respectively during 1992-

94 (criteria: ATPIII). CVD accounted for 39% of deaths in India, attributing it to be the leading

cause of mortality in 2005 (Misra and Vikram, 2008). Ramachandran et al, 2003 (modified

ATP III criteria) documented a higher prevalence of MetS (41%) in 1995 and Deepa et al

5

(2002) reported 11.2% prevalence (criteria: European group for study of insulin resistance-

HOMA model) in urban Chennai during 1996-97. Gupta et al (2004) reported 25%

prevalence (ATP III criteria) in Jaipur. The Sentinel surveillance project by WHO in Indian

Industrial population documented 27% prevalence (ATP III criteria) during 2001-03. Misra et

al (2001) carried out a study among the urban slum population in Delhi, and reported 30%

prevalence (own criteria) of MetS. Kamble et al (2010) also reported the magnitude of MetS

among rural adults of Wardha district, Central India, as 9.3% (modified ATP-III criteria). BMI

of 23.32 kg/m2 and higher was found to predict significant risk of MetS in these study

subjects. Urban Indians are most susceptible to its development owing to affluence of

middle class, urbanization, mechanization, marked changes in diet and sedentary habits

(Misra and Vikram, 2008). The prevalence has been reported as 20.61% among those

residing in urban areas of Mumbai (Sawant et al., 2011) and 22.5% among Indian adults

residing in Malaysia (Rampal et al., 2012). Even among the rural Indian populations rise in

the prevalence of MetS has been observed (Kamble et al, 2010; Prabhakaran et al, 2007;

Mohan et al, 2005). This is an important matter, as without effective intervention strategies,

it can lead to Type 2 DM (T2DM) and CVD in future. Moreover, in comparison with Whites,

South Asians1 exhibit CVD onset and diagnosis at a younger age (Eapen et al, 2009).

1 The term “South Asian” refers to the “1.5 billion people belonging to the southern region of the Asian continent comprising the sub-Himalayan countries”. These countries include India, Pakistan, Nepal, Sri Lanka, Bangladesh, Bhutan, Maldives, and the British Indian Ocean Territory (www.worldbank.org).

6

Table 1: Differential criteria proposed by various expert groups to define Metabolic Syndrome

Expert group/ organization Diagnostic criteria

Impaired fasting glucose (IFG)

Waist circumference (WC)/Waist Hip ratio (WHR)/ Body Mass Index (BMI)

Triglycerides (TG) High Density Lipoprotein Cholesterol (HDL- C)

Blood Pressure (BP)

Any other

World Health Organization

(WHO) 1998

>100mg/dl Waist-to-hip ratio Men > 0.9 Women >0.85 BMI > 30 kg/m2

TG:≥150 mg/dl and/or HDL-C: men < 40 mg/dl women < 50 mg/dl

≥140/90 mmHg Urinary albumin excretion rate ≥20 g/min time (in a timed urine collection) or albumin:creatinine ratio ≥30 mg/g

Insulin resistance plus two of the above

European Group for the

Study of Insulin Resistance (EGIR) 1999

≥110 mg/dl WC: Men≥ 94 cm Women ≥80 cm

TG: ≥150 mg/dl and/or HDL-C: < 39 mg/dl in men or women.

≥140/90 mmHg

Insulin resistance plus two of the above

National Cholesterol

Education Program Adult Treatment Panel III

(NCEP:ATPIII) 2001

≥110 mg/dl WC: Men > 102 cm Women > 88 cm

≥150 mg/dl Men < 40 mg/dl Women < 50 mg/dl

≥130/85 mmHg

Any three or more of the above

American Association of Clinical Endocrinology

(AACE) 2003

Impaired Glucose Tolerance

BMI: ≥30kg/m2 TG: ≥150 mg/dl and/or HDL-C: Men < 40 mg/dl, Women < 50 mg/dl

≥130/85 mmHg

IGT plus two or more of the above

American Heart Association/National Heart,

Lung, and Blood Institute (AHA/NHLBI) 2005

≥100 mg/dl WC: Men 102 cm or greater Women 88 cm or greater


≥130/85 mmHg

Any three of the above

International Diabetes Federation (IDF)2005

≥100 mg/dl BMI > 30 kg/m2or elevated WC*

≥150 mg/dl Men < 40 mg/dl Women < 50 mg/ dl

≥130/85 mmHg

Central obesity plus two of the above

Consensus definition

(incorporating IDF and

AHA/NHLBI definitions) 2005

≥100 mg/dl Elevated WC (according to population and country-specific definitions)*


≥130/85 mmHg

Any three of the above

* Waist circumference: For Europeans, > 94 cm in men and > 80 cm in women; and for South Asians, Chinese, and Japanese, ≥ 90 cm in men and ≥ 80 cm in women. For ethnic South and Central Americans, South Asian data are used, and for sub-Saharan Africans and Eastern Mediterranean and Middle East (Arab) populations, European data are used (IDF, 2005).

The first adverse effects of MetS to emerge in the population in transition are hypertension,

hyperlipidemia and glucose intolerance, while coronary heart disease and the long term

complications of diabetes, such as renal failure begin to emerge several years later

[WHO,2002]. The etiology of the problem is multi-factorial and there are several important

“risk” factors, of which some are modifiable and others are non-modifiable (Table 2).

Table 2: Risk factors for Metabolic Syndrome

Modifiable Non-modifiable

Physical inactivity Age

High total fat intake Genetic factors

High carbohydrate intake

Low fibre intake

Higher body mass index

Higher waist circumference

Alcohol

Smoking

1.5 Risk factors

Metabolic Syndrome (MetS) is a challenging condition to diagnose due to its varying

definitions, cut-offs and limited data for certain populations especially the young adults and

elderly. It is not a discrete entity but consists of multitude of risk factors. The risk varies in

an individual depending on the aggregation of metabolic and non-metabolic risk factors

(Grundy et al., 2005). The associated factors for MetS are age (Sharifi et al., 2009; He et al.,

2006; Adams et al., 2005; Gupta et al., 2004; Hu et al., 2004), sex (Mangat et al., 2010; Smith

and Essop, 2009; Regitz-Zagroek, 2007; Gupta et al., 2004), region (Mangat et al., 2010;

Sarkar et al., 2006; Gupta et al., 2004; Ramachandran et al., 2003), income (Perel et al.,

2006; Dallongeville et al., 2005; Du et al., 2004; Brunner et al., 1997); diagnostic criteria

(ATPIII or IDF) (Kanjilal et al., 2008; Deepa et al., 2007; Florez et al., 2005; Al-Lawati et al.,

2003) and occupation (Reddy et al., 2006; Siedlecka, 1991).

Source: Pencina et al, 2006

A solitary factor cannot purport to augmentation of the syndrome; therefore, interaction

amongst various domains relating to it is pertinent and needs to be evaluated with the help

of longitudinal studies (Misra and Vikram, 2008). Limitation nevertheless exists in the data

published on the prevalence of MetS among adolescents and young adults. Estimates vary

from 1% among adolescents in Japan (mean age-15 years), 3.3% among young adults in

India (17-22 years), 4.5% among adolescents in United States (12-17 years), 6.5% in Mexico

(10-18 years) and 10-15% in Finland (24-39 years) (Usha et al., 2014; Mattsson, 2012; Ford

et al., 2007; Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol

in Adults, 2001). High sensitivity C reactive protein (hsCRP), in addition to lipid monitoring

has shown potential to predict the cardiovascular disease risk early in life, even among the

low risk groups (Ridker et al., 2000; Koenig et al., 1999; Ridker et al., 1998). With hsCRP

being a strong independent predictor of CVD risk, it can also be used as one of the

inflammatory markers for early detection of MetS and its components.

Though MetS portrays low prevalence among youth, clustering of risk factors can result in

the progression towards the syndrome in adulthood, thus, advocating early identification

for alleviation of the problems related to the syndrome (León Latre et al., 2009; Taraghi and

Ilali, 2004). This holds true especially in the Indian context as the prevalence of all individual

components of the syndrome is on the rise (Mangat et al., 2010; Reddy et al., 2006; Gupta

et al, 2004).

1.5.1 Diet and physical activity

Prevalence of Mets is affected by diet and physical activity. A Greek study reported that the

odds of developing MetS was 0.81 among those who consumed a Mediterranean diet, and

0.75 in those who reported little to moderate physical activity than those following a

sedentary lifestyle (Panagiotakos et al., 2004). In the Framingham Offspring study, whole

grain intake was inversely associated with MetS, whereas dietary Glycemic index was

positively associated, when adjusted for confounding factors such as diet and lifestyle

barring BMI (McKeown et al., 2004). Inverse associations of whole grain foods, dietary fiber,

cereals, and fruit fiber, and, positive associations with Glycemic load and Glycemic index

was observed with insulin resistance in the same study. Leisure time physical activity either

moderate or vigourous level relates inversely to MetS prevalence, as demonstrated in a

longitudinal study of 618 Finnish men (Laaksonen et al., 2002). Poor dietary patterns (intake

of high saturated fatty acids) and absence of physical activity hastens the risk of MetS

(Feskens et al., 1995). The high intake of saturated fat, attributed to the recent dietary

transition is directly associated with CVD risk especially in Asian Indians (Ghosh, 2007;

Ghosh, 2006) and can be receded with intake of PUFA (poly unsaturated fatty acids) and

MUFA (Mono unsaturated fatty acids). A study from India revealed that increased dietary ω-

6 PUFA and saturated fat intake are significantly associated with fasting hyperinsulinemia

and subclinical inflammation respectively, and might be responsible for the increasing

prevalence of insulin resistance, the MetS and DM in Asian Indians (Misra and Khurana,

2008; Ghosh, 2009; Misra and Misra, 2003; Feskens, 1995).

1.5.2 Alcohol

Inverse association of high density lipoprotein (HDL) cholesterol, triglycerides and blood

pressure with alcohol consumption also has an impact on MetS (Vernay et al., 2004; Yoon et

al., 2004). In a a meta-analysis of seven observational studies, consumption of alcohol (less

than 40g/day for men and less than 20 g/day) in women contributed to lower prevalence of

MetS in comparison to non-alcoholics (Alkerwi et al., 2009). Moderate alcohol consumption

exerts a protective effect on MetS. Protective effect in wine drinking women (n=4232) has

been seen with lower odds ratio of syndrome development (Odds Ratio=0.60, p<0.05) as

compared to men in Sweden (Rosell et al., 2003). Red wine consumption (0.1–19.9 g day)

also resulted in a twofold decrease in the prevalence of high blood pressure among women

compared to non-consumers (Psaltopoulou et al., 2004); and has also been shown to

improve the CVD risk profile in a Spanish population based study (Schroder et al., 2005). In

the National Heart Study and DESIR French study, higher HDL values were observed in

alcohol consumers. The underlying mechanism of this protective effect is the direct effect

that alcohol has on HDL cholesterol synthesis, by modifying the activity of lipoprotein lipase,

hepatic lipase, and cholesterol-esterase (Vernay et al., 2004). However, heavy alcohol

consumption has detrimental effects on the syndrome as well as its components (Baik and

Shin, 2008; Freiberg et al., 2004; Yoon et al., 2004; Djousse et al., 2002).

1.5.3 Tobacco use

Studies have indicated that smokers have a higher risk of becoming insulin resistant, hence,

tobacco smoking can be considered as a modifiable risk factor for MetS (Ronnemaa et al.,

http://www.ncbi.nlm.nih.gov/pubmed/19900153

1996; Facchini et al., 1992). In a cross-sectional study of 3452 men, ≥20 years of age from a

nationally representative sample of Koreans, a positive association between smoking and

MetS was observed (World Health Organization Asian Pacific Guidelines, 2000). Statistically

significant association of current smoking amounts (p=0.023), total packs of cigarettes

smoked during lifetime (p=0.040) in individuals with MetS, indicated smoking as an

independent factor for the syndrome (Oh et al., 2005). Evidence generated from different

population groups has also supported the relation of smoking with hypertension (Dyer et al.,

1982; Elliott and Simpson, 1980) and type 2 DM (Rimm et al., 1995; Feskens and Kromhout,

1989).

With limited data on early identification of indicators of MetS before the development of

the syndrome, a pilot study by Corwin et al (2006) estimated the risk scores in 41 subjects

aged 18 to 39 years with 20 smokers and 21 non-smokers for three indicators viz.

cardiovascular, metabolic, and immune related. Total risk scores were significantly greater

in men (p=0.02) compared to women with only mixed effects of cigarette smoking. Similar

effects of smoking on MetS have also been demonstrated by earlier studies (Oh et al., 2005;

Ronnemaa et al., 1996; Facchini et al., 1992). Interventions focusing on cessation of smoking

should be undertaken.

However, when it comes to smokeless tobacco, not much work has been cited in the

literature (Attvall et al., 1993). It has been associated with various components of the

syndrome such as hyperinsulinemia, adiposity (Norberg et al., 2006), dyslipidemia (Chiolero

et al., 2008), and hypertension (Pandey et al., 2009; Hazarika et al., 2002; Westman, 1995).

Further, tobacco cessation has shown to lower the risk of the syndrome by improving HDL

levels, insulin sensitivity and in some cases even lowering the triglyceride levels (He et al.,

2009; Rosmond and Bjorntorp, 1999).

1.6 Prevention and management

Metabolic Syndrome (MetS) is a progressive disorder. Its components, if not paid attention

to, tend to worsen over time. These components can then cluster leading to MetS and

eventually CVD in the future. Therefore, there is a need to focus on risk reduction early in

life as these components are reversible. Dietary and lifestyle modification is an important

way of reducing the risk of the syndrome. Drugs/pharmacological therapy is secondary, and

may be required for risk reduction of MetS (Grundy, 2007).

1.6.1 Diet and Lifestyle

Diet has an important role to play in MetS risk reduction. Various dietary patterns have

shown their efficacy to reduce the risk of the syndrome. The Mediterranean Dietary pattern

is one that typically emphasizes fruits, cooked vegetables and legumes, grains (whole, not

refined) and, in moderation, wine, nuts, fish and dairy products, particularly yogurt and

cheese. It is a food pattern characterizing a way of life and culture that has the potential of

improving health and quality of life in people who adhere to it appropriately (Serra-Majem

et al., 2003). The efficacy of Mediterranean diet on MetS has been demonstrated through

many studies (Landaeta-Diaz et al., 2012; Jones et al., 2011; Rumawas et al., 2009; Nourian

et al., 2008; Michalsen et al., 2006). However, when the Mediterranean dietary pattern is

not adhered to strongly, there are no changes in the metabolic risk factors. Fruit,

vegetables, cereals, whole fat dairy products, mono unsaturated fatty acids and moderate

alcohol intake in the form of red wine have a protective effect, while intake of red meat

results in increased risk (Babio et al., 2012; Azadbakht and Esmaillzadeh, 2009; Ribeiro,

2009; Liu et al., 2008; Esposito et al., 2004). Similar results with respect to red meat were

observed in the Oxford EPIC cohort (Appleby et al., 2002) with more than 11000 subjects

aged 20-79 years, wherein, no consumption of meat, fish, eggs or dairy products resulted in

decrement in the blood pressure levels by 2-4 mmHg compared to regular meat consumers.

The vegetarian dietary pattern consists of mostly food items that are from plants and plant

products and does not have any flesh food items. However, it may include dairy products,

milk and eggs (Teixeira et al., 2007). The vegetarian dietary pattern can further be

subdivided into lacto-ovo vegetarian (consuming only plant foods, milk, dairy products and

eggs), lacto vegetarian (consuming only plant foods, milk and dairy products) and vegans

(consuming only plant foods and no animal product). The vegetarian dietary pattern has

also shown to lower the risk of MetS (Rizzo et al., 2011; De Baise et al., 2007; Teixeira et al.,

2007).

The term ‘lifestyle’ implies the way of living. It encompasses the existence of individuals,

families and societies with their corresponding behavior in different settings viz. physical,

social, psychological and economic (Trovato, 2012). Regular physical activity along with

proper diet i.e. rich in fiber, low calorie or energy restricted, has shown beneficial effects in

reduction of MetS (Mecca et al., 2012). Decrease in BMI, waist circumference (WC),

triglycerides, low density lipoprotein (LDL), insulin resistance (Bhat et al., 2012; Dutheil et

al., 2010; Goodpaster et al., 2010) and inflammatory markers such as interleukin-1 (IL-1),

interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) (Dutheil et al., 2010) are also some

of the beneficial effects of doing regular physical activity. Most lifestyle intervention

programs are based on weight reduction that has proved successful in demonstrating

significant improvements in all components of syndrome (Phelan et al., 2007; Villareal et al.,

2006; Case et al., 2002). Increased alcohol consumption has shown detrimental effects on all

components of MetS (Baik and Shin, 2008; Freiberg et al., 2004). Tobacco usage in all forms

(smoke and smokeless), stress, and inadequate and erratic sleep pattern are other risk

factors for the syndrome (Balhara, 2012; Yamamoto et al., 2011; Engum, 2007; Raikkonen et

al., 2007; Wilsgaard and Jacobsen, 2007).

Most lifestyle intervention programs are based on weight reduction, which have

demonstrated significant improvements in all components of the syndrome (Phelan et al,

2007; Villareal et al, 2006; Case et al, 2002) (Table 3). Regular physical activity along with

proper diet i.e. rich in fibre, low calorie or energy restricted, has shown beneficial effects in

reduction of MetS (Mecca et al, 2012), increase in the intake of fruits and vegetables (Mecca

et al, 2012; Groeneveld et al, 2011), decrease in body mass index (BMI), waist circumference

(WC), triglycerides, low density lipoprotein (LDL), insulin resistance (Bhat et al, 2012; Dutheil

et al, 2010; Goodpaster et al, 2010) and inflammatory markers such as interleukin – 1 (IL-1),

interleukin – 6 (IL-6) and tumor necrosis factor - α (TNF-α) (Dutheil et al, 2010). A

therapeutic lifestyle management program (TLM) is the most sought after way of tackling

the syndrome. A hospital based intervention consisting of a low calorie diet and regular

aerobic physical activity was conducted for 8 weeks in women (n=44) with MetS. Significant

decrease in all MetS components except HDL - C, along with complete amelioration of the

syndrome in 25% of women was observed (Jen Jou et al, 2010). Impact of TLM was also

assessed among the rural women (n=32) with MetS who were randomized to a 4 week

intervention consisting of health screening, education, exercise, diet and counselling, while

a basic education booklet on MetS was provided to the control group. Significant reduction

in the body weight, waist circumference, triglyceride levels, and positive behaviour change

was noticed in the intervention group compared to the control group (p<0.01). A positive

time effect was noticed with the intervention group which resulted in decrement in the

systolic blood pressure, fasting glucose, and LDL levels, and increment in the HDL levels,

thus, substantiating the role of a TLM intervention in MetS improvement. In a web based

lifestyle intervention for MetS among 160 adults in Iran, it was observed that the

intervention group there was significant decrease in the systolic blood pressure (3-month:

−10 versus −6 mmHg; 6-month: −11 versus −8 mmHg), diastolic blood pressure (3-month:

−10 versus −4 mmHg; 6-month: −11 versus −6 mmHg), weight (3-month: −2 versus −1 kg; 6-

month: −4 versus −1 kg), body mass index (3-month: −0.5 versus −0.2 kg/m2; 6-month: −1.1

versus −0.4 kg/m2) and improvement in HDL (3-month: 2 versus 0.64 mg/dl; 6-month: 6

versus 4 mg/dl) after 3 and 6 months of intervention (Jahangiry et al, 2015). Another

lifestyle intervention encompassing healthy diet evaluating the metabolic and vascular

changes that occur with the syndrome was carried out among seventy five adults with MetS

(30-55 years) in Brazil. They were randomized to a 10,000-steps-a-day exercise program +

healthy, no-sugar diet, a 3-times-a-week fitness (>75% peak VO2) program + healthy, no-

sugar diet, and a 1-hour-walking-a-day program + a tailored low-fat diet for 12 weeks.

Significant increase in Flow Mediated Vasodilation and decrease in arterial pressure was

maximum in the high intensity, no added sugar group (p = .036), wherein, arterial pressure

decrease (p = .0001) and weight loss (p = .0001) was maintained post 1 year (Seligman et al,

2011). Similarly, a pilot study comprising 150 minutes of regular exercise, 200-300 kcal

reduced daily diet for weight reduction, individual psycho-behavioural counselling based on

Trans theoretical model and telephone coaching for behavioural modification, on 43 Korean

adults with Type 2 DM and MetS proved to be beneficial (p<0.05) leading to better glycemic

control, lessened CVD risk, and depression (Kim et al, 2004). So, weight reduction seems to

be a good strategy to target as a component of the syndrome that has the potential

resulting in improvement of the other components of the syndrome.

Table 3: Role of lifestyle interventions (RCTs) in MetS and its components

Author(s) Sample Intervention Duration Salient finding(s) Kim et al,

2015

n=48 male Korean workers

150 min of regular physical activity per week, 200- to 300-kcal reduced daily diet for weight control, one-on-one counseling, and mobile phone text messages)

16 week internet based program

x Significant reduction in body weight (p = .022), visceral fat mass (p = .033), and waist circumference (p = .037

Cena et al,

2013

n=117 adults (28-70 years) with no medical history

Smoking cessation program Respiratory Pathophysiology Unit of San Matteo Hospital, Pavia, Northern Italy

Individual quitting time period for smoking

x Current smokers had high risk of developing MetS (p<0.05).

Mecca et al, 2012

n=50 overweight adults Group I: (n=22 general educational group Group II: n=28 high fibre nutrition group)

Lifestyle intervention focusing on physical activity and high fibre intake via dietary counselling and supervised exercise.

10 weeks x Higher intake of fruits and vegetables, higher plasma β-carotene levels, greater reductions in body fat, waist circumference, obesity class III, obesity class II and 24% reduction in MetS was observed in the group 2 as compared to group 1.

Bhat et al,

2012

n = 60 (mean age 40.0 ± 8.5 years) non-alcoholic fatty liver disease (NAFLD) patients

Regular aerobic exercise for 30 min/d, for at least 5d/week + Moderate Energy restricted diet (25 kcal/kg ideal body weight) containing 60% carbohydrate, 20% fat, 20% protein and 200mg cholesterol (NCEP Step I diet), was advised to patients with high BMI

6 months x Significant decrement in BMI, WC and Alanine amino Transferase (ALT) was observed post 6 months (p<0.01) in 45 exercise compliant patients

x No significant changes in BMI, WC and ALT were seen in 15 non-exercise compliant patients

Groeneveld

et al, 2011

n=816 male blue and white collar workers

Intervention consisted of individual counselling using motivational interviewing techniques, and was delivered by an occupational physician or occupational nurse.

6 months x Statistically significant improvement in the snack (β-1.9, 95%CI -3.7; -0.02) and fruit intake (β 1.7, 95%CI 0.6; 2.9) at 6 months

x Sustained snack and fruit intake improvement at 12 months

x Beneficial impact on smoking (OR:0.3 at 6 months

x No significant impact on leisure time physical activity

http://www.pec-journal.com/article/S0738-3991(14)00441-8/abstract

Wijesuriya

et al, 2011 n=4600 (5-40 years)

Aim of the trial [Intensive (3-monthly) lifestyle modification advice is superior to a less-intensive (12 monthly; control group) lifestyle modification advice]

Ongoing x Ongoing trail: follow up post 5 years of intervention

x Aims to reduce the prevalence of DM, Pre-Diabetes and MetS

Dutheil et

al, 2010

n= 14 (10 M, 4 F, mean age 62.9 ± 6.9 years) adults with MetS

Balanced diet corresponding to 500 Kcal deficit than their daily energy expenditure (DEE) and they exercised 2 to 3 hours per day

3 week intervention + 6 month follow-up

x Significant improvement in triglycerides, total, LDL and HDL cholesterol, insulin, leptin and adiponectin levels, CRP and pro-inflammatory interleukines IL1, IL6 and TNF α were observed at 3 weeks

x No changes in cytokines were observed

x Changes were sustained at 6 months

Goodpaster

et al, 2010 n=130 (37% African American) severely obese (class II or III) adults without diabetes

Group1: diet + physical activity 12 months (60 minutes for 5 days in a week); group2: diet but physical activity only from 6 months onwards)

1 year x Weight loss in group 1 was significantly higher as compared to group 2 at 6 months (p=0.02)

x Similar weight loss in both groups at 12 months (p=0.25)

x Reductions in waist circumference, visceral abdominal fat, hepatic fat content, blood pressure, and insulin resistance in both groups (p<0.05)

Straznicky et al, 2010

n= 59(n=20 Weight Loss group; n=20 Weight Loss (WL) +Exercise (EX); n=19 control)

dietary weight loss (WL, n = 20); dietary weight loss and moderate-intensity aerobic exercise (WL+EX, n = 20); no treatment (n=19)

12 weeks x Decrement in body weight (p < 0.001), Resting sympathetic nervous system activity (p<0.01), muscle sympathetic nerve activity (p<0.01) was observed in both WL and WL+EX group as compared with the control group.

x Increment in fitness levels were seen only in WL+EX group (P< 0.001)

Lofrano-

Prado et al, 2009

n=66 obese adolescents (41 girls and 25 boys; BMI: 35.62 ± 4.18 kg/m2)

Multidisciplinary lifestyle therapy composed of medical, dietary, exercise and psychological programs

short-term = 12 weeks and long-term = 24 weeks

x Long term therapy resulted in decreased depression and binge eating symptoms, body image dissatisfaction, and improved Quality of Life in girls (p<0.05)

x Reduced anxiety trait/state, symptoms of binge eating and improvement in quality of life was observed in boys (p<0.05)

Lerman et

al, 2008

n=49 (aged 25–80 years adults with MetS) Group I: MED (n = 19) Group II: PED (n = 25)

MED-Mediterranean-style, low glycemic load diet group; Phytochemical enriched diet (PED)-Mediterranean diet + phytochemicals

12 weeks x Weight loss was achieved in both groups

x Higher reductions in the cholesterol levels, triglycerides, cholesterol/HDL and TG/HDL ratio was observed in PED group (p<0.05) compared to MED

x Increased HDL(p < 0.05), decreased TG/HDL(p < 0.01),and resolution of more number of patients (43%) from MetS was seen only in the PED group.

With urbanization and globalization, emergence of lifestyle diseases is on the rise, owing to

longer life span and faulty lifestyle. The resultant non-communicable and chronic diseases

impose burden on health services of a country especially the developing nations. This leads

to longer years of disability and death, eventually leading to poor productivity and thus,

hampering the growth of a nation (Trovato, 2012). Hence, interventions to promote healthy

lifestyle to curb the development of MetS are the need of the hour.

1.6.2 Drugs

Although not as important as dietary and lifestyle modification, drugs do play a significant

role in management of MetS. Specific drugs are not recommended for treatment of MetS;

though, there are some pertaining to specific risk factors (AHA, 2005). For atherogenic

dyslipidemia, primary target is to lower LDL cholesterol; and in case of clinical management

of the same, lipid lowering drugs are required, for which statins, ezetimibe, and bile acid

sequestrants are recommended (AHA, 2005). Other drugs like nicotinic acid and fibrates

lower LDL cholesterol moderately and raise HDL cholesterol subsequently after lowering has

occurred. However, there are some contra-indications of using particular combinations of

drugs like fibrates and statins that heighten the risk of myopathy when used together. In

case of elevated blood pressure (≥140/90 mm Hg), recommendation for drugs are followed

using current hypertension guidelines. For individuals with elevated plasma glucose or

insulin resistance, no drug therapy is recommended, but once DM develops, it is required as

proven by various clinical trials. Another common state associated with those having MetS is

prothrombosis and proinflammation, for which drugs like aspirin are recommended (AHA,

2005). The AHA update is the last update on diagnosis and management of MetS since 2005

and is still followed by practioners across the globe.

1.7 Need for early intervention

The syndrome is on the rise among young adults as well (Usha et al., 2014; Mattsson, 2012;

Ford et al., 2007; Cook et al., 2003; Steinberger et al., 2001; Arslanian and Suprasongsin,

1996). Early interventions have a better potential of targeting the syndrome than doing it at

a later stage, where much improvement cannot occur. A cohort of healthy young

individuals in Amsterdam was followed for 24 years from the age of 13 years to 36 years to

ascertain the prevalence of MetS in them (NCEP-ATPIII criteria) in relation to fatness, fitness

and lifestyle (Ferriera et al., 2005). The prevalence was estimated as 10.4% (18.3% in men

and 3.2% in women) at 36 years of age. There was marked increase in the total body

fatness, specifically, abdominal fat, decrease in cardiopulmonary fitness levels, increase in

physical activity of light to moderate intensity but decrease in levels of vigorous physical

activity, trend of higher energy intake over the years and decreased alcoholic beverage

consumption. A Life Style Modification Program for Physical Activity and Nutrition program

(LiSM10!) on metabolic parameters conducted among male office workers (30-59 years) in

Japan and demonstrated significant improvement in various components of MetS

(Maruyama et al., 2010). Another team based 12 week worksite intervention in North

America also resulted in significant reductions in weight (p<0.0001), BMI (p=0.0047), WC

(p<0.0001), diastolic blood pressure (DBP) (p=0.0018) and systolic blood pressure (SBP)

(p=0.0012) (Daubert et al., 2012). Likewise, a multidisciplinary school based intervention in

Belgium resulted in significant weight loss (p < 0.001), decrement in BMI (p < 0.001), WC (p

= 0.011) and FBG (p = 0.005) after 6 months of intervention (Vissers et al., 2008).

The foundation of treatment for MetS is diet and lifestyle modification (AHA, 2005). To

achieve maximum benefit, weight reduction through diet modification and increased

physical activity results in risk reduction concurrently. However, the key is to intervene at an

early stage and workplace offers itself as one potential setting where dietary and lifestyle

modification can occur. Worksite interventions are an important and significant step

towards a pro-active approach for prevention of MetS. Either as a worksite health screening

program for prediction of syndrome or an intervention to combat and reduce the same;

both types function effectively. Lin et al (2010) used initial screening records of 1384 middle

aged Taiwanese employees who did not have MetS. After five years of follow up, among

those having one and two components during initial screening time, 175 (13%) developed

MetS (Odds ratio [OR] of 2.8; p<0.01). Synergistic effects were also observed with coupling

of MetS components – those with high BP plus low HDL had an OR of 11.7 (p<0.01) and high

BP plus hyperglycemia an OR of 7.9 (p<0.01) for MetS development. In another 3 year

prospective randomized control trial of 2492 adults in a community health center in Spain,

significant decrease was observed in abdominal circumference p < 0.001), systolic blood

pressure (p = 0.004), diastolic blood pressure (p < 0.001) and HDL-cholesterol (p = 0.05);

however, there were no differences in fasting plasma glucose and triglyceride concentration

( p = 0.43 and p = 0.28). The intervention consisted of following a controlled Mediterranean

diet and regular aerobic exercise program by primary healthcare professionals (Gomez-

Huelgas et al, 2015). Thus, MetS component count and combination can be useful indicators

and predictors of syndrome, thus, substantiating their role in finding new cases and

assessing risk. Application of health promotion programs in worksite not only reduces total

health risk, but also lowers economic burden of treatment (Prabhakaran et al., 2009;

Schultz, Chen and Edington 2009). While on one hand, worksite interventions seem an

appropriate strategy to target MetS; on the other, it is very important that these should be

sustainable to be proven as competent.

Prevalence of the MetS is widespread in Asia, with India contributing 30% of it (Misra et al.,

2007). Young adulthood is a critical period to target intervention strategies that prevent

excess weight gain and central fat deposition. Public health interventions targeting young

people by focusing on modifiable risk factors for the syndrome like weight control and

regular physical activity can go a long way in restraining the development of DM and CVD in

future (Ferreira et al., 2005).

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http://www.sciencedirect.com/science/article/pii/S0953620515001028?np=y

1.8 BPO industry

It is well established that globalization, particularly in terms of the mobility of capital and

the spread of communication technologies, has had a profound effect on the global

economy. The rapid increase in service sector ‘outsourcing’ and ‘off shoring’ during the last

decade has created a new and rapidly growing ‘business process outsourcing’ industry in

India. Business process outsourcing (BPO) is a subset of outsourcing that involves the

contracting of the operations and responsibilities of specific business functions (or

processes) to a third-party service provider (Tas and Sunder, 2004). While this industry has

experienced phenomenal growth rates and has contributed significantly to India's export

earnings, it has also thrown up new challenges in relation to health (Kuruvilla and

Ranganathan, 2010).

Globally, there has been:

x an increased energy intake due to availability of energy-dense foods that are high in

fat, sugar and salt but low in vitamins, minerals and other micronutrients (WHO,

2002); and

x a decrease in physical activity due to the increasingly sedentary nature of many

forms of work (Sisson et al, 2009), changing modes of transportation, and increasing

urbanization, leading to no or very less leisure time physical activity (LTPA). There is

enough evidence suggesting beneficial effects of LTPA such as greater life expectancy

(Moore et al, 2012), lower systemic inflammation, improved insulin sensitivity

(Pischon et al, 2003), and reduction in all-cause mortality along with cardio-

respiratory fitness (Lee et al, 2011).

1.9 India's Business Process Outsourcing Industry

India enjoys a dominant position in the global market for business process outsourcing—a

48–50 per cent market share (The Economic Times, 2007). Growing at an annual average

rate of over 50 per cent since 1999, this industry has seen employment rise from 50,000 in

1999–2000 to 553,000 by mid-2007. Table 4, which reports basic industry data for the

outsourcing industry, shows that the BPO industry is growing very rapidly. The BPO segment

was valued at $9.5 billion in 2006–07 and contributed $8.4 billion of the outsourcing

industry's total exports of $31 billion (Ranganathan and Kuruvilla, 2007). BPO exports

http://en.wikipedia.org/wiki/Outsourcing

http://en.wikipedia.org/wiki/Contracting

http://en.wikipedia.org/wiki/Business_process

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expected to reach USD 16 billion in Financial Year (FY) 2012, growing by over 12 per cent

over FY2011. The industry continues to be a net employment generator (fig 2) – and added

230,000 jobs in FY2012 and even more in FY2013, thus providing direct employment to

about 2.8 million, and indirectly employing 8.9 million people (www.nasscom.in).

Figure 2: Indian BPO Exports and Employment

Source: NASSCOM (www.nasscom.in)

Table 4: Growth of India's outsourcing industry

Year Total

industry

value

(US$

billions)

Total

industry

growth

rate (%)

Software

segment

value (US$

billions)

Software

segment

growth rate

(%)

BPO

segment

value (US$

billions)

BPO

segment

growth

rate (%)

2000–01 12.1 48 7.8 47 1.0 66 2001–02 13.4 11 8.7 12 1.6 60 2002–03 16.1 21 9.9 14 2.7 68 2003–04 21.6 34 10.4 5.5 3.4 26 2004–05 28.4 31 13.5 30 5.2 53 2005–06 37.4 32 17.8 32 7.2 38 2006–07 47.8 28 23.7 33 9.5 32 2009 62 24 28 9 21 64 2012 148 46 55 32 64 68 Source: NASSCOM (www.nasscom.in) 1.9.1 Profile of employees

The nature of the employees (in terms of their skills distribution) varies in accordance with

the nature of the work done in the BPO industry. The profile of employees in BPO firms that

http://www.nasscom.in/



provide a range of services in the customer care arena is quite different. According to a

survey 75 per cent of workers in the BPO firm are graduates, educated in convent schools

(noted for their superior and English-based education) (Remesh, 2004). Ninety four per cent

of their fathers and 63 per cent of their mothers were also graduates, many of them

working for the government (Remesh, 2004). The prototypical BPO firm therefore employs a

largely young middle class cross-section of India's population, often well versed in English.

The age ranges from 18 to 24, while the average age at firms employing postgraduates

tends to be in the mid-20s. The employees in the BPO sector mainly comprise young adults

working in a rotational shift system, with each shift of 8-9 hours. Their work largely involves

attending calls and providing support depending on the process involved, with strict

deadlines. Meals are provided to them at the workplace at subsidized prices along with free

beverages such as tea and coffee. These employees also have high disposable income. For

middle-class employees who live with their parents, this earning capacity represents a

massive increase in ‘disposable’ income. Though the BPO sector has been generating

employment opportunities for a large number of young people, it is facing several peculiar

problems that require managerial attention. Two particular human resource problems that

the industry has to deal with are the very high levels of turnover and the diminishing supply

of skilled graduates for the industry, both of which threaten industry’s growth (Nellis and

Parker, 2006; www.nasscom.in).

1.10 Rationale

The advent of globalization and development of new facilities has led to sedentary lifestyle

and consumption of high caloric diet leading to an imbalance between the energy intake

and energy expenditure. This has led to rise in obesity which predisposes to co-morbidities

such as elevated blood pressure, insulin resistance, dyslipidemia. These can eventually

leading to MetS (Grundy, 2003) which acts as a precursor to CVD. According to World Bank

Report (2009), as urban populations continue to grow globally, there is an increasing need

to focus on urban health.

With focus solely on tackling malnutrition and infectious diseases for more than three

decades, there has been transference towards the pandemic of obesity and consequent

emergence of non-communicable diseases along with it that kill more than 36 million


people each year (WHO, 2011). This double burden of disease is affecting the health

economics of all countries especially the developing countries influencing not only the

middle age group, but even young adults (Prentice, 2006; Doak et al, 2005). Indian

Information technology (IT)-BPO industry has generated aggregated revenues of USD 100

billion in the financial year 2012 according to a NASSCOM report (www.nasscom.in). As a

proportion of national Gross Domestic Product (GDP), the sector revenues have grown from

1.2 per cent in FY1998 to an estimated 7.5 per cent in FY2012 from the IT-BPO sector, with

the industry being on a boom generating employment for a large number of young people

(www.nasscom.in). The BPO industry due to its sheer nature of work poses problems related

to employees’ health. The work profile of the employees indicates that their work is largely

sedentary with a frequently changing shift system and also strict working hours which may

damage their health due to work related stress (WHO, 2011). Thus, there are more chances

of these adults to be predisposed to the risk of developing nutrition related chronic diseases

which hamper their work performance and health. For young adults, behavior patterns and

trajectories established now will influence their health for a lifetime, as they are at a critical

transition period in their lives. They establish adulthood health behaviors, move from their

parents' home to live independently, and, for some, begin having children during this life

stage (Devine, 2005). Behavior patterns or decisions about lifestyle choices (e.g., dietary

intakes, physical activity, and smoking) made in early adulthood initiate health trajectories

that predict chronic-disease risk later in life (Lynch et al, 2006; Von et al, 2004; Frontini et al,

2003). Thus, young adults may be strategically poised to influence health behaviors

throughout all stages of the life cycle (Haire-Joshu et al, 2004). Given that the young

employees are increasingly spending more time at work than at home, it is leading to

situations of stress or mental pressure to complete a task within a given deadline. Due to

their odd working hours, they prefer eating subsidized food and free tea and coffee

provided by the company. Besides being desk bound and having job stress and burnout

owing to lack of physical activity, new types of occupational hazards are affecting the youth

like overweight and obesity, muscular pain, spondilytis, slip disk, hypertension, depression,

osteoporosis, acidity, diabetes, arthritis and sleeping disorders. Hence, the workplace has

become a critical place for successful prevention strategies and the employers have an

important role to play in changing the sedentary lifestyles of employees by providing a

facilitating environment and infrastructure to motivate employees to practice healthy eating

habits, physical exercise, stress-relieving measures and counseling for preventive health

care.

Therefore, it is of great importance to know the occurrence of MetS among young BPO

employees, a population group on which very limited data are available, especially in the

Indian context. Any intervention at this stage may be useful in modifying their lifestyle by

developing lifestyle management program especially suitable for them to promote healthy

eating behavior and physical activity, and proper lifestyle choices, thus, leading to healthier

future for this population group.

1.11 Broad objective

To map the prevalence of Metabolic Syndrome among BPO employees (21-30 years) in

National Capital Region (NCR) and to develop a lifestyle management program to reduce the

risk of NCDs among them.

Specific objectives

x To screen BPO employees for MetS.

x To assess their nutritional status.

x To assess their physical activity pattern.

x To ascertain the consumption of alcohol and tobacco usage among them.

x To assess perceived stress among them.

x To determine the clustering of risk factors of MetS among them.

x To develop a lifestyle management program and implement it by testing the

acceptability and feasibility of its various components.

1.12 Hypotheses

x The prevalence of MetS among BPO employees (21-30 years) of National Capital Region

is not less than 15%.

x Lifestyle factors viz. diet, physical activity, alcohol consumption, tobacco usage and

perceived stress are associated with MetS among BPO employees.

1.13 Operational definitions

METABOLIC SYNDROME: It is a cluster of interrelated factors characterized by high FBG,

increased level of triglycerides, low levels of HDL, elevated blood pressure and abdominal

obesity (IDF, 2005).

BPO INDUSTRY: The BPO industry is a subset of outsourcing that involves the contracting of

the operations and responsibilities of specific business functions (or processes) to a third-

party service provider

BPO EMPLOYEES: The employees in the BPO sector mainly comprise young adults (21-40

years) working in a rotational shift system, with each shift of 8-9 hours. Their work includes

attending calls and providing support or managing teams and tasks (for managerial level

employees) depending on the process involved, with strict work related deadlines.

VIGOROUS INTENSITY ACTIVITY: These are those activities that cause a large increase in

breathing and/or heart rate and include gardening, carrying heavy loads, fast cycling,

running and aerobics (WHO STEPS, 2008).

MODERATE INTENSITY ACTIVITY: These are those activities that cause a small increase in

breathing and/or heart rate and include cleaning (Vacuuming, mopping, polishing,

scrubbing, sweeping, ironing), washing (beating and brushing), brisk walking and dancing

(WHO STEPS, 2008).

PERCEIVED STRESS: The stress perceived by the BPO employees due to their sedentary

lifestyle and odd working hours coupled with strict deadlines.

LIFESTYLE MANAGEMENT PROGRAM: This is a worksite based nutrition education program

focusing mainly on promoting healthy diet and physical activity among young BPO

employees along with encouraging them for smoking cessation and avoiding use of

smokeless tobacco products and alcohol for promoting healthy lifestyle with the goal of

reducing risk of non-communicable diseases among them.

http://en.wikipedia.org/wiki/Outsourcing

http://en.wikipedia.org/wiki/Contracting

http://en.wikipedia.org/wiki/Business_process

CHAPTER 2: METHODOLOGY

The present study was conducted to assess the occurrence of MetS among BPO employees

(21-30 years) in National Capital Region (NCR) and to implement a lifestyle management

program to reduce the risk of NCDs among them. This chapter describes the methodology

used to collect research data.

The present study was carried out in two phases and the phase wise study plan is illustrated

in fig 3.

Fig 3: Phase-wise depiction of study plan

Various methods were used to gather data in order to achieve the study objectives. They

have been described in detail in the following sections. The study design is briefly presented

in Fig 4.

Phase I: Mapping of Metabolic Syndrome among BPO employees (calling level & managerial)

•Screening of calling level (21-30 years) & managerial level (25-40 years) BPO employees for MetS using ATPIII and IDF criteria

•This entailed following measurements:

• Dietary intake pattern • Physical activity pattern • Alcohol consumtpion • Tobacco usage • Perceived stress • hsCRP • Hemoglobin

•Determining clustering of risk factors of MetS

Phase II- Development and implementation of a Worksite Lifestyle management Program

•Results from Phase I •Focus group discussions with BPO employees

•Key informant interviews with HR managers, Admin managers and cooks of canteen/catering managers

•Development of a lifestyle management program based on the Ecological Approach

•Assesing acceptability and feasibility of various program components and implementing the program

•BPOs in the National Capital Region (NCR) Locale

• Cross-sectional analytical study Phase 1: Mapping the occurrence of MetS and its risk factors among BPO employees

• Action Research Phase 2: Development of a nutrition education program and assesing the acceptability and feasibility of its various components.

Research Design

• Sampling technique: Purposive sampling -- Selection of 7 BPO companies in NCR • Sample size: 415 young adults 21-30 years of age working in the selected BPO companies at calling level + 61 managerial level employees (25-40 years of age)

• Inclusion criteria: Apparently healthy young BPO employees (age: 21-30 years) working at the calling level

• Exclusion criteria: Not on medication for any diagnosed medical condition

Sampling

PHASE I: Mapping of MetS and its risk factors MEASUREMENTS

TOOLS/TECHNIQUES

x Anthropometry Height Weight Waist circumference Body composition

Microtoise Digital balance Measuring tape (fibre glass) Body Composition Analyzer (Bioelectric Impedance)

x Biochemical analysis

HDL cholesterol Fasting blood glucose Total triglycerides Hemoglobin hsCRP

Enzymatic method Glucose oxidase method Enzymatic method Cyanmethemoglobin method Nephelometry

x Blood Pressure Digital Blood Pressure Monitor x Dietary Assessment Food frequency questionnaire

24 hour diet recall (on a random sub-sample)for 2 non-consecutive days

x Physical activity level x Lifestyle (Alcohol & Tobacco usage)

STEPS questionnaire (WHO, 2008) STEPS questionnaire (WHO, 2008)

x Perceived stress INTERHEART study questionnaire (Rosengren et al., 2004) PHASE II: Development and implementation of a Lifestyle management Program using Ecological Approach targeting at 3 levels:

(I) Intrapersonal (II) Social and cultural (III) Physical environment

Information on diet, physical activity and selected aspects of lifestyle of BPO employees gathered in Phase I to aid in program development • Focus group discussions with BPO employees to:

o Understand their eating habits, dietary intake pattern and other lifestyle factors; o Identify the changes that they think are needed in their diet and lifestyle; o Assess acceptability of various lifestyle modifications desired and perceived barriers to the modifications suggested

• Key informant interviews with HR Managers, admininstrative managers, and catering managers; Live demonstrations, skill enhancement, changes in the workplace environment, integrated approach to build social support x Program implementation

Summarization of quantitative and qualitative data: Frequency, mean, median, mode, minimum, maximum, standard deviation and descriptive narrative approach. Statistical tests applied: Chi-square, Anova, T-test, Pearson’s correlation, Multivariate regression, Wilcoxon’s sign rank test (All results were tested at 5% level of significance)

Study Data

Data analysis

Figure 4: Research Design

2.1 Locale: National Capital Region

National Capital Region (NCR) in India was constituted under the National Capital Region

Planning Board Act, 1985, with a rationale to promote balanced and harmonized

development of the Region. This was to contain haphazard and unplanned urban growth by

channelizing the flow and direction of economic growth along more balanced and spatially-

oriented paths. The NCR encompasses an area of over 33,500 sq kms, comprising National

Capital Territory (NCT) of Delhi, and 15 districts in the states of Uttar Pradesh, Haryana and

Rajasthan. This region also boasts of some of the very important centers in India’s BPO

industry; specifically, New-Delhi, Gurgaon and the emerging Noida. Hence, these three

centers constituted the locale for sample selection.

2.2 Sampling

2.2.1 Sample: The selection of the BPO companies for the present study depended on:

x Getting permission and co-operation for conducting the study from the company’s

management authorities.

x Availability of requisite number of employees aged 21-30 years working at the calling

level and cooperation from those working at the managerial level.

On this basis, a total of seven BPO companies in the NCR (Fig 5) were purposively selected.

Figure 5: Map of National Capital Region of Delhi – Location of BPO companies included in

the present study

Source: National Capital Region Planning Board

(http://ncrpb.nic.in/NCRBP%20ADBTA%207055/repository/images/map.jpg)

The employees in the BPO sector mainly comprise young adults working in a rotational shift

system, with each shift of 8-9 hours. Their work includes attending calls and providing

support depending on the process involved, with strict deadlines. The processes in which

the employees are usually engaged are customer support, tele-marketing, technical support,

accounts management, order management, document management, and transaction and

payment processing. The BPO employees were selected for the study based on the

following:

1. Inclusion criteria- Young adults (21-30 years) working at the calling level in seven BPOs

across Delhi-NCR, were included in the study sample. Informed consent was taken

individually from each employee. All the managerial level employees working in the

Key: BPO Company

selected BPOs were also included in the study after taking their informed consent

(Annexure 1).

2. Exclusion criteria- Those suffering from diagnosed medical condition(s) and under

medication were excluded from Phase I of the study. Out of the 420 calling level

employees approached for participation in the study, five were excluded due to this

reason.

2.2.2 Sampling technique: Purposive sampling was used for selection of BPOs. In these

companies, the employees who consented to participate were included in the study sample.

The sample size was calculated with an estimated anticipated prevalence of MetS among

young adults as 23% based on the available prevalence data from Indian adults aged 20-40

years. The prevalence has been reported as 20.61% among those residing in urban areas of

Mumbai (Sawant et al., 2011) and 22.5% among Indian adults residing in Malaysia (Rampal

et al., 2012). The confidence interval was taken as 95% and the design effect was assumed

to be 0.05. The estimated sample size using the above formula was 246. The sample size

was inflated to 302, which was 5% extra in order to obtain complete information on 246

subjects needed for assessing the prevalence of MetS in this group. In the 7 selected BPOs,

the investigator was permitted access to employees of certain process sections only.

Therefore, informed consent form was distributed among all employees of the sections

Sample size The sample size was calculated according to the following formula:

n = Z2 1-α/2

d2

where,

n is the sample size

p is anticipated prevalence (0.23)

Z is the normal standard deviate (1.96)

1-α is the confidence level (95%)

d is the absolute precision (0.05)

p(1-p)

provided; of which, 420 agreed to participate. As mentioned earlier, five employees were

excluded and the remaining 415 were included in the study sample.

In each of these companies, managerial level employees were approached for assessing the

occurrence of MetS among them. Those who gave consent for participation were included

in the study sample. Out of a total of 73 managerial level employees, 61 agreed to

participate in the study. Thus, 415 calling level and 61 managerial level BPO employees

comprised the study sample.

2.3 Study Design

Phase I: A cross-sectional analytical study was conducted to achieve the objectives in the

following manner:

Phase 1: Mapping the occurrence of MetS and its risk factors among BPO employees and

managers

The primary focus in this phase was to map the occurrence of MetS and its risk factors

among BPO employees and managers according to the ATP III (2001) and IDF (2005) criteria.

For this purpose, WC, triglycerides, blood pressure, HDL cholesterol, FBG, hemoglobin and

hsCRP were measured for all the BPO employees included in the study sample. Further,

their BMI, diet intake, physical activity pattern, alcohol consumption, tobacco usage, and

perceived stress were also assessed.

Phase 2: Action Research

Development and implementation of a lifestyle management program for BPO employees

to promote healthy eating habits and physical activity among them.

Step 1- Information collected on diet, physical activity and selected aspects of lifestyle of

BPO employees gathered in Phase I was used to aid in program development. Focus group

discussions (FGDs) were conducted with BPO employees to: (a) Understand their current

eating habits, dietary intake pattern and other lifestyle choices such as tobacco use in any

form, drinking alcohol, leisure time activities, perceived stress (b) Understand what are the

changes that they think are needed in their current diet and lifestyle, the perceived gaps

and barriers in practicing healthy food choices and physical activity. Along with this, key

informant interviews (KIIs) with human resource (HR) managers, administrative managers,

and canteen managers were also conducted.

Step 2- Based on the results of phase 1 and FGDs, a lifestyle management program was

developed for BPO employees using the ecological model of behavior change (Green,

Richard and Potvin, 1996) as the basis. This entailed identifying key messages, designing

program activities, educational material and tool for monitoring behavior change. The

acceptability and feasibility of the program was assessed in one BPO company by trial of

various components of the program to promote healthy eating habits and physical activity,

focusing on modifiable risk factors mainly eating habits and physical activity. The Trials for

Improved Practices (TIPs) technique along with live demonstrations was used for the same.

This program was then implemented in one of the seven BPOs.

2.4 Tools and techniques

The data collection was carried out on various measures (as listed earlier) using different

tools and techniques. Each one of them has been described in detail in the following

sections.

2.4.1 Questionnaire

A questionnaire is a written list of questions, the answers to which are given by the

respondents after interpreting them (Kumar, 2011). It is not same as survey, but is a

technique that is used for obtaining information in them (Guthrie, 2010). It is a quick and

less expensive method of data collection (Kumar, 2011). In the present study, three

questionnaires were used. Information regarding age, sex, income, working hours, family

composition and educational qualification were collected in the background information

questionnaire. Information was elicited on lifestyle practices like alcohol consumption,

smoking and level of physical activity using WHO STEPS questionnaire; and perceived stress

was assessed using modified INTERHEART study questionnaire. All these questionnaires

were administered to a group of employees, six at a time in the presence of the investigator,

since the audience was captive and it was easier for the participants to assemble at one

place. This ensured a high response rate, since personal contact could be established with

participants to explain them the purpose and relevance of study and to clarify any

difficulties that they had in answering any question(s). The type of information elicited using

each of these questionnaires was as follows:

2.4.1.1 Background information questionnaire

This questionnaire was used to obtain information with respect to age, sex, marital status,

educational qualification, income, family type, family medical history and personal medical

history of participants (Annexure 2). Inclusion and exclusion of participants was based on

this questionnaire, with BPO employees’ having any diagnosed medical conditions and

under medication were excluded. This questionnaire included simple, specific and

unambiguous questions to obtain valid and reliable responses.

2.4.1.2 WHO STEPS Instrument

To gather information on lifestyle practices (alcohol consumption, tobacco usage, and

physical activity level), a standardized modified WHO STEP wise approach to chronic disease

risk factor surveillance instrument (Version 2.1, 2008) was used (Annexure 3). The STEPS

approach (Fig 6) focuses on obtaining core data on the established risk factors that

determine the major disease burden. This instrument provides an entry point for low and

middle income countries to get started on chronic disease surveillance activities. It is also

designed to help countries build and strengthen their capacity to conduct surveillance.

The STEPS Instrument covers three different levels or "steps" of risk factor assessment.

These steps are:

x Questionnaire based assessment

x Physical measurements

x Biochemical measurements

The instrument was made language and culture specific to facilitate reliable responses. Both

open ended as well as close ended questions were included in the questionnaire, with a

logical progression for order of questions with respect to level of difficulty/complexity. It

was divided into sections with introduction to build rapport and develop question-answer

routine.

Step 1- Questionnaire-based assessment

The STEPS approach has three levels and within each level, risk factor assessment is divided

into core, expanded, and optional modules. Step 1 contains the core or “minimum set”, self-

report measures. In addition to socio-economic data, data on tobacco and alcohol use, some

measure of nutritional status and physical inactivity are included as markers of current and

future health status. The questionnaires used in the core data set are simple and few in

number and are not intended to give a complete picture of each behavior but rather to

provide information on the population distribution of risk.

Step 2- Simple physical measurements

Step 2 complements the information collected in the preceding step by the inclusion of

simple physical measurements, such as height, weight, waist circumference, and blood

pressure. Step 1 and Step 2 are desirable and appropriate for most developing countries for

chronic disease risk factor surveillance.

Step 3- Biochemical Measurements

Step 3 completes the disease risk factor data collection process by conducting biochemical

measurements. However, additional information at Step 3 requires access to the

appropriate standardized laboratories. Collecting and analyzing blood samples is a relatively

complex process and can be done only in the context of a comprehensive survey and in

settings where appropriate resources are available.

Fig 6: STEPS framework Source: http://www.who.int/chp/steps/framework/en/

Validity and reliability of the STEPS instrument has been established (www.who.int). Ninety

four countries across all six WHO Regions have published the results of their STEPS survey in

STEPS country reports, data books, fact sheets, journal articles, presentations or posters.

The countries cover various regions of the world - African Region, Region of the Americas,

South-East Asia Region, European Region, Eastern Mediterranean Region, and Western

Pacific Region (www.who.int). India has conducted a sub-national STEPS survey in 6 centers

in 2004 viz. Ballabargh, Chennai, Delhi, Dibrugarh, Nagpur, Trivandrum (ICMR, 2006), and

another STEPS survey including 7 states in 2007 viz. Andhra Pradesh, Kerala, Madhya

Pradesh, Maharashtra, Mizoram, Tamil Nadu, Uttarakhand (National Institute of Medical

Statistics, 2009).

2.4.1.3 INTERHEART study questionnaire

Assessment of perceived stress of the employees’ was a dimension that was considered

important as these young employees work in rotational shifts with targeted workloads and

stress is inevitable. INTERHEART study perceived stress questionnaire was slightly modified,

made context relevant and used to assess perceived stress among BPO employees in the

present study (Rosengren et al., 2004). The aspects of perceived stress covered were stress

at work, stress at home, general stress, financial stress, stressful life events and depression

(Annexure 4).

2.4.2 Dietary Assessment

Comprehensive information was collected on the diet history of the subjects. Food habits,

meal pattern, food preferences, information on cooking medium and eating out pattern

were assessed. A food frequency questionnaire was used to assess frequency of intake of

various foods. On a random sub-sample 24- hour dietary recall was conducted for two days-

one weekday and one weekend day (n = 105; 25% of the study sample was included for this

purpose). Standardization was carried out for various food items and preparations. Canteen

cooks/catering managers were interviewed for standardization especially of the meals

provided by the BPOs. The dietary data were gathered using interview technique. The

advantages of collecting data via the interview technique are that the respondents are

willing to respond to the interviewer and there are less chances of refusal. Besides adding

less response burden, they do not alter the eating behavior in case the interview takes place

unannounced (Beaton et al., 1983).

2.4.2.1 Food frequency questionnaire

Food frequency questionnaire (FFQ) is a widely used tool for nutritional assessment that

provides descriptive qualitative information on which food items or food groups are

consumed over a specific time period. It also provides information on consumption pattern

(Gibson, 2005). Hence, a food frequency questionnaire was used in the present study for all

the participants to obtain information on their dietary pattern. For this purpose, the

participants were asked to fill a comprehensive list of food items (covering all food groups

and beverages) by asking them to tick the option (For frequency of eating eg: per day/ per

week/ per month/ per year/ seasonal/ never) and filling the appropriate response which

was most suitable according to them (Annexure 5). This method of diet assessment is easy,

less time consuming, has low response burden and represents usual intake over an

extended period of time (Gibson, 2005). Information on usual portion size requires the

availability of the participant for a protracted period of time. Since the participants were not

available as required due to the nature of work in the BPO industry, portion size could not

be individually estimated.

2.4.2.2 Twenty four hour dietary recall

Twenty four hour diet recall is a retrospective method of nutritional assessment used to

measure food consumption of individuals. It is a quick and inexpensive method that can be

used both with literate as well as illiterate individuals. It provides estimate of current diet

intake. Being a quantitative method, it is designed to estimate the quantity of food items

consumed over a one day period. However, as the number of days increase, it tends to

provide quantitative estimates of usual intake of an individual (Gibson, 2005). So, for usual

intake estimation, one day recall is not enough, thus, multiple day recalls are preferred

possibly on non-consecutive days (Beaton et al., 1979). For the same reason, the dietary

recall in this study was conducted for two non-consecutive days – one week day and one

week end day (Annexure 6). Since, it was not feasible to conduct repeated diet recalls on all

participants due to logistic constraints, 24 hour diet recall was conducted on a sub sample

(25%; n=105 and n=16). A four stage multiple pass technique was used for conducting the

24 hour dietary recall (Gibson and Ferguson, 1999). Before conducting the diet recall, a

comprehensive list of food items that were commonly consumed by the participants was

made; collected through basic dietary information questionnaire on all participants. Of this

list, some items were cooked and standardized, for some nutritional information was

gathered through looking at labels via a market survey; and for the rest information was

sought from interviews with food service providers in few companies. In the first pass, each

participant was asked to recall all the foods and beverages consumed in the previous 24

hours and a complete list of all the food items consumed was obtained. In the second pass,

a detailed description of foods and beverages consumed, cooking methods followed

information on mixed dishes and their preparation, brand names of food items consumed,

type of milk consumed, cooking medium used, consumption of food and nutrient

supplements was asked. In the third pass, estimates of amount of each food item consumed

were obtained in household measures.

To aid further in recall, each participant was shown salted replicas of commonly consumed

foods (chapatti, parantha, rice, seasonal curry vegetable, dal and dry vegetable). Salted

replica is a sample of cooked food which is prepared like the food which is usually consumed

by that population group and contains salt as a preservative. It can be used during diet recall

to improve the estimation of portion size of the food consumed by the respondent. Some

Standardized utensils used for 24 hour dietary recall

utensils (spoons, ladle, mug, cups, katoris, measuring cups) were used for assisting in better

recall (Annexure 7). The digital food weighing balance (0.5 gm sensitivity) was needed for

standardization and recall of portion size of various food preparations consumed by

weighing salted replicas.

DRY VEGETABLE PULSE PREPARATION

CURRY VEGETABLE GREEN LEAFY VEGETABLE PREPARATION

RICE CHAPATTIS

Salted replicas used during 24 hour diet recall

It was calibrated using standard weights to check for its accuracy and precision during

measurement. Finally, in the fourth pass, a complete review of all the items listed in recall

was done to jog the memory of the interviewee in case he/she forgot to recall any food

item(s), along with questions on use of food and nutrient supplements.

2.4.3 Anthropometric assessment

Anthropometric methods involve measurements of physical dimensions and gross

composition of the body (WHO, 1995). The measurements are relatively quick and easy,

when performed using standardized procedures and calibrated equipment (Gibson, 2005).

Height, weight and WC were measured using standard methods (Cameron, 1984). Body

composition was determined using bioelectrical impedance method. For this purpose,

microtoise, digital balance, non-stretchable fibre glass tape and Body Composition Analyzer

were used. Standardized procedures were followed for all the anthropometric

measurements and these were taken in duplicate. Technical Error of Measurement (TEM)

was computed for all the measurements.

2.4.3.1 Weight

Instrument: Digital balance Sensitivity: 0.1 kg

Procedure: The scale was put on a firm, flat surface and was turned on. When the display

showed 0.0, the participant was asked to remove their footwear (shoes, slippers, sandals,

any heavy clothes, coats, belts etc) and socks. He/she was then asked to step onto scale

with one foot on each side of the scale. Further, they were told to stand still, face forward,

place arms on the side and wait until asked to step off. The weight was recorded in

kilograms.

A TANITA digital weighing scale (Fig 7) was used

for weight measurement (Cameron, 1984). It was

standardized using dead weights and was

regularly rechecked for its precision after every 15

readings. For each person, the reading was taken

in duplicate. It was ensured that the weight of the

employees was not measured after a full meal.

Fig 7: Digital weighing scale

A portable stature meter (Fig 3.7) was used for

measuring height (UNICEF, Copenhagen). It was

fixed on the wall at the height of 200 cm ensuring

that the steel tape wound down vertically without

any obliquity. Generally, screws are provided with

the instrument to fix it permanently on the wall but

since the locations were different, a double sided

tape was used to temporarily fix it in the BPOs. For

each person, the reading was taken in duplicate.

2.4.3.2 Height

Instrument: Microtoise Sensitivity: 0.1 cm

Procedure: The participant was asked to remove their: footwear (shoes, slippers, sandals,

etc), head gear (hat, cap, hair bows, comb, ribbons, high buns/plaits, hair clips etc) and

stand facing the investigator. He/she was further asked to stand with feet together, knees

straight, heels against the back wall, to look straight and not to tilt their head up. The

investigator made sure that the participant’s eyes were at the same level as the external

ears (Frankfurt Plane). The measure arm of the microtoise was gently pulled down onto the

head of the participant firmly and he/she was asked to breathe in and stand tall. The height

was read at the eye level in centimeters at the exact point (Cameron, 1984).

2.4.3.3 Waist Circumference

Instrument: Flexible fiberglass tape Sensitivity: 0.1 cm

Waist circumference (WC) is the preferred anthropometric measurement that correlates

best with abdominal fat, total body fat and BMI, but is unrelated to height (WHO, 2000).

There are considerable variations in WC of different ethnic groups for both males and

females. World Health Organization, the International association for the study of obesity,

and the International Obesity Task Force (IOTF) (2000) jointly recommended the use of

lower cutoffs for detecting abdominal obesity among urban Asians (i.e., >80cm for women

and >90cm for men). This is because they have high rates of obesity related disorders at

lower levels of body fat percent, and WC; and are more prone to central obesity as

compared to other ethnic groups (Ramachandran et al., 1997; McKeigue, 1996). A non-

Fig 8: Microtoise fixed on the

wall using a double sided tape

8

stretchable fiber glass tape was used for measuring waist circumference. For each person,

the reading was taken in duplicate.

Procedure:

This measurement was taken without clothing, that is, directly over the skin. If this was not

possible, the measurement was taken over light clothing. Measurements should not be

taken over thick or bulky clothing. This type of clothing must be removed. This

measurement should be taken at the end of a normal expiration; with the arms relaxed at

the sides; at the midpoint between the lower margin of the last palpable rib and the top of

the iliac crest (hip bone).

The investigator stood at the side of the participant to locate the last palpable rib and the

top of the hip bone. The distance between the two points was measured and the mid points

was marked with a marker. The participant’s assistance was also taken in locating these

points on their body. He/she was asked to wrap the tension tape around him/herself. The

investigator then positioned the tape at the midpoint of the last palpable rib and the top of

the hip bone, making sure to wrap the tape over the same spot on the opposite side. It was

checked that the tape was horizontal across the back and front of the participant and was

parallel with the floor. The participant was asked to stand with his/her feet together with

weight evenly distributed across both feet, hold the arms in a relaxed position at the sides;

breathe normally for a few breaths, then make a normal expiration. The WC was measured

and the measurement was read at the level of the tape to the nearest 0.1 cm. It was

ensured that the measuring tape snugs but was not tight enough to cause compression of

the skin.

2.4.4 Technical Error of Measurement

Anthropometry has certain limitations that include measurement error and the time taken

for each measurement. Measurement error is of important concern because it can influence

interpretation of nutritional status based on anthropometric measurements; therefore,

accurate instruments and standard techniques need to be followed. Measurements such as

weight and height are comparatively easy to measure than circumferences; hence, training

is required to reduce the chances of error and attain a measureable level of expertise

(Ulijaszek and Kerr, 1999). The anthropometric error encompasses imprecision, unreliability,

undependability and inaccuracy (Heymsfield et al., 1984; Habicht, Yarbrough and Martorell,

1979). Technical error of measurement (TEM) is a very commonly used technique to

ascertain imprecision. It is computed as the square root of measurement error variance

(Mueller and Martorell, 1988). In order to calculate it, repeated measurements are carried

out on one participant either by the same observer or by two or more observers to observe

intra or inter observer differences. For two repeated measurements on the same individual

by one investigator, TEM is obtained using the equation given below.

In the present study, standardized procedures were followed for all the anthropometric

measurements (Cameron, 1984) for which the investigator underwent training at the

Nutrition Foundation of India (NFI), New-Delhi. All the measurements were taken in

duplicate and recorded. For all the measurements, TEM as well as %TEM was computed

separately. The TEM for all the measurements in the present study was well within the

acceptable limits (Table 5) for both males and females (Table 6) (Ulijaszek and Lourie, 1994)

indicating that precision was maintained during the data collection (R = 0.999 for all the

measurements).

Calculation of Technical Error of Measurement

TEM = √(∑D2)/2N where, D is the difference between measurements N is the number of individuals measured % TEM was also calculated for all the measurements using the following formula:

%TEM = (TEM/Mean)*100 where, TEM is the Technical Error of Measurement Mean is the mean of each set of observations calculated separately for weight, height, MUAC and WC

Table 5: Reference values for technical error of measurement Maximum acceptable TEM Age group (years)

Height (m) Weight (kg) Arm circumference (mm)

Triceps skinfold (mm)

Subscapular skinfold (mm)

R- 0.95, males 18-64.9 0.0152 13.06 7.3 1.38 1.79 R- 0.99, males 18-64.9 0.0068 2.61 3.3 0.62 0.80 R- 0.95, females 18-64.9 0.0139 16.74 9.8 1.94 2.39 R- 0.99, females 18-64.9 0.0062 3.35 4.4 0.87 1.07 R- Coefficient of reliability Source: Ulijazek and Kerr, 1999 Table 6: Technical Error of Measurement for various anthropometric measurements Measurements TEM %TEM Acceptable value* R (coefficient of

reliability) Males

n=274 Females n=141

Males n=274

Females n=141

Males n=274

Females n=141

Males n=274

Females n=141

Height (m) 0.0002 0.0002 0.01 0.01 0.0068 0.0062 0.999 0.999 Weight (kg) 0.0416 0.1762 0.06 0.30 2.61 3.35 0.999 0.999 WC (cm) 0.0854 0.0231 0.09 0.03 - - 0.999 0.999 TEM- Technical error of measurement; R- Coefficient of reliability; WC- Waist circumference * Ulijazek and Kerr, 1999

2.4.5 Body Composition Analysis

A TANITA body composition analyzer (BC-420) working on bioelectrical impedance analysis

was used for estimating the percent body fat in adults (Fig 9). Bioelectrical impedance

analysis is based on the principle that there is difference in the electrical conductivity of fat

free mass and fat. As the current is passed through the individuals’ body, impedance is

measured. The impedance is related to the volume of the conductor (human body) and the

square of the length of the conductor – a distance which is the function of height of an

individual. Bioelectrical impedance estimates body water, from which fat free mass is

estimated on the assumption that human body contains 73% water. Fat mass is the

difference between body weight and fat free mass (Gibson, 2005; Chumlea and Guo, 1994).

Fig 9: BC 420 MA High Capacity Body

Composition Analyzer

Special precautions were taken for stable measurements to avoid any errors that could

affect the validity and precision of the measurements. These were: avoidance of alcohol and

vigorous exercise for 24-48 hours before testing, prohibition of eating for 2 hours before

measurement, passing of 3 hours of time after getting up and initiation of normal lifestyle

activities during this period, avoidance of dust and wetness on the sole of the feet while

taking the measurement. Also, individuals with implants/pacemaker/pregnancy (n=1) were

not allowed to step on the machine.

2.4.6 Biochemical Analysis

Biochemical analysis using standardized methods was carried out to estimate triglycerides,

HDL cholesterol, FBG, and hemoglobin. These measurements are required primarily for

mapping of MetS and for nutritional assessment, in addition to anthropometry and dietary

assessments. All the estimations were carried out using calibrated equipment with

standardized and validated techniques that were monitored continuously by appropriate

quality control procedures in a reputed and ISO 9001:2000 certified and NABL accredited

laboratory. This facilitated participation by increasing the credibility of the study as it was

difficult to obtain blood samples otherwise. The estimation techniques used were as

follows:

Source:http://www.tanita.eu/products/catagory/detail/professional-body-composition analyzers/74-bc-420-ma-high-capacity-body-composition-analyser-with-integral-printer.html

The TANITA Body Composition

Analyzer measures body composition

using a constant current source with a

high frequency current (50kHz,

90μA). The 8 electrodes are

positioned so that electric current is

supplied from the electrodes on the

tips of the toes of both feet, and

voltage is measured on the heel of

both feet; with current flowing into

the upper limbs or lower limbs.

http://www.tanita.eu/products/catagory/detail/professional-body-composition%20analyzers/74-bc-420-ma-high-capacity-body-composition-analyser-with-integral-printer.html




2.4.6.1 Triglycerides

Method: Enzymatic method

Principle: Triglycerides in the plasma are hydrolyzed by lipase to glycerol and fatty acids. The

glycerol is then phosphorylated by adenosine-5-triphosphate to glycerol-3-phosphate and

adenosine-5-diphosphate in a reaction catalyzed by glycerol kinase. Glycerol-3-phosphate is

then oxidized to dihyroxy acetone phosphate and hydrogen peroxide by glycerophosphate

oxidase. The hydrogen peroxide then reacts with 4-aminoantipyrine and 4-chlorophenol in a

reaction catalyzed by peroxidase to yield a red colored quinone which is measured at 505

nm (Varley, 1988).

Reagents

Enzyme reagent: The enzyme reagent is reconstituted with buffer solution.

Standard triglycerides: 200 mg%

Procedure

10μl of distilled water, standard triglycerides and plasma were added into three clean dry

test tubes labeled as blank, standard and test. 1.0 ml of enzyme reagent was added to all

the test tubes, mixed well and incubated at 37°C for 5 minutes. The color developed was

read in a spectrophotometer at 505 nm. The value was expressed as mg/dl plasma.

2.4.6.2 High Density Lipoprotein cholesterol

Method: Enzymatic method

Principle: HDL cholesterol is measured by phosphotungstic acid precipitation and enzymatic

method. The very low density lipoprotein (VLDL) and LDL fractions of plasma are

precipitated using phosphotungstic acid and then HDL in the supernatant is separated by

centrifugation and measured for its cholesterol content. The enzyme cholesterol ester

hydrolase hydrolyzes the cholesterol esters. Then cholesterol is oxidized to cholest-4-en-3-

one and hydrogen peroxide. Hydrogen peroxide in presence of the enzyme peroxidase

reacts with 4-amino antipyrine and phenol to produce a red coloured complex, whose

absorbance is proportional to HDL cholesterol concentration (Varley, 1988).

Reagents: Enzyme reagent: The enzyme reagent is reconstituted with buffer solution.

HDL cholesterol standard: 50 mg%

Procedure

Step I: Precipitation of VLDL and LDL

0.1ml of plasma was mixed with 0.1 ml of precipitating reagent in a clean dry centrifuge

tube. After mixing well, it was allowed to stand at room temperature for 5 minutes, and

centrifuged at 2000-3000 rpm for 10 minutes to get a clear supernatant.

Step II: Assay of HDL cholesterol

50μl of distilled water, cholesterol standard and plasma were added into three clean dry

test tubes labeled blank, standard and test. 1.0 ml of enzyme reagent was added to all the

test tubes, mixed well and incubated at 37°C for 5 minutes. The color developed was

measured at 505 nm. The value was expressed as mg/dl plasma.

2.4.6.3 Fasting blood glucose

Method: Glucose oxidase method

Principle: Glucose is oxidized by glucose oxidase (GOD) into gluconic acid and hydrogen

peroxide. Hydrogen peroxide in presence of peroxidase (POD) oxidizes the chromogen 4-

aminopyrine/phenolic compound to a red colored compound. The intensity of the red

colored compound is proportional to the glucose concentration and is measured at 505 nm

(Trinder, 1969).

Reagents

Reagent 1(Buffer / Enzymes / Chromogen): The reagent is reconstituted with distilled water.

Standard: 100 mg% glucose

Procedure

10μl of distilled water, glucose standard and plasma were added into three clean dry test

tubes labeled blank, standard and test. 1.0 ml of enzyme reagent was added to all the test

tubes, mixed well and incubated at 37°C for 15 minutes. The color developed was measured

at 505 nm.

2.4.6.4 Hemoglobin

Method: Cyanmethemoglobin Method

Principle: The method of choice for hemoglobin determination is the cyanmethemoglobin

method (This is a type of colorimetric method). When blood is mixed with a solution

containing potassium ferricyanide and potassium cyanide, the potassium ferricyanide

oxidizes iron to form methemoglobin. The potassium cyanide then combines with

methemoglobin to form cyanmethemoglobin, which is a stable color pigment read

photometrically at a wave length of 540nm.

Reagents:

Hemoglobin standard

Cyanmethemoglobin reagent (Drabkin’s solution)

Procedure: A series of tubes were labelled as blank, standard and test. 5 ml of

Cyanmethemoglobin reagent was pipetted in all the tubes. 20 μl of the appropriate sample

was added into each tube. In the blank only Cyanmethemoglobin reagent was added. The

tubes were allowed to stand for 10 minutes. Absorbance was read in the

spectrophotometer at 540 nm, zeroing the spectrophotometer with the blank solution.

Absorbance vs. Hemoglobin concentration in grams % was plotted on a linear graph paper.

Hemoglobin was expressed in gm/dl (http://www.who.int/hemoglobin)

2.4.6.5 hsCRP (High sensitivity C Reactive Protein)

Method: Nephelometry

The hs-CRP test can more accurately detect lower concentrations of the protein (it is more

sensitive), which makes it more useful than the CRP test in predicting a healthy person’s risk

for cardiovascular disease. Hs-CRP is promoted by some as a test for determining the

potential risk level for cardiovascular disease, heart attacks, and strokes. The current

thinking is that hs-CRP can play a role in the evaluation process before one encounters one

of these health problems. More clinical trials that involve measuring hs-CRP levels are

currently underway in an effort to better understand its role in cardiovascular events and

may eventually lead to guidelines on its use in screening and treatment decisions. Some

experts say that the best way to predict risk is to combine a good marker for inflammation,

like hs-CRP, along with the lipid profile. People with higher hs-CRP values have the highest

risk of cardiovascular disease, and those with lower values have less of a risk. Specifically,

individuals who have hs-CRP results in the high end of the normal range have 1.5 to 4 times

the risk of having a heart attack as those with hs-CRP values at the low end of the normal

range (Burtis and Ashwood, 1999).

http://labtestsonline.org/understanding/conditions/cvd

http://labtestsonline.org/understanding/conditions/heart-attack

http://labtestsonline.org/understanding/conditions/stroke

http://labtestsonline.org/understanding/analytes/lipid

http://labtestsonline.org/understanding/conditions/cvd

http://labtestsonline.org/understanding/conditions/heart-attack

Procedure: Blood is collected in a serum-separating tube, and is analysed using laser

nephelometry. The test gives results in 25 minutes with sensitivity down to 0.04 mg/L.

2.4.7 Blood Pressure

Blood pressure of the employees was measured using Omron HEM-7201 Automatic Blood

Pressure Monitor (Omron Healthcare, Kyoto, Japan). It is an upper arm; oscillometric

measuring device designed for blood pressure self-measurement and has been previously

validated by the Association for the Advancement of Medical Instrumentation (AAMI)

protocol at normal altitude (AAMI, 2009) and European Society of Hypertension

International Protocol revision 2010 (ESH-IP2) at high altitude (Cho et al., 2013). Cuff

inflation and deflation is automated and model comes with a standard sized cuff applicable

to arm circumferences ranging from 22 to 32 cm. OMRON automatic blood pressure

monitor is also recommended by WHO; hence, was used (Fig 10). Readings were taken in

triplicate in a relaxed environment with an interval of 3 minutes (WHO, 2008).

Procedure: The left arm of the participant was placed on the table with the palm facing

upward. The clothing on the arm was either removed or rolled up. The appropriate cuff size

for the participant was selected using the following table:

Arm Circumference (cm) Cuff Size 17 -22 Small (S) 22-32 Medium (M) >32 Large (L)

The cuff was positioned above the elbow aligning the mark on the cuff with the brachial

artery. It was wrapped snugly onto the arm and securely fastened with the Velcro. The

lower edge of the cuff was placed 1.2 to 2.5 cm above the inner side of the elbow joint. The

monitor was then switched on and START button was pressed.

Fig 10: Omron HEM – 7201 automatic blood pressure monitor Source: http://www.omron-healthcare.com/eu/en/our-products/blood-pressure-monitoring

The monitor started measuring blood pressure as

soon as it detected the pulse and the “heart” symbol

began to flash. The systolic and diastolic blood

pressure readings were displayed within a few

moments (systolic above and diastolic below). The

participant’s blood pressure reading was recorded.

The monitor was switched off with the cuff in place.

After three minutes, the same procedure was

repeated twice.

http://en.wikipedia.org/wiki/Blood

http://en.wikipedia.org/wiki/Serum-separating_tube

http://en.wikipedia.org/wiki/Nephelometry

2.5 Pretesting of tools and techniques

The questionnaire on background information and modified STEPS instrument that has been

used for assessing physical activity level, alcohol consumption and tobacco usage, and

modified INTEHEART study questionnaire for assessing perceived stress were pretested by

administrating these on BPO employees (n=20) ̴ 5% of the estimated sample size who were

not part of the study sample. The questionnaires were administered on employees and

responses were obtained. The main aim was not to collect data but to identify problems

related to comprehension and interpretation of questions (Kumar, 2011). Based on the

responses obtained, the questionnaires were modified and thus, corrected for any

infallibility. Pre-testing of 24 hour diet recall was done using interview technique; and food

frequency questionnaire was administered in the investigator’s presence. Appropriate

modifications were incorporated into the food frequency questionnaire’s list of food items.

Training was received by the investigator for accurately measuring all the anthropometric

measurements viz. weight (kg), height (m) and WC (cm) at NFI. Standardized procedures

were followed for all the measurements (Cameron, 1984). The measurements were taken in

duplicate and TEM as well as %TEM was calculated for each measurement.

2.6 Program development and implementation

In the phase II of the study, a lifestyle management program was developed to promote

healthy eating habits and physical activity among BPO employees. The development of the

program entailed identifying key results from phase I, conducting FGDs to obtain insight

with respect to the employees’ current eating habits, their lifestyle choices, and, the

changes that they think can be made to improve their diet and lifestyle. Various key

informant interviews with specifically identified key respondents were also carried out. The

ecological approach has been used for program development because it is a well-rounded

approach since it considers the role of environment apart from the individual, in influencing

behavioral change. The use of this approach adds to the additional levels of influence on

behavior, along with the individual’s knowledge and psychosocial factors, which is more

effective in bringing behavior change. The focus of the program was on diet and physical

activity. The program was designed using the ecological approach, to create awareness and

modify behavior to bring about a change in the participants in an acceptable manner. It was

a multilevel approach targeting three levels of the ecosystem viz. intrapersonal level, social

and cultural level, and, physical environment level. After testing its feasibility and

acceptability, the program was implemented.

2.7 Ecological Approach

Health behavior of an individual is determined by various factors (Fig 11). To understand the

complexity of these influencers further, the Ecological approach was developed (Fig 12). The

approach involves the interaction between an individual and his/her environment (Richard,

Gauvin and Raine, 2011). It has now been adopted to play an important role in health

promotion.

Figure 11: Factors affecting health behavior

Source: Adapted from Reynolds, Klepp and Yaroch, 2004.

Ecological models came into existence during the 1980s in various fields viz. public health,

education, sociology, biology, psychology (Bronfenbrenner, 1986; McLeroy et al., 1988;

Simons-Morton et al., 1989; Stokols, 1992) and have evolved over the years to understand

the complex inter-relationship between the individual and environment (Table 7).

HEALTH BEHAVIOR

Individual beliefs

Friends and family

Laws and regulations

Physical environment

Fig 12: Ecological approach

Source: Green et al., 1996

Green and colleagues (1996) stated “The ecological model of health promotion presents

health as a product of the interdependence between the individual and the subsystems of

the ecosystem”. This includes the family, community, culture, physical and social

environment. Therefore, health is not an entity defined only by an individual but, is also

determined by the factors outside the individual and interaction between them. Table 7

highlights the contemporary ecological models developed in the field of health promotion.

Table 7: Contemporary ecological models developed in the field of health promotion Author, Year Model focus Key concepts

Stokols et al., 2003 Typology of community assets for health promotion

x Material resources: economic capital, natural capital, human-made environmental capital, and technological capital

x Human resources: social capital, human capital, and moral capital

Best et al., 2003 An integrative framework for community partnering to translate theory into effective health-promotion strategy

x Social ecology model x PRECEDE-PROCEED model x Life course health development model x Community partnering

Hovell et al., 2009 The behavioral ecological model

x Principles of learning with emphasis on contingencies of reinforcement

x Influences from genetic, biological, and behavioral learning history interact with influences from the physical and social environment

Burke et al., 2009 A theoretical approach to social context

x The relationship between individuals and their social context is complex and is shaped and constituted by social, cultural, economic, political, legal, historical, and structural forces

x This relationship is multidirectional, co-constitutive, and constantly in formation

x The multilayered influences in which individuals are embedded are often beyond the level of individual consciousness

INTRAPERSONAL LEVEL

(Knowledge, attitudes and beliefs)

SOCIAL AND CULTURAL LEVEL

(Friends, coworkers, organization, institution, governmental laws and

policies)

PHYSICAL ENVIRONMENTAL LEVEL

(Climate, geography, availability of food in home and neighborhood, organizational infrastructure, and

nature of occupation)

For the ecological system to function, the environment has to be conducive to change. It

should be thriving for an individual, where it should provide necessary information to alter

behavior and has the availability of the healthful options. This is necessary to facilitate the

behavior change in an individual (Thorogood, 1992). So, health behavior is affected by both

intrapersonal as well as environmental factors.

2.7.1 Why ecological approach?

As clearly stated above, the ecological approach is a more well-rounded approach since it

considers the role of environment apart from the individual in influencing behavioral

change. The use of this approach adds to the additional levels of influence on behavior,

along with the individual’s knowledge and psychosocial factors, which is more effective in

bringing behavior change. Many times, this approach is effective without changing an

individual’s attitudes, beliefs, knowledge or skills directly. Such interventions are known as

passive interventions and have proven to last longer durations. Programs designed using

this approach move from one-to-one interactions to settings such as schools, colleges,

churches, workplaces, etc. Moreover, being focused on different levels, the ecological

approach does not put the entire burden for behavior change solely on the individual; which

is otherwise known as ‘victim blaming’ (Ruchards, Reid and Watt, 2003). Hence, it is better

to include both the individual as well as the environment while developing programs for

health promotion. Therefore, in the present study an ecological approach was used to

develop the nutrition education program for BPO employees focusing on healthy eating

habits and physical activity.

2.7.2 Levels of organization in the ecological approach

Over the years, the ecological models being a complex entity have been described by

various researchers in different ways. Due to this complexity, a multilevel approach is used

(Green, Richard and Potvin, 1996). However, in the present study, we have used the version

that uses three simple levels of the ecological approach which can influence behavior. These

levels are intrapersonal, social and cultural environment, and physical environment. Each of

these has been described next.

2.7.2.1 Intrapersonal level

This level includes the attitudes, beliefs and perceptions of an individual towards diet that

exist in an individual which may or may not be shared with other people. Perceived self-

efficacy is one such intrapersonal factor that implies belief in an individual that he/she can

bring about a specific change in their behavior. For example, consumption of low fat snacks,

increasing fruit and vegetable consumption etc. Another factor is perceived benefits to

dietary change. For example, if a person believes that introducing vegetable oils in his diet is

healthy as compared to consumption of saturated fats such as Vanaspati (hydrogenated

vegetable oils) which are harmful, he/she may stop using them.

2.7.2.2 Social and cultural environment

This level includes the interaction of an individual with their family, friends, institutions such

as worksites, culture and governmental laws and policies. It is imperative to understand the

relationship between these factors and linkages between them so as to appreciate the

impact that they would have on human behavior ultimately. For example, if there is a new

food security act introduced by the government, it is bound to be covered by the media.

Seeing this, the beneficiaries can get knowledge about the act and they can make their

purchasing choices accordingly which can also affect the price and availability of food items.

Thus changes in the government laws and policies can trigger changes at the intrapersonal

level, social and cultural and physical environment levels. Peer groups also hold a strong

influence on an individual. An individual’s food choices are usually guided by the peer group

of which he/she is a part of.

2.7.2.3 Physical environment

This level comprises the food availability, geography, and other infrastructure that helps to

determine the food choices along with the concerns regarding physical activity. For

example, food labels if understood by the consumers can go a long way in influencing the

food choices of an individual. Another factor of the physical environment is availability of

different types of food in the market. Foods that are readily available will be more

consumed than those which are not. Brown rice is very healthy and is being promoted as a

rich source of fiber, however, it is not available commonly in the shops. Therefore, the

consumption of brown rice is low. Apart from availability, also seasonal availability of foods

is another environmental factor that also has an impact on the pricing and purchasing

power of the foods. Even if the food items are healthy but are not available in a particular

season or have high prices due to lower supply, the consumption of those foods may be

affected considerably. This can be seen during drought, when the prices of vegetables such

as onion and tomato which are used commonly in household increases, as a result of which

the purchasing power decreases and individuals use less of them or find other substitutes.

The geography of an area can limit the physical activity of the individuals residing there.

Those areas which are densely populated and have restriction in movement and do not have

enough open spaces, further contribute to the sedentary lifestyle of the individual. Various

health promotion programs have used ecological approach to bring about behavior change

(Table 8).

Program Setting Target group Aim Levels of ecological approach used Intrapersonal Social and cultural Physical

The Black Churches United for Better Health Project Campbell et al, 2000

North Carolina, USA

2519 rural African-American adult church members

To increase fruit and vegetable consumption

x Increasing self-efficacy and preference towards fruits and vegetables by sending personalized messages related to fruits and vegetables.

x Creation of a cookbook featuring healthy recipes of fruits and vegetables.

x Distribution of printed materials on fruits and vegetables during church gatherings.

x Serving fruits and vegetables at all church events.

x Forming a support group with pastors by providing them with educational material (newsletters and manuals) to guide other church attendees.

x Increasing availability of fruits and vegetables by planting of trees by members at church sites.

x Promoting local vendor produce by offering coupons, recipes and discounts to the church attendees.

Fruit and vegetable subscription program Bere et al, 2005

Norway School children (grades 1-10)

To increase fruit and vegetable consumption among school children

x Increasing awareness regarding benefits of eating more fruits and vegetables by distribution of brochures to school children for their parents.

x Creation of a webpage for increasing awareness/ providing more information.

x Peer modelling – encouraging consumption by seeing other children eating fruits and vegetables at school.

x Involving children in the distribution of fruits and vegetables in their own class on a rotational basis.

x Increasing availability of fruits and vegetables in the school premises.

x Partnership with the private sector to distribute fruits and vegetables at a subsidized cost.

The Baby Friendly Hospital Initiative Labbock, 2012

Africa Mothers with young children working in the health care facilities

To promote exclusive breast feeding for first 6 months

x Improving knowledge of women regarding early breastfeeding and its benefits, continuation of breast feeding by providing them with educational material.

x Creation of a written breastfeeding policy in the health care facility and training the health care staff regarding the same.

x Formation of breastfeeding support groups

x Banning artificial teats and pacifiers in the health care facility.

x Allowing mothers and infants to spend more time together by restructuring hospital wards.

Table 8: Health promotion programs and the ecological approach

2.7.3 Limitations of the Ecological approach

Besides advantages, the approach also has certain limitations which need to be taken into

account. Complexity is one term that describes it all. The ecological approach has many

levels and to understand those levels and then the factors within those levels is a

complicated task. The way these levels interact with each other makes the approach a

complex one, which makes intervening at more than one level, a complex affair (Reynolds,

Klepp and Yaroch, 2004).

In the present study, a multilevel ecological approach was undertaken for the development

of the nutrition education program.

2.8 Focus group discussion

Focus group discussion (FGD) is a discussion on a topic of interest among a group of

individuals with selected characteristics initiated by a moderator. These are also called

“focus interviews” or “group depth interviews” (Stewart and Shamdasani, 1990). Usually the

FGDs consist of 7-10 people who are not familiar with each other. The basic idea is that the

group should be consistent enough to generate rich data and therefore, the number of the

individuals should not be large that some participants are left out. It gives an insight into the

opinions held by the group on a particular topic and the reasons behind it. Besides, it is a

very useful technique to plan and design new programs (Krueger, 1988). In the present

study, FGDs were conducted with the BPO employees in groups of nine. In total, three FGDs

were conducted as a saturation point was reached with the information being generated.

Each FGD lasted for an hour, with the moderator (investigator) facilitating the discussion.

The FGD was initiated by inviting the BPO employees to participate in a discussion focusing

on their eating habits and physical activity pattern. A FGD guide with themes and probes

was developed for the discussion (Annexure 8). It was designed in such a way that it had

engaging questions, exploratory questions and exit questions. Demographic information

was obtained from the BPO employees at the beginning of the FGD, following which the

discussion was initiated. The FGD was digitally recorded with the group’s consent and

transcribed soon after. The discussion began with the moderator (investigator) welcoming

the employees. The purpose of the discussion was explained and some basic ground rules

were set before the discussion. The important instructions included employees doing all the

talking as it was explained to them that their opinions were important. Since, there was no

right or wrong answer, they were told to speak whether they agreed or disagreed to

something. It was also informed to them that their responses would be kept confidential

and the FGD was being recorded. This was followed by the FGD and at the end all the

participants were thanked for their cooperation. The next step was transcribing the FGDs

and synthesizing and elucidating important points from the discussion. Microsoft Excel was

used for coding and synthesizing data. The data were then used in the planning of the

program. The detailed findings have been described later in another chapter.

2.9 Key informant interviews

Key informant interviews (KII) are in-depth qualitative interviews of certain selected people

who have firsthand knowledge about the situation (University of Illinois, 2004; USAID,

1996). They involve conversations that flow in a smooth comfortable manner to generate in-

depth knowledge about an issue(s). These are best suited for program development

purposes, right from the planning stage as they have the capacity to provide with very

useful in-depth information pertaining to the issue at hand and to influence decision

making. The major advantages of using this method of data generation are its ability to

generate rich information without being expensive, ability to clarify questions and ask the

respondent. They also provide flexibility in asking additional questions as per the situation,

establishing rapport for future discourse, and above all, furnish information directly from

the knowledgeable person(s), besides raising interest around it (Carter and Beaulieu, 1992).

In the present study, various key informant interviews were conducted as a process of

aiding in the program development for the BPO employees (Annexure 9).

At first, phase I results were analyzed followed by FGDs with BPO employees to understand

the situation of the industry, their existing practices and behaviors and reasons for those

behaviors. The focus was on diet, physical activity, shift working pattern, changes the

employees felt were needed in their diet and lifestyle, barriers perceived by them in

introducing/making the desired changes and the ways to overcome them. Further, it was

considered pertinent to get information from certain key informants who are an important

part of the industry and had a say in decision making in terms of affecting the employees

directly. The three categories of key informants identified were: HR managers,

Administrative/facilities managers and Catering managers. To gather in-depth information,

around 15 – 25 KII are needed to be conducted (University of Illinois, 2004; USAID, 1996;

Carter and Beaulieu, 1992). However, considering the logistics and availability of key

informants, it was possible to conduct a total of 10 interviews (HR Managers [n=4];

Administrative managers [n=3]; Catering managers [n=3]).

Face-to-face interviews were conducted with all key informants. Being intensive in nature,

these required prior planning and the availability of time of the interviewee. The major

advantage of conducting a face-to-face interview was that it established good rapport and

facilitated free flow of ideas besides explaining the questions with clarity. The interview

schedule was designed and pretested. It was semi-structured and also allowed for involving

spontaneous questions depending on the situation. The interviews began with the brief

introduction of the interviewer, followed by explaining the purpose, establishing the need

and utilization of the information required. The questionnaire guide included key questions

to tackle the issue at hand as well as probing questions. This was to fathom the reasons for

the responses and reflecting on them in a thoughtful manner. The interviews were digitally

recorded and transcribed after taking consent of the interviewee to maintain their

anonymity. This method was used along with taking brief notes as it allowed free exchange

of ideas without having the need to write down everything. The type of information

gathered from the key informants has been listed in fig 13.

Figure 13: Type of information collected from various Key Informants

On the basis of the data collected in phase I, the lifestyle management program was

developed, designed and implemented in one company for a period of 3 months. This

included a follow up for 6 weeks as more could not be carried out because time permission

for the same was not granted by the company. The program implementation entailed the

following steps:

The program development and implementation details have been described in a separate

chapter.

HR MANAGER

•Organizational demographics •Food access - Canteen menu,

worksite vending machines, food subsidy etc.

•Smoking - Smoking ban, incentives on no smoking, ban on sale of tobacco products near worksite

•Physical activity - On site exercise facility, membership facility, facility for leisure time physical activity, exercise area.

•Stress - Employee assistance program, workplace harrasment policy

•Worksite policy on smoking, food availability, alcohol consumption, employee health, medical check up services, preventive screening

•Health promotion and health care - Health insurance, prescription coverage, employee incentives

•Activities in past 1 year, display of health messages, sessions for employees on nutrition, smoking, physical activity, alcohol, stress management, any activity on promotion of physical activity

ADMINISTRATIVE MANAGER

•Worksite wellness committee •Objectives set for wellness of

the employees •Health club memberships •Role of senior management in

employee wellness •Health as a factor in

recruitment •Role of administrative

department in conducting any health related activity

•Flexible work schedule policy •Subsidy on health and medical

insurance •Health leave policy

CATERING MANAGER

•Contractual policy •Staff employment •Employee strength catered

everyday •Food preparation •Usual menu and it's type •Daily cooking quantity,

procurement of ingredients •Factors influencing menu

planning •Cooking medium (Oils) used •Plate waste •Changes in menu •Special menu •Feedback of employees on

acceptability of food served to them

Pre implementation: Knowledge,

practices, and self-efficacy assessment

Conducting of sessions on

nutrition, physical activity, and tobacco

and alcohol usage

6 weeks follow up

Post implementation: Knowledge, practices,

and self-efficacy assessment

2.10 Data analysis

Data were analyzed using SPSS 16 for all variables. Results are expressed as mean ±

standard deviation with 95% confidence intervals. A p value of <0.05 was deemed

statistically significant. To maintain data quality, all anthropometric measurements were

taken in duplicate and had a high coefficient of reliability (R=0.99). The technical error of

measurement for them was well within the limits (Ulijazek and Lourie, 1999). Unpaired t-

test for gender was performed to ascertain the difference in assessment of MetS, and

biochemical parameters between males and females. The analysis of variance was used in

cases of multiple groups. To measure the strength of linear association between two

variables, Pearson’s correlation coefficient was used. Chi-square test of association was also

used to ascertain independence of two attributes to determine if there was any relationship

between them. Wilcoxon’s sign rank test was used to compare the knowledge level of the

employees before and after the health sessions. All the significant univariate results were

subjected to multivariate analysis and logistic regression was used with MetS as the

outcome variable. A descriptive narrative approach was used to highlight the findings of the

FGDs and KII to be incorporated in the second phase of the study.

CHAPTER 3: RESULTS AND DISCUSSION

The present study was carried out to map the occurrence of MetS among young employees

working in the BPO sector in Delhi-NCR and to develop and implement a lifestyle

management program for them. The study was carried out in two phases:

Phase I: Mapping the occurrence of Metabolic Syndrome among BPO employees

Phase II: Development of a lifestyle management program for nutrition promotion among

BPO employees

The results of phase I of the study are presented in this chapter.

I. METABOLIC SYNDROME AMONG BPO EMPLOYEES

The present study was carried out among 415 calling level and 61 managerial level

employees working in the BPO sector in the Delhi NCR region.

3.1 Socio-demographic profile of the calling level BPO employees

The study sample consisted of employees working at the calling level in the BPO sector aged

21-30 years (Table 9). Two-thirds of them were males, and rest females (Figure 14).

The mean age of the group was 26.1±2.6 years, with more than half of them (56.9%) being

in the age range of 25-30 years and rest (43.1%) in the age range of 21-25 years. Nearly

three-fourths of them were single (74.0%) and remaining one-fourth (26.0%) were either

married or divorced. Majority of the employees were graduates (51.6%) or post-graduates

66.02%

33.98%

Figure 14: Sex-wise distribution of calling level employees (n=415)

Males Females

(44.6%) and a few (3.9%) had studied till the high school level. Nearly half of them resided in

nuclear families (48.4%), one fourth either stayed alone or as paying guests (25.8%), and the

remaining one fourth in joint families (25.8%). More than one third of them (35.2%) had

monthly income ranging between 10,000-20,000 Indian Rupee (INR) per month, 39.5% of

them earned between 20,000 – 50,000 INR per month and one sixth (16.6%) earned more

than 50,000 INR per month depending on their experience and educational qualification.

Their work involved providing outsourcing services for 5 days in a week with time bound

targets.

Table 9: Socio-demographic profile of calling level BPO employees

Socio-demographic variables Total (n=415) Males (n=274) Females (n=141) Age (years) (Mean±SD) 26.09±2.57 26.53±2.53 25.23±2.41 Marital status

Single Married Divorced

307(74.0) 105(25.3) 3(0.7)

199(72.6) 74(27.0) 1(0.4)

108(76.6) 31(22.0) 2(1.4)

Educational qualification High school Graduate Post graduate

16(3.9) 214(51.6) 185(44.6)

8(2.9) 142(51.8) 124(45.3)

8(5.7) 72(51.1) 61(43.3)

Family type Nuclear Joint Staying alone/PG*

201(48.4) 107(25.8) 107(25.8)

128(46.7) 79(28.8) 67(24.5)

73(51.8) 28(19.9) 40(28.4)

Monthly income (INR) 5,000-10,000 10,000-15,000 15,000-20,000 >20,000

36(8.7) 53(12.8) 93(22.4) 163(39.3)

19(6.9) 35(12.8) 59(21.5) 108(39.4)

17(12.1) 18(12.8) 34(24.1) 56(39.7)

>50,000 69(16.6) 53(19.3) 16(11.3)

3.2 Profile of Managerial level BPO employees

Prevalence of MetS was also assessed among 61 managerial level employees of the selected

BPOs. Mean age of this group was 32.74±2.35 years (25-40 years). Nearly 90% of them were

males and rest females (11.5%). Unlike calling level employees who were majorly single

(74%), majority (83.6%) of the managers were married and stayed with their families. About

half of them (44.3%) were earning more than Rs 50,000 monthly. The general profile of

managers is depicted in Table 10.

Figures in parentheses represent percentages *Paying guest

Table 10: Socio-demographic profile of managerial level BPO employees

Socio-demographic variables Total (n=61) Males (n=54) Females (n=7) Age (years) [Mean ± SD] 32.74±2.35 32.57±2.4 34.00±1.9 Family type

Nuclear Joint Staying alone/PGs*

42(68.9) 11(18.0) 8(13.1)

37(68.5) 10(18.5) 7(13.0)

5(71.4) 1(14.3) 1(14.3)

Marital status Single Married Divorced

10(16.4) 51(83.6) 0(0)

9(16.7) 45(83.3) 0(0)

1(14.3) 6(85.7) 0(0)

Educational qualification High school Graduate Post graduate

1(1.6) 16(26.2) 44(72.1)

0(0) 14(25.9) 40(74.1)

1(14.3) 2(28.6) 4(57.1)

Monthly income (Rupees) 5,000-10,000 10,000-15,000 15,000-20,000 >20,000 >50,000

1(1.6) 2(3.3) 7(11.5) 24(39.3) 27(44.3)

1(1.9) 2(3.7) 5(9.3) 22(40.7) 24(44.4)

0(0) 0(0) 2(28.6) 2(28.6) 4(57.1)

Figures in parentheses represent percentages *Paying guest

3.3 Prevalence of Metabolic Syndrome

Metabolic Syndrome (MetS) is a cluster of interrelated factors characterized by high fasting

blood glucose, increased level of triglycerides, low levels of HDL, elevated blood pressure

and abdominal obesity (NCEP-ATPIII, 2001). Prevalence of MetS was assessed using NCEP-

ATPIII criteria (2001) and IDF criteria (2005). The IDF criterion was used along with the NCEP-

ATPIII criteria, as it is ethnic group specific i.e for South Asians and thus, appropriate for the

study group. According to both these criteria, an individual having abnormality in at least 3

or more components, is diagnosed as having MetS. However, in case of IDF criteria,

abnormality in WC is the mandatory component to be included while diagnosing MetS. The

prevalence of MetS among BPO employees was estimated as 11.8% using the ATPIII and

18.3% using the IDF criteria (Figure 15).

In case of managerial level BPO employees, MetS was estimated as 21.3% (males-22.3%;

females-14.3%) according to ATPIII criteria and 31.1% (males-33.3%; females-14.3%)

according to IDF criteria (fig 16); and it was significantly higher than the prevalence among

calling level BPO employees (t=3.142 (ATPIII criteria), t=3.456 (IDF criteria); p<0.05).

In the sentinel surveillance project by WHO in Indian industrial population, MetS prevalence

was estimated as 27% using the ATPIII criteria (Reddy et al., 2006). Several studies have also

observed varying prevalence of MetS among adults engaged in different occupations. The

11.8 14.6

6.4

18.3

22.3

10.6

0

5

10

15

20

25

Total Males Females

P

e

r

c

e

n

t

Figure 15: Prevalence of Metabolic Syndrome among calling

level BPO employees according to ATPIII and IDF criteria

(n=415)

ATPIII IDF

21.3 22.2

14.3

31.1 33.3

14.3

0

5

10

15

20

25

30

35

Total Males Females

P

e

r

c

e

n

t

Figure 16: Prevalence of Metabolic Syndrome among

managerial level BPO employees according to ATPIII and IDF

criteria (n=61)

ATPIII IDF

prevalence of MetS has ranged from 18.4% in bus and tram drivers as compared to 11.8% in

laborers, 9.3% in office employees and 7.7% in managers in Sweden (Rosengren, Anderson

and Wilhelmsen, 1991). More than one third (35.9%) of the bus and truck drivers in Iran had

MetS (Saberi et al., 2011). Among office workers, the prevalence has ranged from 30% in

male and 9.8% in female office workers in Korea (Kim and Oh, 2012), 17% in male and 6.5%

in female workers in Spain (Leon-Latre et al., 2009) and 22.9% (ATPIII criteria), 20.6% (IDF

criteria), and 15.3% (Chinese Diabetes Society criteria) among retired employees from

government institutions, universities and companies in China (Wang et al., 2015). The

variability in prevalence exists across age and occupation groups and can be attributed to

the lack of congruent diagnostic criteria as well as to the differences in exposure to various

risk factors due to the nature of occupation (Ford et al., 2002; Rantala et al., 1999; Bonora et

al., 1998).

3.4 Components of Metabolic Syndrome

There are basically five components that cluster together to develop MetS. These are FBG,

total triglycerides, HDL cholesterol, blood pressure and WC; and they have been used for

diagnosing the syndrome among both calling and managerial level employees (Table 11).

Abnormalities in their levels result in the syndrome. Among the calling employees, FBG

levels were similar among males and females. Total triglycerides (t=7.27; p=0.000), systolic

blood pressure (t=13.7; p=0.000), and diastolic blood pressure (t=6.55; p=0.000) were

significantly higher in males (Table 11).

Table 11: Gender differences in the components of Metabolic Syndrome among calling

level BPO employees Component Total (n=415)

Mean ± SD Males (n=274) Mean ± SD

Females (n=141) Mean ± SD

t value

p value 95% CI

FBG (mg/dl) 86.72+12.19 86.89±8.39 86.40±17.38 0.31 0.754 [-2.57, 3.54]

HDL (mg/dl) 44.05±8.33

41.98±7.15 48.06±9.00 -- -- --

TG (mg/dl) 125.38±77.90 144.18±84.78 88.84±43.55 7.27 0.000* [40.38, 70.30]

BP x SBP

(mm/Hg) x DBP(mm/H

g)

119±13.63 75±9.91

125.00±11.48 77.00±9.67

109.00±11.11 71.00±9.04

13.66 6.55

0.000* 0.000*

[13.62, 18.20] [4.40, 8.18]

WC (cm) 88.62±10.22 91.77±9.06 82.50±9.56 -- -- -- *Significant at p<0.05 -- t was not computed due to physiological gender differences in the cutoffs FBG – Fasting blood glucose; HDL- High density lipoprotein cholesterol; BP- Blood pressure; SBP- Systolic blood pressure; DBP- Diastolic blood presuure; WC- Waist circumference

Table 12: Gender differences in the components of Metabolic Syndrome among

managerial level BPO employees Component Total (n=61)

Mean ± SD Males (n=54) Mean ± SD


t value

p value 95% CI

FBG (mg/dl) 87.26±7.2 87.35±6.6 86.57±11.2 0.27 0.788 -5.01, 6.57

HDL (mg/dl) 43.36±8.1 42.24±7.3 52.00±9.9 -- -- -- TG (mg/dl) 151.24±87.7 161.29±87.8 73.71±27.9 2.605 0.011* 20.3,15

4.9 BP x SBP

(mm/Hg) x DBP(mm/H

g)

124±11.4 79±10.4

125±10.9 80±10.1

113±10.7 72±10.7

2.746 1.956

0.008* 0.054

3.25, 20.75 -0.16, 16.17

WC (cm) 94.84±12.9 95.94±11.5 86.41±20.0 -- -- -- *Significant at p<0.05 -- t was not computed due to physiological gender differences in the cutoffs FBG – Fasting blood glucose; HDL- High density lipoprotein cholesterol; BP- Blood pressure; SBP- Systolic blood pressure; DBP- Diastolic blood presuure; WC- Waist circumference

Among the managerial level employees, FBG levels and diastolic blood pressure was similar

among males and females. Total triglycerides (t=2.605; p=0.011) and systolic blood pressure

(t=2.746; p=0.008) were significantly higher in males (Table 12). The mean levels of all the

biochemical parameters except HDL cholesterol were significantly higher among the

managerial level employees as compared to those working at the calling level.

3.5 Anthropometric status of BPO employees

Anthropometry is an important means of nutritional assessment as it is quick, easy, non-

invasive and economical. Various anthropometric measurements were taken for phase 1

(Table 13). These included weight, height, WC and body composition. Of these, WC was

included as one of the measures in the screening for MetS. It is a simple and useful indicator

to evaluate obesity irrespective of gender or race (Pouliot et al., 1994).

Table 13: Anthropometric and Biochemical profile of calling level BPO employees

Measurement Males (n=274) Mean ± SD/No.

Females (n=141) Mean ± SD/No.

Height (m) 1.68±0.06 1.57±0.07 Weight (kg) 73.11±11.47 58.93±11.00 WC (cm) IDF criteria M≥90cm, F≥80cm

91.77±9.06 159(58.0)

82.50±9.56 84(59.6)

Index/Ratio Total (n=415) Mean ± SD/No.

Males (n=274) Mean ± SD/No.

Females (n=141) Mean ± SD/No.

t value

p value 95% CI

BMI (kg/m2) BMI >23kg/m2

25.11±3.80 304 (73.2)

25.74±3.48 228 (83.2)

23.88±4.11 76 (53.9)

4.84 0.000* [1.11, 2.62]

Waist to height ratio WHt ratio≥0.5

0.54±0.06 330 (79.5)

0.54±0.05 218 (79.6)

0.53±0.06 112 (79.4)

3.33 0.001* [0.01, 0.03]

CI- Confidence Interval *Significant at p<0.05 WC – Waist circumference; BMI – Body Mass Index Figures in parentheses are percentages

Mean WC for males and females was 91.77±9.06 cm and 82.50±9.56 cm, respectively.

According to the ATPIII criteria, 12.4% males and 26.2% females had WC values higher than

the prescribed cutoffs for abdominal obesity, while these figures were 58.0% in males and

59.6% in females according to the IDF criteria. This difference was due to the fact that cut

offs for WC for the above mentioned criteria are different. They are >108 cm for males and

>88 cm for females according to ATPIII criteria and ≥90 cm for males and ≥80 cm for females

according to IDF criteria. Waist to height ratio was also computed (Table 13) (Ashwell, Gunn

and Gibson, 2012). Only one fifth of them (20.5%) had waist to height ratio below 0.5,

whereas the rest (79.5%) had it ≥ 0.5, which is an indicator of obesity (Ashwell, Gunn and

Gibson, 2012). As is evident from the data, almost three fourths of the employees had BMI

and Wht ratio values indicative of overweight and obesity. This waist to height ratio has

been agreed upon after a meta-analysis that included robust statistical evidence from

studies with more than 300,000 adults from Asia, Middle East, Europe, Caribbean, South

America and Australasia. It concluded that waist to height ratio was a better indicator of

cardio metabolic risk factors than BMI or WC.

Our results showed that the managers had a mean BMI of 25.9±7.3 kg/m2 among females

and 26.9±4.3 kg/m2 among males. This was more than the mean BMI of male as well as

female calling level employees. Mean waist circumference was 95.9±11.5 cm among males

and which is significantly higher than those among calling level employees (t=2.920,

p=0.004). However, these differences were not significant among females (t=0.987;

p=0.325) (Table 14).

Table 14: Anthropometric and Biochemical profile of managerial level employees

Measurement Males (n=54) Mean ± SD


Height (m) 1.68±0.1 1.52±0.1 Weight (kg) 75.79±14.3 60.82±19.2 WC (cm) IDF criteria M≥90cm, F≥80cm

95.94±11.5 86.41±20.0

Index Total (n=61) Mean ± SD

Males (n=54) Mean ± SD


t value

p value 95% CI

BMI (kg/m2) BMI >23kg/m2

(n)

26.80±4.6 49 (80.3)

26.90±4.3 44 (81.5)

25.96±7.3 5 (71.4)

0.498 0.619 -2.83,4.71

Waist to height ratio WHt ratio≥0.5 (n)

0.6±0.1 61 (100.0)

0.6±0.1 54 (100.0)

0.6±0.1 7 (100.0)

0.000 1.000 -0.08,0.08

CI- Confidence Interval WC – Waist circumference; BMI – Body Mass Index Figures in parentheses are percentages

The mean BMI was 25.74±3.48 kg/m2 for males and 23.88±4.11 kg/m2 for females working

at the calling level. The calling level employees were classified into various BMI categories

based on IOTF (2000) cutoffs (Table 15). Nearly three-fourths (73.5%) of the employees had

BMI ≥23kg/m2; with half (50.6%) of them being obese (BMI ≥25kg/m2). A significantly higher

proportion of males (57.3%) were obese as compared to females (37.6%) according to the

IOTF classification (Table 15).

Table 15: BMI of calling level BPO employees classified according to the IOTF (2000)

criteria BMI categories Total

(n=415) Males (n=274)

Females (n=141)

ᵡ2 p value

Underweight (<18.5 kg/m2) 17(4.1) 5(1.8) 12(8.5) 42.13 0.000* Normal (18.5-22.99 kg/m2) 94(22.7) 41(15.0) 53(37.6) At risk (23-24.99 kg/m2) 94(22.7) 71(25.9) 23(16.3) Obese I (25-29.99 kg/m2) 175(42.2) 131(47.8) 44(31.2) Obese II (≥30 kg/m2) 35(8.4) 26(9.5) 9(6.4) Figures in parentheses represent percentages *Significant at p<0.05

The mean BMI was 26.90±4.3 kg/m2 for males and 25.96±7.3 kg/m2 for females working at

the managerial level. The managerial level employees were classified into various BMI

categories based on IOTF (2000) cutoffs (Table 13). Majority (80.3%) of the managerial level

employees had BMI ≥23kg/m2; with half of them (49.2%) being obese (BMI ≥25kg/m2). A

significantly higher proportion of males (70.4%) were obese as compared to females (43.2%)

according to the IOTF classification (Table 16).

Table 16: BMI of managerial level BPO employees classified according to the IOTF (2000)

criteria BMI categories Total (n=61) Males (n=54) Females (n=7) ᵡ2 p value Underweight (<18.5 kg/m2) 1(1.6) 0(0) 1(14.3) 9.961 0.041* Normal (18.5-22.99 kg/m2) 11(18.0) 10(18.5) 1(14.3) At risk (23-24.99 kg/m2) 8(13.1) 6(11.1) 2(28.9) Obese I (25-29.99 kg/m2) 30(49.2) 28(51.9) 2(28.9) Obese II (≥30 kg/m2) 11(18.0) 10(18.5) 1(14.3) Figures in parentheses represent percentages *Significant at p<0.05

Body mass index (BMI), WC (males) and waist to height ration was significantly high among

the managerial level employees (Table 17).

Table 17: Comparison of anthropometric measurements between calling and managerial

level employees

Measurement Mean±SD t value p value 95% CI

BMI Calling level (n=415) Managerial level (n=61)

25.11±3.80 26.80±4.6

3.1518

0.001*

-2.74,-0.64

WC (males) Calling level (n=274) Managerial level (n=54)

91.77±9.06 95.94±11.5

2.9483

0.003*

-6.95,-1.39

WC (females) Calling level (n=141)

82.50±9.56

0.9898

0.323

-11.7,3.89

Managerial level (n=7) 86.41±20.0 Waist to height ratio Calling level (n=415) Managerial level (n=61)

0.54±0.06 0.6±0.1

6.5889

0.000*

-0.08,-0.04

*Significant at p<0.05

Ascertaining body fat percentage is an important way to determine the risk of MetS which is

an important risk factor of CVD (Daniels et al., 2000). Body fat percent was ascertained in

the study sample using body fat analyzer (Table 18). The body fat percent ranges included in

the table have been developed using prediction formulas based on the BMI limits (Gallagher

et al., 2000). At the calling level, only one third of the male employees (30.7%) were

categorized as healthy (Body fat: 14-22%) whereas half of the female employees (49.6%)

were categorized as healthy (Body fat: 26-34%). Half of the males (50.7%) were overfat

(Body fat: 23-27%) and nearly one sixth (15.0%) were obese (Body fat: ≥28%). In comparison,

one fifth of the females (21.3%) were categorized as over fat (Body fat: 35-39%) and one tenth

(11.3%) were obese (Body fat: ≥40%). At the managerial level, nearly one fourth (24.1%) of

the male employees were categorized as healthy (Body fat: 14-22%) whereas more than half

of the female employees (57.1%) were categorized as healthy (Body fat: 26-34%). In

comparison, nearly half of the male employees (42.6%) were overfat (Body fat:23-27%) and

nearly one third (31.5%) were obese (Body fat: ≥28). Table 18: Body fat percent among calling and managerial level BPO employees

Calling level BPO employees Managerial level BPO employees

Body fat percent Males

(n=274)

Females (n=141) Males (n=54) Females (n=7)

Under fat (F: upto 25; M: upto 13)

10 (3.6) 25 (17.7) 1(1.9) 1(14.3)

Healthy (F:26-34; M: 14-22)

84 (30.7) 70 (49.6) 13(24.1) 4(57.1)

Over fat (F: 35-39; M: 23-27)

139 (50.7) 30 (21.3) 23(42.6) 1(14.3)

Obese (F: ≥40; M: ≥28) 41 (15.0) 16 (11.3) 17(31.5) 1(14.3) Source: Gallagher et al., 2000 Correlations were drawn between various anthropometric and biochemical parameters

(Table 19a and 19b). A significant positive correlation was observed between BMI and body

fat % (r=0.452; p=0.000), WC and body fat % (r=0.223; p=0.000), and BMI and WC (r=0.839;

p=0.000) among the employees working at the calling level. A significant negative

correlation was observed between HDL cholesterol and weight (r= -0.228; p=0.000), WC (r= -

0.244; p=0.000), BMI (r= -0.172; p=0.000), SBP (r= -0.257; p=0.000), DBP (r= -0.146; p=0.003)

and triglycerides (r= -0.319; p=0.000); implying that higher values of these measures were

associated with lower levels of HDL cholesterol which is an indicator of physical inactivity

(Cooper et al, 2015; Yang et al, 2015; Björck and Thelle, 2010; Kokkinos and Fernhall, 1999).

Among the calling level employees, WC was a measure that was significantly correlated with

all other anthropometric and biochemical measures and/or components of MetS. This may

be an effective non-invasive measure for estimating the risk of MetS in the young age group.

Table 19a: Correlation matrix between anthropometric, biochemical and physiological measures among calling level BPO employees

(n=415) hsCRP WC BMI SBP DBP Body fat% Hb FBG HDL TG Wht

hsCRP

r

p value

1

0.186*

0.000

0.251*

0.000

0.031 0.530

0.048 0.333

0.243*

0.000

-0.038 0.444

0.069 0.159

-0.158*

0.001

0.032 0.521

0.027 0.584

WC r

p value

0.186*

0.000

1

0.839*

0.000

0.322*

0.000

0.235*

0.000

0.223*

0.000

0.325*

0.000

0.144*

0.003

-0.244*

0.000

0.327*

0.000

0.894

0.000*

BMI

r p value

0.251* 0.000

0.839* 0.000

1

0.239* 0.000

0.209* 0.000

0.452* 0.000

0.216* 0.000

0.072 0.144

-0.172* 0.000

0.283* 0.000

0.855 0.000*

SBP

r

p value

0.031 0.530

0.322*

0.000

0.239*

0.000

1

0.783*

0.000

-0.225*

0.000

0.477*

0.000

0.035 0.473

-0.257*

0.000

0.288*

0.000

0.179

0.000*

DBP r

p value

0.048 0.333

0.235*

0.000

0.209*

0.000

0.783*

0.000

1

-0.037 0.450

0.038*

0.000

0.036 0.468

-0.146*

0.003

0.212*

0.000

0.180

0.000*

Body fat%

r

p value

0.243*

0.000

0.223*

0.000

0.452*

0.000

-0.225*

0.000

-0.037 0.450

1

-0.354*

0.000

0.119*

0.016

0.087 0.076

0.003 0.952

0.441

0.000* Hb

r

p value

-0.038 0.444

0.325*

0.000

0.216*

0.000

0.477*

0.000

0.308*

0.000

-0.354*

0.000

1

-0.024 0.619

-0.195*

0.000

0.333*

0.000

0.141

0.004*

FBG r

p value

0.069 0.159

0.144*

0.003

0.072 0.144

0.035 0.473

0.036 0.468

0.119*

0.016

-0.024 0.619

1

-0.007 0.888

0.051 0.301

0.145

0.003*

HDL

r p value

-0.158* 0.001

-0.244* 0.000

-0.172* 0.000

-0.257* 0.000

-0.146* 0.003

0.087 0.076

-0.195* 0.000

-0.007 0.888

1

-0.319* 0.000

-0.180 0.000*

TG

r

p value

0.032 0.521

0.327*

0.000

0.283*

0.000

0.288*

0.000

0.212*

0.000

0.003 0.952

0.333*

0.000

0.051 0.301

-0.319*

0.000

1

0.260

0.000*

Wht r

p value

0.027 0.584

0.894

0.000*

0.855

0.000*

0.179

0.000*

0.180

0.000*

0.441

0.000*

0.141

0.004*

0.145

0.003*

-0.180

0.000*

0.260

0.000*

1


Table 19b: Correlation matrix between anthropometric, biochemical and physiological measures among managerial level BPO employees (n=61) hsCRP WC BMI SBP DBP Body fat% Hb FBG HDL TG Wht

hsCRP

r p value

1

0.199 0.125

0.126 0.334

0.073 0.579

0.232 0.072

0.038 0.772

0.009 0.945

0.037 0.774

-0.127 0.331

0.258* 0.044

0.147 0.258

WC

r

p value

0.199 0.334

1

0.927*

0.000

0.428*

0.001

0.566*

0.000

0.617*

0.000

0.052 0.693

0.319*

0.012

0.000 0.998

0.322*

0.011

0.919

0.000*

BMI

r

p value

0.126 0.334

0.927*

0.000

1

0.379*

0.003

0.469*

0.000

0.717*

0.000

-0.056 0.669

0.301*

0.018

0.020 0.881

0.242 0.060

0.923

0.000* SBP

r

p value

0.073 0.579

0.428*

0.001

0.379*

0.003

1

0.678*

0.000

0.171 0.187

0.104 0.425

0.295*

0.021

0.086 0.510

0.260*

0.043

0.349

0.006*

DBP

r

p value

0.232 0.072

0.566*

0.000

0.469*

0.000

0.678*

0.000

1

0.248 0.054

0.019 0.887

0.213 0.099

0.173 0.184

0.141 0.279

0.492

0.000*

Body fat%

r

p value

0.038 0.772

0.617*

0.000

0.717*

0.000

0.171 0.187

0.248 0.054

1

-0.182 0.159

0.280*

0.029

0.086 0.508

0.105 0.419

0.710

0.000* Hb r

p value

0.009 0.945

0.052 0.693

-0.056 0.669

0.104 0.425

0.019 0.887

-0.182 0.159

1

0.049 0.708

-0.212 0.101

0.138 0.288

0.038 0.772

FBG

r

p value

0.037 0.774

0.319*

0.012

0.301*

0.018

0.295*

0.021

0.213 0.099

0.280*

0.029

0.049 0.708

1

-0.042 0.745

0.294*

0.022

0.298

0.020*

HDL

r

p value

-0.127 0.331

0.000 0.998

0.020 0.881

0.086 0.510

0.173 0.184

0.086 0.508

-0.212 0.101

-0.042 0.745

1

-0.058 0.658

-0.137 0.291

TG

r p value

0.258* 0.044

0.322* 0.011

0.242 0.060

0.260* 0.043

0.141 0.279

0.105 0.419

0.138 0.288

0.294* 0.022

-0.058 0.658

1

0.294 0.022*

Wht

r

p value

0.147 0.258

0.919

0.000*

0.923

0.000*

0.349

0.006*

0.492

0.000*

0.710

0.000*

0.038 0.772

0.298

0.020*

-0.137 0.291

0.294 0.022*

1


Various studies have observed positive correlation between BMI and WC among patients

with MetS. WC was significantly correlated with BMI in Polish men (32-80 years) with MetS

(r = 0.78, p < 0.01) using ethnic group specific cutoffs for WC of ≥80 cm for females and ≥94

cm for males (Gierach et al., 2014). In another study among healthy adults from Nigeria (20-

27 years), BMI was significantly correlated with WC (r=0.63), body weight (r=0.76) and

height (r= -0.31) in them (p<0.01). This association between BMI and WC and its

effectiveness in determining DM has also been highlighted in a meta-analysis based on

published studies from 1966 to 2004 (Vazquez et al., 2007). Clinically, central obesity as

measured by WC is known to generate diabetogenic substances and both BMI and WC have

been observed to be associated with DM (Vazquez et al, 2007).

3.6 Hemoglobin level

Hemoglobin was also measured for the BPO employees both at the calling as well as

managerial level using the Cyanmethemoglobin technique and they were classified

according to their hemoglobin levels as non-anemic or anemic (WHO, 1968). This was

estimated in the group to check the prevalence of anemia in the group, as anemia is a

common health problem especially among women in our country (NFHS-3). In male and

female employees, the mean hemoglobin levels were 14.96±1.14 g/dl and 12.37±1.32 g/dl,

respectively. Majority of males (96.0%) and more than two-thirds (68.1%) of female

employees had hemoglobin in the normal range. Nearly one third of females (31.9%) were

anemic whereas very few of the male employees (4.0%) were anemic (Table 20). Of those

anemic, majority had mild or moderate anemia. In case of managers, the mean hemoglobin

levels were 14.58±1.11 g/dl for males and 12.86±1.31 g/dl for females. Among the

managers, all the female employees were non-anemic, while among the males only three

were anemic of the mild and moderate level.

Table 20: Hemoglobin levels of calling and managerial level BPO employees

Hemoglobin (g/dl)* Calling level Managerial level

Males (n=274)

Females (n=141)

Males (n=54)

Females (n=7)

Healthy (M ≥13 ; F ≥12) 263(96.0) 96(68.1) 51(94.4) 7(100.0) Mildly anemic (M 11-12.9 ; F 11-11.9) 10(3.6) 29(20.6) 2(3.7) 0(0) Moderately anemic (M/F 8-10.9) 1(0.4) 15(10.6) 1(1.8) 0(0) Severely anemic (M/F <8) 0(0.0) 1(0.7) 0(0) 0(0) *WHO classification of anemia, 1968 Figures in parentheses represent percentages; M – Male; F- Female

http://www.hindawi.com/76078480/

In a study among North Indian adults (20-50 years), the prevalence of anemia was higher

among lower socio-economic groups with sedentary lifestyle (Verma et al., 2012).

Prevalence of anemia was also higher among females in the age group of 20-29 years

(29.32%) as compared to males in the same age group (19.53%) (Verma et al., 2012). In the

present study also, anemia prevalence was higher among the females as compared to male

employees.

3.7 High sensitive C Reactive Protein (hsCRP) level

High sensitive C Reactive Protein (hsCRP) is an inflammatory biomarker that has the ability

to detect elevated cardiovascular risk early in life (Ridker, 2016). It can be critical for primary

prevention of CVD. Adipose tissue, being the major source of inflammatory cytokines and

inflammation, plays a causal role in progression of insulin resistance to DM (Donath and

Shoelson, 2011). High sensitive C Reactive Protein relates to the components of MetS and

thus can predict cardiovascular risk especially among those with insulin resistance (Sattar et

al, 2003; Pradhan et al, 2001). In the present study, hsCRP was assessed among all the BPO

employees included in the study sample. The mean hsCRP level of the calling level

employees was 2.27±2.37 mg/dl. Females had higher mean values of hsCRP as compared to

male employees, although these differences were not statistically significant (Table 21).

Table 21: Comparison of hsCRP levels among calling and managerial level BPO employees

Calling

level

Total

Mean±SD

(n=415)

Males

Mean±SD

(n=274)

Females

Mean±SD

(n=141)

t value p value 95% CI

hsCRP (mg/dl)

2.27±2.37 2.25±2.30 2.32±2.52 0.273 0.785 -0.07,0.25

Managerial

level

Total

Mean±SD

(n=61)

Males

Mean±SD

(n=54)

Females

Mean±SD

(n=7)


hsCRP (mg/dl)

2.67±1.88 2.75±1.93 2.06±1.34 0.273 0.914 -0.82,2.20

At the managerial level, the mean hsCRP level of the employees was 2.67±1.88 mg/dl.

Among them, males had higher mean values of hsCRP as compared to females, though

these differences were not significant (Table 21). The differences in hsCRP levels between

calling and managerial level employees were also not statistically significant (t=1.26;

p=0.208).

The BPO employees were categorized according to the risk levels of hsCRP. Those with

values <1mg/dl had low risk; 1-3 mg/dl had average risk; 3-10mg/dl high risk; and >10mg/dl

were at highest risk of persistent inflammation (American Heart Association and US Center

for Disease Control, 2001). According to this classification, more than one fourth of the

calling level employees (27.7%) were categorized as having high/highest risk of persistent

inflammation (Table 22). The genderwise distribution of the employees was similar across

the hsCRP risk categories.

Table 22: Distribution of calling level BPO employees according to hsCRP risk categories

hsCRP risk level Total (n=415) Males (n=274) Females (n=141)

Low (<1mg/dl) 166(40.0) 104(38.0) 62(44.0) Average (1.0-3.0mg/dl) 134(32.3) 95(34.7) 39(27.7) High (3.0-10.0mg/dl) 103(24.8) 68(24.8) 35(24.8) Highest (>10.0mg/dl) 12(2.9) 7(2.6) 5(3.5) American Heart Association and US Centers for Disease Control, 2001 Figures in parentheses are percentages

The managerial level employees were also categorized according to the risk levels of hsCRP.

According to the classification, more than one third of male managers (37.7%) and more

than one fourth of female managers (28.6%) fell into the high/highest risk categories (Table

23).

Table 23: Distribution of managerial level BPO employees according to hsCRP risk

categories

hsCRP risk level Total (n=61) Males (n=54) Females (n=7)

Low (<1mg/dl) 7(11.5) 6(11.1) 1(14.3) Average (1.0-3.0mg/dl) 31(50.8) 27(50.0) 4(57.1) High (3.0-10.0mg/dl) 22(36.1) 20(37.0) 2(28.6) Highest (>10.0mg/dl) 1(1.6) 1(1.9) -- American Heart Association and US Centers for Disease Control, 2001 Figures in parentheses are percentages

Among the calling level employees with MetS (ATPIII criteria) less than one third (28.6%)

were categorized in the low risk category while the corresponding figure for employees

without MetS was 41.5% (Table 24). However, the association between hsCRP risk levels and

status of MetS (ATPIII) was not statistically significant among these employees (p=0.143).

Table 24: Distribution of calling level BPO employees according to hsCRP risk levels and

Metabolic Syndrome (ATPIII and IDF criteria) hsCRP risk

level

ATPIII criteria ᵡ2 p

value

IDF criteria ᵡ2 p

value With

MetS

Without

MetS

With

MetS

Without

MetS

Low

(<1mg/dl)

14(28.6) 152(41.5) 5.423 0.143 19(25.0) 147(43.4) 16.276 0.001*

Average (1.0-

3.0mg/dl)

20(40.8) 114(31.1) 27(35.5) 107(31.6)

High (3.0-

10.0mg/dl)

15(30.6) 88(24.0) 30(39.5) 73(21.5)

Highest

(>10.0mg/dl)

-- 12(3.3) -- 12(3.5)

According to the IDF criteria, a significant association was observed between hsCRP risk

levels and MetS status of the calling level employees (ᵡ2 = 16.276, p=0.001) (Table 24). Among

those with MetS, significantly higher proportion of the employees (39.5%) had hsCRP levels

corresponding to high risk of inflammation compared to those without the syndrome

(25.0%).

Nearly two-thirds of the managerial level employees (61.5%) with MetS (ATPIII) had hsCRP

levels indicative of high risk (>3mg/dl) compared with one third of those without the

syndrome (31.3%) (Table 25).

Table 25: Distribution of managerial level BPO employees according to hsCRP risk levels

and Metabolic Syndrome (ATPIII and IDF criteria) hsCRP risk level ATPIII criteria ᵡ2 p

value

IDF criteria ᵡ2 p

value With

MetS

Without

MetS

With

MetS

Without

MetS

Low (<1mg/dl) 1(7.7) 6(12.5) 4.756 0.191 1(5.3) 6(14.3) 3.893 0.273 Average (1.0-

3.0mg/dl)

4(30.8) 27(56.2) 8(42.1) 23(74.2)

High (3.0-

10.0mg/dl)

8(61.5) 14(29.2) 10(52.6) 12(54.5)

Highest

(>10.0mg/dl)

0(0) 1(2.1) -- 1(2.4)

According to the IDF criteria, 52.6% of the managers with MetS had high risk of persistent

inflammation as compared to 56.9% of those without the syndrome (Table 25). However,

the association of MetS with hsCRP risk levels among these employees was not observed to

be statistically significant.

Among the calling level employees, mean hsCRP values of those with the syndrome were

higher as compared to those without it. However, this difference was not statistically

significant (ATPIII p=0.942; IDF p=0.102), (Table 26).

Table 26: Comparison between hsCRP levels of calling level employees according to

Metabolic Syndrome diagnosis

MetS criteria MetS diagnosis hsCRP

(mg/dl)


ATPIII Present(Mean±SD) 2.30±1.89 0.073 0.942 -0.74,0.68

Absent (Mean±SD) 2.27±2.43

IDF Present(Mean±SD) 2.68±2.07 1.639 0.102 -1.08,0.09


Among the managerial level employees, comparison of hsCRP values between those who

had MetS and those who did not have the syndrome yielded similar results (Table 27).

Table 27: Comparison between hsCRP levels of managerial level employees according to

Metabolic Syndrome diagnosis

MetS criteria MetS diagnosis hsCRP

(mg/dl)


ATPIII Present(Mean±SD) 3.43±1.77 1.673 0.100 -2.13,0.19


IDF Present(Mean±SD) 3.14±1.69 1.332 0.188 -1.72,0.35


As the number of MetS components in the abnormal range increased, the mean hsCRP

values increased significantly according to both ATPIII (p=0.025) and IDF criteria (p=0.001)

among the calling level BPO employees (Table 28a and b).

Table 28a: Comparison between hsCRP levels of calling level employees categorized

according to number of Metabolic Syndrome (ATPIII) components in abnormal range

No: of

components#

Number of

employees

hsCRP

Mean(mg/dl)

SD 95% CI for

the mean

F value p value

0 114 1.77 1.90 1.42,2.13 3.717 0.025* 1-2 252 2.50 2.60 2.17,2.82 ≥ 3 49 3.62 1.88 2.92, 3.40 #Number of components of Metabolic Syndrome in abnormal range

Table 28b: Comparison between hsCRP levels of calling level employees categorized

according to number of Metabolic Syndrome (IDF) components in abnormal range

No: of

components#

Number of

employees

hsCRP

Mean(mg/dl)

SD 95% CI for

the mean

F value p value

0 66 1.29 1.73 0.87,1.72 7.356 0.001* 1-2 273 2.39 2.52 2.10,2.70 ≥ 3 76 2.67 2.08 2.20,3.15 #Number of components of Metabolic Syndrome in abnormal range

Though similar trend was observed among the managerial level employees, it did not reach

statistical significance (Table 29a and b). This could be attributed to smaller sample size in

case of managers.

Table 29a: Comparison between hsCRP levels of managerial level employees categorized

according to number of Metabolic Syndrome (ATPIII) components in abnormal range

No: of components#

Number of employees

hsCRP Mean±SD (mg/dl)

95% CI for the mean

F value p value

0 12 2.10±2.06 0.79,3.41 4.925 0.234 1-2 36 3.34±2.08 1.70,3.79 ≥ 3 13 3.46±1.85 2.25,4.60 #Number of components of Metabolic Syndrome in abnormal range

Table 29b: Comparison between hsCRP levels of managerial level employees categorized

according to number of Metabolic Syndrome (IDF) components in abnormal range

No: of components#

Number of employees


95% CI for the mean

F value p value

0 6 1.70±2.22 -0.62,4.03 1.250 0.299 1-2 36 2.55±1.85 1.63,3.47 ≥ 3 19 4.08±1.78 1.29,4.86 #Number of components of Metabolic Syndrome in abnormal range

High sensitive C Reactive Protein (hsCRP) is a stable biomarker that can accurately diagnose

systemic inflammation and predict CVD risk (Baumeister et al, 2010; Ockene et al, 2001). In

a study by Nyandak et al (2007), it was observed that hsCRP was associated with

inflammation and was much higher in patients of coronary artery disease as compared to

those who had normal angiograms (p=0.003). The study included 48 patients diagnosed with

heart condition and 15 were controls in a hospital of New Delhi.

Table 30: Comparison of hs-CRP levels between employees working at the calling level

with and without various components of metabolic syndrome

Metabolic syndrome component



SBP <130mm/Hg ≥130mm/Hg

2.368±2.47 1.967±2.27

1.440

0.152

-0.15,0.94

DBP <85mm/Hg ≥85mm/Hg

2.267±2.38 2.374±2.72

0.321

0.748

-0.76,0.55

TG <150mg/dl ≥150mg/dl

2.279±2.38 2.294±2.59

0.056

0.956

-0.54,0.51

FBG (ATPIII) <110mg/dl ≥110mg/dl

2.259±2.41 3.634±3.33

1.486

0.138

-3.19,0.45

FBG (IDF) <100mg/dl ≥100mg/dl

2.294±2.43 2.068±2.52

0.406

0.685

-0.87,1.32

WC (ATPIII) M<102cm,F<88cm M≥102cm, F≥88cm

2.323±2.46 2.078±2.31

0.754

0.451

-0.39,0.88

WC (IDF) M<90cm,F<80cm M≥90cm, F≥80cm

2.172±2.42 2.362±2.44

0.781

0.435

-0.67,0.29

HDL M<40mg/dl, F<50mg/dl M≥40mg/dl, F≥50mg/dl

2.194±2.43 2.366±2.43

0.718

0.473

-0.64,0.29

Table 31: Comparison of hs-CRP levels between employees working at the managerial

level with and without various components of metabolic syndrome

Metabolic syndrome

component

hsCRP

Mean±SD (mg/dl)


SBP <130mm/Hg ≥130mm/Hg

2.689±1.89 2.382±1.85

0.571

0.570

-0.76,1.37

DBP <85mm/Hg ≥85mm/Hg

2.450±1.58 2.942±2.39

0.952

0.345

-1.53,0.54

TG <150mg/dl ≥150mg/dl

2.241±1.44 3.246±2.35

2.072

0.043*

-1.97,-0.03

FBG (ATPIII)

<110mg/dl ≥110mg/dl

2.578±1.87 4.100±1.00

0.806

0.424

-5.30,2.25

FBG (IDF) <100mg/dl ≥100mg/dl

2.507±1.84 4.467±1.48

1.805 0.076 -4.13,0.21

WC (ATPIII) M<102cm,F<88cm M≥102cm, F≥88cm

2.556±1.62 2.737±2.49

0.332

0.741

-1.27,0.91

WC (IDF) M<90cm,F<80cm M≥90cm, F≥80cm

1.940±1.53 2.820±1.93

1.605

0.114

-1.97,0.22

HDL M<40mg/dl, F<50mg/dl M≥40mg/dl, F≥50mg/dl

2.497±1.96 2.767±1.74

0.547

0.586

-1.25,0.72


In the present study, when hsCRP levels were compared between those with and without

various components of MetS in the abnormal range, it was observed that in case of

managerial level employees those with ≥150mg/dl triglycerides level had significantly higher

values of hsCRP as compared to those with TG levels below 150 md/dl. For none of the

other components the hsCRP levels were significantly different for both calling as well as

managerial level employees (table 30 and 31).

Nevertheless, results of the present study demonstrated that as the number of components

of MetS (IDF criteria) in the abnormal range increased among calling level BPO employees,

the mean hsCRP levels also increased significantly. These findings are similar to a study by

conducted by Bo et al (2005) among 1877 patients of 45-64 years residing in Italy who were

enrolled for metabolic screening. It was reported that there was a gradual but significant

increase in the values of hsCRP (p=0.001) with increase in number of metabolic

abnormalities. Another prospective study including 91 diagnosed MetS patients of a tertiary

care center in South India, also corroborated these findings (Vidyasagar et al, 2013). While

18.3% of the calling BPO employees in the present study had MetS, nearly one third (27.7%)

of them hsCRP levels corresponding to high risk, thus, probably indicating that hsCRP could

be an early marker for MetS.

3.8 Association of socio-demographic, anthropometric and biochemical measures with

Metabolic Syndrome

At the calling level, males had twice the risk of developing the syndrome (p=0.040). Those

having income more than 20,000 INR per month and age of more than 25 years had 2.5

times risk of having MetS (p<0.05). Body mass index less than 23 kg/m2 was protective

among the calling level employees. None of these associations were significant at the

managerial level.

Table 32: Association of socio-demographic, anthropometric and biochemical measures

with Metabolic Syndrome among calling and managerial level employees

Measures

Calling level

ATPIII IDF

Wald’s statistic

p value Odds ratio

Wald’s statistic

p value Odds ratio

Sex (Male) 4.227 0.040* 2.249 3.545 0.060 1.999 Income (>20000INR) 4.171 0.041* 2.550 3.988 0.046* 3.609 Age (>25 years) 5.253 0.022* 2.409 0.170 0.680 1.150 BMI (<23 kg/m2) 8.860 0.003* 0.048 14.071 0.000* 0.191 hsCRP (>3mg/dl) 1.637 0.201 0.912 0.675 0.411 0.958

Measures

Managerial level

ATPIII IDF

Wald’s statistic

p value Odds ratio

Wald’s statistic

p value Odds ratio

Sex (Male) 1.916 0.166 1.123 0.559 0.455 0.392 Income (>20000INR) 2.867 0.090 3.729 2.251 0.134 2.171 Age (>25 years) 0.935 0.334 0.790 2.345 0.126 0.739 BMI (<23 kg/m2) 1.412 0.121 0.780 1.089 0.221 0.815 hsCRP 1.007 0.316 1.173 2.367 0.124 1.263 *Significant at p<0.05

Key Findings

x Two thirds of the calling level employees (n=415) working in the BPO industry across Delhi NCR included in the study sample were amle while the rest were females. At the managerial level, majority were males (n=54).

x Prevalence of MetS was 11.8% according to the ATPIII criteria and 18.3% according to the IDF criteria among the employees at calling level. At the managerial level, prevalence of MetS was 21.3% according to ATPIII criteria and 31.1% according to IDF criteria. The prevalence was significantly higher in the male employees (p<0.05) both at calling as well as managerial level.

x As the number of diagnostic components of MetS in the abnormal range increased, there was a progressive derangement of the metabolic profile as reflected by increase in the level of WC and triglycerides and decreased in the levels of HDL of both calling and managerial level employees.

x At both calling and managerial level, the mean hsCRP levels were more than 27.7% for calling level employees and 37.7% for managerial level employees who were categorized in high/higher risk categories for persistent inflammation based on hsCRP levels.

x As the number of components of MetS (IDF criteria) in the abnormal range increased among calling and managerial level BPO employees, the mean hsCRP levels also increased significantly (Calling level p=0.025; managerial level p=0.001).

3.9 Risk factors for Metabolic Syndrome

Metabolic Syndrome (MetS) like all NCDs has four major risk factors – unhealthy diet,

harmful use of alcohol and tobacco products and physical inactivity, along with family

history. Further, psychosocial stress is being increasingly recognized for its role as one of the

precipitating factors. Each of these factors was assessed and is described in detail in the

light of findings of the present study.

3.9.1 Family medical history

Metabolic Syndrome (MetS) is also an outcome of strong interplay of gene-environment

interactions, wherein, certain components are affected more by genetics and others by

environment. However, it is difficult to point out the exact mechanism (Zabaneh and

Balding, 2010). Family medical history of chronic diseases such as DM, CVD and

hypertension is an important factor that has a relationship with MetS (Lee et al., 2005). To

ascertain the same, questions pertaining to family medical history were asked from

employees working at the calling and managerial levels. Nearly two thirds of them (65.3%)

working at the calling level had medical history in the family for DM, high blood pressure,

heart disease or thyroid disorders. Almost 40% reported history of DM and high blood

pressure, and one-seventh had family history of heart disease (14.5%) and thyroid disorders

(14.7%) (Table 33). Among them, female employees reported family history of diabetes and

thyroid disorders in their family significantly higher in comparison to male employees.

However, there was no association between gender of employees and presence of family

medical history of the chronic diseases.

Table 33: Family medical history of calling level BPO employees

Characteristic Total (n=415) Males (n=274)

Females (n=141)

ᵡ2 p value

Family medical history presenta 271(65.3) 173(63.1) 98(69.5) 1.664 0.197 History of diabetes 174(41.9) 109(39.8) 65(46.1) 1.526 0.217 History of high blood pressure 154(37.1) 89(32.5) 65(46.1) 7.397 0.007* History of heart disease 60(14.5) 36(3.1) 24(17.0) 1.135 0.287 History of thyroid disorders 61(14.7) 26(9.5) 35(24.8) 19.651 0.000* Figures in parentheses represent percentages * Significant at p<0.05 a These include diabetes, high blood pressure, heart disease and thyroid disorders

Among the managerial level employees, nearly sixty percent of them had positive family

medical history in the family for DM, high blood pressure, heart disease or thyroid disorders.

Almost 40% reported family history of diabetes and more than one fourth (27.9%) for high

blood pressure. However, in case of managerial level employees also, no association was

observed between gender and presence of family medical history of these disorders (Table

34).

Table 34: Family medical history of managerial level BPO employees

Total (n=61)

Males (n=54)

Females (n=7)

ᵡ2 p value

Family medical history presenta 36(59.0) 28(51.9) 3(42.9) 0.789 0.411 History of diabetes 25(41.0) 23(42.6) 2(28.6) 0.504 0.478 History of high blood pressure 17(27.9) 16(29.6) 1(14.3) 0.726 0.394 History of heart disease 7(11.5) 6(11.1) 1(14.3) 0.061 0.804 History of thyroid disorders 8(13.1) 8(14.8) 0(0) 1.194 0.275 Figures in parentheses represent percentages a These include diabetes, high blood pressure, heart disease and thyroid disorders In case of positive family medical history, employees were also asked to report their

relationship with the concerned family member (Table 35 and 36). Majority working at the

calling level reported that their parents had family history of one or more of the above

mentioned disorders (97.8%). A higher proportion of female employees reported family

history for DM, heart disease, high blood pressure and/or thyroid disorders for their siblings

and grandparents on both paternal and maternal side, than their male counterparts (Table

35). Also among managers, more than three fourths of them (78.7%) reported that their

parents had family history of one or more of the above mentioned disorders. However, no

significant association was observed between gender of employees and relation with family

history of these disorders (Table 36).

Table 35: Relatives of calling level BPO employees with medical history of diabetes and/or

heart disease and/or high blood pressure and/or thyroid disorder

Relationship with employee Total (n=415)

Males (n=274)

Females (n=141)

ᵡ2 p value

Father 271(65.3) 98(35.8) 56(39.7) 0.622 0.430 Mother 135(32.5) 84(30.7) 51(36.2) 1.289 0.256 Siblings 21(5.1) 9(3.3) 12(8.5) 5.292 0.021* Mother’s father 20(4.8) 10(3.6) 10(7.1) 2.405 0.121 Mother’s mother 14(3.4) 3(1.1) 11(7.8) 12.845 0.000*

Father’s father 25(6.0) 9(3.3) 16(11.3) 10.690 0.001* Father’s mother 21(5.1) 11(4.0) 10(7.1) 1.835 0.175 Mother’s brother 14(3.4) 9(3.3) 5(3.5) 0.020 0.889 Mother’s sister 13(3.1) 6(2.2) 7(5.0) 2.362 0.124 Father’s brother 21(5.1) 17(6.2) 4(2.8) 2.197 0.138 Father’s sister 18(4.3) 10(3.6) 8(5.7) 0.919 0.338 Figures in parentheses represent percentages * Significant at p<0.05

Table 36: Relatives of managerial level BPO employees with medical history of diabetes

and/or heart disease and/or high blood pressure and/or thyroid disorder

Relationship with employee Total (n=61) Males (n=54)

Females (n=7)

ᵡ2 p value

Father 27(44.3) 24 3 0.006 0.937 Mother 21(34.4) 20 1 1.421 0.233 Siblings 7(11.5) 6 1 0.061 0.804 Mother’s father 1(1.6) 1 0 0.132 0.717 Mother’s mother 2(3.3) 2 0 0.268 0.605 Father’s father 4(6.6) 4 0 0.555 0.456 Father’s mother 2(3.3) 2 0 0.268 0.605 Father’s brother 3(4.9) 3 0 0.409 0.522 Father’s sister 2(3.3) 2 0 0.268 0.605 Figures in parentheses represent percentages 3.9.1.1 Association of family medical history with Metabolic Syndrome

Those with presence of family medical history had twice the risk of developing MetS at the

calling level (OR 2.3) but the association was not significant at the managerial level

(p=0.562). Presence of heart disease and/or hypertension and/or thyroid disorders and/or

diabetes in paternal grandfather had three times (OR 2.95) the risk of MetS among the

calling level employees.

Table 37: Association of family medical history with Metabolic Syndrome among calling

and managerial level employees Family medical history

Calling level

ATPIII IDF

Wald’s statistic

p value Odds ratio

Wald’s statistic

p value Odds ratio

x Family medical history (present)

0.193 0.661 0.787 4.246 0.039* 2.391

x Family medical history (paternal grandfather)

0.001 0.977 1.018 4.956 0.026* 2.957

Family medical history

Managerial level

ATPIII IDF

Wald’s statistic

p value Odds ratio

Wald’s statistic

p value Odds ratio

x Family medical history (present)

0.982 0.442 1.231 0.834 0.562 1.387

x Family medical history (paternal grandfather)

-- -- -- -- -- --


3.9.2 Alcohol consumption

Every year, alcohol consumption is responsible for 3.3 million deaths worldwide and more

than half of them can be attributed to NCDs (Lim et al., 2012). Being a potential modifiable

risk factor for MetS, alcohol consumption was determined in the present study among the

BPO employees working at the calling as well as at the managerial level in past one year as

well as past 30 days (for reliable recall of consumption). More than half of the employees

(51.6%) working at the calling level had consumed alcohol in the past one year, and nearly

half (44.3%) had consumed it in past 30 days. Out of the total alcohol consumers who had

consumed alcohol (n=214) in the past one year, one-tenth (11.2%) consumed it 1-4 days in a

week, one-third (33.6%) consumed it 1-3 days in a month and more than half (53.3%)

consumed it less than once a month. Regarding the alcohol consumption during past 30

days (n=184), nearly half of the employees (44.3%) consumed it. One sixth (16.3%) of them

consumed it 1-4 days in a week, nearly 40% consumed it 1-3 days in a month and nearly half

(42.9%) consumed it less than once in a month. Significantly higher proportion of the male

employees consumed alcohol during past one year (p=0.000) as well as during past 30 days

as compared to female employees (p=0.000) (Table 38).

Table 38: Frequency of alcohol consumption in calling level BPO employees

Pooleda (n=415)

Malesa

(n=274) Femalesa

(n=141) ᵡ2 p value

Past 1 yearb 214(51.6) 168(61.3) 46(32.6) 30.68 0.000*

Key findings

x More than half of the employees at the calling level had positive family history for DM, high blood pressure, heart disease and thyroid disorder.

x Nearly sixty percent of managerial level employees had positive family medical history for DM, high blood pressure, heart disease or thyroid disorders.

x Presence of positive family medical history of DM/thyroid disorders/hypertension/heart disease or paternal family history (grandfather) were significantly associated with MetS among calling level employees (p=0.039). However, these associations were not significant among managerial level employees (p=0.562).

x Daily x 5-6 days a week x 1-4 days a week x 1-3 days per month x Less than once a month

1(0.5) 3(1.4) 24(11.2) 72(33.6) 114(53.3)

0(0.0) 3(1.8) 22(13.1) 61(36.3) 82(48.8)

1(2.2) 0(0.0) 2(4.3) 11(23.9) 32(69.6)

0.030 0.863

Past 30 daysb 184(44.3) 146(53.3) 38(27.0) 26.16 0.000* x Daily x 5-6 days a week x 1-4 days a week x 1-3 days per month x Less than once a month

1(0.5) 3(1.6) 30(16.3) 72(39.1) 79(42.9)

0(0.0) 3(1.4) 27(18.5) 61(41.8) 56(38.4)

1(2.6) 0(0.0) 3(7.9) 11(28.9) 23(60.5)

0.050 0.823

Figures in parentheses represent percentages * Significant at p<0.05 a Total number of employees (consumers as well as non-consumers); b Alcohol consumers

Among the managerial level employees, more than half of them had consumed alcohol in

past 1 year (60.7%) and past 30 days (54.1%). Out of the total alcohol consumers who had

consumed alcohol (n=37) in the past one year, nearly half of them (45.9%) consumed it less

than a month, while forty percent consumed it 1-3 days per month. Regarding the past 30

days consumption, , nearly half of them (45.9%) consumed it less than a month, while more

than forty percent consumed it 1-3 days per month. However, in case of managers, there

was no association between gender and consumption of alcohol for past 1 year and past 30

days (Table 39).

Table 39: Frequency of alcohol consumption in managerial level BPO employees

Pooleda (n=61)

Malesa

(n=54) Femalesa

(n=7) ᵡ2 p value

Past 1 yearb 37(60.7) 32(59.3) 5(71.4) 0.385 0.535


0(0) 2(5.4) 3(8.1) 15(40.5) 17(45.9)

0(0) 2(6.3) 3(9.4) 11(34.4) 16(50.0)

0(0) 0(0) 0(0) 4(80.0) 1(20.0)

0.330 0.565

Past 30 daysb


33(54.1) 0(0) 1(3.0) 3(9.1) 14(42.4) 15(45.5)

28(51.9) 0(0) 1(3.6) 3(10.7) 10(35.7) 14(50.0)

5(71.4) 0(0) 0(0) 0(0) 4(80.0) 1(20.0)

0.956 0.184

0.328 0.668

Figures in parentheses represent percentages a Total number of employees (consumers as well as non-consumers); b Alcohol consumers

3.9.2.1 Type of alcohol consumed and drinking pattern of the employees

There are various types of alcoholic beverages which are available and consumed in India. In

the present study, among the calling level BPO employees consuming alcohol (n=214), beer

was the most popular beverage (39.3%), followed by whisky (27.0%), vodka (21.0%) and rum

(13.5%). Few of them (11.1%) also opted for wine, gin and breezer. Alcoholic beverage

consumed most commonly by male employees was beer (50.0%), whereas among females it

was vodka (22.7%). Moreover, significantly higher proportion of males consumed beer,

whisky and rum than the females (ᵡ2 = 9.845; p=0.043) (Fig 17a). Among the managers (fig

17b), beer (42.6%) was the most popular beverage among the males as well as females

(71.4%) followed by whisky (33.3% and 42.9%).

39.3

27 21

13.5 8.9

1.2 1

50

37.2

20.1 17.9

10.2

1.5 0.7

18.4

7.1

22.7

5 6.4

0.7 1.4

0

10

20

30

40

50

60

Beer Whisky Vodka Rum Wine Gin Breezer

Percent

Figure 17a: Type of alcoholic beveragea consumption gender-wise in calling level BPO employees (n=214)

Total Males Females

aMultiple responses

3.9.2.2 Alcohol consumption with meals

Consumption of alcohol with meals has been shown to modify food intake (Yeomans et al,

2004). In a review on the mechanism of effect of alcohol on food intake, the authors

explained that alcohol consumption suppresses fatty acid oxidation, increases

thermogenesis (short-term) and affect various neurochemical and peripheral systems

related to appetite control; resulting in an overall increase in appetite, even to the extent of

overeating (Yeomans et al., 2004). In the present study, among the alcohol consuming

employees (n=214) at the calling level, more than half (55.1%) were consuming alcohol

usually with meals, whereas, one-fifth of them (20.1%) never consumed it with meals during

past 30 days (Table 23). Higher proportion of males (72.7%) at the calling level were

consuming alcohol with meals (usually/sometimes) in comparison to females (63.1%),

however, these differences were not significant (p= 0.296)(Table 40). Among the managers,

nearly half (48.9) were consuming alcohol usually with meals and more than one fourth

(27.0%) were consuming it sometimes with meals (Table 41). However, there was no

significant association between gender and alcohol consumption with meals among the

managers. Thus, alcohol consumption with meals was a common practice among

significantly higher proportion of BPO employees at the calling level (ᵡ2 = 36.187; p=0.000) as

well as managerial level (ᵡ2 =9.757; p=0.002).

45.9

34.4

18

14.8

8.2

1.6

42.6

33.3

16.7 14.8

9.3

1.9

71.4

42.9

28.6

14.3

0 0 0

10

20

30

40

50

60

70

80

Beer Whisky Vodka Rum Wine Gin

P

e

r

c

e

n

t

Figure 17b: Type of alcoholic beveragea comsumption genderwise

among managerial level employees (n=37)

Total Males Females

aMultiple

responses

Table 40: Alcohol consumption with meals during past 30 days in calling level BPO

employees Total (n=214) Males

(n=168) Females (n=46)

ᵡ2 p value

Usually with meals 118(55.1) 93(55.4) 25(54.4) 3.697 0.296 Sometimes with meals 33(15.4) 29(17.3) 4(8.7) Rarely with meals 20(9.4) 16(9.5) 4(8.7) Never with meals 43(20.1) 30(17.9) 13(28.3) Figures in parentheses represent percentages

Table 41: Alcohol consumption with meals during past 30 days in managerial level BPO

employees Total (n=37) Males


ᵡ2 p value

Usually with meals 18(48.6) 14(43.8) 4(80.0) 1.550 0.956 Sometimes with meals 10(27.0) 10(31.3) 1(20.0) Rarely with meals 2(5.4) 5(15.6) 0(0) Never with meals 7(18.9) 3(9.4) 0(0) Figures in parentheses represent percentages

3.9.2.3 Association of alcohol consumption with Metabolic Syndrome

Alcohol consumption during past 1 year and past 30 days as well as occasional drinking was

not associated with MetS both at the calling as well as the managerial level.

Table 42: Association of alcohol consumption with Metabolic Syndrome among calling and

managerial level employees

Alcohol consumption

Calling level

ATPIII IDF

Wald’s statistic

p value Odds

ratio Wald’s statistic

p value Odds

ratio

x Past 1 year 0.561 0.454 1.559 .017 0.896 0.928 x Past 30 days 0.169 0.681 0.765 0.147 0.701 1.270 x Occasional drinking 0.029 0.864 0.900 0.365 0.546 0.717 Alcohol consumption

Managerial level

ATPIII IDF Wald’s statistic

p value Odds

ratio Wald’s statistic

p value Odds

ratio

x Past 1 year 0.062 0.803 1.568 0.306 0.580 2.269 x Past 30 days 0.430 0.512 0.280 0.744 0.388 0.272 x Occasional drinking 0.447 0.504 0.334 0.008 0.930 0.903

3.9.3 Tobacco usage

Tobacco usage is one of the major risk factors for MetS and NCDs (Balhara, 2012; Wilsgaard

and Jacobsen, 2007; Miyatake et al., 2006; www.ncdalliance.org; www.who.int). Various

studies have demonstrated the association between MetS and tobacco smoking (Ronnemaa

et al., 1996; Facchini et al., 1992). Smokers have a higher risk of becoming insulin resistant,

therefore, smoking can be considered as a modifiable risk factor for MetS (Mozaffarian et al,

2016; Pagani et al, 2015; Ronnemaa et al., 1996; Facchini et al., 1992). In the present study,

tobacco usage pattern was ascertained among all the BPO employees working at the calling

as well at the managerial level.

3.9.3.1 Current and past smoking pattern and use of smokeless tobacco

The current smoking pattern was assessed by asking the employees whether they currently

smoked any tobacco products, such as cigarettes, cigars or pipes (Table 43). Among those at

the calling level, nearly one fourth (23.9%) smoked currently, of which majority (89.5%)

smoked daily. Current and daily use of tobacco was seen in significantly higher proportion of

males (32.5% and 29.6%) as compared to females (7.1% and 5.7%) (p<0.05). Usage of

smokeless tobacco products such as guthka, pan and pan masala was also ascertained

among the employees. Very few of them opted for smokeless tobacco currently (6.3%) and

daily (5.1%). Significantly higher proportion of males were current and daily users (8.8% and

6.9%) of smokeless tobacco as compared to females (1.4% and 1.4%) (p<0.05). One sixth

(15.2%) of the employees smoked daily in the past and only a handful (5.3%) reported use of

smokeless tobacco in the past. Past use of tobacco (smoke and smokeless forms) was also

observed in significantly higher proportion of males as compared to females (p<0.05).

Overall, use of any form of tobacco was higher among male employees.

Key findings

x Alcohol consumption during past 1 year and past 30 days was reported by significantly higher proportion of men at the calling level (p=0.000). No such association of gender with alcohol consumption was observed among managerial level employees (p=0.535).

x Beer was the most popular alcoholic beverage among male employees at the calling level and male and female employees at the managerial level.

x Occasional drinking was significantly higher in individuals with MetS at the calling level (p=0.546) while no association was observed between occasional drinking and MetS at the managerial level (p=0.930).

http://www.ncdalliance.org/

http://www.who.int/

Table 43: Tobacco use (Current and past) among calling level BPO employees Total

(n=415) Males (n=274)

Females (n=141)

ᵡ2 p value

Current use of tobacco (smoke)

99(23.9) 89(32.5) 10(7.1) 33.037 0.000*

Daily use of tobacco (smoke) 89(21.4) 81(29.6) 8(5.7) 31.534 0.000* Current use of tobacco (smokelessa)

26(6.3) 24(8.8) 2(1.4) 8.542 0.003*

Daily use of tobacco (smokelessa)

21(5.1) 19(6.9) 2(1.4) 5.896 0.015*

Past use of tobacco daily (smoke)

63(15.2) 58(21.2) 5(3.5) 22.451 0.000*

Past use of tobacco (smokelessa)

22(5.3) 21(7.7) 1(0.7) 8.970 0.003*

Figures in parentheses represent percentages *Significant at p<0.05 a Smokeless tobacco included guthka, paan and paan masala Guthka: A mixture of betel quid with tobacco that is consumed by placing a pinch of the mixture in the mouth between the gum and cheek and gently sucking and chewing. Paan/paan masala: It is a preparation combining betel leaf with areca nut, lime, some spices/condiments and sometimes also with tobacco. Paan masala: It is a dehydrated version of the paan sold in packed form. Among the managerial level employees nearly one third of them smoked currently (32.8%)

and daily (32.8%). None of the female employees were using tobacco in any form. Very few

managers (6.6%) opted for use of smokeless tobacco products (Table 44).

Table 44: Tobacco use (Current and past) among managerial level BPO employees Total (n=61) Males (n=54) Females (n=7) Current use of tobacco (smoke) 20(32.8) 20(37.0) 0(0) Daily use of tobacco (smoke) 20(32.8) 20(37.0) 0(0) Current use of tobacco (smokelessa) 4(6.6) 4(7.4) 0(0) Daily use of tobacco (smokelessa) 4(6.6) 4(7.4) 0(0) Past use of tobacco daily (smoke)

15(24.6) 15(27.8) 0(0)

Past use of tobacco (smokelessa)

7(11.5) 7(13.0) 0(0)

Figures in parentheses represent percentages a Smokeless tobacco included guthka, paan and paan masala The mean age of starting smoking among the calling level employees was 20.42±3.11 years,

with males (20.21±3.14) starting to smoke significantly two years earlier than females

(22.10±2.30 years) (p<0.05) as depicted in table 45. Among the various forms of tobacco,

majority of them (97.8%) smoked manufactured cigarettes with one person each smoking

hand-rolled cigarettes (beedi) and hookah/cigar. Manufactured cigarettes’ usage ranged

from 1 to 15 cigarettes per day, with male smokers smoking an average of five cigarettes per

day as compared to four smoked by female smokers. Very few employees (5.1%) opted for

smokeless forms of tobacco, among which guthka was consumed more in comparison to

pan and pan masala on a daily basis (Table 45).

Table 45: Tobacco use among calling level BPO employees Total

Mean ±SD Males Mean ±SD

Females Mean ±SD


Age at first smoking (years)

20.42±3.11 20.21±3.14 22.10±2.30 2.446 0.027* -3.52,-0.24

Manufactured cigarettes smoked daily (n)

4.85±3.35 4.94±3.46 4.00±2.00 1.228 0.240 -0.70,2.59

Daily intake of guthka (number of packets)

3.14±2.85 3.25±3.02 2.50±2.12 0.432 0.712 -7.72,9.22

*Significant at p<0.05 Beedi and Cigar/hookah smoked each day could not be compared between males and females as there was only one individual smoking beedi daily and one individual smoking cigar/hookah daily. Paan/Paan masala consumption could not be compared between males and females as it was only being consumed by males (n=8). Beedi: A cigarette that is made from rolling loose tobacco in papers by hand and is often sold loose in bundles Guthka: A mixture of betel quid with tobacco that is consumed by placing a pinch of the mixture in the mouth between the gum and cheek and gently sucking and chewing. It ranges from 2-7 grams in weight/packet costing between rupees 2-5. Paan: It is a preparation combining fresh betel leaf with areca nut, lime, some spices/condiments and sometimes also with tobacco. Paan masala: It is a dehydrated version of the paan sold in packed form.

Table 46: Tobacco use among managerial level BPO employees Total

Mean ±SD Males Mean ±SD

Females Mean ±SD

Age at first smoking (years) 17.79±1.54 17.94±1.51 0

Manufactured cigarettes smoked daily (n)

1.80±3.88 2.04±4.07 0

Daily intake of guthka (no. of packets)

0.06±0.36 0.07±0.38 0

Among the managerial level male employees, the mean age of smoking was 17.79±1.54

years with an average of two cigarettes daily. However, the use of smokeless form of

tobacco was very less (Table 46). Tobacco use is an important risk factor for NCDs causing 1

in 6 of all NCD deaths worldwide both due to direct and indirect smoke as well as smokeless

forms of tobacco (WHO, 2010). It will account to 10 million deaths by 2020 (WHO, 2010).

Recently, the Indian government has also passed a regulation with effect from 1st April, 2015

which has made it mandatory for the tobacco companies to carry health warnings covering

at least 85% of the product regarding the ill-effects of tobacco. This has made India the

world leader in implementing plain packaging on the lines of advocacy by WHO (The

Economic Times, 2015). Though, it is a step in the right direction but more needs to be done

in terms of creating awareness and helping people quit smoking.

3.9.3.3 Association of tobacco usage with Metabolic Syndrome

Current use of tobacco in its smoked form had twice the risk (OR 2.3) of developing MetS

among the managerial level employees. No such associations were observed between use

of tobacco and MetS at the calling level.

Table 47: Association of tobacco usage with Metabolic Syndrome among calling and


Tobacco usage

Calling level

ATPIII IDF

Wald’s statistic

p value Odds

ratio

Wald’s statistic

p value Odds

ratio

x Current use (smoke) 0.008 0.929 1.100 0.244 0.622 1.591 x Daily use (smoke) 0.677 0.411 1.443 1.355 0.244 1.516

Tobacco usage

Managerial level

ATPIII IDF

Wald’s statistic

p value Odds

ratio

Wald’s statistic

p value Odds

ratio

x Current use (smoke) 4.317 0.038* 2.371 2.750 0.097 4.449 x Daily use (smoke) 3.146 0.051 2.101 2.178 0.214 2.368

Key findings

x One fifth of the employees at the calling level were regular tobacco smokers. One third (29.6%) of them were male employees.

x Among the managerial level employees nearly one third of them smoked tobacco currently and daily. None of the female managers reported use of tobacco in any form.

x Very few employees were using tobacco in its smokeless form at the calling (5.1%) and managerial level (6.6%).

x Current and daily smoking was most common among those with MetS at the calling level. Past smoking was most common among those with MetS at the managerial level.

x Current smoking was significantly associated (p=0.038) with MetS among managerial level employees.

x Males started smoking cigarettes significantly two years earlier than females. None of the female managers reported smoking.

x Those with MetS smoked more number of cigarettes at a time and had higher exposure to periods of passive smoking during a week among calling level employees. No such associations were observed at the managerial level.

3.9.4 Perceived Psychosocial Stress

Psychosocial stress is an understated risk factor for MetS (Rosengren et al, 2004). Sedentary

lifestyle, odd working hours coupled with strict work deadlines, are potential sources of

stress among young employees working in the business process outsourcing (BPO) sector.

Perceived stress levels were assessed among BPO employees on various parameters (Table

48). It was majorly divided into 4 categories namely – stress at work, stress at home, general

stress (both home and work) and financial stress. More than 90% of the employees

experienced stress at work; with women having more severe periods of stress and

permanent stress (34.0%) than men (26.3%). Stress at home and general stress (several

periods of stress and permanent stress) was also more among women (19.9% and 24.1%)

than men (13.9% and 19.0%). Financial stress of moderate to severe levels was perceived

more by men (54.0%) compared to women (47.5%).

Table 48: Distribution of various perceived stress related parameters among calling level

BPO employees

Total (n=415) Males (n=274) Females (n=141) Stress at work Never Some of the time Several periods Permanent

35(8.4) 260(62.7) 91(21.9) 29(7.0)

27(9.9) 175(63.9) 55(20.1) 17(6.2)

8(5.7) 85(60.3) 36(25.5) 12(8.5)

Stress at home Never Some of the time Several periods Permanent

87(21.0) 262(63.1) 49(11.8) 17(4.1)

63(23.0) 173(63.1) 31(11.3) 7(2.6)

24(17.0) 89(63.1) 18(12.8) 10(7.1)

Stress (at home and work) Never Some of the time Several periods Permanent

39(9.4) 290(69.9) 67(16.1) 19(4.6)

29(10.6) 193(70.4) 41(15.0) 11(4.0)

10(7.1) 97(68.8) 26(18.4) 8(5.7)

Financial stress Little or none Moderate High or severe

200(48.2) 182(43.9) 33(8.0)

126(46.0) 126(46.0) 22(8.0)

74(52.5) 56(39.7) 11(7.8)

Stressful life events None 1 2 or more

259(62.4) 104(25.1) 52(12.5)

170(62.0) 69(25.2) 35(12.8)

89(63.1) 35(24.8) 17(12.1)

Feeling depressed (past 1 year) Yes

294(70.8)

184(67.2)

110(78.0)

No 121(29.2) 90(32.8) 31(22.0) Depression (past 1 year) 0–1 items 2–4 items 5 or more items

213(51.3) 165(39.8) 37(8.9)

152(55.5) 103(37.6) 19(6.9)

61(43.3) 62(44.0) 18(12.8)

Feeling depressed (past 2 weeks) Yes No

144(34.7) 271(65.3)

92(33.6) 182(66.4)

52(36.9) 89(63.1)

Depression (past 2 weeks) 0–1 items 2–4 items 5 or more items

315(75.9) 74(17.8) 26(6.3)

212(77.4) 48(17.5) 14(5.1)

103(73.0) 26(18.4) 12(8.5)

Figures in parentheses represent percentages

Participants were also asked to indicate if they had faced various stressful events in life such

as marital separation or divorce, loss of job or retirement, major financial loss, violence,

major intra-family conflict, major personal injury or illness, death or major illness of a close

family member, death of a spouse (husband/wife), or other major stress. They were

analyzed by categorizing them into three categories: None, 1 event, and 2 or more. It was

observed that nearly 62.4% of the participants did not face any of the events and very few

faced 1, or 2 or more events. More than two-thirds (70.0%) of the employees felt depressed

for past 1 year and one third (34.7%) were depressed for continuously 2 weeks or more.

More women were depressed than men for past 1 year and for continuously 2 weeks.

Depression was assessed using following situational indicators – lose interest in things, feel

tired or low on energy, gain or lose weight, trouble falling asleep, trouble concentrating,

feeling worthless, think of death. Overall depression was more in case of females, since they

felt 2 to 7 situational indicators more than males. Thus, it was observed that a higher

proportion of young employees were stressed and depressed in all parameters, except a

few of them.

Perceived stress was also assessed among BPO managers (Table 49) and it was observed

that several periods of general stress (both at home and at work) was higher (13.1%) than

severe financial stress (9.8%). Stress at work (several periods and permanent) was among

more number of managers (32.8%) as compared to calling level employees (28.9%) (ᵡ2 =

0.384; p=0.535), whereas, stress at home (15.9%) (ᵡ2 = 0.803; p=0.370) and general stress

(20.7%) (ᵡ2 = 1.942; p=0.163) was experienced by more number of calling level employees;

however, these differences were not significant. Perception of moderate and severe

financial stress was significantly higher (ᵡ2 = 5.078; p=0.024) in managers (67.2%) as

compared to calling level employees (51.9%). On the other hand, a higher proportion of

calling level employees experienced sadness and depression over past 1 year (70.8%) and

past 2 weeks (34.7%) compared with managers (67.2% and 27.9%); but, these differences

were not statistically significant.

Table 49: Distribution of various perceived stress related parameters among managerial

level employees

Total (n=61) Males (n=54) Females (n=7) Stress at work Never Some of the time Several periods Permanent

4(6.6) 37(60.7) 17(27.9) 3(4.9)

4(7.4) 31(57.4) 16(29.6) 3(5.6)

0(0) 6(85.7) 1(14.3) 0(0)

Stress at home Never Some of the time Several periods Permanent

8(13.1) 46(75.4) 6(9.8) 1(1.6)

8(14.8) 39(72.2) 6(11.1) 1(1.9)

0(0) 7(100.0) 0(0) 0(0)

Stress (at home and work) Never Some of the time Several periods Permanent

9(14.8) 44(72.1) 8(13.1) 0(0)

9(16.7) 37(68.5) 8(14.8) 0(0)

0(0) 7(100.0) 0(0) 0(0)

Financial stress Little or none Moderate High or severe

20(32.8) 35(57.4) 6(9.8)

16(29.6) 32(59.3) 6(11.1)

4(57.1) 3(42.9) 0(0)

Stressful life events None 1 2 or more

38(62.3) 19(31.1) 4(6.6)

32(59.3) 18(33.3) 4(7.4)

6(85.7) 1(14.3) 0(0)

Feeling depressed (past 1 year) Yes No

41(67.2) 20(32.8)

36(66.7) 18(33.3)

5(71.4) 2(28.6)

Depression (past 1 year) 0–1 items 2–4 items 5 or more items

34(55.7) 22(36.1) 5(8.2)

30(55.6) 19(35.2) 5(9.3)

4(57.1) 3(42.9) 0(0)

Feeling depressed (past 2 weeks) Yes No

17(27.9) 44(72.1)

16(29.6) 38(70.4)

1(14.3) 6(85.7)

Depression (past 2 weeks) 0–1 items 2–4 items 5 or more items

49(80.3) 9(14.8) 3(4.9)

42 9 3

7 0 0

Figures in parentheses represent percentages

In this study, psychosocial stress (depression for past 1 year and past 2 weeks) was

reportedly perceived more in females as compared to males. Similar results have been

reported by Engum (2007) among 37291 free living adults (>18 years) in a prospective

population based study where perceived stress scores using the inventory to measure

psychosocial stress (IMPS), were also reported to be significantly higher among females

(p<0.001). Thus, psychosocial stress is an important risk factor for MetS.

Table 50: Association of perceived stress with Metabolic Syndrome at the calling and

managerial level

Depression

Calling level

ATPIII IDF

Wald’s statistic

p value Odds

ratio

Wald’s statistic

p value Odds

ratio

x Feeling depressed (past 1 year)

1.889 0.169 0.629 1.818 0.178 0.679

x Feeling depressed (past 2 weeks)

2.401 0.121 0.538 2.376 0.123 0.613

Depression

Managerial level

ATPIII IDF

Wald’s statistic

p value Odds

ratio

Wald’s statistic

p value Odds

ratio

x Feeling depressed (past 1 year)

0.576 0.448 1.978 1.829 0.176 2.987

x Feeling depressed (past 2 weeks)

0.017 0.897 0.853 0.627 0.429 2.096

Key findings

x More than 90% of the employees at the calling and managerial level perceived stress at work (some of the time + several periods + permanent).

x Higher proportion of women at the calling and managerial level perceived stress at work, home and general stress; whereas higher proportion of males perceived financial stress at both, calling and managerial level.

x Depression was reported significantly in higher proportion of female employees at the calling level (p=0.042) who felt depressed during past 1 year, tired or low on energy, and had gained or lost weight.

x Depression during past 1 year and past 2 weeks reported by significantly higher number of employees with MetS at the calling level. No such association was observed among the managerial level employees (p=0.448; p=0.877).

3.9.5 Physical activity

Physical inactivity is an important risk factor for MetS and has important repercussions

leading to CVD in the future (Bankoski et al., 2011; Bianchi et al., 2008; Ford et al., 2005;

Laaksonen et al., 2002). In the present study, time spent on physical activities of vigorous

and moderate intensities was assessed among calling and managerial level BPO employees.

These activities were:

x Work related

x During leisure time

3.9.5.1 Work related physical activity

Work related physical activity was defined as activities done for paid or unpaid work,

study/training, household chores and computer work. These were further divided into

activities of vigorous and moderate intensities (WHO STEPS, 2008).

The activities of vigorous intensity were defined as those activities that cause a large

increase in breathing and/or heart rate and include gardening, loading furniture, cutting

crops and doing sports aerobics (WHO STEPS, 2008). In the present study, only two calling

level male employees (0.5%) were engaged in work related activities of vigorous intensity

such as doing sports aerobics for at least 10 minutes continuously at a time. They were

doing it for two days in a week for 30 minutes each. None of the female employees were

engaged in work related activities of vigorous intensity. None of the managers were

vigorously active.

Decline in physical activity becomes most common from adolescence onwards especially in

case of vigorous physical activity, therefore, measures need to be taken to incorporate

physical activity as a part of lifestyle (Brodersen et al., 2007).

The activities of moderate intensity were defined as those activities that cause a small

increase in breathing and/or heart rate and include cleaning (Vacuuming, mopping,

polishing, scrubbing, sweeping, ironing), washing (beating and brushing) and woodwork

(WHO STEPS, 2008). Nearly one-third (32.5%) of the calling level employees were engaged in

work related activities of moderate intensity for 10 minutes continuously at a time. Of them,

significantly higher proportion of females (44.0%) were engaged in moderate intensity

http://bjsm.bmj.com/search?author1=Naomi+Henning+Brodersen&sortspec=date&submit=Submit

activities viz. cleaning, washing and gardening for longer duration in comparison to males

(26.6%) (ϰ2 12.738; p=0.000) as depicted in figure 18. Of those engaged in work related

moderate intensity activity (n=135), one-third of them (31.1%) were engaged in these

activities on a daily basis, while others were engaged in such activities less frequently (2-7

days per week) (Fig 19).

Figure 18: Calling level BPO employees engaged in work related moderate intensity activities

32.5%

(135) 67.5%

(280)

Total (n=415)

26.6%

(73)

73.4%

(201)

Males (n=274)

44% (62) 56%

(79)

Females (n=141)

13.3

17

13.3

11.1

11.1

3

31.1

13.7

21.9

12.3

8.2

11

2.7

30.1

12.9

11.3

14.5

14.5

11.3

3.2

32.3

0 5 10 15 20 25 30 35

1

2

3

4

5

6

7

Percent

Number of days

Figure 19: Percent distribution of calling level BPO employees according to the number of days in a week they were engaged in

work related moderate intensity activities

Females (n=62) Males (n=73) Total (n=135)

Engaged in moderate intensity activities

Not engaged in moderate intensity activities

At the managerial level, nearly one third of them (31.1%) were engaged in activities of

moderate intensity for at least ten minutes with higher proportion of female employees

(42.9%) engaged in such activities as compared to males (29.6%) but this was not statistically

significant (ϰ2 = 0.506; p=0.48) (fig 20). Of those engaged in work related moderate intensity

activity (n=19), none of them were engaged in these activities on a daily basis, nearly half

(43.6%) were engaged in such activities less frequently (1-3 days per week). However, the

sample size in case of female managers is too small (n=7) to draw reliable conclusions for

this group.

Figure 20: Managerial level BPO employees engaged in work related moderate intensity activities

Higher proportions of female employees (46.8%) working at the calling level were engaged

in work related activities of moderate intensity for more than four days in a week as

compared to their male counterparts (43.8%). The time spent in these activities varied

considerably from <30 minutes at a time up to two hours. Significantly higher proportions of

females were spending more than 30 minutes on work related moderate intensity activities

(Table 51). Very few (2.2%) were engaged in such activities for 180 minutes or longer.

Table 51: Time spent on work related moderate intensity activities among calling and managerial level BPO employees

Calling level Duration Total (n=135) Males (n=73) Females (n=62) ϰ2 p value ≤ 30 minutes 70 (51.9) 45 (61.6) 25 (40.3) 6.105 0.013* > 30 minutes 65 (48.1) 28 (38.4) 37 (59.7) Managerial level Duration Total (n=19) Males (n=16) Females (n=3) ϰ2 p value ≤ 30 minutes 11(57.9) 10(62.5) 1(33.3) 7.655 0.364 > 30 minutes 8(42.1) 6(37.5) 2(66.7) Figures in parentheses represent percentages *Significant at p<0.05

31.1% 68.9

%

Total (n=61)

29.6%

70.3%

Males (n=54)

42.9% 57.1

%

Females (n=7)

Engaged in moderate intensity activities

Not engaged in moderate intensity activities

At the managerial level, no association was observed between gender and time spent on

moderate intensity activities (table 51).

3.9.5.2 Physical activity during leisure time

Leisure time activities were defined as those activities that were done in spare/free time

including sports, fitness and recreational activities (leisure) and time spent at home (WHO

STEPS, 2008). These were further divided into activities of vigorous and moderate

intensities.

The activities of vigorous intensity during leisure time included running, heavy gymming

such as push-ups/pull-ups, treadmill, skipping, or playing football for at least 10 minutes

continuously at a time. A total of forty percent of the calling level BPO employees were

engaged in activities of vigorous intensity during their leisure time, with significantly higher

proportion of employees (59.5%) not engaging in any such activity (ϰ2=15.039; p=0.000). A

significantly higher proportion of male employees (45.3%) engaged in such activities as

compared with female employees (31.2%) (p=0.006) (Table 52).

Table 52: Leisure time related vigorous physical activities among BPO employees

Calling level Leisure time vigorous activity

Total (n=415)

ϰ2 p value Males (n=415)

Females (n=141)

ϰ2 p value

Doing 168(40.5) 15.039 0.000* 124(45.3) 44(31.2) 7.627 0.006* Not doing 247(59.5) 150(54.7) 97(68.8) Managerial level Total

(n=61) ϰ2 p value Males


ϰ2 p value

Leisure time vigorous activity

Doing 18(29.5) 10.246 0.001* 16(29.6) 2(28.6) 0.003 0.954 Not doing 43(70.5) 38(70.4) 5(71.4) Figures in parentheses represent percentages *Significant at p<0.05

At the managerial level, less than one third (29.5%) were engaged in activities of vigorous

intensity, with significantly higher proportion of them (70.5%) not doing such activities

(ϰ2=10.246; p=0.001). However, there was no significant difference in the proportion of the

two sexes engaged in such activities (Table 52).

Of those calling level employees engaged in activities of vigorous intensity during leisure

time, more than half of them (total 57.7%; males 54.0%; females 68.1%) were doing such

activities for 5-7 days in a week (Fig 21). At the managerial level, all the female employees

who were engaged in such activities were doing so for 5-7 days in a week whereas in case of

majority of the males (81.4%), it was 2-5 days in a week.

The activities of moderate intensity during leisure time included bicycling, jogging, light

gymming such as warm up exercises, yoga, treadmill (slow pace), playing basketball, cricket,

badminton, tennis, squash, golf, swimming, dancing and gardening was also ascertained

among calling and managerial level BPO employees. More than half (53.7%) of the calling

level employees were engaged in such type of leisure time activity of moderate intensity for

at least ten minutes continuously at one time in a week, with significantly more males

(57.3%) engaged in it as compared to females (46.8%) (Table 53).

Table 53: Leisure time moderate intensity activities among calling and managerial level

BPO employees

Calling level

Leisure time moderate intensity activity

Total (n=415)


Females (n=141)

ϰ2 p value

Doing 223(53.7) 2.316 0.128 157(57.3) 66(46.8) 4.121 0.042* Not doing 192(46.3) 117(42.7) 75(53.2)

5.4

14.3 14.9

7.7

22.6

14.9

20.2

6.5

16.1 14.5

8.9

22.6

14.5 16.9

2.3

9.1

15.9

4.5

22.7

15.9

29.5

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7

Perc

ent

Number of days

Figure 21: Percent distribution of calling BPO employees according to the number of days in a week they were engaged in LTPA of

vigorous intensity

Total (n=168) Males (n=124) Females (n=44)

Managerial level

Leisure time moderate intensity activity

Total (n=61)


Females (n=7)

ϰ2 p value

Doing Not doing

27(44.3) 34(55.7)

0.803 0.370 25(46.3) 29(53.7)

2(28.9) 5(71.4)

0.789 0.374

Figures in parentheses represent percentages *Significant at p<0.05

Of those engaged in the activities of moderate intensity during leisure time (n=223), more

than half (56.1%) were engaged in it for 1-4 days in a week. This was similar in case of males

(58.6%) and females (50.0%) (Fig 22). However, one fourth of the females (24.2%) were

doing such activities on a daily basis.

At the managerial level, less than half of them (44.3%) were engaged in activities of

moderate intensity during leisure time. More males were doing these activities than female

managers but this difference in proportion was not significant (Table 53). Of those engaged

in activities of moderate intensity during leisure time (n=27), more than half (60.0%) were

engaged for 1-4 days in a week.

More than sixty percent of the calling level employees (61.9%) as well as managerial level

employees (64.0%) were engaged in leisure time activities of moderate intensity for ≤ 30

14.8

17.0

12.6

11.7

16.6

10.3

17.0

14.0

19.1

13.4

12.1

15.9

11.5

14.0

16.7

12.1

10.6

10.6

18.2

7.6

24.2

0.0 5.0 10.0 15.0 20.0 25.0 30.0

1

2

3

4

5

6

7

Percent

Number of days

Figure 22:Percent distribution of calling level BPO employees according to the number of days in a week they were engaged in

activities of moderate intensity during leisure time


minutes at a time (Table 54). A significantly higher proportion of the BPO employees

working at calling level (ϰ2= 12.596; p=0.000) were engaged in leisure time physical

activities of moderate intensity for ≤30 minutes at a time. However, there was no significant

difference in the proportion of managerial level employees engaged in such activities for ≤

30 or > 30 minutes (ϰ2= 3.000; p=0.083).

Also no significant association was observed between time spent on such activities and

gender of the employees (calling level ϰ2= 3.459; p=0.063) and managerial level (Table 54).

Table 54: Time spent on activities of moderate intensity during leisure by calling and

managerial level BPO employees

Calling level

Duration

Total (n=223)


Females (n=66)

ϰ2 p value

≤ 30 minutes 138(61.9) 12.596 0.000 91(58.0) 47(71.2) 3.459 0.063 > 30 minutes 85(38.1) 66(42.0) 19(28.8) Managerial level

Duration

Total (n=61)


Females (n=7)

ϰ2 p value

≤ 30 minutes 18(66.7) 3.000 0.083 16(64.0) 2(100.0) -- -- > 30 minutes 9(33.3) 9(36.0) 0(0) Figures in parentheses represent percentages

In a cross sectional study of civil servants (45-68 years) in Europe, it was observed that there

were lower odds (OR-0.78 95%CI: 0.63, 0.96) of having MetS among those doing leisure time

moderate intensity activity (Metabolic equivalent [MET] ≥3 to <5). Though age has an

important role to play in the development of MetS, but in this study the effects were

independent of age (Rennie et al, 2003). The Copenhagen City Heart Study of 10,135 men

and women (21-98 years), a prospective study with a follow-up period of 10 years among

free living population showed that odds ratio of developing MetS in individuals doing leisure

time moderate (2-4 hours/week) and/or vigorous physical activity (>4 hours/week) was 0.71

(95%CI: 0.50-1.01) (Laursen et al., 2012).

Thus, the protective effect of leisure time physical activity against development of MetS is

evident among BPO employees in the present study.

3.9.5.3 Sitting time – office, travel and recreational

Sitting time of BPO employees was ascertained by asking them to report the time they

usually spend in the following activities viz. office sitting time/sitting at desk, travel sitting

time and sitting time for other recreational activities such as sitting with friends, playing

cards, watching television, internet surfing, reading newspaper/magazine, chatting on

phone and doing household chores. Based on the employees’ reporting of the time spent on

above mentioned recreational activities per day, a rough estimate of the average time spent

was obtained as they were engaged in multiple activities at the same time.

Sitting at desk time ranged from four hours to more than eight hours for both the calling

and managerial level employees (4 - 8.5 hours). Nearly two thirds of the calling level

employees (64.8%) were spending on an average more than 7 hours sitting at desk (Table

55). Both males (63.5%) and females (67.2%) were spending similar amount of time sitting

and working at their desk.

Table 55: Office sitting time of calling and managerial level BPO employees

Office sitting time (hours) among calling level employees

Gender 4.00-5.00 5.01-6.00 6.01-7.00 >7.01 Males (n=274) 5(1.8) 20(7.3) 75(27.4) 174(63.5) Females (n=141) 4(2.8) 18(12.8) 24(17.0) 95(67.2) Total (n=415) 9(2.2) 38(9.2) 99(23.9) 269(64.8)

Office sitting time (hours) among managerial level employees

Gender 4.00-5.00 5.01-6.00 6.01-7.00 >7.01 Males (n=54) 3(5.6) 8(14.8) 15(27.8) 28(51.9) Females (n=7) 0(0) 0(0) 2(28.5) 5(71.5) Total (n=61) 3(9.8) 8(13.1) 17(27.9) 33(54.1) Figures in parentheses represent percentages

More than half (54.1%) of the managerial level employees were spending on an average

more than 7 hours sitting and working at desk (Table 55). Majority of male managers

(79.7%) and all the female managers (100.0%) were spending on an average more than 6

hours sitting and working at desk.

Travel time from home to office and back to home was also ascertained from the

employees. Most of the employees availed the free cab service provided by BPO companies

for travelling to work place. They usually spent this time sitting and interacting with their

colleagues or on personal phone. Nearly 40% of the calling level employees were spending

up to an hour for traveling back and forth, one third (31.3%) were spending up to two hours,

while another third (29.6%) were spending more than two to three hours (Table 56).

Table 56: Total traveling time of calling level BPO employees

Traveling time (hours) Up to 1.00 1.01-2.00 2.01-3.00 >3.01 Males (n=274) 56(39.7) 41(29.1) 23(16.3) 21(14.9) Females (n=141) 106(38.7) 89(32.5) 53(19.3) 26(9.5) Total (n=415) 162(39.0) 130(31.3) 76(18.3) 47(11.3) Figures in parentheses represent percentages

The distribution of managerial level employees according to the amount of total time spent

while travelling to workplace and back home was similar to the calling level employees

(Table 57).

Table 57: Total traveling time of managerial level BPO employees

Traveling time (hours) Up to 1.00 1.01-2.00 2.01-3.00 >3.01 Males (n=54) 25(46.3) 12(22.2) 11(20.4) 6(11.1) Females (n=7) 2(28.6) 3(42.9) 0(0) 2(28.6) Total (n=61) 27(44.3) 15(24.6) 11(18.0) 8(13.1) Figures in parentheses represent percentages

Recreational sitting time which involved activities viz. sitting with friends, playing cards,

watching television, internet surfing, reading newspaper/magazine, chatting on phone and

doing household chores was also elicited from all the employees. More than forty percent of

the calling level employees (44.3%) were spending up to 4 hours while a similar proportion

(42.9%) were spending anywhere between 4 to 8 hours on these activities (Table 58).

Table 58: Sitting time for recreational activities of calling level BPO employees

Recreational sitting time (hours) Up to 4.00 4.01-8.00 >8.01 Males (n=274) 124(45.3) 115(42.0) 35(12.8) Females (n=141) 60(42.6) 63(44.7) 18(12.7) Total (n=415) 184(44.3) 178(42.9) 53(12.7) Figures in parentheses represent percentages

However, at the managerial level, sixty percent (60.7%) were spending up to 4 hours for

these activities (Table 59). Both male and female employees were spending nearly similar

amount of time on these activities.

Table 59: Sitting time for recreational activities of managerial level BPO employees

Recreational sitting time (hours) Up to 4.00 4.01-8.00 >8.01 Males (n=54) 33(61.1) 20(37.0) 1(1.9) Females (n=7) 4(57.1) 3(42.9) 0(0) Total (n=61) 37(60.7) 23(37.7) 1(1.6) Figures in parentheses represent percentages

The American College of Sports Medicine (2015) has recently issued a guidance stating “for

those occupations which are predominantly desk based, workers should aim to initially

progress towards accumulating 2 h/day of standing and light activity (light walking) during

working hours, eventually progressing to a total accumulation of 4 h/day (prorated to part-

time hours)”. It is further advised that seat based work should be broken by taking short

active standing breaks and companies need to promote awareness among their employees

regarding the CVD risk associated with prolonged sitting (ACSM, 2015). In the present study,

it was observed that the employees were bound by strict time based deadlines for the

amount of work to be accomplished each day. The employees reported that due to the

nature of their work, it was not possible for them to leave their desk, and at times due to

work pressure they did not take any break from their work and ate while sitting at their

desk.

3.9.5.4 Travel to and from places

Another important aspect pertaining to physical activity was considering the mode of travel

to and from places such as work, shopping, market and place of worship. Majority (82.2%)

of the calling level employees reported that they walked daily for at least 10 minutes

continuously to get to and from places (Table 60). However, with respect to walking, there

was variability among employees regarding both the number of days in a week and the time

spent per day. Significantly higher proportion of the employees at the calling level were

walking for at least 10 minutes continuously (ϰ2=17.178, p=0.000).

Table 60: Daily walking for at least 10 minutes continuously by the calling level BPO

employees

Daily walking

Total (n=415)


Females (n=141)

ϰ 2 p value

Yes 341 (82.2) 17.178 0.000* 224 (81.8) 117 (83.0) 0.096 0.757 No 74 (17.8) 50 (18.2) 24 (17.0) Figures in parentheses represent percentages *Significant at p<0.05

Nearly 60% of the managerial level employees agreed that they walked daily for at least 10

minutes continuously to get to and from places (Table 61).

Table 61: Daily walking for at least 10 minutes continuously by the managerial level BPO

employees

Daily walking

Total (n=61)


Females (n=7)

ϰ 2 p value

Yes 36(59.0) 1.984 0.159 32(59.3) 4(57.1) 0.011 0.915 No 25(41.0) 22(40.7) 3(42.9) Figures in parentheses represent percentages

The employees were also asked regarding the means of transportation they used for

commuting to work. Most of the calling level employees were using a combination of

transportation such as walking by foot to the nearest shop from where they boarded metro,

train, bus or company cab or by private car or two wheeler (motorbike/scooter) (Fig 23 and

24). Among them, the most popular means of transportation were company cab (58.1%),

two wheeler (12.3%), and bus (12.0%). In case of managers, the most popular means of

transportation were company cab (45.9%), private car (24.6%) and two-wheeler (16.4%).

Since, most BPOs were located in the NCR region which is far from several parts of Delhi and

employees have to work in the rotational shifts, provision of cab is one of the facilities that

are provided from the employer’s end. Moreover, keeping in mind the security issues, most

female employees preferred to use cab services provided by the company.

58.1

7 12 11 10.8

12.3

1.6 0.4 0.5

51.1

8.4 12.4 11 12.8

17.2

1.9 0.8 0

71.6

4.3

11.3 11.3 7.1

2.8 1.4 0 1.4

0

10

20

30

40

50

60

70

80

Percent

Figure 23: Means of transportation used by calling level BPO employees

for travel to and from work*

Total Males Females#Public means of transportation ##Transportation facility provided by the BPO company 's ###Privately owned vehicles

45.9

8.2 6.6 4.9

24.6

16.4

44.4

9.3 7.4 3.7

25.9

16.7

57.1

0 0

14.3 14.3 14.3

0

10

20

30

40

50

60

Office cab## Auto rickshaw# Bus# Metro# Car (own) Two wheeler

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Fig 24: Means of transportation used by managerial level BPO employees

for travel to and from work*

Total Males Females

### ###

*Multiple responses

*Multiple responses

#Public means of transportation

##Transportation facility provided by the BPO company

###Privately owned vehicles

3.9.5.5 Association of physical activity with Metabolic Syndrome

Engaging in 4 or more days of physical activity for at least 10 minutes continuously had

lower odds for developing the syndrome among the calling level employees (OR 0.334). No

associations were observed with other physical activity parameters and MetS at the calling

and managerial level.

Table 62: Association of physical activity with Metabolic Syndrome among calling and


Physical activity

Calling level

ATPIII IDF

Wald’s statistic

p value Odds ratio

Wald’s statistic

p value Odds ratio

x Work related moderate activity 1.725 0.189 0.429 1.355 0.244 0.523 x Leisure time vigorous activity 0.332 0.565 1.377 0.157 0.282 0.759 x Leisure time moderate activity 0.255 0.613 0.771 2.441 0.118 0.217 x 4 or more days of physical

activity for at least 10 minutes continuously

1.778 0.182 0.459 3.886 0.049* 0.334

Physical activity

Managerial level

ATPIII IDF

Wald’s statistic

p value Odds ratio

Wald’s statistic

p value Odds ratio

x Work related moderate activity 0.181 0.671 0.470 0.828 0.363 3.216 x Leisure time vigorous activity 0.752 0.386 2.874 0.209 0.647 0.660 x Leisure time moderate activity 0.053 0.818 0.637 0.326 0.568 0.463 x 4 or more days of physical

activity for at least 10 minutes continuously

0.006 0.940 0.964 0.906 0.660 1.313


Key findings

x Only two calling level male employees (0.5%) were engaged in work related activities of vigorous intensity. None of the managers were vigorously active.

x Significantly higher proportion of females (44.0%) were engaged in moderate intensity activities viz. cleaning, washing and gardening for longer duration in comparison to males (26.6%) (ϰ2 12.738; p=0.000). At the managerial level, higher proportion of female employees (42.9%) engaged in such activities as compared to males (29.6%) but this was not statistically significant (ϰ2 = 0.506; p=0.48).

x A total of forty percent of the calling level BPO employees were engaged in activities of vigorous intensity during their leisure time. At the managerial level, less than one third (29.5%) were engaged in activities of vigorous intensity during leisure time.

x More than half (53.7%) of the calling level employees were engaged in leisure time activity of moderate intensity for at least ten minutes continuously at one time in a week. At the managerial level, less than half of them (44.3%) were engaged in activities of moderate intensity during leisure time.

x Sitting at desk time ranged from four hours to more than eight hours for both the calling and managerial level employees (4 - 8.5 hours).

x Significantly higher proportion of the employees at the calling level were walking for at least 10 minutes continuously (ϰ2=17.178, p=0.000).

x Engaging in 4 or more days of physical activity for at least 10 minutes continuously had lower odds for developing the syndrome among the calling level employees (OR 0.334).

3.9.6 Diet

Nutrition transition has resulted in changing of the dietary patterns with a shift towards

foods rich in calories, fats and sugars. This transition is hugely impacting LMICs and leading

to the rise of NCDs (Popkin, 2001). Diet is one of the major risk factors for NCDs

(www.who.int). Being an important risk factor for MetS, (Carnethon et al., 2004), dietary

intake pattern of the BPO employees working at the calling and managerial level was

assessed in the present study. It included assessing dietary habits, frequency of

consumption of various food items and food and nutrient intkae.

3.9.6.1 Food preferences

The employees were asked to classify themselves as vegetarian, non-vegetarian, or ovo-

vegetarian (Fig 25a and 25b). At the calling level, more than half of them were non-

vegetarians (59.5%), nearly one third were vegetarians (29.6%) and one-tenth of them were

ovo-vegetarians (10.8%). Nearly two-thirds of the male employees (63.5%) and half of the

female employees (51.8%) working at the calling level were non-vegetarian. At the

managerial level, less than half of them were vegetarian (45.9%) and non-vegetarian

(47.9%), while the rest were ovo-vegetarian (6.6%). More than half (57.1%) of the female

managers were vegetarian, while half (50.0%) of the male managers were non-vegetarian.

Figure 25a: Food preferences of calling level BPO employees

29.60%

59.50%

10.80%

Total (n=415)

26.6%

63.5%

9.9%

Males (n=274)

35.5%

51.8%

12.8%

Females (n=141)

Figure 25b: Food preferences of managerial level BPO employees

3.9.6.2 Meal pattern

The meals that were usually consumed by the BPO employees at the calling and managerial

level included early morning meal, breakfast, mid-morning meal, lunch, tea-time snack,

dinner and post-dinner; though, all these meals were not consumed by all the employees on

a regular basis (Fig 26a). At the calling level, frequency of consumption was higher in case of

dinner (98.3%) and lunch (94.9%) as compared to breakfast (78.6%), evening tea (64.3%),

mid-morning (24.8%) and post dinner (2.9%) meal. A higher proportion of women

employees consumed breakfast (83.7%) as compared with their male counterparts (75.9%).

At the managerial level, frequency of consumption was highest for dinner (98.4%) and lunch

(96.7%) as compared to breakfast (69.8%), evening tea (68.9%), and mid-morning (18.0%)

(Figure 26b). The favorite dishes commonly eaten by the employees at the calling and

managerial level at home were rajma rice, choley rice, shahi paneer, kadhi rice, stuffed

paranthas and aloo puri.

45.90% 47.50

%

6.60%

Total (n=61)

44.40%

50%

5.60%

Males (n=54)

57.10%

28.60%

14.30%

Females (n=7)

Vegetarian: A person who does not eat food derived from animals such as meat, fish, chicken, eggs etc, and only eats plant foods such as vegetables, fruits, nuts, grains, and milk and milk products as the only animal foods

Non-vegetarian: A person who eats food derived from animals as well as from plants

Ovo-vegetarian: A person who eats plant foods, milk and milk products and eggs, but does not consume animal flesh

3.9.6.3 Meal skipping

Skipping of meals was a commonly reported practice by calling level employees, with

majority (79.5%) of them skipping one or the other meal. However, less than one third

(31.1%) of the managerial level employees were skipping meals (Table 63). Skipping of

breakfast, lunch and dinner was observed in both male (65.6%) and female (78.0%) calling

level employees. At the managerial level, nearly forty percent were skipping breakfast. Of

the various meals, breakfast was the most commonly skipped meal (44.8%) among both

44.1

78.6

24.8

94.9

64.3

98.3

2.9

41.2

75.9

22.3

94.2

61.3

98.5

2.9

49.6

83.7

29.8

96.5

70.2

97.9

2.8 0

20

40

60

80

100

120

Percent

Figure 26a: Meals usually consumed by calling level BPO employees*


32.7

69.8

16.4

96.7

68.9

98.4

31.5

70.4

20.4

96.3

64.8

100

28.6

71.4

42.9

85.7

71.4

85.7

0

20

40

60

80

100

120

Early morning Breakfast Mid-morning Lunch Tea time Dinner

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Figure 26b: Meals usually consumed by managerial level BPO

employees*


*Multiple responses

*Multiple responses

males (44.5%) and females (45.4%), followed by tea time snack (44.3%) and lunch (14.9%) at

the calling level. At the managerial level also, breakfast was most commonly skipped meal

among males (38.9%) and females (42.9%), followed by tea time snack (39.3%) and lunch

(11.5%). None of the managers skipped dinner. At the calling level, since the meal skipping

pattern was similar among males and females, no associations were observed between

gender and meal skipping, except for skipping dinner where the association was significant

(p=0.003) as a higher proportion of female employees usually skipped dinner. There were

no significant associations between gender and meal skipping at the managerial level. Meal

timings were not regular due to rotational shift system. All the employees who were

skipping breakfast/first meal after waking in the forenoon cited lack of time as the major

reason for not being able to eat breakfast. They explained further that since they worked in

rotational shifts, their sleep cycle gets altered and they were able to wake up only an hour

before the office cab arrived. They had limited time to get ready and therefore did not get

time to have breakfast. When shifts started late i.e. 12:00 am/pm, they did not like eating at

that time as it was not actually time for breakfast.

Table 63: Meals usually skipped by calling and managerial level BPO employees*

Calling level Meal skipped Total (n=415) Males (n=274) Females

(n=141) ϰ 2 p value

Breakfast 186(44.8) 122(44.5) 64(45.4) 0.028 0.867 Lunch 62(14.9) 39(14.2) 23(16.3) 0.316 0.574 Tea time 184(44.3) 130(47.4) 54(38.3) 3.156 0.076 Dinner 42(10.1) 19(6.9) 23(16.3) 9.000 0.003* Managerial level Meal skipped Total (n=61) Males (n=54) Females (n=7) ϰ 2 p value Breakfast 24(39.3) 21(38.9) 3(42.9) 0.041 0.840 Lunch 7(11.5) 6(11.1) 1(14.3) 0.061 0.804 Tea time 24(39.3) 23(42.6) 1(14.3) 2.081 0.149 Dinner 0(0) 0(0) 0(0) -- -- Figures in parentheses represent percentages *Multiple responses

In a study of night shift work employees (n=100) in a tertiary care hospital in Mangalore,

India, it was observed that the shift work contributed to skipping meals viz. breakfast (38%),

lunch (4%) and dinner (16%). This skipping pattern was attributed to shift work as well as

irregular meal timings (Vijayalaxmi, George and Nambiar, 2014). Lennernas et al (1994) also

observed that shift work resulted in decreased meals consumption due to changes in the

circadian rhythm affecting appetite among 16 healthy Swedish male paper mill workers.

3.9.6.4 Eating in between meals

Nibbling in between meals was a common practice among both calling and managerial level

employees. More than half (56.9%) of the employees at the calling level and half (50.8%) at

the managerial level were nibbling frequently to occasionally (Table 64). Higher proportions

of females at the calling (19.9%) and managerial level (14.3%) were nibbling frequently

between meals and higher proportions of males at the calling (40.9%) and managerial level

(46.3%) were nibbling occasionally between meals. However, no significant association was

observed between gender and frequency of eating in between meals.

Table 64: Frequency of eating in between meals among calling and managerial level BPO employees

Frequency

Calling level

Total

(n=415)

Males

(n=274)

Females

(n=141)

ϰ 2 p value

Frequentlya 70(16.9) 42(15.3) 28(19.9) 2.408 0.492 Occasionallyb 166(40.0) 112(40.9) 54(38.3) Rarely 158(38.1) 108(39.4) 50(35.5) Never 21(5.1) 12(4.4) 9(6.4)

Frequency

Managerial level

Total

(n=61)

Males

(n=54)

Females

(n=7)

ϰ 2 p value

Frequentlya 3(4.9) 2(3.7) 1(14.3) 1.819 0.611 Occasionallyb 28(45.9) 25(46.3) 3(42.9) Rarelyc 27(44.3) 24(44.4) 3(42.9) Never 3(4.9) 3(5.6) 0(0) Figures in parentheses represent percentages aFrequently – Daily or every alternate day bOccasionally – Once in 2 weeks cRarely – Once in a month or less often

A variety of food items were consumed by the calling and managerial level employees in

between meals, majority of which were high calorie, high fat snacks (namkeen [deep fried,

spicy mixture prepared from pulse and cereal products along with nuts/dry fruits], biscuits,

and chips usually consumed with beverages viz. coffee, tea, carbonated beverages) except a

few which were healthy options (fruit, nuts, milk, egg). Tea (54.0% and 55.7%), biscuits

(51.6% and 47.5%), namkeen/mixture (42.4% and 50.8%) were being consumed by more

than half of the employees at the calling and managerial level (Fig 27a and 27b). More than

one fourth of them opted for coffee at the calling (26.5%) and managerial level (27.9%).

Significantly higher proportion of calling level female employees consumed fruits (ϰ2=5.025;

p=0.025) whereas significantly higher proportion of males consumed carbonated beverages

(ϰ 2 =6.428; p=0.025) between meals. Only a handful of them consumed sandwich (1.0%),

sprouts (0.5%), green tea (0.5%), banana shake (0.5%), patties (0.2%), protein bar (0.2%),

milk (0.2%) and egg (0.2%) in between meals. These items were particularly chosen by the

employees as according to them these were easy to eat while working at their desk as they

purchased these items during the main meal break time and ate them while working.

12.5 14.7

22.9 26.5 27.0

32.5

42.4

51.6 54.0

11.7 13.5

26.6 27.0 24.5

28.8

43.8

52.9 56.2

14.2 17.0 15.6

25.5

31.9

39.7 39.7

48.9 49.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

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Figure 27a: Types of food items consumed usually by calling level BPO employees in between the meals*


*Multiple responses

3.9.6.5 Cooking medium

Various types of oils and fats were used in combination as a medium for cooking (Table 65a

and 65b). At the calling level, commonly preferred oils as a medium for cooking were desi

ghee (clarified butter) (59.8%), soybean oil (54.7%) and butter (49.4%). Male employees

preferred desi ghee and soybean oil while female employees preferred butter as a cooking

medium. However, no significant association was observed between gender and cooking

medium used. Nearly one third of them were using mustard oil (31.3%) and sunflower oil

(28.9%) for cooking, with mustard being preferred by higher proportion of males (33.2%)

and sunflower by higher proportion of females (36.9%). Significantly higher proportion of

females used sunflower oil (p=0.010) and olive oil (p= 0.030) for cooking and mayonnaise

(p=0.043) for food preparations.

16.4 19.7 19.7

27.9 27.9

47.5 50.8

55.7

14.8 18.5 18.5

25.9 25.9

46.3 50

53.7

28.6 28.6 28.6

42.9 42.9

57.1 57.1

71.4

0

10

20

30

40

50

60

70

80

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Figure 27b: Types of food items consumed usually by managerial

level BPO employees in between the meals*


*Multiple responses

Table 65a: Cooking medium preferred by calling level BPO employees#

Oil/fat type Total (n=415)

Males (n=274)

Females (n=141)

ϰ2 p value

Desigheea 248(59.8) 168(61.3) 80 (56.7) 0.811 0.368 Vanaspatib 31(7.5) 24(8.8) 7(5.0) 1.939 0.164 Soybean 227(54.7) 154(56.2) 73(51.8) 0.738 0.390 Groundnut 11(2.7) 6(2.2) 5(3.5) 0.664 0.415 Sunflower 120(28.9) 68(24.8) 53(36.9) 6.589 0.010* Safflower 11(2.7) 7(2.6) 4(2.8) 0.029 0.865 Sesame 3(0.7) 2(0.7) 1(0.7) 0.001 0.981 Pasteurized table butter 205(49.4) 130(47.4) 75(53.2) 1.230 0.267 Margarine 1(0.2) 1(0.4) 0(0.0) 0.516 0.473 Olive 43(10.4) 22(8.0) 21(14.9) 4.723 0.030* Canola 2(0.5) 1(0.4) 1(0.7) 0.230 0.631 Cream 26(6.3) 18(6.6) 8(5.7) 0.127 0.721 Mayonnaise 27(6.5) 13(4.7) 14(9.9) 4.114 0.043* Mustard 130(31.3) 91(33.2) 39(27.7) 1.334 0.248 Coconut 7(1.7) 5(1.8) 2(1.4) 0.093 0.761 Saffola goldc 42(10.1) 25(9.1) 17(12.1) 0.880 0.348 Saffola actived 11(2.7) 5(1.8) 6(4.3) 2.131 0.144 Rice bran 2(0.5) 2(0.7) 0(0.0) 1.034 0.309 White butter 1(0.2) 0(0.0) 1(0.7) 1.948 0.163 Figures in parentheses represent percentages *Significant at p<0.05 #Multiple responses a Desighee: Clarified butter used as a cooking medium b Vanasapati: Hydrogenated vegetable oil used as a cooking medium c Saffola Gold: It is a blend of rice bran oil and safflower oil used a cooking medium d Saffola active: It is a rice bran oil (80%) and soyabean oil (20%) blend used as a cooking medium

Table 65b: Cooking medium preferred by managerial level BPO employees#

Oil/fat type Total (n=61)

Males (n=54)

Females (n=7)

ϰ2 p value

Desigheea 41(67.2) 36(66.7) 5(71.4) 0.064 0.801 Vanaspatib 4(6.6) 4(7.4) 0(0) -- -- Soybean 34(55.7) 30(55.6) 4(57.1) 0.006 0.937 Groundnut 5(8.2) 5(9.3) 0(0) -- -- Sunflower 27(44.3) 25(46.3) 2(28.6) 0.789 0.374 Safflower 4(6.6) 3(5.6) 1(14.3) 0.771 0.380 Sesame 1(1.6) 1(1.9) 0(0) -- -- Pasteurized table butter 26(42.6) 21(38.9) 5(71.4) 2.683 0.101 Olive 9(14.8) 9(16.7) 0(0) -- -- Cream 1(1.6) 1(1.9) 0(0) -- -- Mayonnaise 2(3.3) 2(3.7) 0(0) -- -- Mustard 32(52.5) 28(51.9) 4(57.1) 0.070 0.792 Coconut 1(1.6) 1(1.9) 0(0) -- -- Saffola goldc 6(9.8) 4(7.4) 2(28.6) 3.130 0.077 Saffola actived 1(1.6) 1(1.9) 0(0) -- -- Rice bran 1(1.6) 1(1.9) 0(0) -- -- Figures in parentheses represent percentages

#Multiple responses a Desighee: Clarified butter used as a cooking medium b Vanasapati: Hydrogenated vegetable oil used as a cooking medium c Saffola Gold: It is a blend of rice bran oil and safflower oil used a cooking medium d Saffola active: It is a rice bran oil (80%) and soyabean oil (20%) blend used as a cooking medium

At the managerial level, the commonly preferred oils were desighee (clarified butter)

(67.2%), soyabean oil (55.7%), mustard oil (52.9%) and butter (42.6%). Female managers

preferred these oils/fats as a cooking medium more than the male managers. However, no

significant association was observed between gender and cooking medium used at the

managerial level.

The reasons cited for consumption of a particular oil/fat by employees at the calling and

managerial level respectively were taste (74.0% and 72.1%), followed by health benefits

(36.4% and 45.9%) and easy availability (22.7% and 18.0%). Cost (9.6% and 18.0%) and

media influence/advertisements (3.4% and 3.3%) were also mentioned by a few as the

reasons which influenced their consumption of specific oils.

3.9.6.6 Consumption of food and nutrient supplements

Consumption of food1 and nutrient supplements2, and health foods3 was also ascertained

among the BPO employees (Table 66). The food supplements consumed commonly by the

employees were beverages prepared using milk as a base and free dried powders available

in the market (Horlicks, Bournvita, Proteinex, Boost and Complan). The nutrient

supplements consumed by the employees were Iron, Vit B12, and multivitamin capsules etc.

The health foods consumed by the employees were organic tea, and organic fruits and

vegetables. One tenth of the employees (9.9%) at the calling level used food supplements.

Significantly higher proportion of females (17.0%) consumed food supplements as

compared to males (6.2%) (ϰ 2 = 12.234; p = 0.000). Less than one tenth of them (7.7%) also

used nutrient supplements with significantly higher proportion of females (12.1%)

consuming them. More than one tenth of them (12.0%) consumed health foods.

1Food supplements - Food supplements are defined as the substances that help to increase the intake of vitamins, minerals and amino acids in our diets. 2Nutrient supplements are those products that include vitamins, minerals, herbs, meal supplements, sports nutrition products and other related products used to boost the nutritional content of the diet. 3Health foods include food items such as organic tea and coffee, organic spices herbs and seasonings, organic grains, flour and pastas, organic seeds and pulses, organic fruits and vegetables.

Moreover, significantly higher proportions of females (17.7%) were also consuming health

foods as compared to males (9.1%) (Table 66). Some employees (10.1%) considered organic

foods as prestige foods with special health benefits and thus, were consuming them.

At the managerial level, nearly one sixth of them (16.4%) used food supplements, with

significantly higher proportion of female managers (42.9%) using them as compared to male

managers (13.0%) (ϰ 2 = 4.040; p=0.044) (Table 66). Very few managers used nutrient

supplements (8.2%) and health foods (6.6%).

Table 66: Consumption of supplements and health foods among calling and managerial level BPO employees

Figures in parentheses represent percentages *Significant at p<0.05

Supplement use was ascertained in community college students (n=502) from Arizona

(Elridge and Sheehan, 1994). Nearly 37% were consuming supplements weekly or daily and

25% were taking them less than once a week such as Vitamin C, multivitamins, Vitamin E,

Calcium and fish oil. Benefits such as increase in energy, reduced stress, proper nutrition

and protection from cold were significantly perceived by users as compared to non-users

(Elridge and Sheehan, 1994). In another study of young adults (n=2451) in seven Western

Calling level Supplements Total

(n=415) Males (n=274)

Females (n=141)

ϰ 2 p value

Food supplements x Yes x No

41(9.9) 374(90.1)

17(6.2) 257(93.8)

24(17.0) 117(83.0)

12.234

0.000*

Nutrient supplements x Yes x No

32(7.7) 383(92.3)

15(5.5) 259(94.5)

17(12.1) 124(87.9)

5.668

0.017*

Health foods x Yes x No

50(12.0) 365(88.0)

25(9.1) 249(90.9)

25(17.7) 116(82.3)

6.507

0.011*

Supplements Managerial level Total (n=61) Males (n=54) Females (n=7) ϰ 2 p value Food supplements

x Yes x No

10(16.4) 51(83.6)

7(13.0) 47(87.0)

3(42.9) 4(57.1)

4.040

0.044*

Nutrient supplements x Yes x No

5(8.2) 56(91.8)

4(7.4) 50(92.6)

1(14.3) 6(85.7)

0.390

0.533

Health foods x Yes x No

4(6.6) 57(93.4)

4(7.4) 50(92.6)

0(0) 7(100.0)

--

--

states, majority of them (66.6%) were consuming food supplements. They cited prevention

from cold and illnesses and compensating for nutrients not in the daily diet as most

common benefits for their consumption (Schutz et al., 1982).

3.9.6.7 Eating out

In the present study, eating out referred to consumption of freshly cooked/ready to eat

packed food prepared away from home. This included: (i) eating subsidized meals/snacks

provided in the office cafeteria (ii) all meals/snacks consumed at a restaurant/local

vendors/dhabas and (iii) meals/snacks ordered from food outlets and eaten at home/office.

(i) Eating office cafeteria food

Eating food from the office cafeteria was very common among calling and managerial BPO

employees, with 42.9% at the calling level and one third (32.8%) at the managerial level

consuming cafeteria food on a daily basis (Table 67). There was no association between

gender and frequency of eating cafeteria food among calling and managerial level

employees (Table 67). In some companies, the employees were given coupons for

subsidized meals - either lunch or dinner depending on their shift, during which they ate the

meals in the office cafeteria.

Table 67: Frequency of office canteen food consumption among calling and managerial level BPO employees

Calling level Frequency Total (n=415) Males (n=274) Females (n=141) ϰ 2 p value Never 49(11.8) 31(11.3) 18(12.8) 1.650 0.799 Daily 178(42.9) 118(43.1) 60(42.6) Once in 2-3 days 78(18.8) 54(19.7) 24(17.0) Once a week 55(13.3) 38(13.9) 17(12.1) Once in 2 weeks 33(8.0) 18(6.6) 15(10.6) Once in a month 22(5.3) 15(5.5) 7(5.0) Managerial level Frequency Total (n=61) Males (n=54) Females (n=7) ϰ 2 p value Never 11(18.0) 11(20.4) 0(0) 7.233 0.204 Daily 20(32.8) 16(29.6) 4(57.1) Once in 2-3 days 7(11.5) 5(9.3) 2(28.6) Once a week 9(14.8) 9(16.7) 0(0) Once in 2 weeks 8(13.1) 8(14.8) 0(0) Once in a month 6(9.8) 5(9.3) 1(14.3) Figures in parentheses represent percentages

(ii) Eating at restaurants/local vendors/dhabas

Nearly one fourth (25.1%) of the BPO employees at the calling level reported eating at a

restaurant/from local vendors/dhabas either daily or once in 2-3 days (Table 68). More than

one third (34.5%) of them preferred eating out once a week. Around one fifth of them

(20.7%) also preferred to eat out once in two weeks. At the managerial level, nearly one

tenth (8.2%) of the employees were eating out either daily or once in 2-3 days. Slightly more

than one-third (34.4%) preferred eating out once a week and nearly one fourth (24.6%) ate

out once in two weeks (Table 68). The main reasons for eating out were meeting friends

(64.8% and 47.5%), attending social gatherings/parties (50.6% and 52.5%), feeling

happy/sad (17.3% and 26.2%) and lack of time to prepare meals (15.7% and 13.1%) for

calling and managerial level employees, respectively (Fig 28a and 28b). Among managers,

staying alone (52.5%) was one of the major reasons for eating out. However, there was no

significant association between gender and eating out at restaurant/local vendors/dhabas

among calling (p=0.352) and managerial level (p=0.731). The most frequently visited joints

were KFC, Mc Donalds, Pizza Hut, Dominos, Haldirams, Kareems, local dhabas and street

food hawkers for the unique taste and flavor of the food served by them. During the FGDs,

the employees reported that weekend was one time that they were free and relaxed. Since

they had to work five days and sometimes six days in a week, weekend was the only time

when they could meet their friends, watch a movie and have food together. This was the

routine followed by most of the employees and was their way of socialization and

relaxation.

Table 68: Frequency of eating out among BPO employees

Calling level Frequency Total (n=415) Males (n=274) Females

(n=141) ϰ 2 p value

Never 9(2.2) 5(1.8) 4(2.8) 5.559 0.352 Daily 24(5.8) 18(6.6) 6(4.3) Once in 2-3 days 80(19.3) 51(18.6) 29(20.6) Once a week 143(34.5) 93(33.9) 50(35.5) Once in 2 weeks 86(20.7) 52(19.0) 34(24.1) Monthly 73(17.6) 55(20.1) 18(12.8) Managerial level Frequency Total (n=61) Males (n=54) Females (n=7) ϰ 2 p value Never 3(4.9) 3(5.6) 0(0) 2.797 0.731 Daily 1(1.6) 1(1.9) 0(0) Once in 2-3 days 4(6.6) 4(7.4) 0(0)

Once a week 21(34.4) 17(31.5) 4(57.1) Once in 2 weeks 15(24.6) 13(24.1) 2(28.6) Monthly 17(27.9) 16(29.6) 1(14.3) Figures in parentheses represent percentages Multiple responses

(iii) Ordering food from outside

64.8

50.6

17.3

15.7

4.1

4.3

0.5

0.2

1.0

61.7

51.5

18.6

16.1

2.9

4.0

0.4

0.4

1.1

70.9

48.9

14.9

14.9

6.4

5.0

0.7

0.0

0.7

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Meeting friends

Social gatherings/parties

Feeling happy/sad

Lack of time to cook

During stress

Mood dependent

To drink alcohol

For in between snacking

Staying alone

Percent

Figure 28a: Reasons for eating out by calling level BPO employees*


52.5

6.6

1.6

13.1

26.2

52.5

47.5

55.6

7.4

1.9

11.1

29.6

55.6

46.3

28.6

0.0

0.0

28.6

0.0

28.6

57.1

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Staying alone

Mood dependent

During stress

Lack of time to cook

Feeling happy/sad

Social gatherings/parties

Meeting friends

Percent

Figure 28b: Reasons for eating out by managerial level BPO

employees*


*Multiple responses

*Multiple responses

More than half of them at the calling (53.5%) and managerial level (60.7%) ordered food

from outside (Table 69). Of them, very few (1.4%) or none were ordering it daily at the

calling and managerial level respectively. Very few were ordering it once in 2-3 days at the

calling (9.0%) and managerial level (5.4%), while nearly one third (30.6%) of the calling level

employees and less than one fifth (18.9%) at the managerial level were ordering food once a

week. There was no significant association between gender and ordering food from outside

at both the calling (p=0.309) and managerial level (p=0.375) (Table 69). The dishes most

frequently ordered were pizza, pasta, burger, shahi paneer, dal makhani, butter naan, malai

kofta, butter chicken, fried chicken, mutton, noodles, pepsi, and ice cream.

Table 69: Frequency of ordering food from outside among calling and managerial level BPO employees

Calling level Frequency Total

(n=415) Males (n=274)

Females (n=141)

ϰ 2 p value

Never 193(46.5) 127(46.4) 66(46.8) 5.967 0.309 Daily 3(1.4) 3(2.0) 0(0.0) Once in 2-3 days 20(9.0) 17(11.6) 3(4.0) Once a week 67(30.2) 45(30.6) 34(45.3) Once in 2 weeks 57(25.7) 34(23.1) 23(30.7) Monthly 75(33.8) 48(32.7) 27(36.0) Managerial level Frequency Total (n=61) Males (n=54) Females (n=7) Never 24(39.3) 23(42.6) 1(14.3) 4.234 0.375 Daily 0(0) 0(0) 0(0) Once in 2-3 days 2(5.4) 2(6.5) 0(0) Once a week 7(18.9) 5(16.1) 2(33.3) Once in 2 weeks 11(29.7) 10(32.3) 1(16.7) Monthly 17(45.9) 14(45.2) 3(50.0) Figures in parentheses represent percentages Multiple responses

3.9.6.8 Diet intake pattern

Diet intake pattern of the calling and managerial level employees was assessed using 24

hour diet recall for two non-consecutive days (one week day and weekend day/one holiday)

and a food frequency questionnaire. The food frequency questionnaire was self-

administered whereas employees were interviewed by the researcher to elicit 24 hour diet

recall. It was carried out on a random sub-sample for calling level (n=105) and managerial

level (n=16) employees as detail diet assessment is very tedious and time consuming.

3.9.6.8.1 Food intake

Employees at the calling and managerial level were asked to respond regarding the specific

food items that they consumed usually. These food items were listed and categorized into

food groups. Each food group has been described in detail next (Table 70, 71 and Fig 29).

Cereals and cereal products

The mean daily intake of cereals and cereal products was 236±104 grams per day for males

and 128±55 grams per day for female calling level employees (Table 70a). It was 229±131

grams per day for male and 152±147 grams per day for female managers (Table 70b). Both

the calling level and managerial level employees did not meet daily recommendation for

cereal consumption which is 375 grams for males and 270 grams for females (NIN, 2011). At

the calling level, mean percent adequacy was 62.9±38.52% for males and less than 50% for

females, while at the managerial level, it was 61.1±31.3% for males and 56.3±35.8% for

females (Fig 29a and b). The percent adequacy was significantly higher among male

employees at the calling level (p=0.000) as illustrated in Table 71a. However, no difference

was observed in percent adequacy among male and female managers (Table 71b). For both

male and female employees working at the calling and managerial level, intake of cereal and

their products was higher on weekday as compared to weekend day (Table 70a and b). The

employees were consuming wheat (mostly as chapatti and parantha) and rice as the main

cereals.

The food frequency data for calling and managerial level employees further revealed that

majority of the employees (92%) were consuming chapatti daily, nearly half (42%)

consumed plain boiled rice daily and 8.7% were consuming white bread daily. Biscuits were

being consumed daily by 42% of the employees while 37% were consuming them for 3-4

days in a week. More than one third of them were consuming parantha (37%) and

pasta/noodles/macaroni (34%) weekly whereas one fourth of them were consuming white

bread (29%) and non-vegetarian biryani (21%) weekly. More than half of them were

consuming pizza (54%) and burger (42%) monthly, more than one third were consuming

poori (36%) monthly and one fourth opted for bathura (26%), fried rice (21%), khichdi (23%)

and butter naan (19%) once a month. The proportion of employees eating food items for

less than a month for porridge was 2%, cornflakes with milk was 3%, brown bread was 6%,

poha was 1%, upma was 1% and brown rice was 1%.

Pulses

The mean daily intake of pulses was 47±42 grams in males and 41±31 grams in females at

the calling level and 25±10 grams for males and 25±15 grams for females at the managerial

level. This was lower than the daily requirement of 75 grams for males and 60 grams for

females (Table 70a and b). At the calling level, the mean percent adequacy for pulses among

male vegetarians was 74.01±60.21% while for female vegetarians, it was 71.27±43.07%. At

the calling level, the mean percent adequacy for pulses among male non-vegetarians was

74.57±66.57% while for female non-vegetarians; it was 76.18±41.26% (Table 71a). At the

managerial level, the mean percent adequacy for male vegetarians was 34.2±13.2%, while

for female vegetarians, it was 35.8±18.9%. At the managerial level, the mean percent

adequacy for male non-vegetarians was 38.5±11.1%, while for female non-vegetarians, it

was 39.7±30.1% (Table 71b). However, these differences were not significant both at the

calling and managerial level (Table 71a and b). For both, males and female employees at the

calling and managerial level, the pulse consumption was higher on weekend as compared to

weekday (Table 70a and b). The most commonly consumed pulses by the employees were

chana dal, masoor dal (dehusked) and moong dal (dehusked). Other items included sancks,

besan, nutrinuggets/soya products. Based on the food frequency data among the calling

and managerial level employees, it was observed that the less than one tenth of the

employees were consuming chana dal (8%), masoor dal dehusked (7%) and moong dal

dehusked daily. Others were consuming the dehusked pulses such as chana dal (55%),

masoor dal (50%), moong dal (50%), and urad dal (41%), kala chana (26%) and rajmah (41%)

1-2 times in a week. Less than one-third of them included whole pulses in their diet on a

weekly basis (whole masoor (25%), whole moong (24%) and whole urad (21%)). More than

one tenth (13.0%) of the employees consumed sprouts once in a month. The employees

were consuming dehusked pulses more frequently as compared to whole pulses.

Green leafy vegetables

The consumption of green leafy vegetables was very low among both male and female

employees at the calling and managerial level. The mean daily intake in males was 11±34

grams and females was 18±47 grams at the calling level, while it was 17±16 grams among

males and 25±14 grams among females at the managerial level (Table 70a and b). This was

far below the recommended daily intake which is 100 grams per day. At the calling level, the

intake was higher for both males (12±34 grams) and females (25±56 grams) on weekdays

while for the managers the intake was higher for males on weekend (20±16 grams) as

compared to female managers for whom it was higher on weekdays (27±14 grams) (Table

70a and b). Thus, the mean percent adequacy was only 11.46±33.82% for males and

18.41±46.59% for female employees at the calling level and 17.0±30.7% for males and

25.0±34.4% for females at the managerial level according to recommended daily intake (Fig

29a and b). Although, the mean percent adequacy was higher in female employees both at

the calling and managerial level as compared to males, these differences were not

significant (Table 71a and b). The main source of green leafy vegetables in the diet of the

employees was spinach (palak), and fenugreek leaves (methi) and mustard leaves (sarson) in

season. It was observed from the food frequency data (n=415) that less than one fifth of

them (19%) were consuming spinach once a week. Other employees opted for green leafy

vegetable preparations such as ‘saag’ (a traditional vegetarian preparation made with

combination of spinach, mustard and goosefoot leaves) which was consumed weekly by

23% of the employees and monthly by 28% of the employees in winters. Employees were

also consuming fenugreek leaves (methi) (19%) once in a month in winters. Apart from

these, no other green leafy vegetables were being consumed.

Table 70a: Mean food group intake of calling level BPO employees (n=105)

Food group Males Males (n=65) Females Females (n=40) Recommended daily intakea

Intake (Average of 2 days) (Mean±SD)

Weekday (Day 1)

Weekend (Day 2)

Recommended daily intakea


Weekday (day 1)

Weekend (Day 2)

Cereals and cereal products (gm)

375 236±104 239±106 232±104 270 128±55 136±59 120±50

Pulses (gm) x Vegetariansb (n=63) x Non-vegetariansc (n=42)

75 47±42 56±45 33±30

44±39 45±36 60 41±31 43±26 38±36

36±23 45±36

Leafy vegetables (gm) 100 11±34 12±34 10±34 100 18±47 25±56 12±34 Other vegetables (gm) 200 61±71 70±57 56±83 200 40±41 44±38 36±43 Roots and tubers (gm) 200 109±64 108±62 109±66 200 92±80 85±59 98±97 Milk and milk products (ml) 300 228±224 259±218 203±226 300 163±192 165±189 162±197 Fruits (gm) 100 84±14 91±25 93±24 100 95±23 92±21 81±24 Meat and poultry (gm) -- 51±102 44±85 56±114 -- 25±53 15±41 36±62 Fats and edible oils (gm) 25(visible) 37±20(total) 34±18 39±22 20(visible) 34±16(total) 30±18 38±15 Sugars (gm) 20 35±15 36±16 34±15 20 34±10 35±11 32±10 Nuts and oil seeds (gm) -- 2±5 2±6 1±4 -- 2±5 1±4 2±6 a Dietary Guidelines for Indians, National Institute of Nutrition, 2011 bVegetarian: A person who does not eat food derived from animals such as meat, fish, chicken, eggs etc, and only eats plant foods such as vegetables, fruits, nuts, grains, and milk and milk products as the only animal foods cNon-vegetarians: A person who eats food derived from animals as well as from plants

Table 70b: Mean food group intake of managerial level BPO employees (n=16)

Food group Males Males (n=11) Females Females (n=5) Recommended daily intakea


Weekday (Day 1)

Weekend (Day 2)

Recommended daily intakea


Weekday (day 1)

Weekend (Day 2)


375 229±131 226±124 233±128 270 152±147 161±47 148±42

Pulses (gm) x Vegetariansb (n=10) x Non-vegetariansc(n=6)

75 25±10 30±31 27±36

24±10 27±20 28±29

25±11 33±40 29±27

60 25±15 31±28 29±20

22±10 33±28 24±22

24±11 30±35

Leafy vegetables (gm) 100 17±16 18±13 20±16 100 25±14 27±14 23±14 Other vegetables (gm) 200 53±63 77±74 49±41 200 56±22 58±29 54±30 Roots and tubers (gm) 200 112+28 101±26 116±25 200 119±46 120±44 113±49 Milk and milk products (ml)

300 268+217 260±215 275±229 300 157±73 158±77 157±78

Fruits (gm) 100 129±54 110±59 127±55 100 112±53 109±56 111±50 Meat and poultry (gm) -- 77+36 76±29 78±49 -- 69±60 44±62 73±34 Fats and edible oils (gm) 25(visible) 35±20(total

) 36±22 33±19 20(visible) 26±14(total) 19±5 33±17

Sugars (gm) 20 29±14 26±13 31±14 20 28±17 24±19 31±26 Nuts and oil seeds (gm) -- 1±2 0±0 1±3 -- -- -- -- a Dietary Guidelines for Indians, National Institute of Nutrition, 2011 bVegetarian: A person who does not eat food derived from animals such as meat, fish, chicken, eggs etc, and only eats plant foods such as vegetables, fruits, nuts, grains, and milk and milk products as the only animal foods cNon-vegetarian: A person who eats food derived from animals as well as from plants

Table 71a: Mean percent adequacy of food groups with respect to recommended daily intakes or calling level BPO employees (n=105)

Food group Males (n=65) Females (n=40)

t value p value Employees meeting mean percent adequacy

Percent adequacy (Mean±SD)


0-50% 51-75% >75%

Total M F Total M F Total M F


62.9±38.52 47.44±14.56 11.85 0.000* 40 (38.1)

13 (20.0)

27 (67.5)

17 (16.2)

12 (18.5)

5 (12.5)

48 (45.7)

40 (61.5)

8 (20.0)

Pulses (gm) x Vegetarians# x Non-vegetarians#

74.21±63.24 74.01±60.21 74.57±66.57

73.25±42.15 71.27±43.07 76.18±41.26

1.132 0.259 49 (46.7)

30 (46.2)

19 (47.5)

14 (13.3)

9 (13.8)

5 (12.5)

42 (40.0)

26 (40.0)

16 (40.0)

Leafy vegetables (gm) 11.46±33.82 18.41±46.59 1.356 0.177 95 (90.5)

60 (92.3)

35 (87.5)

1 (0.9)

1 (1.5)

0 (0.0)

9 (8.6)

4 (6.2)

5 (12.5)

Other vegetables (gm) 30.50±35.43 20.03±20.25 2.410 0.017* 61 (58.1)

34 (52.3)

27 (67.5)

25 (23.8)

16 (24.6)

9 (22.5)

19 (18.1)

15 (23.1)

4 (10.0)

Roots and tubers (gm) 54.53±31.99 45.74±40.03 1.795 0.074 86 (81.9)

50 (76.9)

36 (90.0)

12 (11.4)

9 (13.8)

3 (7.5)

7 (6.7)

6 (9.2)

1 (2.5)

Milk and milk products (ml)

76.01±74.69 54.32±63.94 2.227 0.027* 55 (52.4)

30 (46.2)

25 (62.5)

15 (14.3)

10 (15.4)

5 (12.5)

35 (33.3)

25 (38.5)

10 (25.0)

Fruits (gm) 84.44±28.88 95.03±15.30 0.553 0.558 55 (52.4)

36 (55.4)

19 (47.5)

7 (6.7)

3 (4.6)

4 (10.0)

43 (41.0)

26 (40.0)

17 (42.5)

Sugars (gm) 175.34±43.23 170.87±26.16 2.089 0.038* 20 (19.0)

11 (16.9)

9 (22.5)

16 (15.2)

8 (12.1)

8 (20.0)

69 (65.7)

46 (70.8)

23 (57.5)

*Significant at p<0.05 #According to the Dietary Guidelines for Indians, one portion of pulse may be exchanged with one portion (50g) of egg/meat/chicken/fish for non-vegetarians. For vegetarians, 75g (for males) and 60g (for females) were considered as the recommended daily intakes of pulses for computing percent adequacy, while for non-vegetarians who had consumed flesh foods/eggs on the days for which diet recall was taken, 45g (for males) and 30g (for females) were considered as the recommended daily intakes for computation.

Table 71b: Mean percent adequacy of food groups with respect to recommended daily intakes for managerial level BPO employees (n=16)

Food group Males (n=11)

Females (n=5)

t value

p value

Employees meeting mean percent adequacy



0-50% 51-75% >75% Total M F Total M F Total M F


61.1±31.3 56.3±35.8 0.288 0.778 5 (31.3)

3 (27.3)

2 (40.0)

10 (62.5)

7 (63.6)

3 (60.0)

1 (6.3)

1 (9.1)

0 (0.0)

Pulses (gm) x Vegetarians# x Non-vegetarians#

33.3±10.0 34.2±13.2 38.5±11.1

41.7±28.2 35.8±18.9 39.7±30.1

0.909 0.378 7 (43.8)

5 (45.5)

2 (40.0)

9 (56.3)

6 (54.5)

3 (60.0)

0 (0.0)

0 (0.0)

0 (0.0)

Leafy vegetables (gm) 17.0±30.7 25.0±34.4 0.493 0.629 9 (56.3)

6 (54.5)

3 (60.0)

7 (43.8)

5 (45.5)

2 (40.0)

0 (0.0)

0 (0.0)

0 (0.0)

Other vegetables (gm) 26.5±31.9 28.0±28.6 0.096 0.925 7 (43.8)

5 (45.5)

2 (40.0)

9 (56.3)

6 (54.5)

3 (60.0)

0 (0.0)

0 (0.0)

0 (0.0)

Roots and tubers (gm) 56.0±22.4 59.5±23.6 0.302 0.767 6 (37.5)

4 (36.4)

2 (40.0)

8 (50.0)

6 (54.5)

2 (40.0)

2 (12.5)

1 (9.1)

1 (20.0)


89.3±72.3 52.3±63.2 1.051 0.310 5 (31.3)

4 (36.4)

1 (20.0)

7 (43.8)

4 (36.4)

3 (60.0)

4 (25.0)

3 (27.3)

1 (20.0)

Fruits (gm) 129.0±54.7 112.0±48.9 0.634 0.536 0 (0.0)

0 (0.0)

0 (0.0)

5 (31.3)

4 (36.4)

1 (20.0)

11 (68.8)

7 (63.6)

4 (80.0)

Sugars (gm) 145.0±67.8 140.0±44.6 0.161 0.874 0 (0.0)

0 (0.0)

0 (0.0)

3 (18.8)

2 (18.2)

1 (20.0)

13 (81.3)

9 (81.8)

4 (80.0)

#According to the Dietary Guidelines for Indians, one portion of pulse may be exchanged with one portion (50g) of egg/meat/chicken/fish for non-vegetarians. For vegetarians, 75g (for males) and 60g (for females) were considered as the recommended daily intakes of pulses for computing percent adequacy, while for non-vegetarians who had consumed flesh foods/eggs on the days for which diet recall was taken, 45g (for males) and 30g (for females) were considered as the recommended daily intakes for computation.

62.9

74

74.6

11

30.5

54.5

76

84

175

47.4

71.3

76.2

18

20

46

54.3

95

170

0 50 100 150 200


Pulses (vegetarians)

Pulses (non-vegetarians)

Leafy vegetables

Other vegetables

Roots and tubers

Milk and milk products

Fruits

Sugars

Mean percent adequacy

Figure 29a: Mean percent adequacy of daily food intake (Food group wise) among calling level employees (n=105)

Females Males

61.1

34.2

38.5

17

26.5

56

89.3

129

145

56.3

35.8

39.7

25

28

59.5

52.3

112

140

0 50 100 150 200


Pulses (vegetarians)

Pulses (non-vegetarians)

Leafy vegetables

Other vegetables

Roots and tubers


Fruits

Sugars


Figure 29b: Mean percent adequacy of daily food intake (Food group

wise) among managerial level employees (n=16)

Females Males

Other vegetables

The other vegetables include all vegetables that are not green leafy or roots and tubers. The

intake of these vegetables was low among both sexes at the calling and managerial level.

The mean daily intake of the other vegetables was 61±71 grams in male and 40±41 grams

for female employees at the calling level, and 53±63 grams for males and 56±22 grams for

females at the managerial level (Table 70a and b). The mean percent adequacy was low,

31±35.43% for males and 20±20.25% for females at the calling level and 26.5±31.9% for males

and 28.0±28.6% for females at the managerial level, falling short of the recommended daily

intake of 200 grams (Fig 29a and b). The mean percent adequacy was significantly higher for

males compared to females at the calling level (t=2.410; p=0.017) (Table 71a), while no

significant differences were observed between male and female managers (Table 71b). The

consumption of other vegetables was high on weekdays as compared to weekend days for

employees at calling (males 70±57 grams; females 44±38 grams) and managerial levels

(males 77±74 grams; females 58±29 grams) (Table 70a and b). The food frequency data at

the calling and managerial level revealed that the employees had consumed brinjal (26%),

lady’s finger (24%), ridge gourd (21%), beans (19%), mushroom (19%), bottle gourd (17%),

and cabbage (15%) once in a month. Remaining were consuming these vegetables less

frequently. Tomato was consumed daily by 95.6% as it was used for preparing various

vegetable preparations.

Roots and tubers

Out of all the vegetable categories, consumption of roots and tubers was the highest. The

daily intake in males was 109±64 grams and for females it was 92±80 grams at the calling

level (Table 70a and 70b), and was 112+28 grams among males and 119±46 grams among

females at the managerial level. At the calling level, mean percent adequacy was

54.53±31.99% for males and 45.74±40.03% for females, while at the managerial level the

mean percent adequacy was between 50-60% for both males and females as compared with

daily recommended intake (Fig 29a and b), however, no significant gender differences were

observed (Table 71a and b). The intake was higher on weekend for both males (109±66

grams) as well as females (98±97 grams) at the calling level, while at the managerial level,

the intake was higher on weekend for males while it was higher on weekdays in case of

females (Table 70a and b). The main vegetable included in the diet of the employees in this

category was potato. Based on the food frequency data, nearly half of them (48%) were

consuming potato daily either as a vegetable preparation in cafeteria or as a snack –

samosa, pakora and patty. More than half of them (53%) were also consuming potato once

a week. Other root vegetables which were consumed once a week when in season by less

than one fourth of the employees were carrot (24%), turnip (8%), and radish (9%).


Mean intake of milk and milk products was 228±224 ml in a day among male employees as

compared to 163±192 ml in female employees at the calling level (Table 70a). At the

managerial level as well, the mean intake of milk and milk products was 268+217ml in a day

for males as compared to 157±73ml in a day for females (Table 70b). Among male

employees at the calling level, it was meeting three fourths of the daily recommended

intake (76.0%) (Fig 29a), with higher intakes during weekday (259±218 ml) as compared to

weekend days (203±226 ml) (Table 4.56a). In comparison, among female employees at the

managerial level, the mean percent adequacy was 54.3% (Fig 29a), similar intake during

weekday (165±189 ml) as well as weekend day (162±197 ml) (Table 70a). At the managerial

level, the daily intake was meeting most of the recommended intake for male managers

(89.3%), while for females, it met slightly more than half (52.3%) (Fig 29b). The consumption

was high on weekends for male managers (275±229 ml) and on weekdays (158±77ml) for

female managers (Table 70b). The mean percent adequacy was significantly higher in males

as compared to females (Table 71a and b). The main sources of milk and milk products were

milk, paneer and curd. The food frequency data revealed that all three types of milk – full

creama, tonedb and double tonedc were being consumed by the employees. Nearly one third

(24%) were consuming full cream milk, one sixth (14%) were consuming toned milk and less

than one-tenth (9%) were consuming double toned milk daily. One fifth of them (21%) were

consuming curd daily while nearly one third (31%) were consuming it 1-2 times in a week.

Various preparations in which milk and milk products were being consumed were paneer

curry (43%), palak paneer (19%), porridge (10%), milk with cornflakes (8%) and milk with

muesli (3%). These preparations were consumed once a week by the employees at the

calling and managerial level. Milk was also being added to tea (71%) and coffee (22%) daily

by the employees. The proportion of employees consuming items such sweet lassi and milk

shake once a month was 21% and 17% respectively.

Fruits

The mean daily consumption of fruits was slightly less than the recommended intake for

both males (84±14 grams) and females (95±23 grams) at the calling level as shown in table

70a. However, it was more than the recommended daily intake for both male (129±54

grams) and female (112±53 grams) managers (Table 70b). The mean percent adequacy was

84.44±28.88% for males and 95.03±15.30% for females at the calling level and 129.0±54.7% for

males and 112.0±48.9% for females at the managerial level (Fig 29a and b). Though, the

mean percent adequacy was higher in females as compared to males at the calling level and

vice versa at the managerial level, but these differences were not significant (Table 71a and

b). The consumption among males was higher during weekends as compared to females at

the calling level, while it was higher during weekend for both male and female managers

(Table 70a and b).

Based on the food frequency data at the calling and managerial level, 17% of the employees

were consuming apple and 9.2% were consuming banana daily. Others were consuming

banana (38%) and/or apple (40%) 1-2 times in a week. One third to one sixth of the

employees were consuming seasonal fruits such as orange (30%), mango (27%), guava

(20%), grapes (20%) and papaya (16%) once a week when in season. The focus group

discussions further revealed that many did not think of fruit as an important part of the daily

diet. They felt it was fine to consume it on the days it was available. Some even mentioned

that even if the fruit was available at home, they did not remember to eat it.

Meat and poultry

Meat and poultry included the consumption of flesh foods and eggs. The daily intake of

meat and poultry was for 51±102 grams for males as compared to 15±53 grams for females

at the calling level (Table 70a). At the managerial level, the daily intake was 77+36 grams for

males and 69±60 grams for females (Table 70b).The consumption pattern was similar

among both male and female employees at the calling and managerial level, with intake

being higher on weekend as compared to weekday (Table 70a and b). The main sources of

aFull cream milk: Milk having fat content 6-8%. bToned milk: Milk having fat content 3%. cDouble toned milk: Milk having fat content 1.5%.

meat and poultry in the diet of the employees were egg and chicken. Based on the food

frequency data, one fifth of the employees (21%) were consuming butter chicken once a

week while nearly one sixth (14%) consumed fried chicken once in a month. Thirteen

percent of the employees were consuming eggs daily as boiled egg, omlette, scrambled,

poached, fried egg or as egg curry. Of them, nearly one third were consuming egg once a

week as boiled egg (28%) or omelette (27%). Fish consumption was limited to once a month

among both calling (n=415) and managerial level employees (n=61). Eight percent of them

preferred fish as a fish curry preparation, while 8% preferred fried fish and 6% preferred

grilled fish (6%). One fifth (20%) of the total employees were also consuming mutton curry

once a month. Sea food such as prawn, crab, shell fish, mollusks and lobster were consumed

only by very few employees 1-6 times in a year.

Fats and edible oils

The mean daily total fat intake was 37±20 grams in males and 34±16 grams in female

employees at the calling level, and 35±20 grams in males and 26±14grams in female

employees at the managerial level. (Table 70a and b). The consumption was high for males

(39±22 grams) and female employees (38±15 grams) during weekend as compared to

weekday at the calling level. At the managerial level, the consumption was high for males

during the weekday (36±22 grams) and for females during the weekend days (33±17 grams).

The focus group discussions revealed that weekend (Saturday and Sunday) were the off days

for the employees and it was the time when most of them went out and had outside food,

which might be a contributing factor to high fat intake during the weekends (Table 70a and

b). Besides this, outside food was being consumed daily as cafeteria food and/or ordered

from outside. The commonly consumed sources of fats and edible oils were desi ghee (60%),

soybean oil (55%) and butter (49%), which were being used as a cooking medium. However,

fats are also derived from other food items which are hidden sources and this is known as

‘invisible fat’. The sources of these in the diet of employees were chicken (with skin), egg,

mutton, milk and milk products. In addition, certain food preparations which were

purchased for consumption such as pizza, burger, biscuit, chips, namkeen,, sweets such as

burfi and gulab jamun, ice cream, pakora, patty, samosa and mathri also contributed to total

fat intake.

Sugars

The sugar consumption daily was 35±15 grams for males and 34±10 grams for females at

the calling level, and was 29±14 grams for males and 28±17 grams for females at the

managerial level (Table 70a and b). This was more than the daily recommendation which is

20 grams per day (ICMR, 2011). The mean intake was more during weekend as compared to

weekday for both male and female employees at the calling and managerial level (Table 70a

and b). The percent adequacy for sugars was 175% and 170% in males and females at the

calling level and 145% for males and 140% for females at the managerial level respectively

(Fig 29a and b). While the percent adequacy was significantly higher among males at the

calling level, no differences were seen between males and females percent adequacy at the

managerial level (Table 71a and b). According to food frequency data at the calling and

managerial level, one fourth (25%) of the BPO employees were consuming cream biscuits

daily while another one fifth (22%) were consuming them 2-3 times in a week. One third of

them were consuming cake (33%), ice cream (34%) and gulab jamun (36%) 3-4 times in a

month while one fourth were consuming pastry (24%), kheer (27%), kaju burfi (22%),

rasgulla (25%) and besan ladoo (23%) 3-4 times in a month. One fifth of the employees were

consuming jalebi (21%) and khoa burfi (19%) 3-4 times in a month and on tenth opted for

custard (12%), milk chocolate (12%) and dark chocolate (12%) 3-4 times in a month.

Beverages such as tea (71%) and coffee (18%) were consumed daily by the employees.

Nearly half of them (45%) were consuming cold drink/aerated beverages 2-3 times a week

while one fourth were consuming tetra pack juice (200ml pack) 2-3 times a week. They also

consumed fresh fruit juice with sugar (21%), Frooti (200ml) pack (11%) and cold coffee

(11%) 2-3 times in a week. All these food items contributed to the sugar intake among the

employees.

Nuts and oil seeds

The daily consumption of nuts and oil seeds was 2±5 grams among calling level employees,

while only male managers were consuming nuts and oil seeds (1±2 grams) (Table 70a and

b). The food frequency data revealed that nearly one fourth of them (25%) were consuming

4-5 almonds daily while one sixth (17%) were consuming groundnuts once a week.

Consumption of other nuts was less frequent (one in a month) which included cashewnuts

(19%), and walnuts (12%).

Miscellaneous food items

Besides this, there were certain other popular food items that were being consumed by the

BPO employees both at the calling and managerial level. While one sixth to nearly one tenth

of the employees preferred to consume namkeen/fried snack mixtures (16%), chips/wafers

(8%), and samosa (8%) on a daily basis; other items such as pakora (22%), popcorn (24%),

patties (20%), mathri (11%) and cheese slices (11%) were consumed once in a month.

3.9.6.8.2 Nutrient intake

Adults need several nutrients from diet to remain physiologically healthy. All the nutrients

must be provided in balanced amounts, as deficiency or excess of one or more nutrients is

not desirable (ICMR, 2010). The proportional percentage of calories derived from

macronutrients (carbohydrates, protein and fat) was estimated (Table 72). Among male

employees at the calling level, the mean percent calories derived from carbohydrates were

55.71%, from protein were 12.87% and from fat were 32.85%, while at the managerial level,

the percent calories derived from carbohydrates were 56.78%, from protein were 15.74%

and from fat were 35.24%. Among females at the calling level, the percent calories

contributed by carbohydrates were 52.78%, from protein were 12.42% and from fat were

37.26%, while at the managerial level, the percent calories contributed by carbohydrates

were 52.24%, from protein were 14.04% and from fat were 37.54%. The mean percent

calories derived from fat were higher than 30% among male as well as female employees at

both levels. Nearly half (47.6%) of the calling level employees and more than sixty percent

(62.5%) of the managerial level employees derived more than 30% of their dietary energy

from fat.

Table 72: Mean percent calories derived from macronutrients in the diet of calling and managerial level BPO employees

Macronutrients Calling level

Recommendationa Total (n=105)

Males (n=65) Percent calories

Females (n=40) Percent calories

Carbohydrates 55-60% 55.71±11.89 52.78±12.42 Protein 10-15% 12.87±4.45 12.42±4.39 Fat Up to 30% 32.85±12.11 37.26±9.87 %calories from fat >30% (n) (WHO, 2003) 50(47.6) 36(55.4) 14(35.0) %calories from fat >25% (n) (ICMR,2011 ) 95(90.5) 57(87.7) 38(95.0) Macronutrients Managerial level

Recommendationa Total (n=16)

Males (n=11) Percent calories

Females (n=5) Percent calories

Carbohydrates 55-60% 56.78±12.21 52.24±12.59 Protein 10-15% 8.07±3.46 9.59±4.24 Fat Up to 30% 35.24±6.87 37.54±10.22 %calories from fat >30% (n) (WHO, 2003) 10(62.5) 7(63.6) 3(42.8) %calories from fat >25% (n) (ICMR,2011) 12(75.0) 8(72.7) 4(80.0) a Hooper et al., 2012; FAO, 2010; WHO, 2003

Based on two days (non-consecutive) 24 hour dietary recall, the nutrient intake was also

ascertained among the calling and managerial level BPO employees. Each nutrient has been

described in detail next (Table 73, 74 and Fig 30).

Table 73a: Mean daily nutrient intake of calling level BPO employees (n=105)

Nutrient RDAa for males

Males (n=65) RDAa for females

Females (n=40) Total intake (Average of

2 days) (Mean±SD)

Weekday (Day 1)

Weekend (Day 2)

Total intake (Average of

2 days) (Mean±SD)

Weekday (Day 1)

Weekend (Day 2)

Energy (kcal) 2320 2082±574 2060±593 2077±547 1900 1546±430 1481±374 1611±476 Protein (gm) 60 67±25 68±25 67±25 55 48±17 44±12 52±19 Fat (total) (gm) 25

(visible) 76±28 75±30 77±26 20 (visible) 64±23 62±23 67±23

Calcium (mg) 600 783±369 821±376 749±358 600 727±384 725±391 728±381 Vitamin A (mcg) 600 524±506 548±539 482±458 600 554±568 639±707 468±373 Thiamine (mg) 1.2 1.39±0.61 1.45±0.57 1.34±0.64 1.0 0.93±0.32 0.96±0.32 0.91±0.33 Riboflavin (mg) 1.4 1.06±0.62 1.16±0.67 0.97±0.55 1.1 0.80±0.36 0.81±0.35 0.78±0.37 Niacin (mg) 16 11.93±5.52 12.07±5.09 11.83±5.95 12 7.50±3.29 7.71±2.97 7.28±3.61 Vitamin C (mg) 40 47±25 41±25 45±15 40 48±28 42±13 44±17 Iron (mg) 17 15.15±6.42 15.27±6.05 14.99±6.84 21 10.44±5.09 10.62±4.89 10.26±5.34 Crude Fibre (gm) -- 8.09±4.35 7.93±4.10 8.31±4.55 -- 6.65±4.54 7.04±4.55 6.27±4.55

a Nutrient Requirements and Recommended Dietary Allowances for Indians, Indian Council of Medical Research, 2010 # Figures in parentheses represent percentages

Table 73b: Mean daily nutrient intake of managerial level BPO employees (n=16)

Nutrient RDAa for males

Males (n=15) RDAa for females

Females (n=5)

Total intake (Average of 2

days) (Mean±SD)

Weekday (Day 1)

Weekend (Day 2)

Total intake (Average of

2 days) (Mean±SD)

Weekday (Day 1)

Weekend (Day 2)

Energy (kcal) 2320 2132±699 2216±629 2049±785 1900 1835±229 1698±139 1972±228 Protein (gm) 60 43±37 41±41 42±36 55 44±16 50±12 40±13 Fat (total) (gm) 25 (visible) 84±33 85±33 82±35 20 (visible) 77±14 71±12 82±14 Calcium (mg) 600 719±340 716±333 718±304 600 761±416 766±339 759±452 Vitamin A (mcg) 600 559±526 557±484 549±570 600 493±199 562±241 424±138 Thiamine (mg) 1.2 1.26±0.68 1.29±0.61 1.24±0.78 1.0 0.90±0.23 1.02±0.12 0.78±0.27 Riboflavin (mg) 1.4 1.51±1.01 1.76±1.18 1.26±0.77 1.1 0.89±0.15 0.84±0.19 0.95±0.08 Niacin (mg) 16 11.04±6.66 11.49±6.37 10.59±7.22 12 7.02±2.79 8.33±1.16 5.72±3.45 Vitamin C (mg) 40 45±26 42±26 50±25 40 27±17 31±16 22±19 Iron (mg) 17 13.84±7.22 14.57±6.70 13.12±7.95 21 9.32±3.17 10.85±0.99 7.79±3.97 Crude Fibre (gm) -- 6.23±3.58 6.20±3.83 6.25±3.50 -- 4.85±2.42 6.08±2.45 3.61±1.86

a Nutrient Requirements and Recommended Dietary Allowances for Indians, Indian Council of Medical Research, 2010 # Figures in parentheses represent percentages

Table 74a: Mean percent adequacy of nutrients with respect to Recommended Dietary Allowances for calling level BPO employees (n=105)

Nutrient Males (n=65) Females (n=40)

t value p value




0-50% 51-75% >75%

Total M F Total M F Total M F

Energy (kcal) 89.72±24.78 81.38±22.64 2.502 0.013* 8 (7.6)

5 (7.7)

3 (7.5)

27 (25.7)

15 (23.1)

12 (30.0)

70 (66.7)

45 (69.2)

25 (62.5)

Protein (gm) 112.09±40.87 87.38±30.14 5.002 0.000* 4 (3.8)

1 (1.5)

3 (7.5)

22 (21.0)

9 (13.8)

13 (32.5)

79 (75.2)

55 (84.6)

24 (60.0)

Calcium (mg) 130.57±61.56 121.21±63.93 1.054 0.293 7 (6.7)

3 (4.6)

4 (10.0)

13 (12.4)

8 (12.3)

5 (12.5)

85 (81.0)

54 (83.1)

31 (77.5)

Vitamin A(mcg) 87.37±84.29 92.27±94.70 0.379 0.705 19 (18.1)

11 (26.2)

8 (20.0)

35 (34.3)

24 (36.9)

11 (27.5)

51 (48.6)

30 (46.2)

21 (52.5)

Thiamine (mg) 115.79±50.57 93.47±31.97 3.503 0.001* 10 (9.5)

6 (9.2)

4 (10.0)

16 (15.2)

9 (13.8)

7 (17.5)

79 (75.2)

50 (76.9)

29 (72.5)

Riboflavin mg) 75.66±44.16 72.65±32.66 0.559 0.577 32 (30.5)

20 (30.8)

12 (30.0)

30 (28.6)

19 (29.2)

11 (27.5)

43 (41.0)

26 (40.0)

17 (42.5)

Niacin (mg) 74.56±34.50 62.47±27.42 2.806 0.006* 32 (30.5)

15 (23.1)

17 (42.5)

32 (30.5)

20 (30.8)

12 (30.0)

41 (39.0)

30 (46.2)

11 (27.5)

Vitamin C (mg) 117.51±18.19 120.00±13.40 1.429 0.154 18 (17.1)

11 (16.9)

7 (17.5)

10 (9.5)

5 (7.7)

5 (12.5)

77 (73.3)

49 (75.4)

28 (70.0)

Iron (mg) 88.23±37.78 49.70±24.25 8.334 0.000* 34 (32.4)

9 (13.8)

25 (62.5)

26 (24.8)

14 (21.5)

12 (30.0)

25 (23.8)

22 (33.8)

3 (7.5)


Table 74b: Mean percent adequacy of nutrients with respect to Recommended Dietary Allowances for managerial level BPO employees (n=16)

Nutrient Males (n=11) Females (n=5)

t value p value




0-50% 51-75% >75%

Total M F Total M F Total M F Energy (kcal) 91.90±30.15 96.57±12.07 0.469 0.642 4

(25.0) 3 (27.2)

1 (20.0)

5 (31.3)

4 (36.4)

1 (20.0)

7 (43.8)

4 (36.4)

3 (60.0)

Protein (gm) 71.67±43.21 80.00±41.11 0.386 0.705 4 (25.0)

2 (18.1)

2 (40.0)

8 (50.0)

5 (45.5)

3 (60.0)

4 (25.0)

4 (36.4)

0 (0.0)

Calcium (mg) 119.80±56.60 126.83±51.23 0.253 0.804 3 (18.8)

2 (18.1)

1 (20.0)

4 (25.0)

3 (27.2)

1 (20.0)

9 (56.3)

6 (54.5)

3 (60.0)

Vitamin A (mcg)

93.17±36.14 82.22±33.21 0.613 0.549 3 (18.8)

2 (18.1)

1 (20.0)

5 (31.3)

3 (27.2)

2 (40.0)

8 (50.0)

6 (54.5)

2 (40.0)

Thiamine (mg) 105.14±56.85 90.03±23.51 5.746 0.000*

2 (12.5)

1 (9.1)

1 (20.0)

5 (31.3)

3 (27.2)

2 (40.0)

9 (56.3)

7 (63.6)

2 (40.0)

Riboflavin (mg)

107.94±71.8 80.99±13.38 4.672 0.000*

1 (6.3)

1 (9.1)

0 (0.0)

5 (31.3)

2 (18.1)

3 (60.0)

10 (62.5)

8 (72.7)

2 (40.0)

Niacin (mg) 69.01±41.63 58.57±23.26 4.661 0.000*

6 (37.5)

4 (36.4)

2 (40.0)

7 (43.8)

4 (36.4)

3 (60.0)

3 (18.8)

3 (27.2)

0 (0.0)

Vitamin C (mg)

112.5±24.12 67.5±201.6 3.876 0.002*

2 (12.5)

0 (0.0)

2 (40.0)

3 (18.8)

1 (9.1)

2 (40.0)

10 (62.5)

9 (81.8)

1 (20.0)

Iron (mg) 81.46±42.45 44.39±15.09 5.319 0.000*

5 (31.3)

2 (18.1)

3 (60.0)

4 (25.0)

2 (18.1)

2 (40.0)

7 (43.8)

7 (54.5)

0 (0.0)


223

89.7

111.7

130.5

87.3

115.8

75.7

74.6

117.5

88.2

81.4

87.3

121.2

92.2

93

72.7

62.5

120

49.7

0 20 40 60 80 100 120 140

Energy

Protein

Calcium

Vitamin A

Thiamine

Riboflavin

Niacin

Vitamin C

Iron


Figure 30a: Mean percent adequacy of daily nutrient intake among calling level BPO employees (n=105)

Females Males

91.9

71.67

119.8

93.17

105.14

107.94

69.01

112.5

81.46

96.57

80

126.83

82.22

90.03

80.99

58.57

67.5

44.39

0 20 40 60 80 100 120 140

Energy

Protein

Calcium

Vitamin A

Thiamine

Riboflavin

Niacin

Vitamin C

Iron


Figure 30b: Mean percent adequacy of daily nutrient intake among

managerial level BPO employees (n=16)

Females Males

223

Energy

The mean energy intake of the male employees at the calling level was 2082±574 kcal and at

the managerial level was 2132±699kcal (Table 73a and b). On weekdays, the mean intake

was 2060±593 kcal at the calling level and 2216±629 at the managerial level whereas on

weekend day it was 2077±547 kcal at the calling and 2049±785kcal at the managerial level

(Table 73a and b). On comparison with recommended dietary allowances (RDA), the

percent adequacy was 89.72±24.78% at the calling level and 91.90±30.15% at the

managerial level, and was not fulfilling the energy RDA of 2320kcal (Fig 30a and b). In case

of female employees, the mean energy intake was 1546±430 kcal at the calling and

1835±229 kcal at the managerial level (Table 73a and b), with it being 1481±374kcal and

1698±139kcal during the weekdays and 1611±476 kcal and 1972±228kcal during the

weekends at the calling and managerial level respectively (Table 73a and b). The percent

adequacy was 81.38±22.64% at the calling and 96.57±12.07% at the managerial level, with

% females were unable to meet their daily RDA of 1900kcal (Fig 30a and b). The mean

percent adequacy for energy was significantly higher in males as compared to females at the

calling level, however, no significant differences were observed between the two sexes at

the managerial level (Table 74a and b). For both males and females at the calling level, the

mean daily energy intake was higher on weekend as compared to weekday, while at the

managerial level, it was high on weekdays for male employees and higher on weekend for

female employees.

Protein

The mean protein intake at the calling level was 67±25 grams, with male employees

consuming 68±25 grams during the weekday and 67±25 grams during the weekend (Table

73a). At the managerial level, the mean protein intake was 43±37 grams, with male

managers consuming 41±41grams protein during the weekday and 42±36 grams during the

weekend (Table 73b). The percent adequacy of protein intake in males was more than 100%

of the RDA at the calling level (112.09±40.87%) while it was less than 100% of the RDA at the

managerial level (71.67±43.21%) (Fig 30a and b). In case of female employees at the calling

level, the protein intake was 48±17 grams, with it being 44±12 grams during weekday and

52±9 grams during weekend (Table 73a). At the managerial level, the mean intake was

44±16 grams, with it being 50±12 grams during the weekday and 40±13 grams during

224

weekend (Table 73b). However, the percent adequacy of protein in terms of RDA was

87.38±30.14% at the calling and 80.00±41.11% at the managerial level (fig 30a and b). It was

significantly higher in the male employees as compared to the female employees at the

calling level (Table 74a). However, these differences were not significant at the managerial

level (Table 74b).

Fat

The mean total fat intake was assessed among BPO employees at the calling and managerial

level. In case of male employees, it was 76±28 grams at the calling and 84±33 grams at the

managerial level whereas in case of females, it was 64±23 grams at the calling and

77±14grams at the managerial level (Table 73a and b). The total fat intake was higher on

weekends for both males (77±26 grams) and females (67±23 grams) at the calling level,

whereas the intake of fat was higher during weekdays for male managers (85±33 grams) and

on weekends for female managers (82±14 grams) (table 73a and b). However, comparison

with RDA could not be done, as the RDA is given only for visible fat, which does not include

fat present in various food items as invisible fat. Therefore, percent adequacy with respect

to RDA was not computed.

Calcium

The mean calcium intake was more than the recommendation among calling and

managerial level employees. It was 783±369 mg and 719±340 mg for males and 727±383 mg

and 761±416 mg for females at the calling and managerial level respectively (Table 73a and

b); both higher than the recommended intake of 600 mg per day. However, for males, the

calcium intake was higher on weekdays (821±376 mg) unlike females, where it was higher

on weekends (728±381 mg) at the calling level (Table 73a). At the managerial level, the

calcium intake was higher on weekends for males (718±304 mg) and higher on weekdays for

females (766±339 mg) (Table 73b). The percent adequacy in terms of RDA was more than

100% for both males as well females at the calling and managerial level (Fig 30a and b) and

there were no significant differences between them (Table 74a and b).

Vitamin A

The daily mean intake of Vitamin A at the calling level was 524±506 mcg in males and

553±568 mcg in females; and at the managerial level was 559±526mcg in males and

225

493±199mcg in females (Table 73a and b). The percent adequacy was 87.37±84.29% and

92.27±94.70% at the calling level, and 93.17±36.14% and 82.22±33.21% at the managerial

level with respect to the RDA for both males and females respectively (Fig 30a and b), with

no significant gender differences (Table 74a and b). The mean intake was higher on weekday

for both males (548±539 mcg and 557±484 mcg) and females (639±707 mcg and

562±241mcg) as compared to the weekend at the calling and managerial levels (Table 73a

and b).

Thiamine

The mean thiamine intake was more than the RDA for males (1.39±0.61 mg and 1.26±0.68

mg) but less than RDA for females (0.93±0.32 mg and 0.90±0.23 mg) at both calling and

managerial levels (Table 73a and b). The intake was higher on weekday as compared to

weekend for both sexes at calling and managerial levels (Table 73a and b). The mean

percent adequacy with respect to RDA, was more than 100% for males and slightly less than

100% for females (Fig 30a and b), with it being significantly higher in males (Table 74a and

b).

Riboflavin

The mean intake of riboflavin was less than the RDA for both males (1.06±0.62 mg) and

females (0.80±0.36 mg) at the calling level as illustrated in Table 73a. At the managerial

level, the mean intake of riboflavin was slightly more than RDA for males (1.51±1.01mg) but

less than RDA for females (0.89±0.15mg) (Table 73b). The mean percent adequacy was less

among females (72.65±32.66%) in comparison to males (75.66±44.16%) at calling level as

well as managerial level employees (Females 80.99±13.38%; Males 107.94±71.8%) (Fig 30a

and b). There were no significant differences between them at the calling level but

significant differences were observed at the managerial level (Table 74a and b). At the

calling level, for both male and female employees, the mean intake was higher during the

weekday as compared to the weekend (Table 73a) while at the managerial level, the mean

intake was higher during weekday for males and higher during weekend for females (Table

73b).

226

Niacin

Of all fractions of Vitamin B, niacin had the most inadequate mean intake ](Males

11.93±5.52 mg (calling level) and 11.04±6.66mg (managerial level); Females 7.50±3.29 mg

(calling level) and 7.02±2.79mg (managerial level)] compared to thiamine and riboflavin

among both the levels of employees (Table 73a and b). The mean percent adequacy was

74.56±34.50% and 69.01±41.63% in males and 62.47±27.42% and 58.57±23.26% in females

at the calling and managerial levels respectively (fig 30a and b). It was significantly higher in

males as compared to females (Table 74a and b). The mean intake of niacin was higher on

weekday as compared to weekend for both male (12.07±5.09 mg and 11.49±6.37mg vs

11.83±5.95 mg and 10.59±7.22mg) and female employees (7.71±2.97 mg and 8.33±1.16mg

vs 7.28±3.61 mg and 5.72±3.45mg) at both calling and managerial levels (Table 73a and b).

Vitamin C

The mean daily intake of vitamin C was 47±25 mg and 45±26 mg for males and 48±28 mg

and 27±17 mg for females at the calling and managerial level respectively (Table 73a and b).

The mean percent adequacy of Vitamin C was more than 100% for both males and females

at the calling level while it was more than 100% of males and less than 70% for females at

the managerial level (fig 30a and b). There were no significant differences between them at

the calling level, however, significant differences were observed at the managerial level

(Table 74a and b). For both males and females working at the calling level, the intake was

higher on weekend (45±15 mg and 44±17 mg) as compared to weekday (41±25 mg and

42±13 mg) (Table 73a). Howver, the intake was higher during the weekend for males

(50±25mg) and higher during weekday for females (31±16mg) at the managerial level (Table

73b).

Iron

While for males, the mean daily iron intake was 15.15±6.42 mg and 13.84±7.22mg, for

females it was 10.44±5.09 mg and 9.32±3.17 mg at the calling and managerial levels

respectively (Table 73a and b). The mean percent adequacy for iron compared with RDA in

males was 88.23±37.78% and 81.46±42.45% whereas for females it was less than 50%

(49.70±24.25%) and 44.39±15.09% at the calling and managerial levels respectively (fig 30a

and b). The mean percent adequacy was significantly higher in males as compared to

227

females at both the calling and managerial levels (Table 74a and b). For both males and

females, the mean iron intake was higher on weekday [(males 15.27±6.05 mg (calling level)

and 14.57±6.70mg (managerial level); females 10.62±4.89 mg (calling level) and

10.85±0.99mg (managerial level)] as compared to the weekend [(males 14.99±6.84 mg

(calling level) and 13.12±7.95mg (managerial level); females 10.26±5.34 mg (calling level)

and 7.79±3.97mg (managerial level)] (Table 73a and b).

Crude fibre

Among the employees at calling and managerial levels, the mean crude fibre intake was

8.09±4.35 grams and 6.23±3.58 grams in males and 6.65±4.54 grams and 4.85±2.42 grams in

females (Table 73a and b). While, the mean crude fibre intake for males was higher on

weekends [(8.31±4.55 grams (calling level) and 6.25±3.50 grams (managerial level)]; for

females, it was higher on weekday [(7.04±4.55 grams (calling level) and 6.08±2.45 grams

(managerial level)] respectively (Table 73a and b).

3.9.6.8.3 Association of dietary habits and dietary intake with Metabolic Syndrome and its

components

Logistic regression analyses were performed with MetS as the dependent variable with

various dietary variables (table 75).

Table 75: Association between Metabolic Syndrome and dietary habits and intake among

calling (n=415) and managerial level (n=16) BPO employees Dietary habits

Calling level

ATPIII IDF

Wald’s statistic

p value Odds ratioa

Wald’s statistic

p value Odds ratioa

x Skipping breakfast 4.309 0.038* 1.942 0.345 0.557 1.187 x Skipping lunch 4.211 0.040* 2.425 0.658 0.417 1.373 x Fruit (percent adequacy

≥75%b) in females 3.335 0.068 0.264 5.150 0.023* 0.116

x Fruit (percent adequacy ≥75%b) in males

0.056 0.813 0.892 0.074 0.785 0.891

x Sugar (percent adequacy ≥75% b) in females

8.509 0.004* 6.020 3.350 0.060 3.793

x Sugar (percent adequacy ≥75% b) in males

0.620 0.431 1.521 0.742 0.389 1.536

x Pulses (percent adequacy ≥75% b) in females

0.233 0.630 0.624 1.837 0.175 0.344

x Pulses (percent adequacy ≥75% b) in males

0.549 0.459 0.693 0.106 0.745 0.154

228

x Green leafy vegetables (percent adequacy ≥75% b) in females

2.146 0.143 0.395 2.584 0.108 0.125

x Green leafy vegetables (percent adequacy ≥75% b) in males

1.233 0.399 0.327 0.719 0.396 0.707

x Roots and tubers (percent adequacy ≥75% b) in females

1.145 0.002 2.435 0.036 0.849 1.290

x Roots and tubers (percent adequacy ≥75% b) in males

2.703 0.100 2.627 0.549 0.459 1.703

x Milk and milk products (percent adequacy ≥75% b) in females

0.356 0.551 0.407 0.001 0.976 0.974

x Milk and milk products (percent adequacy ≥75% b) in males

1.760 0.185 0.257 1.051 0.305 0.727

Dietary habits

Managerial level

ATPIII IDF

Wald’s statistic

p value Odds ratioa

Wald’s statistic

p value Odds ratioa

x Skipping breakfast 1.451 0.228 0.252 1.775 0.183 0.310 x Skipping lunch 1.535 0.773 0.642 0.866 0.352 0.292 *Significant at p<0.05 aAdjusted odds ratio bAs per recommended daily intake

The results of the logistic regression revealed that among the calling level employees

skipping breakfast (OR 1.94) or lunch (OR 2.42) was associated with twice the likelihood of

having the syndrome. However, no such associations were observed among the managerial

level employees (table 75). Further, associations were drawn between triglyceride levels

(≤150mg/dl and >150mg/dl) and type of oil consumed among calling and managerial level

employees (Table 76 and 77). However, no significant associations were observed.

Table 76: Association of triglyceride levels with type of oil consumed among calling level

employees

Oil type ATPIII/IDF criteria ϰ 2 p value ≤150mg/dl >150mg/dl

Desighee 178(58.4) 70(63.6) 0.936 0.333 Vanaspati 20(6.6) 11(10.0) 1.386 0.239 Soyabean 162(53.1) 65(59.1) 1.165 0.280 Groundnut 10(3.1) 1(0.9) 1.759 0.327 Sunflower 93(30.5) 27(24.5) 1.391 0.238 Safflower 10(3.1) 1(0.9) 1.759 0.327 Butter 153(50.2) 52(47.3) 0.270 0.603 Olive 35(11.5) 8(7.3) 1.537 0.215

229

Cream 20(6.6) 6(5.5) 0.167 0.682 Mayonnaise 21(6.9) 6(5.5) 0.272 0.602 Mustard 96(31.5) 34(30.9) 0.012 0.913 Coconut 5(1.6) 2(1.8) 0.016 0.901 Saffola gold 33(10.8) 9(8.2) 0.618 0.432 Saffola active 7(2.3) 4(3.6) 0.564 0.453 Figures in parentheses represent percentages

Table 77: Association of triglyceride levels with type of oil consumed among managerial

level employees

Oil type ATPIII/IDF criteria ϰ 2 p value ≤150mg/dl >150mg/dl

Desighee 26(66.7) 15(68.2) 0.015 0.904 Vanaspati 3(7.7) 1(4.5) 0.227 0.634 Soyabean 21(53.8) 13(59.1) 0.157 0.692 Groundnut 4(10.3) 1(4.5) 0.610 0.768 Sunflower 15(38.5) 12(54.5) 1.475 0.225 Safflower 2(5.1) 2(9.1) 0.360 0.548 Butter 14(35.9) 12(54.5) 2.000 0.157 Olive 5(12.8) 4(18.2) 0.321 0.571 Mustard 20(51.3) 12(54.5) 0.060 0.806 Saffola gold 2(5.1) 4(18.2) 2.702 0.100 Saffola active 192.6) 2(9.1) 1.281 0.606 Figures in parentheses represent percentages

Among the calling level employees, mean triglyceride levels were significantly higher among

Vanaspati/hydrogenated fat consumers (t=2.262; p=0.019) among the calling level

employees (Table 78). At the managerial level, mean triglyceride levels were significantly

lower among those consuming sunflower oil (t=2.082; p=0.042) and Saffola gold – a blend of

rice bran and safflower oil (t=2.084; p=0.042) (Table 79).

Table 78: Comparison of triglyceride levels w.r.t oil consumption among calling level

employees

Oil type Triglycerides (mg/dl) t value p value Consumers (Mean±SD)

Non–consumers (Mean±SD)

Desighee 248(128.98±82.8) 167(120.03±69.9) 1.149 0.251 Vanaspati 31(157.00±87.3) 384(122.82±76.7) 2.262 0.019* Soyabean 227(124.50±65.7) 188(126.44±90.6) 0.252 0.801 Groundnut 11(105.55±59.9) 404(125.92±78.3) 0.856 0.393 Sunflower 120(121.09±91.2) 295(127.13±71.9) 0.715 0.475 Safflower 11(122.55±116.7) 404(125.46±76.7) 0.122 0.903 Butter 205(122.02±71.6) 210(128.66±83.7) 0.867 0.387 Olive 439(110.65±77.8) 372(127.08±77.8) 1.311 0.191 Canola 2(90.00±12.7) 413(125.55±78.1) 0.643 0.520

230

Cream 26(140.19±137.4) 389(124.39±72.4) 1.001 0.317 Mayonnaise 27(114.18±58.9) 388(126.16±79.1) 0.772 0.441 Mustard 130(132.88±87.2) 285(121.96±73.2) 1.325 0.186 Coconut 7(150.57±156.8) 408(124.95±76.2) 0.862 0.389 Saffola gold 42(141.83±135.1) 373(123.52±68.6) 1.445 0.149 Saffola active 11(123.82±71.2) 404(125.42±78.2) 0.067 0.946 *Significant at p<0.05

Table 79: Comparison of triglyceride levels w.r.t oil consumption among managerial level

employees

Oil type Triglycerides (mg/dl) t value p value Consumers (Mean±SD)

Non–consumers (Mean±SD)

Desighee 41(158.46±99.0) 20(136.45±57.3) 0.919 0.362 Vanaspati 4(152.87±90.3) 57(128.00±29.6) 0.545 0.588 Soyabean 34(147.30±73.3) 27(154.38±98.6) 0.311 0.757 Groundnut 5(136.40±39.4) 56(152.57±90.8) 0.392 0.696 Sunflower 34(130.97±61.0) 27(176.78±108.6) 2.082 0.042* Safflower 4(150.05±90.2) 57(168.25±37.9) 0.398 0.692 Butter 26(165.12±93.6) 35(140.94±82.9) 1.066 0.291 Olive 9(151.00±92.7) 52(152.67±52.6) 0.052 0.959 Mustard 32(148.14±101.2) 29(154.06±74.9) 0.262 0.795 Saffola gold 6(143.73±71.6) 55(220.17±174.9) 2.084 0.042* Saffola active 3(149.39±88.8) 58(187.00±61.8) 0.721 0.473 *Significant at p<0.05

Eating outside in restaurants/dhabas/eating joints as well as ordering food from outside was

not significantly associated with MetS among calling as well as managerial level employees

(Table 80, 81, 82 and 83).

Table 80: Association of eating outside in restaurants/dhabas/eating joints with Metabolic

Syndrome among calling level employees

Frequency of eating out

Metabolic Syndrome (ATPIII) Metabolic Syndrome (IDF) Present

(49) Absent (366)

ϰ 2 p value

Present (76)

Absent (339)

ϰ 2 p value

x Never x Daily&2-3

days in a week

x Weekly to monthly

2(4.1) 14(28.6) 33(67.3)

7(1.9) 90(24.6) 269(73.5)

1.435 0.488 1(1.3) 18(23.7) 57(75.0)

8(2.4) 86(25.4) 245(72.3)

0.446 0.784

Table 81: Association of ordering food from outside with Metabolic Syndrome among

calling level employees

231

Frequency of ordering


(49) Absent (366)

ϰ 2 p value

Present (76)

Absent (339)

ϰ 2 p value

x Never x Daily&2-3

days in a week

x Weekly to monthly

20(40.8) 13(26.5) 16(32.7)

173(47.7) 74(20.4) 116(32.0)

1.210 0.546 28(36.8) 18(23.7) 30(39.5)

165(49.1) 69(20.5) 102(30.4)

3.889 0.143

Table 82: Association of eating outside in restaurants/dhabas/eating joints with Metabolic

Syndrome among managerial level employees

Frequency of eating out


(13) Absent

(48) ϰ 2 p

value Present

(19) Absent

(42) ϰ 2 p

value x Never x Daily&2-3

days in a week

x Weekly to monthly

0(0) 2(15.4) 11(84.6)

3(6.2) 3(6.2) 42(87.5)

1.864 0.310 2(10.5) 3(15.8) 14(73.7)

1(2.4) 2(4.8) 39(92.9)

4.259 0.141

Table 83: Association of ordering food from outside with Metabolic Syndrome among




(13) Absent

(48) ϰ 2 p

value Present

(19) Absent

(42) ϰ 2 p


days in a week

x Weekly to monthly

4(30.8) 3(23.1) 6(46.2)

20(41.7) 6(12.5) 22(45.8)

1.085 0.581 7(36.8) 5(26.3) 7(36.8)

17(40.5) 4(9.5) 21(50.0)

3.037 0.219

Associations were also determined between eating outside in restaurants/dhabas/eating

joints as well as ordering food from outside with components of MetS (Table 84, 85, 86 and

87). However, no significant associations were observed between eating out and

components of MetS.

Table 84: Association of eating outside in restaurants/dhabas/eating joints with

components of Metabolic Syndrome among calling level employees

Frequency of Components (ATPIII) Metabolic Syndrome (IDF)

232

ordering 0 1-2 3 or more ϰ 2 p value 0 1-2 3 or more

ϰ 2 p value

x Never x Daily&2-3

days in a week

x Weekly to monthly

1(0.9) 29(25.4) 84(73.7)

6(2.4) 62(24.6) 184(73.0)

2(4.1) 13(26.5) 34(69.4)

1.918 0.735 1(1.5) 17(25.8) 48(72.7)

6(2.3) 64(24.4) 192(73.3)

2(2.3) 23(26.4) 62(71.3)

0.312 0.988

Table 85: Association of ordering food from outside with components of Metabolic

Syndrome among calling level employees


Components (ATPIII) Metabolic Syndrome (IDF) 0 1-2 3 or more ϰ 2 p value 0 1-2 3 or

more ϰ 2 p value

x Never x Daily&2-3

days in a week

x Weekly to monthly

50(44.6) 29(25.9) 33(29.5)

122(48.6) 47(18.7) 82(32.7)

21(42.9) 11(22.4) 17(34.7)

2.275 0.600 29(44.6) 20(30.8) 116(24.6)

131(50.4) 49(18.8) 80(30.8)

33(37.9) 18(20.7) 36(41.4)

9.368

0.053

Table 86: Association of eating outside in restaurants/dhabas/eating joints with

components of Metabolic Syndrome among managerial level employees


Components (ATPIII) Metabolic Syndrome (IDF) 0 1-2 3 or more ϰ 2 p value 0 1-2 3 or

more ϰ 2 p value

x Never x Daily&2-3

days in a week

x Weekly to monthly

0(0) 1(8.3) 11(91.7)

3(8.3) 2(5.6) 31(86.1)

0(0) 2(15.4) 11(84.6)

3.251 0.517 0(0) 0(0) 6(100.0)

1(2.8) 2(5.6) 33(91.7)

2(10.5) 3(15.8) 14(73.7)

4.575

0.334

Table 87: Association of ordering food from outside with components of Metabolic

Syndrome among managerial level employees


Components (ATPIII) Metabolic Syndrome (IDF) 0 1-2 3 or more ϰ 2 p

value 0 1-2 3 or more ϰ 2 p


days in a week

x Weekly to monthly

6(50.0) 1(8.3) 5(41.7)

14(38.9) 5(13.9) 17(47.2)

4(30.8) 3(23.1) 6(46.2)

1.616 0.806 3(50.0) 0(0) 3(50.0)

14(38.9) 4(11.1) 18(50.0)

7(36.8) 5(26.3) 7(36.8)

3.629 0.459

233

Table 88: Percent adequacy of food group and nutrient intake among male calling level

BPO employees in relation with Metabolic Syndrome

Nutrient/food group

ATPIII criteria IDF criteria With MetS (n=19)

Without MetS (n=46)

t value

p value With MetS (n=27)

Without MetS (n=38)

t value p value

Energy 90.1±26.6 89.6±24.1 0.107 0.915 89.9±25.5 89.6±24.4 0.073 0.942 Protein 119.2±38.7 109.1±41.6 1.277 0.204 117.8±46.1 108.0±36.5 1.341 0.182 Calcium 132.7±66.6 129.7±59.7 0.249 0.804 127.4±61.7 132.8±61.7 0.488 0.626 Vitamin A 68.9±64.3 94.9±90.5 1.609 0.110 79.4±78.2 93.0±88.5 0.908 0.365 Thiamine 117.4±51.7 114.8±50.4 0.262 0.794 120.9±50.8 111.8±50.4 1.002 0.318 Riboflavin 73.4±33.4 76.4±48.0 0.354 0.724 79.5±53.1 72.7±36.6 0.856 0.393 Niacin 78.1±43.9 73.1±29.9 0.743 0.459 78.0±40.4 72.1±29.7 0.958 0.340 Vitamin C 119.2±58.3 113.3±57.8 1.260 0.210 118.7±55.7 114.0±48.8 1.634 0.105 Iron 87.8±37.5 89.7±38.1 0.270 0.795 91.6±39.7 87.4±36.5 0.615 0.540 Cereals and cereal products

90.4±46.1 86.1±35.1 0.574 0.567 90.6±42.5 85.1±35.6 0.799 0.426

Pulses 71.9±55.8 80.4±73.9 0.632 0.528 65.8±54.7 86.5±76.8 1.693 0.093 Leafy vegetables

1.1±4.5 14.9±39.4 2.157 0.033* 5.9±29.1 14.4±36.6 1.410 0.161

Other vegetables

37.9±50.9 27.4±26.3 1.538 0.127 35.4±46.1 27.0±25.0 1.325 0.188

Roots and tubers

53.6±33.3 55.2±31.6 0.258 0.797 59.6±34.1 51.3±30.1 1.469 0.144


69.4±78.0 78.7±73.5 0.645 0.520 70.3±73.9 80.1±75.4 0.739 0.462

Fruits 72.5±68.4 77.7±70.4 0.863 0.389 75.6±70.1 87.4±62.4 0.684 0.495 Sugars 131.9±50.9 122.6±58.6 0.662 0.509 128.3±52.2 123.2±56.6 0.391 0.697

Table 89: Percent adequacy of food group and nutrient intake among female calling level

BPO employees in relation with Metabolic Syndrome

Nutrient/food group

ATPIII criteria IDF criteria With MetS (n=19)

Without MetS (n=31)

t value

p value With MetS (n=16)

Without MetS (n=24)

t value p value

Energy 81.2±25.3 81.5±21.8 0.051 0.959 78.7±26.0 83.2±20.2 0.861 0.392 Protein 83.3±27.7 98.5±34.1 2.051 0.044* 86.5±27.1 88.9±34.7 0.359 0.720 Calcium 114.8±43.0 123.5±70.7 0.545 0.588 106.4±41.9 130.9±73.9 1.707 0.092 Vitamin A 65.7±59.9 102.4±103.6 1.562 0.122 74.4±82.7 104.2±101.0 1.385 0.170 Thiamine 96.2±36.3 92.4±30.4 0.475 0.636 88.8±33.5 96.6±30.9 1.078 0.284 Riboflavin 66.9±19.1 74.7±36.4 0.957 0.341 63.7±22.8 78.4±36.9 2.013 0.048*

Niacin 58.5±23.0 72.8±35.1 2.126 0.037* 60.1±23.9 66.0±32.0 0.952 0.344 Vitamin C 122.7±45.7 114.9±39.6 1.066 0.290 121.8±72.2 118.8±42.6 1.245 0.217 Iron 46.3±15.4 50.9±26.8 0.766 0.446 45.8±15.6 52.3±28.5 1.176 0.243 Cereals and 34.3±15.33 34.1±14.4 0.059 0.953 32.5±14.1 35.2±14.9 0.785 0.435

234

cereal products Pulses 77.1±71.4 64.3±41.1 1.006 0.317 71.1±63.3 65.6±41.6 0.470 0.640 Leafy vegetables

10.9±38.2 21.3±49.4 0.886 0.378 21.9±49.3 16.0±45.1 0.555 0.580

Other vegetables

20.0±22.8 20.0±19.4 0.008 0.993 17.7±19.9 21.6±20.5 0.827 0.411

Roots and tubers

36.9±21.6 49.1±44.8 1.213 0.229 35.3±21.4 52.7±47.6 1.933 0.057


41.1±47.8 59.5±68.9 1.149 0.254 40.4±46.3 63.8±72.4 1.616 0.110

Fruits 62.7±62.7 151.2±69.8 2.374 0.020* 67.9±72.8 166.1±78.7 2.946 0.004*

Sugars 115.4±61.4 77.0±71.7 2.385 0.020* 110.7±56.6 96.1±78.6 0.969 0.336

Hence, in this group it was observed that some food groups and nutrients were adequate as

per the recommendations while others were not. Among the calling level employees, none

of the food groups had 100% adequacy except sugar which was more than 100%. In terms of

nutrient intake, the mean percent adequacy was more than 100% for calcium and vitamin C.

At the managerial level, only fruits met their daily recommendation in terms of food groups

while 100% adequacy was met for nutrients such as calcium and vitamin C. In case of calling

level employees, more than 60% of them were meeting >75% adequacy for energy, protein,

calcium and thiamine. However, more than 60% of the female calling level employees

(62.5%) had their mean percent adequacy of iron as less than 50% of the RDA. This was

similar in case of female managers, where 60% of them also had their mean percent

adequacy of iron as less than 50%. The mean percent adequacy in terms of food groups was

low (< 50%) specifically in case of green leafy vegetables, among both calling and managerial

level employees (Table 88 and 89). At the calling level, the percent adequacy of daily intake

of green leafy vegetables (p=0.033) among males was significantly lower in those with MetS

according to ATPIII criteria. Among females, percent adequacy of daily intake of protein

(p=0.044), niacin (p=0.037), and fruits (p=0.020) according to ATPIII criteria and riboflavin

according to IDF criteria (p=0.048) were significantly lower in those with MetS. Mean

percent adequacy of sugars was significantly higher among female calling level employees

with MetS as compared to those without it (p=0.020). A study on 72 individuals (30-59 years)

with MetS in Southern Brazil, corroborates with the present study where a significantly lower intake

of vegetables (p<0.001) was observed among those with the syndrome (Carvalho et al; 2015).

However, another study among free living subjects with and without MetS (35-55 years)

235

visiting the OPDs of 7 Delhi hospitals, observed contrary findings where the employees with MetS

had significantly higher intake of niacin (p<0.01) (Sharma and Mahna, 2014).

Table 90: Comparison between the mean daily intake of food groups and nutrients among

calling level BPO employees with and without Metabolic Syndrome

In the present study, comparison of mean intake food groups and nutrients among BPO

employees in relation with MetS was assessed (Table 90). The intake of pulses (males ATPIII

p=0.012; females IDF p=0.036) and riboflavin (males ATPIII, p=0.028; females ATPIII,

Nutrient/Food group

ATPIII t value

p value IDF t value

p value With MetS

Mean±SD

Without MetS Mean±SD

With MetS Mean±SD

Without MetS Mean±SD

Energy (kcal)

M F

2095±696 1570±437

2075±510 1245±193

0.186 2.136

0.853 0.001*

2138±737 1570±435

2066±524 1250±227

0.585 1.776

0.560 0.016*

Protein (gm)

M F

65±25 40±11

69±24 49±17

0.855 1.392

0.394 0.168

67±24 36±16

69±27 49±17

0.402 1.820

0.689 0.002*

Fat (total) (gm)

M F

76±33 66±23

76±25 50±16

0.101 1.891

0.927 0.029*

78±35 66±23

75±26 46±19

0.492 2.077

0.624 0.041*

Calcium (mg)

M F

713±259 548±224

817±409 747±393

1.500 1.396

0.136 0.167

754±333 476±163

791±380 748±340

0.467 1.683

0.641 0.007*

VitaminA (mcg)

M F

370±373 506±562

598±545 559±573

2.448 0.721

0.016* 0.804

337±278 383±282

576±542 567±584

2.250 0.764

0.002* 0.447

Thiamine (mg)

M F

1.35±0.56 0.76±0.80

1.47±0.70 0.95±0.33

1.063 1.646

0.290 0.000*

1.34±0.56 0.77±0.80

1.56±0.74 0.95±0.33

1.734 1.318

0.085 0.001*

Riboflavin (mg)

M F

0.92±0.37 0.52±0.16

1.12±0.69 0.83±0.36

1.805 2.383

0.028* 0.001*

0.95±0.40 0.48±0.11

1.09±0.67 0.82±0.36

1.040 2.350

0.300 0.000*

Niacin (mg)

M F

11.63±4.67 6.78±2.75

12.57±6.99 7.55±3.36

0.911 0.459

0.364 0.648

11.41±4.66 5.97±1.80

13.80±7.73 7.62±3.66

2.048 1.187

0.043* 0.239

Vitamin C (mg)

M F

37±29 34±26

42±18 43±22

0.997 3.091

0.321 0.003*

40±31 33±30

44±33 46±11

0.977 2.772

0.330 0.008*

Iron (mg)

M F

15.04±7.46 9.86±2.83

15.21±5.91 10.50±5.29

0.138 0.336

0.891 0.738

16.35±8.08 9.69±3.32

14.82±5.89 10.49±5.22

1.114 0.371

0.267 0.712

Carbohydrate (gm)

M F

297±103 208±65

286±75 160±46

0.663 2.063

0.509 0.042*

296±109 172±44

288±78 206±66

0.423 1.264

0.673 0.210

Crude fibre (gm)

M F

7.67±3.68 6.38±4.35

8.96±5.44 9.09±5.72

1.599 1.623

0.112 0.109

7.73±3.89 6.44±4.31

9.37±5.62 9.33±6.74

1.775 1.514

0.078 0.134


M F

237±119 130±56

235±97 106±41

0.082 1.214

0.935 0.229

250±122 112±43

232±99 129±55

0.822 0.732

0.413 0.466

Pulses (gm) M F

41±35 40±29

60±50 51±42

2.534 1.029

0.012* 0.307

43±38 39±29

59±51 66±38

1.763 2.137

0.080 0.036*

Leafy vegetables (gm)

M F

9±25 18±25

12±37 23±16

0.462 0.260

0.645 0.796

6±16 4±10

12±25 11±13

0.891 0.960

0.375 0.001*

Other vegetables (gm)

M F

67±69 29±23

58±72 41±42

0.628 0.831

0.531 0.408

61±54 28±17

61±75 41±42

0.036 0.788

0.971 0.433

Roots and tubers (gm)

M F

112±61 96±82

108±65 53±41

0.351 1.443

0.726 0.027*

94±82 65±39

92±48 61±75

1.676 0.846

0.048* 0.400


M F

190±167 147±22

246±180 180±195

1.330 2.343

0.186 0.000

201±187 122±123

236±133 175±195

0.731 1.905

0.466 0.040*

Fruits (gm)

M F

89±103 106±237

127±165 120±142

1.394 1.167

0.046* 0.247

88±122 118±106

122±155 102±101

1.070 1.018

0.287 0.312

Meat and poultry (gm)

M F

64±45 23±64

23±89 26±53

2.200 0.157

0.030* 0.876

31±48 28±10

56±40 27±55

1.149 1.215

0.253 0.056

Fats & edible oils (gm)

M F

38±23 30±17

36±20 22±13

0.523 1.388

0.602 0.169

39±27 28±7

36±19 29±17

0.593 0.219

0.554 0.827

Sugars (gm)

M F

15±11 19±7

15±18 15±11

0.180 1.328

0.835 0.188

15±17 14±11

13±11 12±5

0.602 0.399

0.548 0.691

Nuts and oil seeds (gm)

M F

3±7 1±4

1±4 2±5

1.462 0.314

0.146 0.754

3±7 2±4

1±4 2±5

1.653 0.055

0.101 0.956


236

p=0.001; IDF, p=0.000) in both males and females was significantly lower while the intake of

roots and tubers in both males (IDF p=0.048) and females (ATPIII p=0.027) was significantly

higher in individuals with MetS as compared to those without the syndrome. In males with

MetS, the intake of meat and poultry (ATPIII p=0.030) was significantly higher while the

intake of fruits (ATPIII p=0.046), vitamin A (ATPIII p=0.016; IDF p=0.002) and niacin (IDF

p=0.043) was significantly lower. In females, the intake of green leafy vegetables (IDF

p=0.001), milk and milk products (IDF p=0.040), protein (IDF p=0.002), thiamine (ATPIII

p=0.000; IDF p=0.001) and vitamin C (ATPIII p=0.003; IDF p=0.008) were significantly lower

whereas the intake of energy (ATPIII p=0.001; IDF p=0.016), fat (ATPIII p=0.029; IDF p=0.041)

and carbohydrate (ATPIII p=0.042) were significantly higher in individuals with MetS. No

other significant differences were observed with respect to any other nutrients or food

groups.

In the Framingham Offspring-spouse study of 300 healthy women who were followed for a

12 year period, those who developed MetS differed significantly only in their intake of

energy and protein as compared to women without the syndrome (Millen et al., 2006). In

the present study, significant differences were observed for energy, fat, carbohydrate,

protein, thiamine, vitamin C and riboflavin (p<0.05). Presence of MetS (IDF criteria) was

associated with significantly lower intake of Vitamin E (p<0.05), Riboflavin (p<0.01) and

Vitamin B12 (p<0.05) among Iranian adults between the ages of 35-65 years (Motamed et

al., 2013). However, in the present study the intake of riboflavin was significantly lower in

adults with MetS (P<0.05).

237

Key findings

x More than half (59.5%) of the calling level employees and nearly half (47.9%) of the managerial level employees were non-vegetarians.

x At the calling level, 44.8% of the employees skipped breakfast, while at the managerial level 39.3% skipped breakfast.

x More than half (56.9%) of the employees at the calling level and half (50.8%) at the managerial level were eating in between meals frequently to occasionally.

x At the calling level, commonly preferred oils as a medium for cooking were desi ghee (clarified butter) (59.8%), soybean oil (54.7%) and butter (49.4%).

x At the managerial level, the commonly preferred oils were desighee (clarified butter) (67.2%), soyabean oil (55.7%), mustard oil (52.9%) and butter (42.6%).

x Eating food from the office cafeteria was very common among calling and managerial BPO employees, with 42.9% at the calling level and one third (32.8%) at the managerial level consuming cafeteria food on a daily basis.

x Nearly one fourth (25.1%) of the BPO employees at the calling level reported eating at a restaurant/from local vendors/dhabas either daily or once in 2-3 days. At the managerial level, nearly one tenth (8.2%) of the employees were eating out either daily or once in 2-3 days.

x More than half of them at the calling (53.5%) and managerial level (60.7%) ordered food from outside.

x At the calling level, mean percent adequacy of cereals and cereal products (p=0.000), other vegetables (p=0.017), milk and milk products (p=0.027), sugars (p=0.038), energy (p=0.013), protein (p=0.000), thiamine (p=0.001), niacin (p=0.006) and iron (p=0.000) was significantly higher among males than females.

x At the managerial level, there was no significant difference in the percent adequacy of food groups between males and females. However, in terms of nutrients, the mean percent adequacy of thiamine (p=0.000), riboflavin (p=0.000), niacin (p=0.000), vitamin C (p=0.002) and iron (p=0.000) was significantly higher among male managers as compared to female managers.

x Among the calling level employees, skipping breakfast (OR 1.94) or lunch (OR 2.42) was associated with twice the likelihood of having the syndrome. However, no such associations were observed among the managerial level employees.

x Among the calling level employees, mean triglyceride levels were significantly higher among Vanaspati/hydrogenated fat consumers (t=2.262; p=0.019) among the calling level employees. At the managerial level, mean triglyceride levels were significantly lower among those consuming sunflower oil (t=2.082; p=0.042) and Saffola gold (t=2.084; p=0.042).

x Eating outside in restaurants/dhabas/eating joints as well as ordering food from outside was not associated with MetS among calling and managerial level employees

238

CHAPTER 4: DEVELOPMENT AND IMPLEMENTATION OF LIFESTYLE MANAGEMENT

PROGRAM

The second phase of the present study involved the development of a lifestyle management

program for BPO employees with focus on promotion of healthy eating habits and physical

activity along and also efforts to discourage harmful use of alcohol and tobacco products.

The process of program development is as follows.

4.1 Program development

Development of a lifestyle management program for BPO employees involved identification

of the employees’ current eating habits, their lifestyle choices and the changes desired to

improve their diet and lifestyle based on the results of phase I, focus group discussions as

well as key informant interviews conducted with BPO employees.

Program development entailed addressing specific goals and targets focusing on improving

employees’ lifestyle. This can be done by directly changing the individual and/or by

influencing the environment i.e. indirectly affecting factors that lead to behavior change

(knowledge and skill). Modification in the environment to support change requires the basic

framework of theoretical models affecting behavior alongside the practical constraints that

might limit its implementation (Margetts, 2004). Ecological model was therefore used as the

basic framework to modify behavior and bring about a change. Each level of the model

forms the foundation for the development of the program. It is important to understand

each level and its functioning for determining behavior (Reynolds et al., 2004). Since

nutrition or health behavior is not an outcome affected by either the individual or the

environment alone, in order to make modifications in the behavior, there is a need to

modify the individual as well as the environment. Therefore, the ecological model that

encompasses the individual and environment together formed the basis for program

development. The details of program development are described henceforth.

4.2 Lifestyle Management Program

After obtaining information regarding the current situation of the BPO industry with focus

on diet and lifestyle (results from phase I, FGDs and KIIs), the program was developed to

target at multiple levels. It was designed using the ecological approach in such a manner

239

that it targeted at the intrapersonal, social and cultural, as well as at the physical

environment level. The program was able to address the changes desired at these levels to

bring about behavior change among BPO employees. Specific activities were designed for

each level and the program was pilot tested in one BPO company for its acceptability and

feasibility and finally implemented there.

4.3 Setting for the lifestyle management Program

The setting of the program basically refers to the place where the target audience for the

program are going to be identified. In this case, the setting was the workplace where the

program was tested for its acceptability and feasibility and finally implemented. Depending

on the logistics, it was decided to run the feasibility trial and implement the program in one

of the BPOs with the permission and cooperation of the company management.

4.4 Acceptability and feasibility trial

For the acceptability and feasibility trial of the program in the selected BPO, all the

participants who had participated in phase I of the present study from the company were

informed in detail about the purpose of the feasibility trial and their consent was sought for

participation. In phase I of the study, 43 employees participated from this company and due

to the high turnover of the industry, ten of them had moved out of the company when they

were approached for the feasibility trial. Of the 33 employees in the age group of 21-30

years, 20 gave consent to participate in the feasibility trial. Working in the night shift was

cited as the main reason by 13 employees for their inability to participate in the feasibility

trial. Of these 20 participants, nine had MetS based on phase I assessment, and the rest did

not; although, they had 1 or 2 components of the syndrome in the abnormal range. Since

this was a feasibility trial, the basic aim was to ascertain if this strategy could be developed

into an intervention and whether it had the potential of being successful in bringing about a

health behavior change. It is accepted that in case of feasibility trials, computation of

sample size is not mandatory (Billigham, Whitehead and Julious, 2013; Stallard, 2012;

Julious, 2005) therefore, the feasibility trial was carried among 20 employees.

240

4.5 Program development strategy

The program strategy basically refers to the process of program development which is

crucial in determining its acceptability and feasibility in the BPO setting. The process of

development is outlined in Fig 31.

Figure 31: Development of the lifestyle management program

STEP 1: DESIGNING SPECIFIC KEY MESSAGES, GOALS AND TARGETS FOR THE EMPLOYEES

The first step of the program development was to design specific key messages on diet,

physical activity, tobacco usage, alcohol consumption and stress management. The

following messages were specifically formulated for BPO employees based on the findings

of phase I to identify the desirable changes/modifications needed in the diet and lifestyle of

BPO employees, Dietary Guidelines for Indians (NIN, 2011), Nutrition Society of India

Guidelines on diet in MetS, and Consensus Dietary Guidelines on MetS for Asian Indians

(2011).

Step 3: Program trial to assess its acceptability and feasibility

Step 2: Development of communication material, interactive sessions and activities to facilitate achievement of goals and targets

Step 1: Designing specific key messages, goals and targets for the employees

241

KEY MESSAGES- x Diet quality

¾ Include a variety of foods in your daily diet from various foods groups. ¾ Eat adequately by choosing the right portion sizes from different food groups. ¾ Prefer whole grains and pulses over refined grains and dehusked pulses. ¾ Include green leafy vegetables daily or at least every alternate day in your meals. ¾ Consume low fat milk and milk products. ¾ Limit intake of foods high in fat, sugar and salt.

x Regularity of meals ¾ Consume all meals regularly and avoid skipping of meals specially breakfast or meal

after waking up depending on the BPO shift. ¾ Ensure daily intake of preferably 5-6 portions of fruits and vegetables with 1-2 servings

of fresh vegetables. x Eating out

¾ Reduce the frequency of eating outside foods or eating out in restaurants/local vendors/dhabas or ordering food from outside.

¾ While eating out choose wisely. The foods consumed should be low in fat especially saturated fat, sodium and sugar, high in fibre, and safe and clean.

x Healthy beverages ¾ Limit intake of coffee, carbonated drinks and other processed beverages containing added

sugars. ¾ Avoid tea and coffee with main meals. ¾ Drink 8 glasses of clean water (2 litre) daily.

x Use of salt ¾ Limit the use of table salt and prepare food with as little salt as possible. Avoid excessive

use of pickles, sauces and chutneys. x Intake of processed foods

¾ Avoid frequent intake of processed foods as they have additives, preservatives and excess of flavoring agents.

¾ Avoid fried foods. These foods from cafeteria or street vendors are subjected to poor hygiene of the handlers and oil for frying is used repeatedly.

¾ Prefer fresh fruits to fruit products such as juices, squashes and canned jams/marmalades. ¾ Read food labels to make healthy choices. ¾ Prefer home prepared mixes and fruits/salads as healthy snacks in between meals.

x Tobacco usage ¾ Avoid use of tobacco in any form.

x Alcohol consumption ¾ Limit the intake/consumption of alcohol to special occasions. At one time don’t consume

more than 1 alcoholic drink (30 ml). x Physical activity

¾ Do regular physical activity of moderate to vigorous intensity for at least 30-60 minutes daily or at least 5 days a week for maintaining desirable body weight.

¾ Do foot, neck and arm exercises, and walk in the aisle while taking calls at work. ¾ Pursue physically active hobbies such as gardening in pots, playing badminton or table

tennis, skipping rope etc. ¾ Do household chores such as cleaning, dusting, washing and cooking etc. ¾ Climb stairs instead of using elevator. ¾ Get up from your desk every 30 minutes and stretch or take a round of the floor.

x Stress management ¾ Adopt stress management techniques such as yoga and meditation.

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This was followed by designing goals and targets for BPO employees focusing on diet and

physical activity along with tobacco usage and alcohol consumption (Table 91 and 92).

Those identified with MetS require rigorous management and monitoring to prevent

worsening of their condition. Therefore, the targets were more specific for them as

compared to those without the syndrome.

Each goal and target was allotted a 2 week trial period. Specific targets were designed under

each goal, as well as the ways to achieve those targets were suggested. Two sets of targets

were developed (i) for all BPO employees and (ii) for employees with MetS. A total of 4 goals

and 15 targets were identified.

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Table 91: Individual goals and targets for BPO employees

GOAL TARGET(S) WAYS TO ACHIEVE

Eat a healthy diet x Include a fruit at least 5 days in a week

x Have 2-3 servings of vegetable in a

day

-Can be easily carried to office -Can have fruit chat (fresh) available in the cafeteria -Can have 1 portion of each during lunch and dinner (also available in the office) -Can include green leafy vegetables in the form of salads, wraps, rolls or raita (available in the cafeteria)

x Have red meat only occasionally (once or twice in a month)

-Try to go for healthier options such as chicken and fish (roasted or grilled) -If going for red meat occasionally, try and have it in roasted or grilled form such as mutton tikka over mutton curry

x Have 1-2 servings of milk and milk products

-Drinking milk as such or adding fruits to make a milk shake is an interesting way to incorporate milk in daily diet -Curd and paneer are two easier options that can be included

x Have 2 servings of pulses in a day -Pulses can be had as simple pulse preparation available in the office cafeteria during lunch/dinner - Pulses can be had in the form of sprouts salad with vegetables as one serving or in the form of roasted pulses like roasted channa -Include pulses with husk or whole pulses regularly.

x Have 9-10 servings of cereals in a day for males and 8-9 for females

-Prefer to have chapattis over naan or roomali roti -Can opt for whole wheat atta bread over maida bread (read label) -Can have maida preparations on special occasion

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x Have food items prepared in minimal oil (7-8 teaspoon in a day). This is visible fat that you add while food preparation.

-Try to have foods prepared with minimal oil. Limit intake of deep fired and shallow fried food. -Can opt for roasted/grilled/steamed/baked preparations that use minimal oil -Avoid using Vanaspati/hydrogenated oils and use butter or ghee in moderation -Try to use a combination of oils like mustard oil, rice bran oil, olive oil etc -Bakery items such as biscuits, cookies and cakes are made from Vanaspati/margarine/butter. Limit their consumption to a minimum

x Reduce the use of sugar or limit it -Add minimal sugar to the beverages such as milk, tea, coffee, lemonade etc. -Reduce the intake of processed foods like biscuits, cookies, bread, cakes. -Limit the intake of health drinks and beverages like carbonated drinks and packaged juices Limit intake of sweets (candy, toffee, chocolates)and sweet meats (mithai) to special occasions.

Eat outside food occasionally x Reduce the frequency of eating processed foods such as biscuits, cookies, bread, cakes, health drinks, ketchup etc

x Don’t include these foods as part of regular diet as they are high in salt, sugar and oils'

x Always choose foods less in oil while eating out

-Can opt for beverages like coffee, sweet lassi, masala lassi over alcohol, carbonated drinks, packed juices -Whole fruit is always healthier, but you can also opt for fresh fruit juice (with or without sugar) over carbonated beverages -Can also go for nimboo pani, chaach and light tea - Limit the use of table salt and prepare food with as little salt as possible. Avoid excessive use of pickles, sauces and chutneys. -Opt for grilled or roasted preparations -Opt for plain roti instead of naan/butter naan

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Have quick nutritious

meals/snacks

x Try and prepare quick meal or snack using the recipe book “Quick healthy meals”

-These involve minimal cooking and are healthy too -Skill development through the “hands on” session -Trying recipes from the recipe book is not time consuming or difficult -Using partially processed ingredients (rice flakes, nutria nuggets, oats, puffed cereals, roasted pulses) to prepare quick meals.

Be physically active x Know your BMI BMI is easy to calculate. It is Wt (kg)/Ht (m2) x Know your waist circumference -Measuring with a measuring tape

-Training provided x To maintain normal BMI and waist

circumference, do regular physical activity of moderate to vigorous intensity for at least 30 - 60 minutes for 5 or more days in a week.

-Do simple neck and foot exercises while at work desk. -Can walk to cab by not calling cab at your doorstep -Walk with a friend in office after lunch/dinner time or during breaks -Use staircase instead of elevator -Walk while you are on call -Try playing a recreational sport such as badminton/cricket -Don’t sit at your desk for more than 30 minutes. Get up, take a round of the floor and come back.

Quit smoking x Try and quit smoking. x Do not use chewable forms of

tobacco such as guthka and pan masala.

x Avoid passive smoking.

-Try to reduce the number of cigarettes gradually -Reduce the frequency of smoking from daily to alternate days and gradually quit. -Do not stand with individuals who are smoking. -Encourage your colleagues who smoke to also quit.

Avoid harmful use of alcohol x Reduce alcohol consumption for men to 2 pegs and women to 1 peg

x Drink occasionally

-You can opt for other beverages such as lemonade. -Wine is a better option to consume when you drink occasionally.

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Table 92: Specific targets for BPO employees with Metabolic Syndrome#

Goal Target(s)

Eat a healthy diet x Include a fruit daily in your diet. You can go up to 2-3 fruits in a day x Have at least 3 servings of vegetables in a day with consumption of 2 cooked vegetable servings and 1

serving as salad x Include a green leafy vegetable daily or at least alternate days of the week x Do not have red meat at home or outside. Can go for healthier options such as chicken (preferably

without skin) and fish (roasted or grilled) x Have at least 2-3 servings of low fat milk and milk products such low fat curd and paneer daily. Choose

toned or double toned milk over full cream milk. x Choose preferably whole grain cereals and pulses. Use cereal pulse combinations such as adding gram

flour to the wheat flour before making chapattis. This improves overall nutritive value of food. x Incorporate available millets in the diet such as bajra, maize, ragi and oats. x Have food items prepared in minimal oil (4-5 teaspoon in a day). This is visible fat that you add while

food preparation or butter added to prepared food x Restrict use of sugar or limit to 2 servings in a day (1 serving = 1 teaspoon) as

sugar/jelly/jam/marmalade/sweets/cake/pastry

Eat outside food occasionally

x Restrict intake of processed foods such as biscuits, cookies, bread, cakes, health drinks, ketchup etc x Restrict intake of packed beverages or carbonated drinks as they are rich in sugar.

# These are in addition to the general goals and targets for all BPO employees

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STEP 2: DEVELOPMENT OF COMMUNICATION MATERIAL, INTERACTIVE SESSIONS AND

ACTIVITIES TO FACILITATE ACHIEVEMENT OF GOALS AND TARGETS

After designing key messages and setting of individual goals and targets for the BPO

employees, the next step involved the facilitation process. In this step, the ecological

approach was used as a basic framework targeting multiple levels of the ecosystem. The

facilitation process was carried out by targeting three levels viz. intrapersonal, social and

cultural, and physical environment; although, the primary target level was the intrapersonal

level.

I. Intrapersonal level

At the intrapersonal level, the lifestyle management program focused on increasing

awareness and imparting skills. Eight sessions were conceptualized, developed and

conducted with an objective to improve awareness and impart skills to the employees for

bringing about behavior change by emphasizing on diet and lifestyle. It also involved

designing of the communication material and hands-on activities. Table 93 shows the

communication matrix for the eight sessions conducted with the employees. All the sessions

used multiple communication techniques and were made interactive by engaging the

employees in participatory activities. All the sessions, communication materials and

activities were field tested.

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Table 93: Communication matrix of the sessions conducted with the BPO employees

Session Key messages Channel/medium Materials (resource kit)

Metabolic Syndrome – Need for the program

1. Prevalence of Metabolic Syndrome is on the rise in India. 2. 1 out of 5 adults have it in the target group. 3. It is related to unhealthy diet and lifestyle. 4. It leads to diabetes and heart disease in the future. 5. It is reversible. 6. Prevent Metabolic Syndrome and its consequences in

future by taking the Right Step now!

x Power point presentation

x Interaction with participants

x Slides for presentation

The power of food 1. A balanced diet is important for good health. 2. Variety is the basis of balanced diet. 3. Eat whole grain cereals and legumes and their products,

and millets if available 4. Eat plenty of fresh fruits and vegetables especially green

leafy vegetables.


x Interaction with participants through activity-Do you know the food pyramid?

x Slides for presentation x One page handout x SMS service x Facebook page x Email queries portal x Session feedback form

+ Food item cards

Portion size 1. Include food from all food groups. 2. Portion sizes are easy to understand. 3. Eat adequately by choosing the right portion sizes from

different food groups.


x Interaction with participants through activity – Choose healthy! Eat right!

x Live demonstration of usual serving sizes.


+ Real food samples

Food labels

1. Food labels are easy and informative. 2. They tell us about the calories present in food items. 3. Food labels are easy to read. 4. Include as much food in natural form/minimally

processed form as possible.


x Interaction with participants through activity – Read the label!


+ food labels

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Session Key messages Channel/medium Materials (resource kit)

Food choices

1. Choose wisely from a wide variety of foods. 2. Taste is important but should not be the only priority. 3. Develop taste for healthy options. 4. Healthy foods are economical. 5. They are easily available 5. Wise food choices make one healthy.


x Interaction with participants through activity – What to choose?


+ Food item cards Quick meals

1. Easy to prepare meals are nutritious. 2. Preparing healthy food is not very difficult. 3. Simple cooking skills can be learned easily with some

effort. 4. Healthy meals can be prepared easily rather than eating

cooked food usually from outside. 5. Raw and minimally processed food can be used

judiciously to quickly prepare snacks/meals.

x Live demonstration of simple recipes (all meals - food combinations and snacks)

x Hands on approach

x One page handout x SMS service x Facebook page x Email queries portal x Session feedback form + real food samples + recipe book

Be fit and fine

1. Exercise regularly and be physically active to maintain right body weight.

2. Get up from your desk every 30 minutes and move around the floor.

3. Physical activity reduces the risk of heart disease. 4. Simple exercises are easy to do anywhere - at home or

office. 5. It helps to control body weight. 6. It releases happy hormones “endorphins” that elevate

mood and sense of wellbeing. 7. Regular physical activity of moderate to vigorous

intensity for at least 30 - 60 minutes daily is very beneficial.


x Exercise session with group


Tobacco use and alcohol consumption

1.Avoid use of tobacco in any form 2.Quit smoking 3.Avoid passive smoking. It is more harmful than active smoking.


x Problem-solution session with group

x Slides for presentation x Chart papers with stick

notes

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4. If you drink alcohol, drink occasionally 5. Reduce the consumption for men to 2 pegs and women to 1 peg at one time

x SMS service x Facebook page x Email queries portal x Session feedback form

Resource material is appended in annexure 10

CONDUCTING SESSIONS WITH THE BPO EMPLOYEES

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II. Social and cultural environment

The social and cultural environment for the lifestyle management program was the

workplace setting, since all the employees who were the target for the program were

present there. The basic idea was to create a social environment that facilitated change

based on the goals set. A social network was created using the Whatsapp application for the

participants. Two separate Whatsapp groups were created. One group was the common

group for all the participants where all the reminders on following targets were sent to

Preparation of Healthy snack mixes during the “QUICK MEALS” session

Composition of Roasted Snack Mixes

A: Puffed rice, almonds, walnuts, raisins, curry leaves and seasoning *

B: Rice flakes, Puffed rice, almonds, sesame seeds and Seasoning*

C: Rice flakes, peanuts, black chana (roasted), Flax seeds and Seasoning*

D: Puffed rice, black chana (roasted), peanuts, raisins, mustard seeds and seasoning*

*Seasoning included salt, dry mango powder, turmeric powder, and asafoetida powder

A

D C

B

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them. The second level of Whatsapp group was “peer groups”. These were the groups

where 2-3 participants with similar targets were grouped together so that they could

motivate each other to achieve their dietary and physical activity targets as well as interact

with the investigator for seeking answers to queries or looking for suggestions. These groups

were continuously monitored by the investigator since the investigator played the role of a

facilitator.

III. Physical environment

This level involved modification in the physical environment to facilitate change in dietary

lifestyle pattern of the BPO employees. It comprised discussions with the managerial level

people and persuading them to introduce certain changes in the workplace. This endeavor

was to facilitate behavior change among employees along with supporting activities done at

the intrapersonal, and social and cultural level. Various changes were requested for, and

some of them were agreed to by the management.

Changes suggested Accepted/Not accepted

Changes in the existing lunch/dinner menu Not accepted Introduction of packed curd in the cafeteria Accepted Introduction of healthy snacks such as poha, vegetable upma, healthy mixes in the snack menu

Not accepted

Introduction of green leafy vegetables for at least 3 days in the menu

Not accepted

Introduction of fresh fruits in the cafeteria with lemon dressing and without salt

Accepted

Availability of fresh fruit juice along with tetra pack juices and cold drinks in the cafeteria

Accepted

Changes in the break timings Not accepted Fixing of shift timings for a month for the employees Not accepted Increase in walking space in the working area Accepted Creation of a recreation area in the free space in the campus with placement of a badminton net and provision of badminton rackets and shuttlecocks

Accepted

Organizing sports tournament on a monthly basis for the employees Not accepted Creation of walking clubs for employees of different BPO work processes

Not accepted

Posters were put up in the workplace regarding messages pertaining to healthy diet,

physical activity and prohibition of tobacco usage that reinforced the goals and targets. The

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management agreed to the above mentioned changes and therefore, the program was able

to have a multilevel approach.

STEP 3: PROGRAM TRIAL TO ASSESS ITS ACCEPTABILITY AND FEASIBILITY

The basic aim of developing this program was to test it for its acceptability and feasibility.

For determining the acceptability and feasibility, discussion was done with the employees in

a group as well as individually.

Group session

The group session entailed introduction of the lifestyle management program to the

employees who gave their consent to participate. In this brief session, employees were

explained the importance of healthy diet and lifestyle. By following the goals designed for

them and incorporating them into their daily life, would not only help them lead a healthy

present but would also keep diseases at bay in the future. With this background, the

participants filled a small questionnaire outlining their expectations regarding the program.

Program expectations of the employees: Based on the responses obtained from the

questionnaire, all the employees (n=20) who agreed to participate in the program (with and

without MetS) thought that the program would be very useful to them. They felt that the

program would help them manage their daily diet and lifestyle which they were currently

not able to because of their strict work schedule. It would let them know what to eat and

how much to eat, make them aware of the myths and misconceptions and help them

become fit and active. The employees hoped that they would learn how to eat a balanced

diet. They further elaborated that they would know what to consume and how much to

consume, avoid excesses in the diet, focus on quality rather than quantity and avoid

unhealthy lifestyle. They also gave some suggestions so as to what they would want to be

included in the program. Some of the suggestions offered by the employees were (i)

provision of a chart of food items to be included in the daily diet (ii) follow-up sessions (iii)

individual sessions. They were also appreciative of the initiative and felt it would be

beneficial for them.

Keeping in mind their suggestions, the program developed was put to trial wherein the

introductory group session was followed up by individual sessions.

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Finally, this was the last phase to put all the development process into action and gauge for

its acceptability and feasibility. This involved two group sessions with the employees – pre

and post-trial and three individual sessions – pre, mid and post-trial. The trial period

duration was 2 weeks for each goal.

Individual session discussing goals and targets

This involved discussing individual goals and targets for each employee based on their

diagnosis, and explaining the ways to do it. The individual targets were disseminated in the

form of weekly plans that were distributed to the employees after an elaborate discussion

with them. This was followed by the facilitation and reinforcement phase that included

conducting sessions for employees that were designed on the framework of ecological

approach, along with making changes in their social and cultural environment, and physical

environment. Before each session was conducted, employees were tested on their

knowledge regarding the topic to be covered in the session. This was done by assessing

them with a set of five knowledge statements per session to which they had to either agree

or disagree. For this purpose a knowledge statements form was used

Knowledge of the employees regarding diet and lifestyle before the sessions

The knowledge of the BPO employees varied on different aspects of diet and physical

activity on selected statements before the sessions (Annexure 11).

Individual session with the employees

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x Power of food

All the participants agreed that a healthy diet was a diet that had all the nutrients in

adequate amount (20). More than half (16) of them disagreed that fruits and vegetables

were body building foods but there were a few (4) who agreed to it. The fact that fruits and

vegetables should be eaten liberally was supported only by one-third (7) of the employees.

There was hardly any knowledge related to the food pyramid depicting the food items and

the frequency with which they should be eaten. Majority of the employees were not aware

of the food pyramid and therefore, did not agree that it was a good guide in helping them to

choose wisely and eat better (18). Nearly half of them agreed that there are three food

groups (9).

x Portion size

The next set of knowledge statements were pertaining to portion sizes of various foods.

Majority of the employees (18) thought that 1 teaspoon is not equivalent to 5 grams of

oil/sugar. Three fourths (15) of them disagreed that three servings of milk and milk products

(300ml) should be consumed in a day. Only one employee agreed that fruits could be

consumed as a healthy snack option. However, the opinion seemed to be divided over the

choice of mutton over chicken and fish. While 7 of them disagreed to it, rest (13) answered

in affirmative. Also, one fifth of them (4) agreed that one glass of milk is 250 ml.

x Food choices

All the employees (19) except one were of the opinion that taste was the primary factor to

be considered in making food choices. But, all of them agreed that wise food choices made

one healthy. Regarding fast foods, 8 employees felt that they were rich in salt/sugar/ and/or

fat; and more than half (16) agreed that fast foods were precooked/ready to eat or fast to

cook. More than three fourth of them (17) also believed that buying canned foods such as

canned beverages, fruit cocktail etc was a healthy option.

x Food labels

Forty percent (8) of the employees agreed to the statement that food labels helped them to

choose healthy options, while the rest (12) did not agree with the statement. They also

agreed (16) that the information provided on food labels was useless and disagreed that

they were easy to read (19). Half of them (10) agreed that all processed foods are healthy.

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Thirteen of them were aware that food labels were present on the packaged products while

rest (7) were not aware of it.

x Meal preparation

The session on quick meals was mainly designed to enhance the basic cooking skills of the

employees and enable them to cook or prepare simple and fast to cook nutritious recipes

and snacks. So, the statements were not particularly knowledge related but focused on the

outlook of the employees towards cooking and preparing food. Only one fifth of them (4)

felt that preparing meals was easy and rest (16) thought it was difficult. Only one third (7)

agreed that cooking was something that could be incorporated into their daily routine as

cooking methods could be simplified by judiciously selecting ingredients and altering

preparation methods.

x Significance of physical activity

One fifth of the employees (4) agreed that physical exercise could be done at any place and

at any time. Three fourth of them (15) were of the opinion that it was sufficient to do

exercise once a week. Regarding duration of physical activity of moderate intensity, only

one third of them (6) agreed that it should be between 30-45 minutes daily, while rest

disagreed (14). Forty percent of the employees (8) agreed that it was not good to sit at a

place for more than 30 minutes. However, all (19) except one employee agreed to the

statement that exercise helps to control body weight.

4.6 Lifestyle Management Program Trial

The lifestyle management program was then started by conducting the sessions for the

employees, which have already been described in detail earlier. During these sessions, peer

group support was established and groups were formed of employees with similar goals and

working with similar work processes for operational reasons. This also included having

support groups on Whatsapp and a common group with the investigator to post their

queries. To promote awareness among BPO employees, posters on diet and lifestyle were

displayed in the company premises. Changes in the physical environment included:

introduction of packed curd in the cafeteria, encouraging employees to opt for fresh fruits in

the cafeteria with lemon dressing and without salt, availability of fresh fruit juice along with

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tetra pack juices and cold drinks in the cafeteria, increase in walking space in the working

area. Also the suggestions to make use of the recreation area in the free space in the

campus with placement of badminton net and provision of badminton rackets and shuttle

cocks (badminton court) were accepted. Reduction in elevator usage was further

encouraged by putting up messages near the lift as well as on the stairs towards the

cafeteria which was at the fourth floor. These were reinforced by periodically sharing

appropriate SMSs and Facebook messages with the employees.

After the individual sessions, and introducing changes at the intrapersonal level, social and

cultural level, and physical environmental level, the employees were given time to try

different goals. Each goal was allotted a period of 2 weeks for trial. During the trial period,

there was periodic reinforcement that involved:

a) Sending of periodic short service messages highlighting their targets

A list of short service key messages was designed on healthy diet and physical activity, and

were messaged to the employees both on their phones as well as via Whatsapp daily.

b) Use of Self tracking booklet- My healthy diet book

A self-tracking booklet was designed for the employees and each employee was handed

over two copies each for trial period of two weeks. The booklet was used for recording the

general profile of the employees along with their anthropometric measurements viz. weight

and height. The employees were taught how to calculate their BMI which was depicted

separately for males and females using body image figures. These at a glance gave an idea

to the employees regarding their current weight status – underweight, healthy weight,

overweight or obese. Waist circumference (WC) was also recorded and cutoffs were

informed separately to males and females. Using these cut offs, the employees could easily

gauge whether they had high or normal WC. Both these measurements were included in the

booklet along with the reference values. The next page of the booklet had a portion size

guide with pictures of different food items belonging to different food groups along with

their 1 serving size in easy household measures matching with the dietary guidelines. This

portion size guide was utilized by the employees for filling the food items that they had

consumed on a particular day for all seven days of the week. Based on dietary analysis in

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phase I, one serving size picture for each commonly consumed food item was included. The

employees were asked to mark whether they had consumed that item on a particular day

and fill in the quantity consumed. The commonly consumed food items were from all food

groups as well as those that provided empty calories. There was provision of writing more

items in case any employee had consumed an item which was not on the list. The booklet

further had a page to list any recipes (based on the recipe booklet provided in the quick

meals and snacks section) that they had prepared over the week, what they liked and if

there were any problems faced. The next page was used to track physical activity done over

the week where the employees had to list the activity (if they did) along with the duration of

the activity and total minutes per week were estimated. Finally, the last page of the booklet

looked at the employee’s progress with respect to modifications in diet and physical activity.

This progress was ascertained both by the employees based on their experience and by the

investigator with the use of ‘My healthy diet book’ and individual sessions with the

employees.

c) Peer group involvement

This formed an important part of the feasibility trial of the ‘program. The peer groups

formed on Whatsapp were also a part of common group with all the members. This

platform was used by the investigator to deliver diet and lifestyle messages, targets for the

weeks and reminders to the employees. Individuals in a peer group motivated each other,

reported each other’s progress for the day and reminded each other about the targets for

the day. In case they had any query, it was put on the Whatsapp forum and attended to

immediately by the investigator.

d) Answering any specific queries via phone or email or Facebook page

In case the employees had any specific questions, they also contacted the investigator via

phone or email and were responded to immediately. A Facebook page was also created

titled “Food for Health” where health messages were posted regularly. Employees could

comment, like and ask questions through the page as well.

During the entire trial period for each goal, three individual sessions were conducted with

the participants where they were asked for their feedback regarding the acceptability and

feasibility (barriers/obstacles faced), and sustainability of the goal. On the basis of mid-week

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feedback, individuals were offered suggestions as well as asked for suggestions in case they

found the goal difficult to achieve. They were again given a period of another week for trial,

post which a final feedback was obtained from them.

This process was followed for all the goals and finally after individual feedback, a group

feedback was obtained regarding program’s acceptability and feasibility.

4.6 Post trial feedback

The feedback was obtained from the employees individually as well as in a group. The

process involved obtaining feedback regarding different aspects.

I) Knowledge level

After the sessions, the employees were tested on the same knowledge statements as before

the sessions to ascertain whether there was any change in the responses obtained (Fig 32).

The same knowledge statement form was used for this purpose (Annexure 11).

x Power of food

After the session, all the participants agreed that a healthy diet was a diet that had all the

nutrients in proper amount (20). This time 19 of them disagreed that fruits and vegetables

were body building foods except one who still believed that they were body building foods.

The fact that fruits and vegetables should be eaten liberally was supported by 13

employees. The knowledge related to the food pyramid and food groups improved

considerably, as the employees agreed that the pyramid was a good guide in helping people

choose wisely and eat better (19). More than half of them (13) agreed that there are more

than three food groups.

x Portion size

All the participants now agreed to the statement that 1 teaspoon is equivalent to 5 grams of

oil/sugar and one glass of milk is 250 ml. More than half of them (16) agreed that at least

three servings of milk and milk products should be consumed in a day. Regarding

consumption of fruits as a healthy snack option, more than half of them (12) agreed to it.

Sixteen of them reported that they would not choose mutton over chicken and fish, if given

a choice.

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x Food choices

All the employees disagreed that taste was the primary factor to be considered in making

food choices and agreed that wise food choices were important for good health. Regarding

fast foods, 19 employees felt that they were rich in salt/sugar/ and/or fat; and all agreed

that fast foods were ready to eat food and those which could be cooked within minutes.

Also, three fourth of them (15) did not agree to buying canned foods as a healthy option.

x Food labels

Seventy percent (14) of the employees agreed that food labels helped them to choose

healthy options and the information provided on them was useful, while the rest (6) did not

agree. Seventeen employees felt that food labels were easy to read. Processed foods such

as cookies, packed soups, pizza were considered unhealthy by more than half of the

employees (13). Regarding food labels on packaged products, 16 of them were aware of it

while rest (4) were unaware.

x Meal preparation

After the meal preparation session, where a hands-on approach was used to impart and

enhance cooking skills, more than half of them (12) were convinced that preparing meals

was easy. Half of them (10) agreed that cooking was something that could be incorporated

into their daily routine. More than half of them (11) also felt that they could help others

who were not a part of the program by sharing the recipes and also eleven of them agreed

on trying the recipes at home.

x Significance of physical activity

The opinion regarding the statement that physical activity could be done at any place and at

any time changed considerably, with 16 employees now agreeing with it. However, seven of

them still believed that it was sufficient to do exercise or any physical activity once a week.

As far as the duration of moderate intensity physical activity was concerned, 15 of them

agreed that it should be between 30-45 minutes. Seventy percent (14) of the employees

also agreed that it was not good to sit at one place for more than 30 minutes. Further, all of

them (20) agreed that exercise helps to control body weight.

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Fig 32: Agreement to the knowledge statements by the BPO employees before and after education session

BEFORE SESSION AFTER SESSION

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0 5 10 15 20

Number of employees agreeing to a statement

KNOWLEDGE STATEMENTS (Pre/Post): A - A healthy diet is a diet with all nutrients in adequate amount; B- Vegetables and fruits are body building foods; C- Fruits and vegetables should be eaten liberally; D- Food pyramid guides us how to eat properly; E-There are three food groups; F- 1 teaspoon = 5 grams of sugar/oil; G- At least 3 servings of milk and milk products (300ml) should be consumed in a day; H- Fruits are a healthy snack option; I- When given a choice, always opt for mutton over chicken and fish; J- 1 glass of milk = 250 ml; K- Food should be chosen based on taste; L-Wise food choices make one healthy; M- Fast foods are rich in salt, sugar and fat; N- We should buy canned foods as they are healthy; O- Fast foods are already prepared or cooked within minutes; P- Food labels help to choose healthy food items; Q- The information provided on food labels is useless; R- Each packaged food item has a label; S- All processed foods are healthy; T- Food labels are easy to read; U- Preparing meals is easy; V- I can incorporate cooking in my daily routine; W- Physical activity can be done at any time and at any place; X- It is alright to do exercise one day in a week; Y- Duration of physical activity of moderate intensity should be between 30-45 minutes daily; Z- Don’t sit at a place for more than 30 minutes; A1- Exercise helps to control body weight.

Z = -3.912; p = 0.000

262

Employees were given scores on their answers to the knowledge statements. A score of 1

was allotted for each correct answer while no score was given for a wrong answer.

Wilcoxon’s dependent signed rank test was used to test the increment in knowledge level of

the participants after the sessions (Fig 32). Results of the analysis indicated that the sessions

resulted in significant improvement in the knowledge of the BPO employees participating in

the program trial (Z = -3.912; p = 0.000).

II) Sessions’ feedback

A questionnaire was used to obtain feedback after each session was conducted. On the

basis of the responses obtained, the sessions were very well received by all the participants

with all of them rating the session as very useful (Annexure 12). Further, the participants

were asked to rate the sessions on a five point Likert scale (Very poor, poor, good, very

good, excellent) on expertise of the resource person, clarity of message delivery, power

point presentation, time management and handout provided (Fig 33). Majority of them (17)

rated the facilitator excellent on her expertise and rest (3) rated the facilitator very good.

More than half of them (14) felt that the clarity of message delivery was excellent, whereas

one fourth (5) felt it was very good. More than half of them (13) felt that the power point

presentation was excellent and nearly one third (6) felt it was very good. More than half (13)

of them appreciated the time management skills of the facilitator as excellent, and rest

rated it as very good (6) and good (1). Majority of them (17) felt that the handouts provided

were excellent, while the rest (3) rated them as very good. None of the participants rated

the sessions as satisfactory or poor.

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The feedback was further obtained on the sessions’ quality on a scale of strongly agree,

agree, neither agree nor disagree, disagree and strongly disagree (Fig 34). Nearly three

fourth of the employees (15) strongly agreed that the difficulty level of the sessions was just

right. More than half of them (12) strongly agreed that the information from the sessions

could be applied to their daily life. Sixteen of them felt that the facilitator answered a lot of

their questions and more than three fourth of them (16) strongly agreed that the facilitator

involved them actively in the session. Two third of them (14) strongly agreed that they were

motivated to modify their behavior because of the sessions. None of them disagreed or

strongly disagreed to any of the statements on sessions’ quality.

All the participants enjoyed and appreciated different aspects of the various educational

sessions. All of them expressed their willingness to inculcate these practices in their daily

1

1

1

1

0

2

5

6

6

3

17

14

13

13

17

0 5 10 15 20

Expertise of the resourceperson

Clarity of message delivery

Powerpoint presentation

Time management

Handout provided

Number of employees

Fig 33: BPO employees' responses to the education sessions (n=20)

ExcellentVery goodGood

1

1

0

0

1

4

7

5

4

6

15

12

15

16

14

0 5 10 15 20

Difficulty level was right

Information applicable in daily routine

Answered employees' questions

Active involvement of the employees'in the session

Motivated to modify behavior

Number of employees

Fig 34: Employees' responses regarding session quality

Strongly agree Agree Neither agree or disagreenor disagree

264

routine. They liked the activities on trying recipes themselves, how to eat healthy foods,

making healthy mixtures, role of milk in daily diet, combination of healthy meals,

demonstration on healthy and nutritious food recipes, choosing foods wisely, reading labels,

and sitting at desk exercises. None of them reported any problem of understanding the

sessions or found anything unacceptable or offending in the sessions. All the participants

felt that the sessions were very well structured. The managers of the BPO company actively

participated in the sessions and were enthusiastic in motivating the employees to inculcate

what was being communicated in the sessions.

4.7 Acceptability, barriers faced, feasibility and sustainability of the Lifestyle Management

Program

The feedback on acceptability, barriers faced, feasibility and sustainability was obtained

individually for each goal that was put to trial for a period of two weeks. Each target in a

particular goal was assessed for its acceptability, barriers faced, feasibility and sustainability

at two time point intervals – at the end of week one and at the end of two week period. For

this purpose, My Health Book and an open ended questionnaire was used.

a) Acceptability of the targets

The targets were acceptable to all the employees (n=20). All of them agreed that the targets

were not major modifications that were suggested to be incorporated in their daily routine.

They were of the opinion that these targets were minor changes that could be easily

included in the daily routine and if followed, could lead to major improvements in their

existing dietary and physical activity patterns.

b) Barriers faced

The barriers faced by the BPO employees are illustrated in box 1. The major barrier that the

employees faced based on feasibility, was time constraint, due to which they were not able

to eat properly or exercise.

Box 1: Barriers faced by the BPO employees*

*Multiple responses

• Time constraint (n=20) • Rotational shifts (n=19) • No fixed daily routine (n=14) • Irregularity in meals consumption (n=17) • Lack of interest/motivation to do physical exercise (n=18)

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Various ways were suggested by the investigator to overcome most of the barriers faced by

the employees (Box 2).

Box 2: Suggested ways to the BPO employees to overcome barriers

To achieve this, weekly plans were made for the employees in such a way that it considered

the daily routine of the employees. They were given specific suggestions as well as handouts

of the food items which were easily available, easy to prepare as well as nutritious. All the

participants were now able to start using time to their advantage. For instance, a participant

was not able to have a fruit and cited time constraint for the same. She further said “My cab

comes and then I don’t have time to eat fruit”. She was advised to carry a fruit in her bag

and have it on her way to office. This suggestion was positively taken by her and she had a

fruit daily while going to office. Another participant who was staying alone thought that

cooking was tedious and time consuming. After the session, he commented “Actually after

your session, when I tried making simple things myself using the recipe book, I realized it was

very easy to make nutritious things. One of the recipes that I tried was the roasted mixture

DIET • Weekly plans for the employees were made considering the daily routine of the

employees. • Carrying fruit to office as a snack. • Eating fresh fruit with lime introduced in the cafeteria. • Following the simple healthy recipes for meals/snacks demonstrated by the

investigator. • Replacing chips at the desk with healthy low fat mixtures. • Limiting the intake of carbonated beverages and drinking fresh fruit juice

introduced in the cafeteria. • Increasing calcium intake by opting for packed curd introduced in the cafeteria. • Have ‘one bowl’ meals – No second helpings.

PHYSICAL ACTIVITY • Formation of peer groups to motivate each other to do start doing some physical

activity either at home or in the office. • Making use of the company compound for walking during breaks (minimum 15

minutes). • Walking while taking calls in the aisle area of the floor (minimum 15 minutes). • Making use of the stairs to go the cafeteria which was on the fourth floor (minimum

10 minutes). • Not making use of the elevators to reach their respective floors (minimum 10

minutes). A total of 30-50 minutes of walking/climbing stairs/engaging in recreational physically active sport such as badminton per day at the workplace was ensured by adhering to the suggestions offered by the investigator

266

that had roasted channa, murmura, peanuts and a little bit of salt. It was so easy that I have

made a box for myself and carry a small container of it every day to office. I have kept it on

my desk and have it instead of chips and cookies”.

Regarding physical activity, none of the program participants were exercising due to barriers

such as paucity of time and lack of interest or motivation as well as the desire to earn more

by working overtime. This was overcome by creation of peer groups whereby employees of

the same peer group motivated each other to start some physical activity either at home or

in the office. This had a profound effect with many individuals walking in the company

compound after their lunch/dinner breaks and walking while taking calls in the aisle area of

the floor. They started using the stairs to go to the cafeteria which was on the fourth floor,

and refrained from using elevators. Stretching exercises at the workplace were suggested.

These suggestions by the investigator resulted in 10 minutes of walking the aisle while

taking a call + 10 minutes walking during breaks in the company premises + 10 minutes of

climbing stairs comprising a total of an average on 30 minutes of walking/climbing stairs per

day at the workplace. Thus, the program played an important role in overcoming the

barriers faced by the BPO employees.

c) Feasibility of the targets

Feasibility was assessed twice – After 1 week (Based on the tracking booklet/ My Health

Book) and then after 2 weeks. At the end of week 1, the progress of an individual was

assessed through My Health Book, and suggestions for improvement or modifications were

made. After a period of 2 weeks for each goal, the feasibility was finally assessed (Table 94

and 95). The employees felt that though the targets were 100% achievable, they differed

from individual to individual. They also credited the program for being able to provide them

with a lot of information and appreciated the options suggested to achieve the specific

targets.

267

Table 94: Feasibility of general targets for all the BPO employees (n=20)

Targets Achieved/Not achieved Reason(s) for not achieving target x Include a fruit at least 5

days in a week

Yes (14) ; No (6) Forget to carry it from home on some days of the week (6)

x Have 2-3 servings of vegetable in a day

Yes (10); No (10) Have one main meal with vegetable and one with pulse (10)

x Can have red meat (mutton and organ

meats) only occasionally (once or twice in a

month)

Yes (18); No (2) Red meat is very tasty (2)

x Have 1-2 servings of milk and milk products

Yes (11); No (9) Don’t like milk (7), cannot digest it (2)

x Have 2 servings of pulses in a day

Yes (12); No (8) Have one main meal with vegetable and one with pulse (8)

x Have 9-10 servings of cereals in a day for males

and 8-9 for females

Yes (18); No (2) Don’t feel that hungry (2)

x Have food items prepared in minimal oil

(7-8 teaspoon in a day).

Yes (13); No (7) Prepared food was served in the PG accommodation (7)

x Reduce the use of sugar or limit it

Yes (11); No (9) Taste without sugar is not good (9)

x Reduce the frequency of eating processed foods

such as biscuits, cookies,

bread, cakes, health

drinks, ketchup etc

Yes (8); No (12) They are tasty (8) and easily available (4)

x Choose foods less in oil while eating out always

Yes (10); No (10) Have to go with friends’ choice (10)

x Try and prepare quick meal or snack using the

recipe book

Yes (9); No (11) Staying in PG accommodation where they did not have cooking facility (11)

x Do simple neck and foot exercises

Yes (15); No (5) Forget doing it (5)

x Walk to cab by not calling cab at your

doorstep

Yes (19); No(1) Cab comes at the doorstep (1)

x Walk with a friend in

office after lunch/dinner

time or during breaks

Yes (12); No (8) Don’t get free at the same time as colleague (8)

x Use staircase instead of

elevator

Yes (17); No (3) Working area was on the 3rd floor (1), don’t like using stairs (2)

x Walk while you are on call

Yes (12); No (8) The BPO process requires use of computer simultaneously while taking call (8)

x Try playing a recreational sport such as badminton

and cricket

Yes (10); No (10) Don’t get free at the same time as colleague (4); project is too hectic (3) and don’t get time (3)

x Don’t sit at your desk for more than 30 minutes.

Yes (8); No (12) The BPO process requires use of computer while calling (12)

x Do regular physical

activity of moderate

intensity for at least 30 -

60 minutes for 5 or more

Yes (8); No (12) Lack of time due to work shifts (12)

268

days in a week.

Table 95: Feasibility of specific targets for those with Metabolic Syndrome (n=9)

Target Achieved/Not

achieved

Reason(s) for not

achieving the target

Include a fruit daily in your diet. You can go up to 2-3 fruits in a day

Yes (9); No (0) -

Have at least 3 servings of vegetables in a day with

consumption of 2 cooked vegetable servings and 1

serving as salad

Yes (6); No (3) Do not like salads (3)

Include a green leafy vegetable daily or at least alternate days of the week

Yes (4); No (5) Not available in the PG accommodation (2); not included in the cafeteria menu (3)

Do not have red meat at home or outside. Can go for healthier options such as chicken (preferably without

skin) and fish (roasted or grilled)

Yes (7); No (2) Often going out with friends (1), sometime it happens that all order red meat (1)

Have at least 2-3 servings of low fat milk and milk products daily.

Yes (7); No (2) Don’t like milk (1); cannot digest it (1)

Choose toned or double toned milk over full cream milk. Yes (9); No (0) --

Choose preferably whole grain cereals and pulses. Yes (7); No (2) Have refined flour products sometimes when eating with friends (2)

Incorporate available millets in the diet such as bajra,

maize, ragi and oats.

Yes (4); No (5) Not available near the area (3); stay in PG accommodation (2)

Have food items prepared in minimal oil (4-5 teaspoon in a day). This is visible fat that you add while food

preparation or butter added to prepared food

Yes (8); No (1) Stay in PG accommodation (1)

Restrict use of sugar or limit to 2 servings in a day (1

serving = 1 teaspoon) as sugar/jelly/jam/marmalade/sweets/cake/pastry

Yes (7); No (2) Like to have something sweet after every meal (2)

Restrict intake of processed foods such as biscuits,

cookies, bread, cakes, health drinks, ketchup etc

Yes (6); No (3) Not possible sometimes when eating out with friends (3)

Restrict intake of packed beverages or carbonated drinks

as they are rich in sugar.

Yes (6); No (3) It is difficult to digest food otherwise (1); like the taste and have got used to it (2)

Group and individual feedback was also obtained for the posters that were displayed in the

company premises. For this purpose, group discussion and a questionnaire was used. All of

them agreed that they had seen the posters in the premises and liked them. The ones that

were best liked and likely to be followed were “Use Stairs”, “Healthy beverages”, “Meal

timings”, and “No smoking and passive smoking”. They also felt that the messages were

clearly communicated and posters were attractive and easy to understand. Employees

269

agreed that the messages further reinforced the information covered in the sessions and

helped in increasing their knowledge. None of them considered any poster offensive or

difficult to understand.

4.8 Implementation of Lifestyle Management Program

Based on the feasibility and acceptability trial, it was decided to implement the program

after refining some of the communication material and making some modifications in the

program activities. The program catered to all the employees working in the BPO industry

irrespective of their diagnosis with respect to MetS.

Posters displayed in the BPO company

270

Based on the findings of phase I, to bring about change in the eating habits of the BPO

employees, breakfast skipping was used for sample size calculation. The skipping of

breakfast/first meal after waking up was observed in 44.8% of the employees. The program

aimed to reduce breakfast skipping by employees to 10%. The sample size was calculated

using the following formula.

The sample size was estimated to be 39. A total of 41 employees of the BPO selected for

program implementation consented to participate and thus were included. Considering the

findings and lessons learnt from the feasibility and acceptability trial, the program was

implemented. The steps for program implementation are outlined as follows:

Sample size The sample size was calculated according to the following formula:

n = Z*12pq

(p1-p2)2

where,

n is the sample size

Z is the normal standard deviate (1.96)

p1 is the proportion of individuals skipping breakfast (44.8%)

p2 is the changed proportion desired (10%)

p is (p1+ p2)/2

q is (1-p)

n= 1.96*12*0.274*0.726

(0.448-0.100)2

n=4.6787 / 0.1211

n=38.6 -- 39

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4.9 Program description

The lifestyle management program was based on Ecological Model of Health which involves

introducing changes at the intrapersonal, social and cultural, and physical environment level

to bring about behavior change in an individual.

Situational analysis – This involved conducting the first phase of the study, where

employees were screened for MetS using the ATPIII and IDF criteria. It included identifying

dietary and lifestyle habits of BPO employees in detail using Focus group discussions. It also

involved extensive review of literature with an aim to gather data regarding any state level

nutrition interventions, successful interventions at the national level, and any other

community level approaches to bring about behavior change.

Mapping and engaging key stakeholders – Participation of key stakeholders is important

for any strategy to be successful. In development and implementation of this program,

stakeholders’ support was sought. The key stakeholders identified were HR managers,

admin managers and BPO employees. They were integrated and involved at every stage of

the program development and implementation. Griffiths’ model for stakeholder

engagement was used to involve stakeholders for strategy development (2008). This model

encompasses a micro and macro environment in which the stakeholders will interact with

each other for successful implementation (Fig 35). Micro environment includes the key or

directly impacted stakeholders whose support is of utmost importance, while the macro

environment includes those stakeholders whose support is necessary for key stakeholders in

the micro environment to develop and disseminate the strategy. It consists of four phases:

Pre

implementation

: Knowledge,

practices, and

self-efficacy

assessment

Conducting of sessions on nutrition,

health promotion

and prevention of

MetS

6 weeks

follow up

Post

implementation

: Knowledge,

practices, and

self-efficacy

assessment

272

Phase I: Initial involvement – This phase involves all the stakeholders and identification of

specifically those who are highly motivated to interact amongst each other to try and

develop a strategy for implementation.

Phase II: Dissemination – This involves rolling out the strategy developed in phase I and at

the same time clearly explaining to the beneficiaries (in this case, BPO employees) the need

and benefits of the program.

Phase III: Maintenance – In this phase, maintaining the support of all stakeholders in terms

of time and logistic support is required. There is also constant exchange of information

about the benefits of the program.

Phase IV: Feedback - This is the last but the most importance phase of stakeholder

involvement. It involves all stakeholders and loops in the maintenance phase. The progress

made, challenges faced and failures occurred are addressed in this phase critically with an

aim of improving the existing strategy.

Macro-level Micro-level Phase of engagement

Initial involvement

Dissemination

Maintenance

Feedback BPO employees and other stakeholders (HR and

admin managers)

With BPO employees involving changes in the physical environment with support of other

stakeholders

To BPO employees using educational sessions, skill

building activities & peer group formation with support of HR managers

All stakeholders (HR managers, Admin

managers, BPO employees, canteen incharge)

Key stakeholders

Figure 35: Model of stakeholder engagement

Source: Adapted from Griffiths, Maggs and George, 2008

Senior executives of

the BPO company

273

Mobilizing resources – This involved discussions and negotiations with the company’s

higher authorities. The HR managers served as the liaison between the investigators and the

senior manager. Certain changes in the physical environment were requested, of which

some were finally agreed upon. The administrative managers further helped with the

logistics of the knowledge and skill building sessions that were conducted for the

employees.

4.10 Assessing the knowledge level, practices and self-efficacy before implementation

The program began by assessing the knowledge, practices and self-efficacy level of the

employees. This formed as the starting point for the lifestyle management program. For

these, a knowledge statements form (fig 36), practices form and self-efficacy statements

form was used. The employees had to agree/disagree with the statements included in these

forms (Annexure 11, 12, and 13).

Before the program implementation, out of a total of 41 employees, 37 agreed that a

healthy diet had all the nutrients in the adequate amount and another 29 agreed that fruits

and vegetables should be eaten liberally. However, majority (37) agreed that vegetables and

fruits are body building, less than one-fourth of them had knowledge about food pyramid

(8) and equivalent measure in grams of 1 teaspoon (6). Majority (37) liked mutton over

fish/chicken and considered taste (36) to be the primary factor in choosing foods. More than

one – third of them (17) agreed that wise food choices made one healthy. Nearly one third

(14) agreed that fast foods are made within minutes but very few (6) knew that they were

rich in fat, salt and sugar. Majority (37) felt that processed foods were healthy. They did not

rate the food labels highly. Very few (5) agreed that each packaged food item had a label.

They felt that labels were of no use in food selection (4), were difficult to read (28) and had

useless information (37). Cooking/preparing meals was rated difficult by more than half of

them (28) and they (29) were not interested in incorporating it into their daily routine.

Although everyone except two employees agreed that exercise helps to control body

weight, they did not have much idea about the type and frequency of physical activity that

was important for good health.

274

The existing practices were assessed using the practices form. These included practices

related to diet and other lifestyle factors (Table 96).

Less than one fourth (7) of the employees were consuming fruit and salad on a daily basis.

The reason behind it was lack of time and availability. Similar was the case with pulse

consumption as some of the employees did not like having pulses and for some it was a

practice to consume pulse with only one meal in a day. Nearly three fourths (30) preferred

having full cream milk, while others preferred toned (8) and double toned milk (3). The

employees also preferred consuming mutton over chicken and fish (28), as well as refined

cereals and their products (36). All of them were eating out, with three fourth (30) eating

8 8

6 8 8

6 11

9 37

5 36

17 6

17 14

4 37

5 37

13 13

12 6

37 5

7 39

0 5 10 15 20 25 30 35 40Number of employees

Fig 36: Knowledge level of BPO employees before program

implementation (n=41)

A11

Z

Y

X

W

V

U

T

S

R

Q

P

O

N

M

L

K

J

I

H

G

E

D

C

B

A

KNOWLEDGE STATEMENTS: A - A healthy diet is a diet with all nutrients in adequate amount; B- Vegetables and fruits are body building foods; C- Fruits and vegetables should be eaten liberally; D- Food pyramid guides us how to eat properly; E-There are three food groups; F- 1 teaspoon = 5 grams of sugar/oil; G- At least 3 servings of milk and milk products (300ml) should be consumed in a day; H- Fruits are a healthy snack option; I- When given a choice, always opt for mutton over chicken and fish; J- 1 glass of milk = 250 ml; K-

Food should be chosen based on taste; L-Wise food choices make one healthy; M- Fast foods are rich in salt, sugar and fat; N- We should buy canned foods as they are healthy; O- Fast foods are already prepared or cooked within minutes; P- Food labels help to choose healthy food items; Q- The information provided on food labels is useless; R- Each packaged food item has a label; S- All processed foods are healthy; T- Food labels are easy to read; U- Preparing meals is easy; V- I can incorporate cooking in my daily routine; W- Physical activity can be done at any time and at any place; X- It is alright to do exercise one day in a week; Y- Duration of physical activity of moderate intensity should be between 30-45 minutes daily; Z- Don’t sit at a place for more than 30 minutes; A1- Exercise helps to control body weight.

275

out daily and nearly one fourth (9) eating out weekly. The type of food items usually

consumed while eating out were samosa, pizza, burger, chaat, butter chicken, mutton curry,

noodles, momos and chilli potatoes. Majority of them (36) were skipping breakfast daily.

Only five of them were physically active and were engaged in activities of moderate

intensity for 20-45 minutes daily. Three fourths of them were using tobacco (smoke or

smokeless) (30) and consuming alcohol (34).

Table 96: Dietary and lifestyle practices of BPO employees (n=41) before program

implementation

Practice Followers (n=41)

Daily fruit consumption 7 Daily consumption of at least 2 servings of cooked vegetables

12

Daily consumption of salad 7 Daily consumption of 2 servings of pulses

8

Daily consumption of milk/milk products other than milk consumed in tea and coffee

16

Type of milk preferred (if consumed) Full cream (30) Toned (8) Double toned (3)

Preference of mutton over chicken and fish

28

Preference of refined cereals over whole cereals#

36

Oils preferred (Multiple choices) Soyabean (41) Mustard (13) Desighee (15) Butter (22)

Eating out 41 Frequency of eating out Daily (30)

1-2 times a week (6) Once a week (3) 1-2 times in a month (1)

Type of items consumed while eating out

Samosa, pizza, burger, chaat, butter chicken, mutton curry

Breakfast skipping 36 Extra sugar added to beverages 32 Regular physical activity 5 Duration (if doing regular physical activity of moderate intensity)

20-45 minutes

Tobacco use 30 Alcohol consumption 34

#Refined cereal preparations such as noodles, momos, samosa, patty, burger, cookies, pizza, kulcha, bhatura, bread pakora, patty, bread roll, veg/non-veg wraps, pies, sandwich, roomali roti, toasted bread were preferred

276

Self-efficacy was also assessed before the program implementation. The self-efficacy scale

included statements on diet, exercise as well as alcohol and tobacco consumption. The

employees had to rate their self-efficacy on a scale of very uncertain, rather uncertain,

rather certain and very certain (Bandura, 2005).

Before the program implementation, dietary self-efficacy of the employees was assessed

(Fig 37). Nearly half of them (19) were very uncertain of sticking to their dietary goals and

targets for a long time so that it could become a routine. Majority (35) were rather

uncertain of trying out the goals and targets several times to make them work. Half of them

were very uncertain about rethinking their way of looking at nutrition (20), sticking to their

goals and targets in absence of any social support (17) and were not keen of making a

detailed plan (21) to achieve them.

Uncertainty also prevailed among the employees regarding their ability to do physical

activity on a regular basis (Fig 38). This uncertainty was attributed to them having worries

and problems (19), depression (19), tension (21), fatigue (21) or busy schedule (23).

19

6

20 17

21 19

35

13 13 11

3 0

8 11

9

0

5

10

15

20

25

30

35

40

1 2 3 4 5

N

u

m

b

e

r

o

f

e

m

p

l

o

y

e

e

s

Fig 37: Dietary Self-efficacy before program


Very uncertain

Rather uncertain

Rather certain

Very certain

Statements: 1 – Even if I need a long time to develop the necessary routines 2 – Even if I have to try several times until it works 3 – Even if I have to rethink my entire way of nutrition 4 – Even if I do not receive a great deal of support from others when making my first attempts 5 – Even if I have to make a detailed plan

277

The alcohol (34) and tobacco users (30) were uncertain about controlling themselves in

situation where they had access to alcohol or tobacco of any type (Fig 39 and 40). Nearly

half of them were very uncertain (17) of reducing their alcohol consumption and rather

uncertain (18) about reducing their tobacco use. The employees were uncertain w.r.t

quitting alcohol consumption and reducing/giving up smoking.

17 19

16

21 23

19 18

21

17 15

5 4 4

3 3

0

5

10

15

20

25

1 2 3 4 5

N

u

m

b

e

r

o

f

e

m

p

l

o

y

e

e

s

Fig 38: Exercise related self-efficacy before program


Very uncertain

Rather uncertain

Rather certain

Very certain

17

11 13 13

19

13

4 4

8

0

5

10

15

20

1 2 3

N

u

m

b

e

r

o

f

e

m

p

l

o

y

e

e

s

Fig 39: Self-efficacy related to alcohol consumption before program implmentation (n=34)*

Very uncertain

Rather uncertain

Rather certain

Statements: 1 – Even when I have worries and problems 2 – Even if I feel depressed 3 – Even when I feel tense 4 – Even when I am tired 5 – Even when I am busy

Statements: 1 - Reduce my alcohol consumption 2 - Not to drink any alcohol at all 3 - Drink only at special occasions *Of the 41 employees participating in the program, 34 were alcohol consumers

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4.11 Using the ecological approach

As described before, Ecological Model of Health was used as the framework for designing

and implementing program activities and changes. These were implemented at each of the

three levels of the model viz. intrapersonal, social and cultural, and physical environment. At

each level, certain barriers were faced and were subsequently addressed to.

a)Intrapersonal level

This level involved conducting of sessions on nutrition and health promotion with the BPO

employees. The sessions were conducted on topics pertaining to diet, physical activity,

tobacco use and alcohol consumption. The investigator conducted these sessions in a 45

minutes time slot with the employees. For the sessions pertaining to physical activity,

tobacco use and alcohol consumption, experts were invited. Each session began with a

power point presentation describing the session concept followed by an interactive activity

with the employees applying the same concept. Finally, the floor was open for the

employees for their questions/queries which were then answered. The HR and the

16

18

14

12

0

5

10

15

20

1 2

N

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b

e

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o

f

e

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p

l

o

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Fig 40: Self efficacy related to tobacco usage before program implmentation (n=30)*

Very uncertain

Rather uncertain

Statements: 1 - Reduce my tobacco use 2 - Not to use tobacco at all *Of the 41 employees participating in the program, 30 were tobacco users

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administrative managers helped logistically to schedule and conduct the sessions

successfully.

Box 1 Sessions conducted for employees

Metabolic Syndrome – Need for the program: The session focused on explaining to the employees the significance of the program. The employees were told about Metabolic Syndrome, its risk factors, consequences and that it could be reversed if healthy lifestyle was followed.

The power of food: This session introduced the concept of balanced diet, food groups and nutrients required by an individual. It also emphasized the importance of introducing a variety of food items from different food groups in the daily diet.

Portion size: The session focused on consumption of balanced diet for an individual in terms of requisite portions of food items from all the food groups to remain healthy. The employees were explained the concept in household measures which was easy and simple to understand.

Food labels: In this session, the employees were made aware about the concept of food labels. They learnt reading the labels, interpreting them and using them to make healthy food choices.

Food choices: This session focused the importance of making healthy food choices while buying or preparing food. It also emphasized that healthy food could be purchased/prepared at an economical cost.

Quick meals: This was the skill building session for the employees where they participated in preparing quick, easy and nutritious recipes for meals and snacks. This gave hands on experience to the employees to try various nutritious recipes which were simple and quick to prepare.

Be fit and fine#: This session promoted the importance of engaging in regular physical activity to remain fit and healthy. The employees were also taught simple exercises and ways to remain physically active while at work.

Tobacco and alcohol use#: This session engaged the participants in finding a solution to the problem of addiction to alcohol and tobacco products. It made the employees realize the ill-effects of using these substances and how these habits could be overcome.

#These sessions were conducted by external experts Each of these sessions was followed by an interactive activity such as “Do you know the food pyramid?”, “Choose healthy! Eat right!”, “Read the label!” and “What to choose?” Which involved active participation by the employees (Sessions’ details appended)

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b) Social and cultural level

At this level, peer groups were formed among employees to create a support group among

them. These groups (n=6) were formed of employees who were working in the same work

process, so that they could motivate and influence each other regarding the changes to be

made in their diet and lifestyle. For this purpose, a Whatsapp group was also created for

these peer groups where they were sent daily health messages and responses to their

queries. A facebook page was also created that reinforced the messages on healthy diet and

lifestyle and allowed the employees to ask questions. Employees were also provided with

investigator’s email id to post their queries directly. These were then answered on an

individual basis.

Whatsapp group for employees: Posting health messages and answering queries

Box 2

Problems faced while conducting the educational sessions

x The time allotted for sessions were limited due to company policy of not permitting the employees to be absent from their desk for more than 45 minutes.

x Due to the work process of employees, participation in the program was limited and employees from the same process were unavailable for the session.

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c) Physical environment level

At the physical environment level, the aim was to change/modify the surroundings around

the employees which would facilitate them to achieve their goals and targets to modify their

lifestyle practices. This involved negotiations with the managerial staff to make changes in

the environment. Many changes were proposed but only a few were agreed to.

Using the Ecological Model of Health, the program was implemented at all the three levels.

The changes introduced at each level were:

Intrapersonal level

x Knowledge improvement Promotion of awareness regarding their status w.r.t MetS, healthy eating, physical activity and other lifestyle habits to motivate and create demand for the program

x Skill enhancement Enhancement of skill in selection of adequate portions of various foods in daily diet and preparation of healthy meals and snacks using simple and easy to follow cooking methods

Box 3

Problems faced in forming and sustaining peer group activities’

x The shift changed for some employees during the program implementation, thus, they had to be shifted to another peer group.

x A couple of employees did not have smart phones; hence they could not be included in the Whatsapp group and were sent messages via SMS only.

Barriers at the physical environment level

x Certain changes suggested in the physical environment were not agreed by the company management as modification in company policies was difficult to achieve within a short span of time.

x It was not possible to change the existing lunch/dinner menu as it was pre-set and agreed in a contractual form with the contractor.

x Shift work schedule is an inherent part of the nature of work in the BPO industry, therefore, changes/modifications in the break timings could not be agreed upon.

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4.12 Setting pace for program

After making changes at the intrapersonal and physical environment level through health

and nutrition promotion sessions as well as modifications in the physical environment of the

worksite, a group session was conducted with the employees. This session reiterated the

purpose and need of lifestyle management program. The program implementation was

followed by a 6 weeks follow up period. All the queries pertaining to the program were

answered and the program was started.

4.13 Setting individual goals and targets

A set of goals and targets were designed for all the employees who participated in the

lifestyle management program. The program had similar goals and targets for each

employee irrespective of whether they had MetS or not. These were provided to the

employees in the form of a weekly plan that would not only be easy to understand but also

easy to follow. Each employee was a part of an individual session where they were assessed

Social and cultural level

x Creation of peer groups of employees working in the same work process x Creation of WhatsApp groups for each peer group x Setting up of a Facebook page and an email portal to answer queries posed by BPO

employees

Physical environment level

x Introduction of packed curd in the cafeteria x Introduction of fresh fruits in the cafeteria with lemon dressing and without salt x Availability of fresh fruit juice along with tetra packed juices and cold drinks in the

cafeteria x Increase in walking space in the working area x Creation of a recreation area in the free space in the campus with placement of a

badminton net and provision of badminton rackets and shuttlecocks x Introduction of a foot exerciser for use by employees while working at desk. x Display of posters on key messages at the areas frequently visited by employees in

the company premises such as working area, lift, stairs, reception, cafeteria and smoking zone.

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w.r.t to the goals and targets set and were provided suggestions on how could they achieve

them. They were also provided a tracking booklet to track their progress (Annexure 14).

4.14 Tracking of goals and targets

Each employee was handed over a tracking booklet. This booklet was titled My Health Book

and had a profiling page for the employee. They were taught to calculate their BMI and

assess for themselves whether they were underweight, normal weight, over weight and

obese. The employees were also taught to measure their waist circumference and were

informed the cut offs over which they would be classified as overweight. This was followed

by a food portion size chart. It had one serving of food items from all the food groups along

with their equivalent household measure which was easy to comprehend. Further, the

booklet had a list of food items with their pictures. The employee had to check the box for

the item they had consumed on a particular day and mention the corresponding amount.

Then in the next section, they had to mention if they had tried any quick meal recipes and

faced any difficulties. In the last section, the employees had to mention the type and

duration of the physical activity they had engaged on a particular day of the week.

Each employee was given the tracking booklet for 6 weeks during the follow up period. This

tracking booklet was reviewed weekly by the investigator for each week as per each

employees’ goals and targets. The employees tried to modify their dietary and lifestyle

practices during this period. Each week the employee with the help of the investigator

would track their progress w.r.t their goals and targets, and enlist the success and failures

along with the barriers to achieve them. The investigator as well as the employee would

come up with an agreeable solution to achieve the targets that could not be achieved in that

particular week. This process was continued for 6 weeks follow-up period. Changes in

certain targets (practices) happened sooner as compared to the others (table 97 and fig 41).

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Table 97: Gradual change in practices of BPO employees over a 6 week time period (n=41)#

Practice Pre program

(n)

Week1 n

Week2 n

Week3 n

Week4 n

Week5 n

Week6 n

Using multiple oils 14 20 (42.9)

21 (7.1)

21 (0.0)

21 (0.0)

23 (14.3)

24 (7.1)

Preferring mutton over chicken

28 20 (28.9)

20 (0.0)

19 (3.6)

18 (3.6)

18 (0.0)

17 (3.6)

Daily consumption of milk and milk products

16 16 (0.0)

24 (50.0)

26 (12.5)

26 (0.0)

27 (6.3)

28 (6.3)

Change in the type of milk (from full cream to toned/double toned)

30 30 (0.0)

16 (46.7)

15 (3.3)

12 (10.0)

11 (3.3)

10 (3.3)

Breakfast skipping 36 36 (0.0)

19 (47.2)

18 (2.8)

10 (22.2)

8 (5.6)

3 (13.9)

Daily fruit consumption

3 3 (0.0)

7 (11.4)

15 (22.9)

31 (45.7)

35 (11.4)

35 (0.0)

Daily eating out 41 41 (0.0)

38 (7.3)

36 (4.9)

30 (14.6)

29 (2.4)

29 (0.0)

Choosing refined products over whole

wheat products

36 36 (0.0)

34 (5.6)

31 (8.3)

26 (13.9)

26 (0.0)

26 (0.0)

Daily consumption of salad

7 7 (0.0)

7 (0.0)

8 (7.1)

10 (14.3)

14 (28.9)

14 (0.0)

Daily consumption of 2 servings of vegetables

12 12 (0.0)

12 (0.0)

12 (0.0)

14 (10.5)

19 (26.3)

19 (0.0)

Daily consumption of 2 servings of pulses

8 8 (0.0)

8 (0.0)

9 (7.1)

11 (14.3)

14 (21.4)

14 (0.0)

Regular physical activity

5 5 (0.0)

7 (13.3)

10 (20.0)

11 (6.7)

11 (6.7)

15 (26.7)

Tobacco use 30 30 (0.0)

29 (3.3)

27 (6.7)

25 (6.7)

23 (6.7)

19 (13.3)

Alcohol consumption 34 34 (0.0)

33 (2.9)

31 (5.9)

28 (8.8)

26 (5.9)

20 (17.6)

#Denomination is not 41 in each case because this table depicts changes in practices specific for individuals for whom these were identified as targets Figures in parentheses represent percent improvement in practices weekly

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Figure 41: Change in practices of maximum number of employees week wise

4.15 Reinforcement during the follow up period

For reinforcement, they were sent healthy lifestyle related messages daily on WhatsApp

(Annexure 15). They were also given a daily reminder to fill in their health books for the day.

Peer groups were formed for individuals belonging to the same BPO process and a

WhatsApp group was created for each group. Through these groups, healthy lifestyle

messages were delivered daily to all. It was a forum where they could post their queries

which were promptly answered by the investigator.

4.16 Introduction of a foot exerciser

To further aid in helping them to be physically active while working at their desks, the

employees were provided with a foot exerciser (Picture 1). This is a portable instrument that

can be easily kept under the desk and one foot has to be strapped on the exerciser in order

to exercise. This instrument was specially introduced after a thorough market survey

considering the employees’ needs. The purpose was to get an instrument that they could

keep under their desk and use while doing work as they were desk bound for long hours.

After negotiating with the company management, the permission was granted to allow a

few employees to use the instrument for a period of one week and provide their feedback.

Using multiple oils, preferring

chicken and fish over mutton

Daily consumtpion of milk and

milk products, change in the type of milk to toned /double

toned

Reduction in breakfast skipping

Daily fruit consumption, reduction in eating out, choosing

whole wheat products over refined cereal

products

Daily consumption

of salad, 2 servings of

cooked vegetables, and pulses

Regular physical activity, Tobacco

reduction, Alcohol

consumption reduction

Follow up period

1 2 3 4 5 6 WEEKS

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Picture 1: Foot exerciser

4.17 Responding to queries posed by BPO employees and the solutions suggested during

program implementation

During the program implementation, when the employees were asked to modify their

practices w.r.t to the goals and targets provided to them, they had certain queries. The

solutions to these queries were suggested after discussing their acceptability and practical

feasibility with the employees (Table 98).

Table 98: Queries posed and solutions suggested

Query posed Solution suggested

I don’t like milk. I can’t have it on a daily basis. You can opt for curd or paneer. Curd is even available in your office cafeteria.

I like munching when I am at my desk. What are the healthy options that I can have at that time?

You can prepare the healthy mixes (demonstrated during the session on ‘Quick meals’) at home and get them in a container at office. You can also get sprouts chat/vegetable sandwich/fruit salad for that time.

I have vegetable once a day. How can I increase my vegetable intake?

One of the easiest ways is to include vegetables as salad. It is quick to make. Also, you can add vegetables to sprouts/ chaat/sandwich/raita.

At my home, we usually have ‘dal’ once a day. How can I increase my pulse intake?

You can opt for roasted chana/sprouts chat to increase your pulse intake. Both of them are easily available and need no cooking.

With my time schedule, I am not in the habit of having fruit daily. What should I do?

Fruits should be consumed on a daily basis as they are a storehouse of vitamins and minerals, provide immunity and protect us from infections. You can carry a fruit to office and can eat it on the way to office or as snack. Since fruit ‘chaat’ is available in your office cafeteria, you can have that with lemon.

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I like to have burger and pizza usually when I go out. Is there a healthy substitute for these?

Eating out should be occasional. However, if you do go out and want to have pizza or burger, it is better to choose wisely. You can opt for a pizza with wheat crust and with less cheese, and a burger with wheat bun instead of maida crust/bun.

At my place, we only use Fortune (soyabean oil) for cooking. Is it necessary to use multiple oils?

Every oil type has different properties and benefits. Using multiple oils is a healthy option rather than sticking to just one type.

How can I remain physically active at work? There are few simple things that you can do while at work: 1. Take stairs instead of elevator 2. Get up from your desk every 30 minutes, stretch/take a round of the floor and come back. 3. Do simple stretching exercises while at desk (demonstrated during the session ‘be fit and fine’). 4. During your break time, take a walk around the company premises.

I smoke daily. How can I reduce that? Smoking is injurious to health, not only for you but also for the people who are around you. The best way is to decide yourself that you want to reduce and eventually quit smoking. You can do that by reducing the number of cigarettes smoked per day followed by reducing the number of days for smoking.

I have alcohol when I am with my friends/colleagues. Is there a limit to how much I can drink at a time?

Alcohol should be consumed occasionally. For men it is not more than 2 pegs (60 ml) and for women it is not more 1 peg (30 ml) at a time. However, beer has the least amount of alcohol as compared to the other alcoholic drinks, so, it is a relatively safer option.

4.18 Assessment of knowledge, practices, and self-efficacy after program implementation

After the 6 weeks follow up, the employees were again assessed on their knowledge,

practices and self-efficacy.

Knowledge level

Employees were given scores on the basis of their answers to the knowledge statements as

was done before the program implementation (Fig 42). A score of 1 was allotted for each

correct answer while no score was given for a wrong answer. Wilcoxon’s dependent signed

rank test was used to test the increment in knowledge level of the participants before and

after the program. Results of the analysis indicated that the lifestyle management program

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led to a significant improvement in the knowledge level of the BPO employees participating

in the program trial (Z = -2.261; p = 0.02).

Change in practices related to diet and lifestyle

After the program was implemented and each employee was guided individually on their

goals and targets, their diet and lifestyle related practices were assessed after a period of 6

weeks (Table 99 and 100). McNemar’s test for proportions was used to ascertain the change

in practices related to diet and lifestyle. There was significant improvement in the daily

39 5

39 39

5 39

36 39

4 36

8 38

36 6

39 35

3 38

5 35

33 34

37 7

37 39

41

0 5 10 15 20 25 30 35 40 45Number of employees

Fig 42: Knowledge level of BPO employees after 6 weeks follow up

(n=41)

Z = -2.261; p = 0.02

A11 Z Y X W V U T S R Q P O N M L K J I H G E D C B A

KNOWLEDGE STATEMENTS: A - A healthy diet is a diet with all nutrients in adequate amount; B- Vegetables and fruits are body building foods; C- Fruits and vegetables should be eaten liberally; D- Food pyramid guides us how to eat properly; E-There are three food groups; F- 1 teaspoon = 5 grams of sugar/oil; G- At least 3 servings of milk and milk products (300ml) should be consumed in a day; H- Fruits are a healthy snack option; I- When given a choice, always opt for mutton over chicken and fish; J- 1 glass of milk = 250 ml; K- Food should be chosen based on taste; L-Wise food choices make one healthy; M- Fast foods are rich in salt, sugar and fat; N-

We should buy canned foods as they are healthy; O- Fast foods are already prepared or cooked within minutes; P- Food labels help to choose healthy food items; Q- The information provided on food labels is useless; R- Each packaged food item has a label; S- All processed foods are healthy; T- Food labels are easy to read; U- Preparing meals is easy; V- I can incorporate cooking in my daily routine; W- Physical activity can be done at any time and at any place; X- It is alright to do exercise one day in a week; Y- Duration of physical activity of moderate intensity should be between 30-45 minutes daily; Z- Don’t sit at a place for more than 30 minutes; A1- Exercise helps to control body weight.

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consumption of fruit (35), salad (14), and two servings of pulses (14) daily (p<0.05 for all).

However, the improvement in consumption of two servings of cooked vegetables (19) was

not statistically significant (p=0.193). Nearly half of them preferred toned milk (18) and were

consuming milk and milk products daily (28), but improvement in these practices were not

significant. The preference of refined cereals over whole cereals had declined significantly

(p=0.000), however, the decline was not significant in case of preference of mutton over

chicken and fish (p=0.584). The decline in preference for saturated fat sources like desighee

was significant (p=0.020) while for butter, it was not significant (p=0.487). The daily eating

out practice reduced (29) significantly (p=0.000) and the number of employees eating out

daily declined (13). There was a significant decline in breakfast skipping with only 3

employees skipping it after 6 weeks (p=0.002). Fifteen employees started doing regular

physical activity of ≥30 minutes duration on most days of the week, with this change in

practice being significant (p=0.005). Nearly half of them tried to reduce/quit tobacco (19)

and alcohol (20) use after 6 weeks of follow up (p=0.000).

Consumption of fruit at least once a day increased from 7 employees to 35 employees post

6 weeks follow up. Though, there was a significant improvement in the percentage of

employees consuming 2 servings of pulses daily, only 50% were following this practice. This

was because for most of them, either vegetable or pulse preparations were cooked with one

of the main meals (lunch/dinner only) at home or were available in the cafeteria menu. The

investigator offered a suggestion to include vegetables as salad and pulses as roasted chana

or sprouts to increase their intake. The increase in number of employees consuming more

number of servings of vegetables and pulses everyday can be attributed to the suggestion

offered. However, after 6 weeks many employees still found it difficult to achieve this

target. Breakfast was emphasized as the most important meal of the day during the

education sessions and also during follow up. After the follow up period, the number of

employees skipping breakfast reduced to less than one tenth (n=3). A change in the type of

oil for cooking was observed after 6 weeks follow up. In one of the sessions, the need to use

the right type of oil as well as use of multiple oils was emphasized. This was also emphasized

during the follow up. There was a change observed in case of daily eating out for the

employees. From 80% of the employees (n=30) eating out daily, the frequency had reduced

to one third (n=13) after 6 weeks of follow up. The session on food choices for the

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employees emphasized making wise choices while eating out. The quick meals session gave

them hands on training to prepare simple nutritious snacks. However, regular physical

activity was difficult to achieve for most of the employees. Although the change was from 5

employees to 15 employees, but it was still less than half of those participating in the

program (n=41). The employees were demonstrated simple exercises which could be done

at the workplace and some opted to follow and incorporate these in their daily routine.

Table 99: Dietary and lifestyle practices of BPO employees (n=41) after program

implementation Practice Followers

x Daily fruit consumption 35 x Daily consumption of at least 2 servings of cooked

vegetables 19

x Daily consumption of salad 14 x Daily consumption of 2 servings of pulses 14 x Daily consumption of milk/milk in products other than

tea and coffee 28

x Type of milk preferred (if consumed) Full cream (10) Toned (18) Double toned (5)

x Preference of mutton over chicken and fish 17 x Preference of refined cereals over whole cereals 26 x Oils preferred (Multiple choices) Soyabean (41)

Mustard (13) Desighee (11) Butter (14)

x Eating out (daily)a 29 x Frequency of eating outb Daily (13)

1-2 times a week (10) Once a week (8) 1-2 times in a month (9)

x Type of items consumed while eating out Poha, vegetable sandwich, healthy mixes, channa

x Breakfast skipping 3 x Extra sugar added to beverages 16 x Regular physical activity 15 x Duration (if doing regular physical activity) 30-45 minutes x Tobacco use reduction/quitting 19 x Alcohol consumption reduced 20 aEating out - It referred to daily consumption of freshly cooked/ready to eat packed food prepared away from

home. This included all meals/snacks consumed at a restaurant/local vendors/dhabas and meals/snacks ordered from food outlets other than the cafeteria. bFrequency of eating out – it referred to consumption of freshly cooked/ready to eat packed food prepared

away from home. This included all meals/snacks consumed at a restaurant/local vendors/dhabas and meals/snacks ordered from food outlets and eaten at home/office cafeteria.

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To expect the employees to quit alcohol and tobacco use within the short duration of 6

weeks would be ambitious. Hence, more focus was on reduction in both tobacco and

alcohol use. Among those who were using tobacco and consuming alcohol, half of them (out

of 34 employees) had made efforts to reduce their usage. Although 3 of them had quit

tobacco use (cigarette smoking), the same could not be achieved with alcohol.

Table 100: Change in practices of BPO employees before and after 6 weeks of follow up

Practice Before (n) After (n) p value#

Daily fruit consumption 7 35 0.000* Daily consumption of at least 2 servings of cooked vegetables

12 19 0.193

Daily consumption of salad 7 14 0.005* Daily consumption of 2 servings of pulses 8 14 0.007* Daily consumption of milk/milk in products other than tea and coffee

16 28 0.784

Use of full cream milk 30 10 1.000 Preference of mutton over chicken and fish 28 17 0.584 Preference of refined cereals over whole cereals 36 26 0.000* Eating out (daily)a 41 29 0.000* Breakfast skipping 36 3 0.002* Addition of extra sugar to beverages 32 16 0.229 Regular physical activity for ≥30 minutes 5 15 0.005* Reduction in tobacco usage 30 19 0.000* Reduction in alcohol consumption 34 20 0.000* *Significant at p<0.05 aEating out - It referred to daily consumption of freshly cooked/ready to eat packed food prepared away from

home. This included all meals/snacks consumed at a restaurant/local vendors/dhabas and meals/snacks ordered from food outlets and eaten at home/office. #McNemar’s test for difference in proportions

Self-efficacy

Assessment of self-efficacy was done after 6 weeks of follow up after program

implementation. Changes were observed in the self-efficacy levels of the employees with

respect to diet, physical activity, alcohol consumption and tobacco use. The employees self

–efficacy changed from being uncertain in majority of the aspects to achieve their diet and

lifestyle related goals and targets to becoming certain in them. They were very certain of

making necessary routines (p=0.000), change their perception about nutrition (p=0.005) and

try many times (p=0.000) to achieve their dietary goals and targets unlike before the

implementation of the program (Fig 43 and Table 101).

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None of the employees were very certain of making changes in their diet when they had to

incorporate that change by making detailed plans (p=0.087). Participation in the program

enabled the employees to follow the changes suggested in their diet and lifestyle. This

resulted in decrease in the number of employees who were uncertain w.r.t modifying their

diet, and other lifestyle practices post follow up period.

9

3

12

8 9

11

17

13

11 10

11 12

8

13

10 10 9

8 9

12

0

2

4

6

8

10

12

14

16

18

1 2 3 4 5

N

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r

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p

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Fig 43: Diet related Self-efficacy after 6 weeks follow up

(n=41)

Very uncertain

Rather uncertain

Rather certain

Very certain

Self efficacy (response to statements)

Statements: 1 – Even if I need a long time to develop the necessary routines 2 – Even if I have to try several times until it works 3 – Even if I have to rethink my entire way of nutrition 4 – Even if I do not receive a great deal of support from others when making my first attempts 5 – Even if I have to make a detailed plan

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Self-efficacy also improved w.r.t to engaging in physical activity. Although after 6 weeks of

follow up, regularity in physical activity could be achieved only by half of them, some of

them became very certain to carry out physical activity in times of tension (14) and

depression (17), tiredness (14) and even when they were busy (17) or had problems (16)

(p=0.000 for all) as depicted in fig 44 and Table 101. This self-belief can be attributed to

reinforcement of modifications desired each week with the help of messages on physical

activity and during individual sessions emphasizing the benefits of the same and also

suggesting ways of achieving the targets.

10 11

12 13 13

15

13

15 14

11 12

11

7

9

11

4

6 7

5 6

0

2

4

6

8

10

12

14

16

1 2 3 4 5

N

u

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f

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p

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Fig 44: Exercise related self-efficacy after 6 weeks follow

up (n=41)

Very uncertain

Rather uncertain

Rather certain

Very certain

Statements: 1 – Even when I have worries and problems 2 – Even if I feel depressed 3 – Even when I feel tense 4 – Even when I am tired 5 – Even when I am busy

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Among the alcohol consumers and tobacco users, self-efficacy level improved significantly

(p<0.05) after program implementation but the change was not as high as observed in terms

of number of employees expressing certainty w.r.t diet and physical activity related self-

efficacy. Some of them became rather certain of controlling themselves to reduce their

alcohol consumption and tobacco use (p=0.000 for both) as well as to quit using them

(p=0.000) (Fig 45 and 46 and Table 101).

12 10

7 9

14

9

13

10

18

02468

101214161820

1 2 3

N

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Fig 45: Self efficacy related to alcohol consumption after

6 weeks follow up (n=41)

Very uncertain

Rather uncertain

Rather certain

8

11

0

9 10

0

13

9

0 0

2

4

6

8

10

12

14

1 2 3

N

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Fig 46: Self efficacy related to tobacco use after 6 weeks

follow up (n=41)

Very uncertain

Rather uncertain

Rather certain

Statements: 1 - Reduce my alcohol consumption 2 - Not to drink any alcohol at all 3 - Drink only at special occasions

Statements: 1 - Reduce my tobacco use 2 - Not to use tobacco at all

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Table 101: Change in self–efficacy of BPO employees before and after program implementation 6 weeks of follow up (n=41)

Self-efficacy related to: Before After p value#

Very uncertain and rather uncertain (n)

Rather certain and very certain (n)

Very uncertain and rather uncertain (n)

Rather certain and very certain (n)

Diet (n=41) 1 – Even if I need a long time to develop the necessary

routines 2 – Even if I have to try several times until it works 3 – Even if I have to rethink my entire way of nutrition 4 – Even if I do not receive a great deal of support from others when making my first attempts 5 – Even if I have to make a detailed plan

38 41 33 30 32

3 0 8 11 9

20 20 25 19 19

21 21 16 22 22

0.000* 0.000* 0.005* 0.200 0.087

Exercise (n=41) 1 – Even when I have worries and problems 2 – Even if I feel depressed 3 – Even when I feel tense 4 – Even when I am tired 5 – Even when I am busy

36 37 37 38 38

5 4 4 3 3

25 24 27 27 24

16 17 14 14 17

0.000* 0.000* 0.000* 0.000* 0.000*

Alcohol consumption (n=30)a 1 - Reduce my alcohol consumption 2 - Not to drink any alcohol at all 3 - Drink only at special occasions

30 30 26

4 4 8

21 24 16

13 10 18

0.000* 0.000* 0.152

Tobacco use (n=34)a

1 - Reduce my tobacco use 2 - Not to use tobacco at all

30 30

0 0

17 21

13 9

0.000* 0.000*

*Significant at p<0.05 aNumber of current alcohol/tobacco users #McNemar’s test for difference in proportions

296

Overall, there was a significant improvement in the knowledge and practices pertaining to

diet, physical activity and other lifestyle practices (p<0.05). There was also signifcant

improvement in self-efficacy to bring about changes in diet, including physical activity as a

part of their routine, as well as making efforts to reduce tobacco usage and alcohol

consumption after 6 weeks of follow up (p<0.05).

In workplace program, stakeholder engagement is a must to be successful. Senior

management’s support has an important role to play in providing permissions and arranging

logistic help. The role of the HR manager was also important as he/she was the liaison

between the investigator and the employees. Conducting introductory sessions with the

employees before the program convinced them of the need and helped in participation.

Overall, preventive programs like these that focus on diet and lifestyle management are

required as they help in sensitizing the young employees and making them conscious of

their health. However, after 6 weeks of follow up, sustainability of the program could not be

assessed as that would require follow up for much longer duration. Certain workplace

interventions have been conducted to reduce MetS or have an impact on reducing the risk

factors. A systematic review has shown that an energy-prudent diet, coupled with moderate

levels of physical activity, favorably affects several parameters of the metabolic syndrome

and delays the onset of diabetic complications (Magkos et al, 2009). A 12 week worksite

heart health campaign among 87 BMW employees in North America proved its effectiveness

in significantly reducing the risk factors for MetS (Daubert et al, 2012). The health campaign

included three coaching sessions by a registered dietitian (RD), eight educational sessions

led by an RD along with provision of web-based tools and educational booklets for a period

of 12 weeks. At the end of 12 weeks, there were significant reductions in weight (p<.0001),

body mass index (p=.0047), waist circumference (p <.0001), diastolic blood pressure

(p=.0018), and systolic blood pressure (p=.0012) (Daubert et al, 2012). In the present study,

a significant change was demonstrated in the knowledge and practices of BPO employees

after 6 weeks of intervention. Several lifestyle interventions in different population groups

have proved that lifestyle management is an effective way to prevent and reduce MetS

(Lackland and Voeks, 2014; Yamaoka and Tango, 2012; Grave et al, 2010; Hu et al, 2006).

297

4.19 Efforts made to engage the stakeholders in the process of program development and

implementation

x Assessment of nutritional status of BPO employees and screening them for MetS served

as an important starting point for the program.

x Explaining them their current status based on their reports and their health implications

served as an important step for the program.

x Giving them control of their situation by enabling them to choose among the various

options whenever feasible.

x Supportive counseling to motivate them and resolve some of their problems by

suggesting ways to overcome the barriers faced.

x Negotiating with senior company management, canteen operator and HR managers to

improve the physical environment to make it conducive to facilitate behavior change.

x This was the first worksite program of its kind to be conducted in the BPO company,

which allowed the employees to enthusiastically participate and supported the program.

4.20 Program feedback

Overall feedback about the lifestyle management program was obtained from the

employees using a questionnaire (n=41) (Annexure 16). It was positive and encouraging. All

the employees agreed that the program was very useful for them (n=41). They felt that the

program had fulfilled their expectations as it made them realize the importance of a healthy

lifestyle (n=37). They were able to improve their diet through the program (n=33), became

aware of nutritive value of various food items (n=36) and learnt about daily food

requirements (n=40). All the employees agreed to use the information on portion size,

serving adequate portions of various food items at a time for meals and avoid repeated

servings, choosing adequate portions of various food preparations at one time for a meal

and food labels (n=41). They tried preparing simple recipes for nutritious meals/snacks

(n=34). They also learnt the value of a balanced diet and were eager to incorporate it in

their daily lives (n=39). All of them felt that they could improve their diet and lifestyle habits

by strong will and commitment to pursue healthy habits (n=41). Employees were

enthusiastic to inculcate the suggestions offered regarding changes in diet and physical

activity, to improve their lifestyle and thus prevent occurrence of chronic diseases.

220

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ANNEXURE 1: INFORMED CONSENT FORM for BPO employees (21-30 years) in NCR who we are inviting to participate in research, titled

“PREVALENCE AND RISK FACTORS OF METABOLIC SYNDROME AMONG YOUNG BPO EMPLOYEES IN NCR: DEVELOPMENT OF A LIFESTYLE

MANAGEMENT PROGRAM FOCUSING ON MODIFIABLE RISK FACTORS OF METABOLIC SYNDROME”

This Informed Consent Form has two parts:

• Information Sheet (to share information about the study with you)

• Certificate of Consent (for signatures if you choose to participate)

Part I: Information Sheet I, Ishu Kataria, Research Scholar with the Department of Food and Nutrition, Lady Irwin

College, University of Delhi will be conducting this research under the supervision of Dr.

Ravinder Chadha (Associate Professor, University of Delhi) and Dr. Renuka Pathak

(Associate Professor, University of Delhi), as a part of my Ph.D work.

I invite you to be part of this research because we believe that you can help us by telling us

about your diet and lifestyle related practices. We want to know more about people who are

working in this industry and their current health profile as it can predict the future risk of

many chronic diseases like heart disease. It will help us to enable you to modify your current

diet and lifestyle (if inappropriate) for long term good health. You are invited to take part in

this research because we feel that your experience of working as a BPO employee can

contribute much to our understanding and knowledge about the unexplored health related

aspects of this industry.

Your participation in this research is entirely voluntary. It is your choice whether to

participate or not. If you accept, you will be asked to fill out an objective questionnaire and

interviewed regarding your current diet and lifestyle practices. Assessment of height, weight, body fat percentage and blood pressure will be done. The study also involves

estimation of triglycerides, HDL cholesterol, fasting blood glucose and hemoglobin which

will help us to know your current health profile. All estimations will be FREE OF COST.

If you do not wish to answer any of the questions included in the questionnaire, you may skip

them and move on to the next question. The information recorded is confidential, and no one

else except the researcher will have access to the results. We will not be sharing information

about you to anyone outside of the research team. The information that we collect from this

research will be kept private. The knowledge that we get from this research will be shared

with you and your community before it is made widely available to the public.

You do not have to take part in this research if you do not wish to do so, and choosing to

participate will not affect your job or job-related evaluations in any way. If you have any

questions regarding the study, you can mail your queries to [email protected].

Part II: Certificate of Consent I have been invited to participate in research about Metabolic Syndrome and its Risk Factors

among BPO Employees. I have been informed that the study involves understanding

regarding my current nutrition and lifestyle pattern and will enable me to gain knowledge

regarding my health status. I know that my participation in this study is completely voluntary

and I’m free to withdraw consent and to discontinue participation at any time, and can refrain

from answering any questions without penalty or explanation. Every effort will be made to

ensure my confidentiality related to any identifying information that is obtained in connection

with this study, and researcher is the only person who will have access to the results.

I have read the foregoing information. I have had the opportunity to ask questions about it

and any questions I have been asked have been answered to my satisfaction. I consent

voluntarily to be a participant in this study.

Name of Participant__________________

Signature of Participant ___________________

Date ___________________________

Day/month/year

ANNEXURE 2: Background Information Questionnaire

Date : Name: Date of birth:

Instructions: Please read the following questions and answer them carefully and honestly.

Tick from the options provided and fill response where required. This questionnaire will

take only a few minutes of yours. All the responses will be kept confidential and only the

research team will have access to it.

Sex: M F

Address:

Marital status: x Never married

x Currently married

x Separated

x Divorced

x Widowed

x Cohabitating/Live-in Contact number:

x Mobile

x Landline

E mail address: Educational qualification: x Metric

x High school

x Graduate

x Post graduate

x Any other, please specify

______________________________________

Name of the organization in

which currently working:

Designation: Your monthly income: 5000-10,000 Rupees

10,000-15,000 Rupees

15,000-20,000 Rupees

20,000-25,000 Rupees

25,000-30,000 Rupees

30,000-35,000 Rupees

35,000-40,000 Rupees

40,000-45,000 Rupees

45,000-50,000 Rupees

> 50,000 Rupees

Shift timings: Type of family:

Nuclear

Joint

Staying alone/PG

Nuclear family: A social unit composed of father, mother, and children.

Joint family: A social unit composed of grandparents, parents and their children living together in one

household.

CHECKED BY INVESTIGATOR ________________

DATE: ________________

Number of members living in the

household (if living in a

nuclear/joint family/ live in):

Does anybody in your family

(father/mother/ mother’s brother(s)/ mother’s sister(s)/ father’s brother(s)/father’s sister(s)/ brother/ sister/

grandparents) have any of the

following?

x Diabetes/ high blood sugar

x High Blood Pressure

x Heart disease

x Thyroid problem

x Any other disease (Please specify)

__________________________________

If yes, what is the relationship of

that person with you? (You can

tick multiple options)

x Father

x Mother

x Siblings (brother/ sister)

x Mother’s father (Nana ji) x Mother’s mother (Nani ji) x Father’s father (Dada ji) x Father’s mother (Dadi ji) x Mother’s brother (Mama) x Mother’s sister (Masi) x Father’s brother (Chacha/ Taya ji)

x Father’s sister (Bua) x Any other person (Please specify)

__________________________________

Are you undergoing medical

treatment for any ailment/

problem/ disease?

x Yes

x No

If yes, is it for any of the following

problems?

x Diabetes

x Hypertension

x Heart disease

x Thyroid

x Any other disease (Please specify)

__________________________________

If yes, please specify the name of

the medicine that you are taking?

x __________________________________

x __________________________________

x __________________________________

x __________________________________

x __________________________________

ANNEXURE 3: WHO STEPS Instrument

Questionnaire 1 Tobacco Use (T) No. Question Response Code Q1. Do you currently smoke any tobacco

products, such as cigarettes, cigars or

pipes?

Yes 1

No 2

T1

Q2. Do you currently smoke tobacco products

daily?

Yes 1

No 2

T2

Q3. How old were you when you first started smoking daily?

Age (years)

Don’t know 77 └─┴─┘ T3

Q4. *On average, how many of the following

do you smoke each day?

Manufactured cigarettes

└─┴─┘ Hand-rolled cigarettes /

Beedis

└─┴─┘ Cigars / hookahs

└─┴─┘ Any Other (Please

specify)

______________________________________________________

T4

Q5. In the past, did you ever smoke daily?

Yes 1

No 2

T5

Q6. Do you currently use any smokeless tobacco such as [pan masala, chewing tobacco (Guthka), pan, snuff (inhale)]?

Yes 1

No 2

T6

Q7. Do you currently use smokeless tobacco products daily?

Yes 1

No 2

T7

*MANUFACTURED CIGARETTES: A cigarette that has tobacco rolled in paper cylinder using

mechanical techniques and is usually sold in packets of 10 or more.

*HAND ROLLED CIGARETTES: A cigarette that is made from rolling loose tobacco in papers by hand

and is often sold loose like beedis

Q8. On average, how many times a day do

you use

Chewing tobacco

(Guthka)

└─┴─┘ Pan, pan masala └─┴─┘ Any Other (Please

specify)

T8

Instructions: Please read the following questions and answer them carefully and honestly. Tick from the options provided and fill response where required. This questionnaire will take only

a few minutes of yours. All the responses will be kept confidential and only the research team

will have access to it.

______________________________________________________

Q9. In the past, did you ever use smokeless

tobacco such as [chewing tobacco (Guthka), or Pan masala] daily?

Yes 1

No 2

T9

Q10.

During the past 7 days, on how many

days did someone smoke in closed areas

in your workplace (in the building, in a

work area or a specific office) when you

were present?

Number of days

└─┴─┘ Don't know

└─┴─┘ 77

T10

Alcohol use (A) Instructions: Refer to the measures of various beverages given in the table on the

next page and answer the following questions accordingly. No. Question Response Code Q1. Which alcoholic drinks/beverages do you

usually consume?

1 Beer

2 Wine

3 Whisky

4 Vodka

5 Gin

6 Rum

7 Any other

A1

Q2a Have you consumed any of these

alcoholic drinks/beverages within the

past 12 months/past year?

Yes 1

No 2

A2a

Q2b If yes, how frequently have you had at

least one alcoholic drink/beverage?

Daily 1

5-6 days per week 2

1-4 days per week 3

1-3 days per month 4

Less than once a month

5

A2b

Q3a Have you consumed any of these

alcoholic drinks/beverages within the

past 30 days/past 1 month?

Yes 1

No 2

A3a

Q3b If yes, how frequently did you consume

it?

Daily 1

5-6 days per week 2

1-4 days per week 3

1-3 days per month 4

Less than once a month

5

A3b

Q3c Please specify the number of drinks that

you consumed at a time during past 30

days/past month?

Number

Don't know 77

└─┴─┘

A3c

Q4a.

Has there been any occasion where you

have consumed [for men: five or more for women: four or more] standard

alcoholic drinks# in a single drinking

occasion during past 30 days/past 1

month?

Yes 1

No 2

A4a

Q4b.

If yes, please specify the number of

times/ occasions when you have

consumed [for men: five or more for

women: four or more] standard alcoholic

drinks# during past 30 days/past 1

month?

Number

Don't know 77

└─┴─┘

A4b

Q5. During the past 30 days, when you

consumed an alcoholic drink, how often

was it with meals? Please do not count

snacks.

Usually with meals 1

Sometimes with meals 2

Rarely with meals 3

Never with meals 4

A8

#Standard alcoholic drink: A standard drink is a drink that contains a specified

amount of pure alcohol.

Type of drink Available measure Volume

Beer (5% alcohol)

Bottle (large) 650 ml

Bottle (small) 330 ml

Can (large) 500 ml

Can (small) 330 ml

Glass 150 ml

Strong beer(8%alcohol) Bottle 650 ml

Wine (12-15% alcohol) Bottle 750 ml

Glass 90 ml

Whisky/Rum/Gin/Brandy

(42.8% alcohol)

Half peg 30ml

Peg 40-60 ml

Patiala peg 80 ml

Country liquor/ ‘Desi sharaab’ (40-70% alcohol)

Sachet 44ml

Sachet 200 ml

Glass (half peg) 30 ml

Glass/Peg 40-60 ml

Patiala peg 80 ml

Pint/Half (bottle poured into

a glass)

375 ml

Quarter 180ml

Questionnaire 2 Physical Activity (PA) Next I am going to ask you about the time you spend doing different types of physical

activities in a typical week. Think of work as the things that you have to do such as paid or

unpaid work, study/training, household chores, computer work, surfing internet. Please

answer the following questions.

No. Question Response Code WORK Q1. Does your work involve any of the vigorous-

intensity activity(ies)# for at least 10 minutes

continuously? [See from table below]

Yes 1

No 2

PA1

(a) If yes, in a typical week, on how many days

do you do this activity(ies) as part of your

work?

Number of days

└─┘ PA2

(b) Time spent doing vigorous-intensity

activity(ies) #

at work on a typical day

Hours : minutes

└─┴─┘: └─┴─┘ PA3

Q2. Does your work involve any of the above

moderate-intensity activity(ies)#

for at least

10 minutes continuously? [See from table below]

Yes 1

No 2

PA4


do you do this activity(ies) as part of your

work?

Number of days

└─┘

PA5

(b) Time spent doing moderate-intensity

activity(ies)# at work on a typical day

Hours : minutes

└─┴─┘: └─┴─┘ PA6

#Vigorous intensity activity: They are those activities that cause a large increase in breathing and/or heart rate. #Moderate intensity activity: They are those activities that cause a small increase in breathing and/or heart rate.

Work related physical activity Moderate intensity activities Vigorous intensity

activities Cleaning (Vacuuming, mopping, polishing,

scrubbing, sweeping, ironing)

Gardening (digging)

Washing (beating and brushing) Loading furniture

Gardening Cutting crops

Woodwork Instructing sports

aerobics

HOME AND LEISURE TIME Now I would like to ask you about sports, fitness and recreational activities (leisure) and

time spent at home. Leisure time activities are those activities that you do in spare/free

time.

No. Question Response Code Q1. Do you do any of these vigorous activities for

at least 10 minutes continuously?

x Aerobics

x Running x Heavy gymming such as push-

ups/pull-ups x Treadmill x Skipping x Football

Yes 1

No 2

PA7


do you do it? Number of days

└─┘ PA8

(b) Time spent doing vigorous-intensity

activity(ies) at home/during leisure time on a

typical day

Hours : minutes

└─┴─┘: └─┴─┘ PA9

Q2. Do you do any of these moderate intensity

activities for at least 10 minutes

continuously?

x Bicycling x Jogging x Light gymming such as warm up

exercises x Yoga x Treadmill (slow pace) x Basketball x Cricket x Badminton x Swimming x Tennis x Squash x Golf x Dancing x Gardening

Yes 1

No 2 PA10


do you do it? Number of days

└─┘ PA11

(b) Time spent doing moderate-intensity

activity(ies) at home/during leisure time on a

typical day

Hours : minutes

└─┴─┘: └─┴─┘ PA12

Q3. Please specify the time spent during the

following:

x Sitting at desk (at work)

Hours : minutes

└─┴─┘: └─┴─┘ PA13

x Sitting with friends

x Total time travelling from home to

office and office to home

x Playing cards

x Watching television

x Internet surfing

x Reading newspaper/magazine

x Chatting on the phone

x Household chores (dusting, mopping,

dishwashing, sweeping, washing

clothes etc)

└─┴─┘: └─┴─┘ └─┴─┘: └─┴─┘ └─┴─┘: └─┴─┘ └─┴─┘: └─┴─┘ └─┴─┘: └─┴─┘ └─┴─┘: └─┴─┘ └─┴─┘: └─┴─┘ └─┴─┘: └─┴─┘

Q4. At what time do you wake up for going to

office?

Hours : minutes

└─┴─┘: └─┴─┘ PA14

Q5. At what time do you usually go to sleep? Hours : minutes

└─┴─┘: └─┴─┘ PA15

TRAVEL TO AND FROM PLACES Now I would like to ask you about the usual way you travel to and from places. For example

to work, for shopping, to market, to place of worship.

No. Question Response Code Q1. Do you walk for at least 10 minutes

continuously to get to and from places?

Yes 1

No 2

PA16

Q2. In a typical week, on how many days do you

walk for at least 10 minutes continuously to

get to and from places?

Number of days

└─┘

PA17

Q3. How much time do you spend walking for

travel on a typical day?

Hours : minutes

└─┴─┘: └─┴─┘ Hrsmins

PA18

Q4. How do you commute to and from office

daily?

Walking1

Office cab2

Auto rickshaw3

Bus4

Metro5

Car(own)6

Two wheeler7

Any other (Please

specify)8

PA19

Questionnaire 3

No. Question Response Code Q 1. Are you a? 1 Vegetarian*

2 Non-vegetarian*

3 Ovo-vegetarian*

DA 1

Q 2. Please tick the meals and

the place where you have

them every day. Also list

the food items usually

consumed during these

meals.

Meals

usually

consumed

At

Home At

Office Food items

usually

consumed in the

meals

DA 2

1 Early

morning

2 Breakfast

3 Mid-

morning

4 Lunch

5 Tea time

6 Dinner

Any other

(pl. specify)

Q 3. Are you provided

lunch/dinner at your

Yes 1

No 2

DA 3

Instructions: Please read the following questions and answer them carefully and honestly.

Tick from the options provided and fill response where required. This questionnaire will

take only a few minutes of yours. All the responses will be kept confidential and only the

research team will have access to it.

*Vegetarian: A person who does not eat food derived from animals such as meat, fish, chicken, eggs

etc, and only eats plant foods such as vegetables, fruits, nuts, grains etc.

*Non-vegetarian: A person who eats food derived from animals as well as from plants.

*Ovo- vegetarian: A person who eats plant foods and eggs, but does not consume animal flesh.

office? Don’t know Q 4. How often do you eat

food from the office

canteen?

1 Never

2 Daily

3 Once in 2-3 days

4 Once a week

5 Once in 2 weeks

6 Monthly

DA 4

Q 4a

What do you usually eat

from the canteen? (Please

specify)

DA

4a

Q 5. Do you skip any of the

following meals usually?

(You can tick multiple

options)

1 None

2 Breakfast

3 Lunch

4 Evening tea

5 Dinner

DA 5

Q 5a If you skip any of the

above meals, please

specify the reason for it.

DA

5a

Q 6. Do you eat in between

meals?

1 Frequently

2 Occasionally

3 Rarely

4 Never

DA 6

Q 7. What do you usually

eat/drink in between

meals?

1 Namkeen/mixtures

2 Biscuits

3 Fruits

4 Nuts

5 Chips/kurkure

6 Cold drinks

7 Coffee

8 Tea

9 Chocolates

10 Any other (Please specify)

______________________

DA 7

Q 8. Which type of oil/fat

sources do you use at

home for cooking? Please

specify the amount

consumed during a week

or a month (You can tick

multiple options)

Type of oil consumed

Wee

kly

(g/kg

)

Mont

hly

(g/kg)

DA 8

1 Desi ghee

2 Vanaspati

3 Refined

oil

Types

Soyabean oil

Groundnut oil

Sunflower oil

Safflower oil

Sesame /Til oil

4 Butter

5 Margarine

6 Olive oil

7 Canola oil

8 Cream

9 Mayonnaise

10 Mustard oil

11 Coconut oil

12 Oil blends Types

Saffola gold

Saffola tasty

Saffola

active


_______________________

_______

Q 8a What are your reasons for

consuming these oils?

(You can tick multiple

options)

1 Taste

2 Cost

3 Health benefits

4 Easy accesibility

5 Media


_______________________

DA

8a

Q 9. Do you consume food

supplements#?

Yes 1

No 2

DA 9

Q 9a If yes, please specify Name Reason for taking it DA

9a

Q 10 Do you consume nutrient

supplements#?

Yes 1

No 2

DA

10

Q

10a

If yes, please specify Name Reason for taking it DA

10a

Q 11 Do you consume ‘health foods’ such as organic tea and coffee, organic spices

herbs and seasonings,

organic grains, flour and

pastas, organic seeds and

pulses, organic fruits and

Yes 1

No 2

Name Reason for taking it DA

11

vegetables, organic

breakfast foods etc? If

yes, please specify the

name and reason for its

consumption.

Q 12 How often do you go to

eat outside in

restaurants/ café’s/ hotels/ dabhas/ eating

joints? Please specify the

items usually ordered.

1 Never

2 Daily

3 Once in 2-3 days

4 Once a week

5 Once in 2 weeks

6 Monthly

Food items usually ordered

DA

12

Q 13 What are your reasons for

eating out?

1 Parties/ social gatherings

2 Meeting friends

3 When happy/sad

4 Lack of time

5 During stress

6 Any other (Please

specify)_____________________ ____________________________________________

DA

13

Q 14 Do you order food at

home from outside?

Yes 1

No 2

DA

14

Q

14a

If yes, please specify how

often?

1 Daily

2 Once in 2-3 days

3 Once a week

4 Once in 2 weeks

5 Monthly

DA

14a

Q

14b

Which are your favorite

dishes? (Please specify)

At home Eating out/Ordered from outside

DA

14b

Q 15 Which are your favorite

eating out joints and why?

DA

15

#Food supplements: They are the substances that help to increase the intake of vitamins, minerals and amino

acids in our diets. Eg: Horlicks, Bournvita, Mega Mass, Endura Mass, , Amway Products, Pediasure, Glucerna,

Proteinex, Boost, Complan etc.

#Nutrient supplements: They include vitamins, minerals, herbs, meal supplements, sports nutrition products,

and other related products used to boost the nutritional content of the diet.Eg: Calcium, Iron, Zinc, Magnesium

Selenium, Gingko, Vit A,C,D,E,B6,B12, Riboflavin, Niacin, Folate, Biotin, fish oil/ tablets, multivitamin capsules etc.

http://medical-dictionary.thefreedictionary.com/Nutrition

Checked by the investigator: __________________________

Date: __________________________

ANNEXURE 4: INTERHEART stress questionnaire

Tick/Check the response which is most appropriate in your case/which most appropriately describes your situation. You can also highlight the desired response in any color other than black.

S.No Question Response Q1. Stress at work 1. Never

2. Some of the time

3. Several periods

4. Permanent

Q2. Stress at home 1. Never

2. Some of the time

3. Several periods

4. Permanent Q3. General stress (at home and

at work both) 1. Never

2. Some of the time

3. Several periods

4. Permanent Q4. Financial stress 1. Little or none

2. Moderate

3. High or severe Q5. Have you experienced any

specified live events in the past 1 year? (You can tick multiple options)

1. None

2. Marital separation or divorce

3. Loss of job or retirement

4. major financial loss

5. Violence, major intra-family conflict

6. Major personal injury or illness

7. Death or major illness of a close family

member

8. Death of a spouse (husband/wife), or other

major stress

Q6. In the past 12 months, have you ever felt very low or very sad/depressed?

1. Yes

2. No

Q6a. If yes, what do you feel? (You can tick multiple options)

1. lose interest in things

2. feel tired or low on energy

3. gain or lose weight

4. trouble falling asleep

5. trouble concentrating

6. feeling worthless

7. think of death

Q7. Have you ever felt depressed for 2 weeks or more in a row?

1. Yes

2. No

Q7a. If yes, what do you feel? (You can tick multiple options)

1. lose interest in things

2. feel tired or low on energy

3. gain or lose weight

4. trouble falling asleep

5. trouble concentrating

6. feeling worthless

7. think of death

Checked by the investigator: __________________________

Date: __________________________

ANNEXURE 5: Food Frequency Questionnaire

Food items FREQUENCY OF CONSUMPTION Portion size Daily Weekly Monthly No: of times/year Never Seasonal

(Summer/Winter) 1-2 days

3-4 days

Once a

week

1-6 times Per year

7-11 times/year

Cereals

Chapatti NO.

Parantha NO.

Poori NO.

Bathura NO.

Porridge/dalia BOWL

Cornflakes with milk BOWL

Muesli BOWL

Plain rice BOWL

Brown rice BOWL

Vegetable Pulao BOWL

Khichdi BOWL

Pasta/noodles/

Macaroni

BOWL

White bread NO.

Brown bread NO.

INSTRUCTIONS: This questionnaire is basically to record your food habits by asking you to tick the option (For frequency of eating eg: per

day/ per week/ per month/ per year/ seasonal/ never) and filling the appropriate response which is the most suitable according to you. It

will take only few minutes of yours. Please fill the options as accurately as possible so that we will be able to assess your food habits

correctly, and it will be beneficial for you to know about it. Your responses will be kept confidential and only the research team will have

access to it.

Multigrain bread NO.

Pizza PIECES

Burger NO. & SIZE

Upma BOWL

Kulcha NO.

Poha BOWL

Plain /vegetable

Vermicelli

BOWL

Naan (plain) NO.

Naan (butter) NO.

Makki roti NO.

Fried rice (veg) BOWL

Fried rice (Non-veg) BOWL Biryani (Veg) BOWL

Biryani (Non-Veg) BOWL

Any other (Please specify)

Pulses Chana curry: Kala

Kabuli

BOWL

BOWL

Chana dry BOWL

Rajmah curry BOWL

Soyabean curry BOWL

Soyabean dry

(Nutrela/Nutrikeema)

Soyabean chaap BOWL

Rajmah/lobia dry BOWL

Whole dals

BOWL

x Chana dal

x Masoor dal

x Urad dal

x Moong dal

BOWL

BOWL

BOWL

Dehusked/ Dhuli dals

x Masoor dal

x Urad dal

x Moong dal

BOWL

Sambhar BOWL

Sprouts BOWL

Kadhi BOWL

Any other (Please specify)

Vegetable preparations

Paneer curry BOWL

Mix vegetable BOWL

Baigan bhartha BOWL

Aloo gobhi BOWL

Aloo matar BOWL

Saag BOWL

Palak paneer BOWL

Gajar aloo matar BOWL

Ghia subzi BOWL

Kathail subzi BOWL

Malai kofta BOWL

Cabbage matar BOWL

Shalgam BOWL

Tori BOWL

Tinda BOWL

Beans aloo BOWL

Bhindi BOWL

Methi aloo BOWL

Matar mushroom BOWL

Mooli subzi BOWL

Any other(Pl. specify)

Non- vegetarian items Chicken (Roasted) PIECES

Chicken curry (Butter chicken) BOWL

Fried chicken PIECES

Grilled fish PIECES

Fish fry BOWL

Fish curry BOWL

Mutton curry BOWL

Mutton tikka PIECES

Mutton kebab PIECES

Mutton korma BOWL

Liver/brain/kidney BOWL

Sea food

x Prawn

x Lobster

x Crab

x Oyster

x Mollusk

x Shell fish

PIECES

PIECES

PIECES

PIECES

PIECES

PIECES

Egg boiled NO.

Egg poached NO.

Egg scrambled NO.

Egg fried NO.

Egg gravy BOWL

Egg omlette NO.

Non veg rolls NO.

Ham, salaami, bacon NO.

Any other(Pl. specify)

Fruits Banana NO.&SIZE

Apple NO.&SIZE

Orange NO.&SIZE

Mausambi NO.&SIZE

Mango NO.&SIZE

Guava NO.&SIZE

Grapes NO.&SIZE

Pineapple NO.&SIZE

Papaya NO.&SIZE

Pomegranate (anar) NO.&SIZE

Custard apple (Shareefa) NO.&SIZE

Chikoo NO.&SIZE Watermelon NO.&SIZE Strawberry NO.&SIZE

Kiwi fruit NO.&SIZE

Muskmelon(Kharbuja) NO.&SIZE

Fruit cocktail (Tinned) BOWL

Any other (Pl.specify)

Miscellaneous Biscuits (Plain) No.

Biscuits (Cream) No.

Biscuits (salted) No.

Mixture/namkeen Packet/katori

Chips/wafers Packet

Samosa No.

Cake Piece (s)

Pastry Piece (s)

Pudding Bowl

Kheer Bowl

Custard Bowl

Ice cream No. & type

Pakora No.

Patties No.

Mathri No.

Pop corn (small/med/large) No. &size

Honey Tsp

Jam/jelly/marmalade Tsp

Jaggery (Gur) Piece(s)

Pizza (small) No.of slice(s)

Pizza (medium) No.of slice(s)

Pizza (large) No.of slice(s)

Burger (small) No.

Burger (large) No.

Chocolate (milk) No.

Chocolate (dark) No.

Cheese slices No:

Fruit cream BOWL

Burfi (khoa)

Kaju katli/burfi No.

Gulab jamun No.

Rasgulla No.

Rabri Bowl

Jalebi/Imarti No.

Ladoo (besan) No.

Ladoo (atta) No.

Nuts

x Almonds (badam) No.

x Cashewnut

(Kaju)

No.

x Groundnut

(moongfali)

No.

x Pistachio

(pista)

No.

x Raisins

(kishmish)

No.

x Walnut

(akhrot)

No.

Any other (please specify)

BEVERAGE(S) INTAKE QUESTIONNAIRE

Beverages FREQUENCY OF CONSUMPTION Portion size

Daily Weekly Monthly No: of times/year Never Seasonal (Summer/Winter) 1-2

days 3-4

days Once

a week

1-6 times Per year

7-11 times/year

Tea with sugar Cup

Tea without sugar Cup

Coffee with sugar Cup

Coffee without

sugar

Cup

Cold drink (small) Glass

Cold drink

(medium)

Glass

Cold drink (large) Glass

Lassi (sweet) Glass

Lassi (salted) Glass

Chaach Glass

Green tea with

sugar

Cup

INSTRUCTIONS: This questionnaire is basically to record your beverage consumption by asking you to tick the option (For frequency of

drinking eg: per day/ per week/ per month/ per year/ seasonal/ never) and filling the appropriate response which is the most suitable

according to you. It will take only few minutes of yours. Please fill the options as accurately as possible so that we will be able to assess

your beverage consumption correctly, and it will be beneficial for you to know about it. Your responses will be kept confidential and only

the research team will have access to it.

Green tea without

sugar

Cup

Organic tea Cup

Milk shake with ice

cream

Glass

Milk shake without

ice cream

Glass

KFC Krusher (Small) Glass

KFC Krusher (Large) Glass

Frappe Glass

Nimboo pani Glass

De-caffeinated

coffee

Cup

Diet coke (tin) No.

Diet coke (pet

bottle)

Tetra pack juice eg:

Real, Tropicana,

Priyagold

(200ml/small)

No.

Tetra pack juice

(1litre/large)

No.

Frooti (tetra pack

200ml)

No.

Frooti (1litre

bottle)

No.

Coconut water Glass

Cold coffee Glass

Cold coffee with ice

cream

Glass

Badam milk Glass

Fresh fruit juice Glass

Soup Bowl

Vegetable juice Glass

Milk (double

toned)

Glass

Milk (toned) Glass

Milk (full cream) Glass

Tang Glass

Curd Cup/katori

Yoghurt Cup/katori

Flavored milk Glass

Any other (Please

specify)

ANNEXURE 6: 24 HOUR DIETARY RECALL PERFORMA Meal Menu Ingredients

of each dish

Household measure of each

dish

Raw amount

Method of preparation

Consistency/Type/Size

Dry Thick Medium Thin Breakfast

Mid Morning

Lunch

Evening

Dinner

Any other meal

ADDITIONAL INFORMATION SOUGHT-

x Time x Place x Combination foods recipe x Second helpings x Drinking water x Any supplements x Type, cooking method, bought, or cooked at home x Oil used: individual/ family; type of oil used x Meals purchased from office

ANNEXURE 7: STANDARDIZATION OF UTENSILS

Standard katori measures (by volume) For measuring solid ingredients From left to right:

1 katori = 200ml ½ katori = 100ml 1/3 katori = 60 ml ¼ katori = 50 ml

Standard spoon measures (by volume)

1 tablespoon = 15ml 1 teaspoon = 5 ml ½ teaspoon = 2.5 ml ¼ teaspoon = 1.25ml

Standard cup measure (for measuring liquids)

1 cup = 250 ml

ANNEXURE 8a: FOCUS GROUP DISCUSSION PROBES

Theme – Eating habits and physical activity pattern of BPO employees

Probes:

1. Food preferences x Choice of being veg/non-veg/ovo-veg x Meals consumed in a day x Usual meal pattern of BPO employees – at home; at workplace/with friends x Meal timings x Skipping of meals x Reasons for skipping x Items most preferred x Items not preferred x Eating choices – at home (items); at workplace (items)

2. Preparation of food

x Impact on diet/ dietary pattern (staying alone or with family) x Cooking of food x Problems faced

3. Eating out pattern

x Eating out frequency x Ordering food at home x Reasons for both x Places most visited/ordered from x Items usually ordered x Special food preparations prepared/ordered/eating out on holidays and usual

off days

4. Physical activity x Regular exercise/ exercise (if any) x Impact of shift work x Perceived barriers to exercise/ not exercising x Usual time spent on commuting to workplace x Exercise provision at workplace (gym or any other facility) x Mode of commutation x Physical activity during leisure time

5. Impact of shift work x Work hours (number) x Sleep hours (number) x Coping with work related stress (deadlines)/ de-stressing mechanisms x Level of job satisfaction (physical/emotional/monetary) x Duration of food breaks/other breaks

6. Changes desired

x In diet – at home/office/eating out (choices made) x Perceive any need to change x Do you think that the food pattern of BPO employees is healthy? Why? x Any changes in dietary pattern after joining BPO? What type? x Any changes needed? x What changes are desirable? x Possible ways of making changes

Annexure 8b: FOCUS GROUP DISCUSSION GUIDE

Hello,

I am Ishu Kataria, Research Scholar with the Department of Food and Nutrition, Lady Irwin College, University of Delhi. Keeping in view the current scenario, we are developing a Nutrition education program for employees working in the BPO sector. In order to develop this program, we require assistance from you, since you are working in this sector and can give valuable inputs regarding it. For this purpose, a focus group discussion is being organized in your company on DATE____, 2014, at TIME____, in VENUE__________________to gain knowledge regarding eating habits and physical activity pattern of BPO employees. The focus group discussion will last an hour. The information you give us is completely confidential, and we will not associate your name with anything you say in the focus group. We would like to tape the focus groups so that we can make sure to capture the thoughts, opinions, and ideas we hear from the group. No names will be attached to the focus groups and the tapes will be destroyed as soon as they are transcribed. We will be really grateful for your participation, as it will help us develop an enriching nutrition education program.

Welcome and thank you for volunteering to take part in this focus group. Introduce yourself. You have been asked to participate as your point of view is important. I realize you are busy and I appreciate your time. Please fill this short demographic questionnaire before we begin:

Please answer the following questions in the spaces provided, circle or tick the most appropriate options.

1. Name:

2. Age:…………………………………………………………………………

3. Are you: (please tick as necessary) □ Male □ Female

4. Current position / designation:

Thank you for taking the time to complete this questionnaire.

Introduction: This focus group discussion is designed to assess eating habits and physical activity behavior of employees working in the BPO sector.

Anonymity: Despite being taped, I would like to assure you that the discussion will be anonymous.

Review the following: x Who we are and what we’re trying to do x What will be done with this information x Why we asked you to participate

Explanation of the process Ask the group if anyone has participated in a focus group before. Explain that focus groups are being used more and more often in health and human services research.

About focus groups x We learn from you (positive and negative) x Not trying to achieve consensus, we’re gathering information x No virtue in long lists: we’re looking for priorities x In this project, we are doing both questionnaires and focus group discussions.

The reason for using both of these tools is that we can get more in-depth information from a smaller group of people in focus groups. This allows us to understand the context behind the answers given in the written survey and helps us explore topics in more detail than we can do in a written survey.

Logistics

x Focus group will last about one hour

Ground rules x The most important rule is that only one person speaks at a time. There may be a

temptation to jump in when someone is talking but please wait until they have finished.

x There are no right or wrong answers x You do not have to speak in any particular order x When you do have something to say, please do so. There are many of you in the

group and it is important that I obtain the views of each of you x You do not have to agree with the views of other people in the group x Turn off cell phones if possible x Stay with the group and please don’t have side conversations x Does anyone have any questions? (Give answers) x OK, let’s begin

Warm up x First, I’d like everyone to introduce themselves. Can you tell us your name and

which is your home town?

Conclusion x Thank you for participating. This has been a very successful discussion x Your opinions will be a valuable asset to the study x We hope you have found the discussion interesting x I would like to remind you that any comments featuring in this report will be

anonymous x Before you leave, please hand fill your completed personal details questionnaire x That concludes our focus group. Thank you so much for coming and sharing your

thoughts and opinions with us.

Annexure 9a: KEY INFORMANT INTERVIEW - HR MANAGER DATE- COMPANY NAME- POSITION- JOB DESCRIPTION- 1. When did you join the company? 2. Organizational demographics

a) How many employees are currently work in your company? b) Could you please elaborate on the number of males and females? c) What is the average salary of employees? (Monthly or annually) d) What are the shifts allotted to employees – type and timings

3. Nutrition a) Are there any worksite vending machines for food access during worksite

hours? If yes, what items are available? b) Are there vending machines for beverages in the premises? Is it free or

employees pay for it? c) What is the role of management in deciding the menu for cafeteria? d) Do you have any stratification on food- such as health foods in the cafeteria? e) How much subsidy is provided to employees on food? f) Is there any written policy on kind of food to be served? If yes, what is it?

4. Smoking a) Is there a written smoke free work policy for your company? If yes, what is it? b) What is the extent of smoking ban? (in some areas or outside area) c) Has there been any training for management on smoking? If yes, please

explain. d) Are there any incentives for non-smoking? Like material incentives (mugs or

t-shirts), discount on insurance policy, any other benefits. e) Is there any ban of sale of tobacco products on-site?

5. Physical activity a) Is there any exercise facility on-site for employees? b) If yes, when is it accessible/ usage hours?

What equipment is available? Are there any trainers? Are the employees oriented regarding the same?

c) Does the company offer any exercise facility membership of-site to employees?

d) If yes, what type, any discount, to which employees and if their spouses are provided too. Please explain.

e) Are there any facilities to employees for leisure time physical activity? Any outside exercise areas? If yes, what are the same?

f) Does the company sponsor or organize any physical activity events for employees? If yes, which ones?

6. Stress a) Does the company provide any employee assistance program? b) If yes, what type? On-site counselor, telephonic assistance? c) Are any social events celebrated or organized in company? Like employee

birthdays, promotional events etc. d) Is there any employee lounge for break time? e) Is there any place for practicing lounge exercises? f) Is there any written sexual harassment policy for employees?

7. Policy a) Are there written policies for?

x Anti-smoking x Nutrition x Employee health x Healthy foods x Alcohol x Visitors (tobacco)

b) Are there any health screening activities planned for employees? c) Is medical service provided to employees? If yes, please elaborate. d) Is off time given to employees specifically for preventive screening and other

medical services? 8. Health promotion and health care

a) Is health insurance provided to employees? If yes, is there any eligibility criterion for the same?

b) Is prescription coverage provided to employees? c) Is there any kind of assistance provided to employees for preventive services?

If yes, please explain. d) Could you inform the number of mediclaims in the company during past I

year? e) Are there any doctors or specialists’ visits scheduled for employees on a

regular basis? f) Does the company provide any for short/long term disability?

9. Incentives for employees a) Are there any incentives provided to employees for participation in health

programs/activities? If yes, what are those? b) Is there any discount for non-smokers in the company? c) Is any reimbursement provided to employees for using public transport?

10. Health activity a) Has any health activity been planned for employees in past 1 year? If yes,

what was it?

b) Do the following happen/are there in your organization? x Anti – smoking policy messages in premises x Sessions on smoking ban/harmful effects of smoking x Importance of food and health x Fitness oriented programs x Fitness messages display x Organization of company picnics, holidays , parties x Program / sessions on stress related issues x Stress management messages x Educational messages on preventive health screening x Lunch time/after work walking clubs x Multi-purpose room(s) for conducting group activities x Environmental changes for employees like prevention of injuries or to

promote safety (light, ventilations, chairs, other equipment) x Ban on using elevators till 4-5 floors x Display of important messages for promoting the use of stairs x Session on healthy lifestyle and physical activity x Medical room/first aid room for employees in case of emergency x Maintenance of lunch records

Thank you for your time and input. You have provided us with very helpful and useful information.

Annexure 9b: KEY INFORMANT INTERVIEW - ADMINISTRATIVE MANAGER DATE- COMPANY NAME- POSITION- JOB DESCRIPTION- 1. Since when have you been the administrative manager? 2. Is there a worksite wellness committee established in your organization? 3. If yes, who are the members, when do they meet and how much budget is allotted

to it? 4. What is the role of committee? 5. Is role of employee health a part of organization’s mission statement? 6. Are there any objectives set for wellness? 7. Are health facilities provided to employees? If yes, what are they? 8. Is there any group such as a health club for employees? Is yes, what is its

significance? 9. Is there any health club membership for employees? If yes, what is it? 10. Does the senior management or CEO support wellness and employee health? If

so, how? 11. Does the company organize any training program for management w.r.t health and

lifestyle? 12. Is health considered an important indicator in recruitment? If so, how? 13. Is there any policy for employment of differently-abled? If so, what is it? 14. What support does the admin department provide to conduct any health related

activity in your company? 15. Is health, a component considered for employee appraisal? 16. How is the workload of an employee decided? 17. Is there any flexible work schedule policy for employees (in case of any need)? If

yes, what is it? 18. What is the health leave policy in the company? 19. Does the company provide any subsidy on health insurance of employees and

their families? If yes, what is it? 20. What in your opinion are the health/lifestyle related BPO issues that need to be

addressed/ require attention? Thank you for your time and input. You have provided us with very helpful and useful information.

Annexure 9c: KEY INFORMANT INTERVIEW – CATERING MANAGER

DATE- COMPANY NAME- POSITION- JOB DESCRIPTION- 1. Since when have you been the contractor of canteen? 2. Could you briefly explain your contractual policy? And what it covers? 3. How much staff have you currently appointed to work for you? 4. Is the food cooked in office or brought and served? If brought and served in the

premises, where is the cooking done? 5. What is the employee strength that you cater to everyday? 6. What is the usual menu and its type? 7. How much quantity is cooked on a daily basis? Specific the items. 8. Where are the following ingredients procured from?

a) Wheat flour b) Pulses c) Oils/ Desi ghee d) Spices e) Vegetables f) Curd and milk g) Sweets h) Salt (iodized or not)

9. Who decides the menu? 10. What are the factors considered before deciding the menu? 11. If changes have to be made, who makes them? 12. Are there any company specifications regarding menu, method of preparation,

ingredients that the management has requested? If yes, please elaborate on the same?

13. Are there any mandatory items/ items that are served on a regular basis? If yes, why?

14. What are the most liked/popular items? Please name. 15. What are not so liked/not so popular items? Please name. 16. Are special items made for employees on their demand? If yes, what are the

items? 17. Is there any change in the menu on special days or festivals? If yes, please tell

what items are usually cooked /prepared? 18. Which types of oils are used for cooking? How much quantity is used on a daily

basis? 19. On a regular basis, do you encounter problem of plate waste? If yes, which days? 20. How do you manage plate waste? [measure taken, if any] 21. Is calorie counting done for any item that is prepared and served to employees? If

yes, please name them. 22. Are there any ‘special foods’ that are served to employees? If yes, please them. 23. Is acceptability of food served to employees obtained through feedback from

them? If yes, what is the process? Thank you for your time and input. You have provided us with very helpful and useful information.

Annexure 10: Resource kit for the nutrition education program

10a: Sessions for the employees

SESSION 1: METABOLIC SYNDROME – NEED FOR THE PROGRAM

Good evening everyone. Today, we begin a series of sessions on healthy eating habits and physical activity that will be carried out over the course of this month. Firstly, let me tell you the need of doing these sessions. As you are all aware that you were a part of health camp, which was held in your company on Metabolic Syndrome where we did a lot of measurements such as height, weight, waist circumference and also your blood tests. We also gathered information on your diet, physical activity, alcohol and tobacco use. Based on the results obtained from health camp in your company and other companies, as well as from interviews with employees, it has been observed that prevalence of Metabolic Syndrome is on the rise among BPO employees, which is alarming. While, there are some who are currently affected by it; there are others who are at high risk developing it in near future. Therefore, it was considered necessary to develop a strategy for the BPO employees to prevent Metabolic Syndrome and thereby reduce the risk of chronic diseases such as diabetes, high blood pressure and heart disease. On the basis of the health camp conducted, 4 key issues emerged that need attention:

a) Faulty diet b) Low physical activity c) Alcohol consumption d) Smoking

We also had interviews with HR Manager, Admin Manager, and Canteen operator as well as Focus Group Discussions with some of you and they all bring out the need to have a program on eating habits and physical activity for you all.

Target audience: BPO employees

Key messages:

1. Prevalence of Metabolic Syndrome is on the rise in India. 2. 1 out of 5 adults have it. 3. It is related to unhealthy diet and lifestyle. 4. It leads to heart disease. 5. It is reversible. 6. Prevent Metabolic Syndrome in future by taking the Right Step now!

Let us refresh our memory and again introduce you to the concept of Metabolic Syndrome. Metabolic syndrome is a condition that results in the development of heart disease. Its prevalence is increasing at an alarming rate in India. Metabolic Syndrome is a condition/problem that occurs when you have any three of the five conditions listed below:

(1) High blood pressure

ANY THREE OF THESE FIVE CONDITIONS IS CLASSIFIED AS

METABOLIC SYNDROME

(2) High glucose level (3) Obesity (4) High triglyceride level (5) Low HDL-Cholesterol (Good Cholesterol) level

The results show that about 19% of the employees working in this industry have Metabolic Syndrome according to the International Diabetes Federation criteria i.e. 1 out of 5 adults have this syndrome and may not be aware of it. And nearly 35% are at a higher risk of developing it in future. So, in totality, about 54% i.e. half of the population is being affected by this syndrome. This is mainly related to unhealthy diet and lifestyle. So, people with similar lifestyle factors may be at high risk and this problem needs to be addressed. With the busy work schedule as yours, it becomes all the more important to focus on healthy diet and lifestyle.

Metabolic Syndrome has serious consequences on your health and can result in: Heart Disease High Blood Pressure Diabetes High Cholesterol Level Poor Quality Of Life

There are many risk factors that can lead to Metabolic Syndrome. Some of these risk factors are modifiable (that can be changed) such as diet, exercise, smoking etc while others are non-modifiable (that cannot be changed) like age and heredity. However by appropriate intervention the latter can be delayed.

MODIFIABLE NON-MODIFIABLE 1.PHYSICAL INACTIVITY 1. AGE 2.POOR DIET x High total fat and salt intake x High carbohydrate intake x Low fiber intake

2.GENETIC FACTORS (HEREDITY)

3.OBESITY x Higher body mass index x Higher waist circumference 4.ALCOHOL 5.SMOKING 6.STRESS

But, the GOOD NEWS is that we can reverse METABOLIC SYNDROME. This is only possible if we tackle it at an early stage. So, it can be prevented by:

a) Changes in diet b) Changes in lifestyle

This is all the more important because MetS is a significant risk factor for heart disease, diabetes and high blood pressure/ hypertension, which are not reversible; so, if a person has them, he/she has to live with it throughout his/her life. As you all know, the treatment is very expensive in terms of money, requires a lot of care and monitoring and most importantly reduces the quality of life. So, this is our aim- to prevent this syndrome and for which we will be doing a Nutrition Education Program. And the basic aim of this session was to refresh your memory about metabolic syndrome, its consequences and the need to bring about changes in diet and lifestyle through participation in a Nutrition Education Program.

SESSION 2: THE POWER OF FOOD


Key messages:

1. A balanced diet is important for good health. 2. Eat variety of foods to ensure a balanced diet. 3. Eat plenty of fruits and vegetables. 4. Healthy and nutritious diet should be consumed through a variety of foods. A healthy diet is a diet with all nutrients in proper amount. It should be consumed through a wise choice from a variety of foods. We can also call it balanced diet. Nutrients are those substances that make a healthy diet and have different functions. We obtain them from food we have and they have vital effects on growth and development, maintenance of normal body function, physical activity and good health. Healthy food is thus needed to sustain life and activity. Our diet must provide all nutrients in correct amounts. Eating too much or too less at any age can lead to harmful consequences. So, in order to obtain these nutrients, we should choose wisely from a variety of foods. Based on the functions foods perform in our body, they can be categorized simply into three broad types:

a) Energy rich foods – They give us energy for doing our day to day activities. And they area obtained through two nutrients – carbohydrates and fats. The foods that give us energy are whole grain cereals like atta, millets like bajra, jowar, vegetable oils like your cooking oils, ghee, butter, nuts like kaju, badam, kishmish, akhrot etc and sugars like jams, jellies and normal sugar that you use.

b) Body building foods – These help in muscle building and are obtained through one nutrient – Protein. The food sources providing protein are pulses like chana dal, moong dal, chana, rajmah, soyabean, milk and milk products such as curd/dahi, paneer, flesh foods like meat, fish, eggs, nuts and oilseeds.

c) Protective foods – They are responsible for providing immunity/protection from diseases to our body. Immunity providing nutrients are – Vitamins and Minerals. The foods sources that help to build our immunity are green leafy vegetables like palak, methi, sarson, other vegetables like tomatoes, fruits like orange, mango, apple, pineapple etc. some of the body building fruits are also rich sources of vitamins and minerals such as milk and milk products.

Simply, to understand what to eat more and what to eat less can be seen by looking at the food pyramid/ guidelines. These guidelines tell us easily what to eat and how much to eat. This can be understood with the shape of a pyramid – which is simple divided into 4 levels. The lowermost level, which is the broadest one, shows us items that we should eat adequately. These are staple items like cereals (atta), grains (rice, bajra, jowar), and pulses (chana dal, moong dal, chana, rajmah, soyabean etc). The level above it consists of foods that are permitted to eat liberally and these are fruits and vegetables. The top two levels of the food pyramid should be carefully observed about these are those items that should be eaten moderately which are flesh foods like meat, chicken, oils, butter, ghee and sugar. And you have to be most careful, is the top level is to eat sparingly i.e. occasionally which includes junk food. Not to forget, abstain from drinking alcohol and say “No” to tobacco. For the purpose of choosing a healthy diet, all the foods are grouped into 5 food categories. These are:

1. Cereals, millets and pulses 2. Vegetables and fruits 3. Milk and milk products 4. Egg, meat (chicken and mutton) and fish 5. Oils, fats, nuts and oilseeds

So, our diet in a day must have something belonging to each of these groups. This will help us to have a healthy diet. However, do not forget that we learnt about food guidelines in the form of a food pyramid, and all the foods must be eaten according to it. So, at this moment, we shall do one activity for which we need volunteers. Each one of you will tell us which food group belongs to what level in the pyramid. After you finish, we will reveal the answers from our side and see how many are correct.

So, let’s rewind: In this session we learnt about- Healthy diet Food guidelines Food categories Also, we are providing you with one page handout about the session as a takeaway thing for your reference. Before you leave, kindly provide us with your valuable feedback.

Thank you very much for your patience. SESSION 3: PORTION SIZE


Key messages:

1. Include food from all food groups. 2. Portion sizes are easy to understand. 3. Eat adequately by choosing the right portion sizes. 4. Eating from a standard sized bowl containing the entire meal with no second

helpings is a good dietary option – ‘Bowl culture’

In this session, you will learn a very important and useful concept of portion size. A portion size is essential to know and understand because it helps us to know how much of which food to eat, since now we have learned what to eat. So, what I will do is that I will tell you the most common things that you should have in your diet and how much to consume.

The concept of serving size or portion size is thus, very useful. We will now learn about each item in detail.

1. Milk

Milk is of three types that are available in the market. Can anyone tell me, if you know what types are available in the market? Yes, the three types are:

Full cream, toned, double toned, skimmed

The difference in them is in the amount of fat and energy.

x Full cream: maximum fat and energy x Toned: moderate fat and energy x Double toned: moderate fat and energy x Skimmed: no fat and less energy Now, let’s see what is similar in them. Protein – 8gm (all give 8g protein per 100ml) So, 1 serving = 1 glass = 250g or ml You should have at least 2 servings/glasses of milk in a day which can either be as plain milk or as milk products like curd and paneer.

2. Meat , Pulses and legumes

Meat Pulses and legumes So, for all the non-vegetarians, this category is very important

However, for vegetarians, pulses and legumes are very important

It includes: Mutton Egg Chicken Lean fish

1 serving of pulse = 1 katori

Why? I’ll tell you; again it’s because of fat. Mutton and egg – give 6g fat/serving Chicken and fish – give 0.5g fat/serving

The benefit of having them is that they have negligible fat.

Now let’s see what’s similar in them – protein (7g)/ serving

They are similar to meat, chicken, fish and egg, is in the amount of protein which is same – protein (7g)/ serving

So, non-vegetarians can even substitute one serving of mutton, chicken and fish with 1 katori dal. In a day, you should have at least 2 katori dals or its preparations and can have 1 meat serving in a day. But, it is always better to consume chicken, fish and sprouts rather than mutton and egg (though it is rich in many nutrients but you should limit intake) because they don’t have much fat.

3. Vegetables These are very important and should be consumed in any form – be it as subzi, salad, filling in a sandwich or stuffed in a parantha. They provide us with nutrients that improve our immunity. We should at least have 3-4 servings of vegetables. 1 serving of cooked vegetables = ½ katori So, you should include at least 2 katoris of vegetables in your diet. And the best part about vegetables is that they don’t have fat and also give you energy.

4. Fruit It is very important to include fruit in your diet. And I know, most of you told me that that wasn’t the case for you. But, it is very important to have fruit in a day because fruit gives us nutrients, they boost our immunity and it has been seen that people who consume fruits fall less sick than those who don’t. You can have fruits as raw fruits, in the form of chat (but avoid extra salt), or as milkshakes and smoothies. Remember, avoid sugary fruit juices. Whole fruit is always healthier. 1 serving of fruit = 1 medium sized fruit

5. Cereal Now, comes the most important thing in our diet which everyone consumes in large quantity – cereals. By cereals, I mean all the things that you consume and that keep you full. Cereals include atta, maida, rice, other grains such as bajra, jowar, ragi or preparations that you have of them like bread, pasta, poori, chapatti, parantha, etc. 1 serving = 2 chapati (medium) = 2 bread slices / ½ plate rice

1 serving of mutton,

chicken and fish = 2 small

pieces

1 serving of egg = 1

medium sized egg

I serving of egg

Less preferable

More preferable

Potatoes are also included in this group. These don’t give fat, and provide us with energy to perform day to day activities.

6. Fat This includes ghee, oil, butter, cream, nuts and oilseeds. They should be used wisely. 1 serving of fat = 1 teaspoon = 4-5 nuts However, in a day, you should have 5-6 teaspoon of visible fat and not more than that. Invisible fat has to be limited. Not more than 25% energy should be derived from fat. They give excess energy and no other nutritious value, except nuts, which also give some proteins.

7. Sugar Sugar should also be used wisely just as fat, as this also gives only energy and no other nutrient. 1 serving of sugar/ jiggery (gur)/jam/jelly = 1 teaspoon This should also not exceed 4-5 teaspoons in a day. If you can do away with extra added sugar, it will be very beneficial. So, what is most important in choosing portion sizes is – choosing the right type of food in both quantity/amount as well as quality. You need to be very careful so as not to consume too much/excessive or to consume too little/inadequate. So, every item in the food group should be consumed as per your requirement. This can be easily achieved by taking a standard bowl and filling it with the entire balanced meal for lunch/dinner. Don’t allow yourself a second helping, thereby restricting not only quantity but emphasizing quality. Eat right to be bright. Now that we have demonstrated you portion sizes, how much to eat at one go and how to exchange or substitute them, it’s time for another activity. Serving size activity – In this activity, we need volunteers. What all you need to do one by one, is to put out one serving size of the give items as was just explained to you. And then we will see how many of you get it right. All right, let’s go.

Also, we are providing you with one page handout about the session as a takeaway thing for your reference. Before you leave, kindly provide us with your valuable feedback. Thank you very much for your patience.

SESSION 4: FOOD CHOICES Target audience: BPO employees Key messages: 1) Choose wisely from a wide variety of foods. 2) Taste is important but should not be the only priority. 3) Develop taste for healthy options. 4) Healthy foods are economical. 5) They are easily available. 6) Wise choices make one healthy.

Hi everybody, hope everyone is doing fine. So, we are back with another session in our series. Just to revise what we learnt in the last session. So, in the last session we learnt about food labels- which are an important part of our lives because every day we have something or the other that comes with a label. So, now that we have learned about food labels – how to read and interpret them, today we will have another important session on food choices.

Every day, we are often faced with situation- what to choose? So many options are available to us, so, we are always making quick decisions. But, in these decisions that we make, do we think wisely before making them? So, with this question in mind, we are going to find out the answer in today’s session. How to choose? What to choose? A wide variety of foods are available in market today. So, the first step guiding our choice should be: 1. Need

It means that why do we need that particular food item. That is an important question that you need to ask yourself. Can I do away with it? Do I really need to have it? And the second most important reason is

2. Nutrition This is the actual reason why we should choose our foods wisely. So, nutrition is what we will learn about in this session, so that we can make healthy and wise choices.

A lot of food choices are available to you. Firstly are the raw foods that you eat that you cook like your vegetables, grains like atta, rice, dals, fruits etc. This is food in natural form or minimally processed. But then, there are other important foods that are available very frequently – processed foods. These are those foods that are ready to eat/ use foods.eg: canned foods, dehydrated foods like soups, ready to eat dishes, bakery items, chips, chocolate, candy, and dairy products like cheese. However, when such things are consumed very regularly they increase health risk because they are rich in fat or in salt/sugar. They have no vitamins and minerals, or fibre that helps digestion. Also, there are instant foods, fast foods and junk foods. Today, we will learn the difference between them. Instant foods – they undergo some kind of processing, so they are in the form of particles like instant noodles, soup powders, cornflakes. They need not be completely

unhealthy but we need to be careful about some of the additives that are added in them like MSG – mono sodium glutamate which has harmful effects if consumed regularly. Fast foods – these are already made or cooked within minutes for consumption. Examples: noodles, burger, milk shakes, chips, pizza, sandwich. These foods provide extra calories that are not required. Junk foods – these have very little or no proteins, vitamins or minerals. They are rich in salt, sugar, fat and high in energy. Examples- chocolate, aerated drinks (colas), potato chips, French fries, ice creams etc. So, you need to be very careful with them and choose wisely. They can be consumed as occasional treats. With this information, we will now have a group activity, wherein everyone will give their inputs of what to choose and why? And then, finally we will see by comparing the prices of food items that we choose with those that we don’t – Do they really offer value for money? So, here are the choices, and we need two people to them up for the same. You will choose one out of two, and tell us why you chose that? Examples discussed with prices and reasons. So, in this session, we learned about- How to choose wisely? Follow need and nutrition in making wise choices. Just like the last session, we are of last session; we are again providing you with one page handout about the session, a take away thing for your reference. Before you leave, kindly provide us with your valuable feedback. Thank you very much for your patience. SESSION 5: FOOD LABELS Target audience: BPO employees Key messages: 1) Food labels are easy and informative. 2) They tell us calories present in food items. 3) Food labels are easy to read.

Hi everybody. Hope you all are doing great and hope you all remember what we learnt in the last session. We learnt the concept of healthy diet, food categories, food guidelines and portion size. Today’s session, we will learn about another very important aspect that is very useful in our daily lives – FOOD LABELS.

In this session, we are going to learn simply what are food labels?, how do we read them?, and how to choose the right thing to eat?.

Food labels basically tell us what we need to know about choosing foods with respect to calories in them. They are good for judging between the right foods and wrong foods. So, they let us know what to eat and what not to eat. There are a lot of food labels rather food products with food labels, that are available in the market.

Now, we will begin on how to read labels? The important things to look in them are:

1. Amount per serving 2. Serving size 3. Number of servings 4. Total calories 5. Sugar 6. Fat 7. Cholesterol

So, the first label that we are looking at is the thing that is loved by most of you – cheese. So, look at this label. In the nutritive value they provide that it is of 100g amount but do you see how much is the weight of actual cheese block? It is 200gm. So everything is actually double of what is shown in the label. Let’s first look at total calories provided from it – they are 320 X 2 = 640 kcal. Now, let’s see how much fat this popular item has – 26 X 2 = 52gm; now, let’s see the amount of cholesterol – 70 X 2 = 140mg; and one more thing that we should be looking which is often not seen, is the amount of salt in it. The salt is called sodium and is there in all processed items like chips, namkeens, ketchup etc. it has 1400 X 2 = 2800mg sodium. So, I’ll just let you know how much salt in terms of teaspoons we have:

It has 24 tsp salt!!!

Imagine this much salt you are taking with cheese, when what is required is just 1-2 teaspoons for whole day. Excessive salt or sodium as reported in these labels is very important thing to be looked at. Excessive salt intake has harmful effects. Actually, salt is the most important ingredient in food. It is salt that gives the food its taste. All foods have sodium (it is a part of salt). But, the problem is not with foods having natural sodium in them, the problem is when we have added salt. Salt helps to maintain blood pressure and the requirement for a day is 1 teaspoon.

Many foods have added salt in them – such as pickles, papad, ketchup, sauces, canned food, processed food like cheese. Consuming more than 1- 2 teaspoons of salt daily is too much and can lead to harmful effects. It leads to high blood pressure, weakening of bones and in very serious cases, even stomach cancer. So, you need to be careful and look at the labels.

Another label that we are looking at is of potato chips. In this case, the nutritive value is again given for 100 gm. So, the energy provided is 544 kcal of energy and amount of fat is 34 g. but what we need to see first as we saw in the last label is what the amount that we are consuming is. So, let’s look at the packet and we see that we are

consuming 26 gm of chips if we buy a 10rs packet. So, the calories will be in terms of 26gm and not 100gm. So, in this case the calories will be 145 kcal.

Now, since we have learnt how to read labels, we do a group activity. Divide yourselves into groups of 2. Each one of you is being provided with 2 food labels. You will tell us which one of the two provides less calories and also tell us important nutrients to be looked on these respective labels.

Good, so now is the time for another activity and for that we require 2 people. So, this is going to be competition between the two – like a rapid fire quiz. So, I’ll give you two choices each and you will have to select one of the two which you think provides fewer calories. Let’s begin, your choices are:

So, now is the time to tell correct answers and announce who the winner is. Now, I’ll tell you how much calorie each item provides and how much calories you save if you choose wisely. In this way, you will not only be able to manage your diet properly, but also you will know how to incorporate them into your daily routine.

Let’s rewind. So, another session is over, let us revise what we learnt.

Food labels are important and informative. They help us choose the right food. So, now you can say that “I can read and will read food labels”. Just like the last session, we are of last session; we are again providing you with one page handout about the session, a take away thing for your reference. Before you leave, kindly provide us with your valuable feedback. Thank you very much for your patience. SESSION 6: QUICK MEALS

Target audience: BPO employees Key messages: 1) Easy to prepare meals are nutritious. 2) Preparing food is not very difficult. 3) Simple cooking skills can be learned easily with some effort. 4) Home cooked meals are healthier than eating out. 5) Healthy meals can be prepared easily rather than buying food from outside.

Poha Fruity oats Sprouts salad Fruit smoothie with nuts Fruit custard Vegetable salad Vegetable sandwich Boiled/poached egg Milk Paranthas with less ghee/oil Vegetable porridge Cornflakes/wheat flakes Bhelpuri Veg/non veg biryani Curd/raita Kathi roll Dips Almonds Raisins SESSION 7: BE FIT AND FINE


Key messages:

1) Exercise regularly and be physically active to maintain right body weight. 2) Move your body as much as you can. 3) Physical activity reduces the risk of heart disease. 4) Simple exercises are easy to do anywhere in home or in office. 5) It helps to control body weight.

Hi everybody, hope you are doing fine. So having gone through the previous sessions on healthy diet, food choices, and food labels and learnt the techniques of quick meals, we should now focus our attention to a very important topic – and that is physical activity. So, in this session firstly we will learn about physical activity, and then moving forward to important questions like how much to do? So, this will be a short session explaining you about physical activity and its benefits, followed by a live demonstration on doing simple exercises that can be done easily in home as well as in office.

Physical activity is an important part of our life. And, so it is very essential that due importance should be given to it and it should be done regularly. As you can see this diagram, what is does is that, it simply explains the role of physical activity. So, you can see energy input- it is nothing but simply the energy you take in, which you get from the food that you eat. Now, what energy is used in doing your daily activities leads to what is known as the energy output. If there is balance between this energy

Quick breakfast

Quick meals

Quick snacks

intake and energy output, then you have ideal body weight. But, if this energy balance cannot be maintained, you either gain weight or lose weight.

As far as your case is considered, since the nature of the job is sitting, so not much energy is used, therefore, it is very important to do physical activity to maintain energy balance and hence, maintain your weight properly. There are various benefits of doing physical activity: • Increases strength and stamina • Maintains ideal body weight • Prevents heart disease, diabetes, high BP • It increases GOOD cholesterol • Builds strong muscles, bones and joints. • Improves flexibility • Wards off depression • Improves mood, sense of well-being and self esteem • It releases happy hormones “endorphins” that elevate mood and sense of

wellbeing.

So, now coming to the most important question, how much physical activity should we do? A minimum 30-45 minutes brisk walk/physical activity of moderate intensity improves overall health. 45 min per day at least for 5 days / most days is essential. And most importantly, don’t be inactive. So, we will learn how to do simple exercises even in office and at home. And there is no need to join gym to be physically active for good health, here is something you can learn and apply. So, in this session, we learnt about-

• Physical activity should be done regularly • It maintains overall health and well being • 30-45 min per day for at least 5 days / most days

Just like the last session, we are again providing you with one page handout about the session, a take away thing for your reference. Before you leave, kindly provide us with your valuable feedback. Thank you very much for your patience.

SESSION 8: ALCOHOL AND TOBACCO USE


Key messages: x Do not smoke or use smokeless forms of tobacco such as guthka and pan

masala. x Passive smoking is as harmful as active smoking. x Avoid use of alcohol.

Hi everybody, hope you are doing fine. So having gone through the previous sessions on healthy diet, food choices, and food labels and learnt the techniques of quick meals, and simple exercises in the physical activity session, we should now focus our attention to another very important topic – and that is tobacco and alcohol use. Tobacco kills up to half of its users (6 million people each year). There are Two types in which tobacco is used.

1) Smoke (Cigarettes/Cigar/Hookah/Beedi) 2) Smokeless (Pan/Pan masala/Guthka)

Nearly 80% of the world's 1 billion smokers live in low- and middle-income countries. However, there is another form of smoking that you all should know about and this is known as Passive Smoking/ Second hand smoking. Second-hand smoke is the smoke that fills restaurants, offices or other enclosed spaces when people burn tobacco products such as cigarettes and beedis. Tobacco smoke has 250 harmful chemicals and 50 of them cause cancer. So, passive smoking is equally harmful as active smoking. There are various harmful effects of passive smoking such as:

• Heart disease • Lung cancer • Sudden death

Every person should be able to breathe tobacco-smoke-free air! As far as alcohol consumption is concerned, it is becoming common. It starts from being occasional and then turns into regular. In 2012, about 3.3 million deaths were due to alcohol consumption. In males, these deaths were 7.6% and in females, these were 4%.

There are various harmful consequences of alcohol consumption: • Difficulty in walking • Blurred vision • Slurred speech • Slow reaction time • Impaired memory • Liver disease • Cancer • Brain damage

After having understood the background about tobacco and alcohol, we will do a group activity. You will be divided into various groups and each group has to write the harmful consequences of alcohol and tobacco use according to them and then write solutions/strategies/and ways to overcome that. Finally, one person from each group will present their view point. Before you leave, kindly provide us with your valuable feedback. Thank you very much for your patience.

METABOLIC SYNDROME

WHAT?

ANY THREE OF THESE FIVE CONDITIONS TOGETHER IS CLASSIFIED AS METABOLIC SYNDROME

METABOLIC SYNDROME

HIGH BLOOD PRESSURE

LOW HDL-CHOLESTEROL

LEVEL (Good Cholesterol)

OBESITY

HIGH GLUCOSE

LEVEL

HIGH TRIGLYCERIDE

LEVEL

• Prevalence of Metabolic Syndrome is on

the rise in India.

• Young Adults especially, are most

affected by it.

• Based on the latest statistics:

�19% have Metabolic Syndrome according to

International Diabetes Federation criteria.

� 1 out of 5 adults have this syndrome and

may not be aware of it.

� 35% are at a high risk stage.

•Mainly related to unhealthy diet andlifestyle.• People with similar lifestyle are atrisk•This problem needs to be addressed

•With the busy work schedule andsedentary occupation as yours, it

becomes all the more important to

focus on healthy diet and lifestyle.

10c:Power point presentation for the sessions [SESSION 1: METABOLIC SYNDROME – NEED FOR THE PROGRAM]

METABOLIC SYNDROME

HOW?

RISK FACTORSMODIFIABLE

POOR DIET

PHYSICAL INACTIVITY

SMOKING

ALCOHOL

STRESS

OBESITY

NON-MODIFIABLE

AGE

GENDER

GENETIC FACTORS(HEREDITY)

LIFESTYLE

METABOLIC SYNDROME

CONSEQUENCES!

METABOLIC SYNDROME

HIGH CHOLESTEROL

LEVEL

DIABETES

HEART

DISEASE HIGH BLOOD

PRESSURE

POOR QUALITY OF

LIFE

METABOLIC SYNDROME

IT IS REVERSIBLE!!

•Only when prevented.

• If not, problems like heart disease,high blood pressure, diabetesoccur.

• Lifelong problems – Lifelong

treatment• Expensive : Care and Cost• Reduced Quality of Life

Changes in DIET

Changes in LIFESTYLE

NUTRITION EDUCATION PROGRAM• Guide to Eat Right and stay fit!• Prevent Metabolic Syndrome in future by

taking the Right Step now!

SESSIONS ON:

The Power of FOOD

Food Choices

Portion Size

Food Labels

Quick Meals

Be Fit and Fine

SESSION 2: THE POWER OF FOOD

THE POWER OF FOOD!

What do we learn?• Healthy diet• Guidelines to choose healthy

foods• Food categories

Healthy diet

Diet with all nutrients in adequate amounts1. Normal body function2. Physical activity3. Good immunity

• ENERGY RICH FOODSCarbohydrates & fats :Whole grain cereals,

millets; Vegetable oils, ghee, butter; Nuts and

oilseeds; Sugars

• BODY BUILDING FOODSProteins :Pulses, nuts and oilseeds; Milk and

Milk products; Meat, fish, eggs, chicken

• PROTECTIVE FOODSVitamins and Minerals :Green leafy

vegetables; Other vegetables and fruits; Eggs,

milk and milk products and flesh foods

Food pyramid

FOOD GROUPS

Foods are conventionally grouped as :

1. Cereals, millets and Pulses2. Vegetables and Fruits3. Milk and Milk products4. Egg, meat and fish5. Oils & Fats and Nuts & Oilseeds

Cereals, millets and pulses


Junk food,Sugars

Egg, meat and fish

Oils and fats

Vegetables and Fruits

Let’s rewind!

• What did we learn?• Healthy diet• Guidelines to choose healthy

foods• Food categories

SESSION 3: PORTION SIZE

PORTION SIZE

Portion size • Very important

• Tells us:

What to eat?

How much to eat?

Quality and Quantity

MILK Food items Serving size Daily requirement

Males Females

Full cream 1 glass 3 3

Toned /

double

toned

¾ glass

Skim 1 ¼ glass

Curd 1 small

katori

Paneer 2 pieces

Meat, Pulses and LegumesFood items 1 serving size Daily Requirement

Males Females

Mutton 2 small pieces 1 1

Egg I medium size egg

Chicken 2 pieces

Fish 2 pieces

Dals (chana,

moong, rajmah)

1 katori 2 2

Soyabean ½ katori

Sprouts 1 katori

ALWAYS PREFER SABUT DALS (WITH CHILKA) OVER DHULI DALS (WITHOUT CHILKA)

Vegetables

Food items 1 serving size Daily requirement

Males Females

Vegetables ½ katori 3 3

Fruit

Food items 1 serving size Daily requirementMales Females

Fruits 1 medium

sized fruit

1-2 1-2

CerealsFood items 1 serving size Daily requirement

Males Females

Chapati/Roti 2 medium

sized

6-7 5-6

Bread 2 slices

Rice ½ plate

Fat Food items 1 serving size Daily requirement

Males Females

Oil 1 teaspoon 5 5Butter 1 teaspoon

Nuts 4-5 nuts

SugarFood items 1 serving size Daily requirement

Males Females

Sugar 1 teaspoon 5 5Jam 1 teaspoon

Jelly 1 teaspoon

Jaggery (gur) 1 small piece

Let’s rewind!What did we learn?• Importance of Portion size• What to eat?• How much to eat?

SESSION 4: FOOD LABELS

FOOD LABELS

What do we learn?• What are Food labels?• Reading food labels• Knowing the label!• What to choose?

What are food labels?

• Food labels tell you what you need to know about choosing foods.

• Good tool for judging between healthy and not so healthy foods.

ANDTHE

HEALTHY FOODS

NOT SO HEALTHY

FOODS

Reading LabelsThings to look out :• Amount per serving• Serving size• Number of servings• Calories• Sugar• Cholesterol

VEG NON-VEG

Always look for

TOTAL CALORIESFAT

CHOLESTEROL

SODIUM

TOTAL CALORIES = 320 X 2 = 640

LABEL CLAIMS!

Important concepts ..

• CHOLESTEROL• SATURATED FAT• DIETARY FIBRE• SUGAR/ SUGAR FREE• CALCIUM RICH• IRON RICH

THE 5/20 RULE

• Check the % daily values (% DV).

• If %DV is less than 5 – it is a poor source of that nutrient

• If %DV is more than 20 – it is a rich source of that nutrient

Know your label• Group activity

• Look at food labels and tell the

important points to look out for.

Let’s rewind

Food labels are • Important• Informative• Help choose the right food

I can read and will read food labels -

SESSION 5: FOOD CHOICES

FOOD CHOICES

Everyday Questions?

• What do I buy?• There are so many things available!!• How to choose?• Is what I am buying healthy?

• Wide variety of foods available in market• Choice should depend on

NEED

NUTRITION

AFFORDABILITY

TYPES OF FOOD

NATURAL FORM OR

MINIMALLY PROCESSED

PROCESSED FOODS

NATURAL FORM OR MINIMALLY PROCESSED

• Raw foods that you eat or cook simply.

• Eg: Vegetables, grains like atta, rice, dals, fruits, milk & milk products, egg

PROCESSED FOODS � READY TO EAT FOODS/INSTANT /FAST FOODS • Undergo some kind of processing • Need not be completely unhealthy • Give extra calories • Eg: noodles, burger, milk shakes, chips, pizza,

sandwich, instant noodles, soup powders, cornflakes,canned foods, dehydrated foods like soups, ready to eatdishes, bakery items, chips, chocolate, candy, and dairyproducts like cheese.

� JUNK FOODS • Very little or no proteins, vitamins or minerals • Rich in salt; high in energy• Eg: chocolate, aerated drinks (colas), potato chips,

French fries, ice creams

Important factors for a healthy meal

¾Medium of cooking¾Method of cooking¾Spices used for cooking

�Healthy diet is not very expensive

�Develop taste for healthy foods

Points to ponder

Excess saltLow

dietary fibre

Excess sugar

Food safety

High fat and

cholesterol

Excessive spices

Better food choices? Why? • White bread or brown bread?• Fried chips or baked chips?• Maida Maggi or vegetable Atta Maggi?• Roti or Naan?• WHOLE Fruits or Fruit juice?• Regular pizza or thin wheat crust pizza?• Cottage cheese/Paneer or Processed

cheese?

AT HOME CHOICES EATING OUT CHOICES

Chapati over rice Plain roti over butter naan

Brown bread over white bread Vegetable Pasta over noodles

Sabut dal over dhuli dal Nimboo pani over cold drink/aerated beverage

Whole fruit over fruit juice Fish/chicken preparation over mutton preparation

Vegetable prepared in less oil over vegetable prepared in too

much oil and with too many spices/masala

Whole wheat crust pizza over regular pizza

Toned/double toned milk over full cream milk

Vegetable burger/whole wheat bun vegetable burger over

aloo tikki burger

What did we learn?

• How to choose foods wisely?• Based on need, nutrition and

affordability.

SESSION 6: QUICK MEALS – RECIPE BOOK

SESSION 7: BE FIT AND FINE

BE FIT AND FINE

What do we learn?

• Physical activity• Benefits• How much to do?• Learn to do simple exercises.

Physical activity

One should do regular physical activity.

ENERGY INPUT ENERGY BALANCE

ENERGY OUTPUT

Maintenance of body weight

& body composition

Benefits of Physical Activity

�Increases strength and stamina�Maintains ideal body weight�Prevents heart disease, diabetes, high BP�It increases GOOD cholesterol�Builds strong muscles, bones and joints.�Improves flexibility�Wards off depression�Improves mood, sense of well-being and self

esteem

SITTING

How much?• A minimum 30-45 minutes brisk

walk/physical activity of moderateintensity improves overall health.

• 45 min per day at least for 5 days / mostdays– essential.

• Don’t be inactive.

Group activity

• We will learn how to do simple exercises even in office and at home.

• Joining gym is not the only option.

What did we learn?

9Physical activity should be doneregularly9It maintains overall health and well

being945 min per day for at least 5 days / most

days

SESSION 8: ALCOHOL AND TOBACCO USE

10d: FACEBOOK PAGE: FOOD 4 HEALTH

ANNEXURE 11: KNOWLEDGE STATEMENTS FORM (Pre and Post trial and implementation)

Q. Indicate in the space given below whether you agree or disagree to the following statements:

Statements Agree Disagree A healthy diet is a diet with all nutrients in adequate amount.

Vegetables and fruits are body building foods

Fruits and vegetables should be eaten liberally.

Food pyramid guides us how to eat properly.

There are three food groups.

1 teaspoon = 5 grams of sugar/oil

At least 3 servings of milk and milk products (300ml) should be consumed in a day.

Fruits are a healthy snack option.

When given a choice, always opt for mutton over chicken and fish.

1 glass of milk = 250 ml.

Food should be chosen based on taste.

Wise food choices make one healthy.

Fast foods are rich in salt, sugar and fat.

We should buy canned foods as they are healthy.

Fast foods are already made or cooked within minutes.

Food labels help to choose healthy food items.

The information provided on food labels is useless.

Each packaged food item has a label.

All processed foods are healthy.

Food labels are easy to read.

Preparing meals is easy.

I can incorporate cooking in my daily routine.

Physical activity can be done at any time and at any place.

It is alright to do exercise one day in a week.

Duration of physical activity of moderate intensity should be between 30-45 minutes daily.

Don’t sit at a place for more than 30 minutes.

Exercise helps to control body weight.

ANNEXURE 12: SESSIONS’ FEEDBACK FORM

Name of the participant: Contact participant: Date:

Q1. Please tick and rate the session on following aspects: Overall session- Very useful Somewhat useful Not very useful Not at all useful Very poor Poor Good Very good Excellent Facilitator’s expertise

Clarity of message delivery

Power point presentation

Time management

Handout Strongly

disagree

Disagree Neither agree nor disagree

Agree Strongly agree

The difficulty level was about right

I can apply the information in my daily life/routine

The presentation was appropriate and answered my questions

The facilitator actively involved me in the session

I’m motivated to modify my behavior because of this session

Q2. What did you enjoy most today? Q3. What did you learn today that you could use in your daily life? Q4. Was there anything that you did not understand in today’s sessions? Q5. Was there anything that was unacceptable/offending? Q6. How do you think can we improve the session? Q7. Any other comments/Remarks you would like to give.

ANNEXURE 13: SELF EFFICACY SCALE

(I) DIET

How certain are you that you could achieve the goals and targets? I can manage to stick to my goals and targets,

Very uncertain Rather uncertain Rather certain Very certain x Even if I need a long time to

develop the necessary routines

x Even if I have to try several times until it works

x Even if I have to rethink my entire way of nutrition

x Even if I do not receive a great deal of support from others when making my first attempts

x Even if I have to make a detailed plan

(II) EXERCISE

I can manage to carry out my exercise intentions, Very uncertain Rather uncertain Rather certain Very certain x Even when I have worries and

problems

x Even if I feel depressed x Even when I feel tense x Even when I am tired x Even when I am busy

(III) ALCOHOL

I am certain that I can control myself to Very uncertain Rather uncertain Rather certain Very certain x Reduce my alcohol

consumption

x Not to drink any alcohol at all x Drink only at special occasions

(IV) TOBACCO (SMOKE AND/OR SMOKELESS)

I am certain that I can control myself to Very uncertain Rather uncertain Rather certain Very certain x Reduce my tobacco use x Not to use tobacco at all

Annexure 14: Practices form

Practice Yes No x Daily fruit consumption x Daily consumption of at least 2 servings of cooked

vegetables

x Daily consumption of salad x Daily consumption of 2 servings of pulses x Daily consumption of milk/milk in products other

than tea and coffee

x Type of milk preferred (if consumed): Full cream/ toned/double tones

x Prefer: Mutton/Chicken/Fish x Prefer: Maida/Atta x Oils preferred (Multiple choices) x Eating out (daily) x Frequency of eating out x Type of items consumed while eating out x Breakfast skipping: x Extra sugar added to beverages x Regular physical activity x Duration (if doing regular physical activity) x Tobacco use x Alcohol consumption

Annexure 16: List of healthy messages designed for the program

A list of short service key messages was designed on health and physical activity and was

messaged to the employees both on their phones normally as well as via Whatsapp. The

key messages included:

1. Include a variety of foods in your daily diet from various foods groups.

2. Eat adequately by choosing the right portion sizes from different food groups.

3. Consume all meals regularly and avoid skipping of meals.

4. Ensure daily intake of preferably 5-6 portions of fruits and vegetables.

5. Include green leafy vegetables at least once a week in your meals.

6. Reduce the frequency of eating outside foods or eating out or ordering food from

outside.

7. While eating out choose wisely. The foods consumed should be safe and clean.

8. Limit intake of coffee, carbonated drinks, and other processed beverages containing

added sugars.

9. Avoid tea and coffee with main meals.

10. Avoid use of tobacco in any form.

11. Do regular physical activity for at least 60 minutes for maintaining desirable body

weight.

12. Do foot, neck and arm exercises while taking calls at work.

13. Limit the intake/consumption of alcohol to special occasions.

14. Adopt stress management techniques such as yoga and meditation.

ANNEXURE 17: Program Feedback Form Q1. Overall, the program was- x Very useful x Somewhat useful x Not very useful x Not at all useful

Q2. Has this program fulfilled your expectations? Why or why not? Q3. What did you learn that you could use in your daily life? Q4. Was there anything that was unacceptable/offending? Q5. According to you, are the targets suggested sustainable in the future? Q6. How do you think can we improve this program? Q7. Any other comments/Remarks you would like to give.

Summary (500 words):

The present study was conducted to map the occurrence of Metabolic Syndrome (MetS) and its

risk factors among business process outsourcing (BPO) industry employees in the National

Capital Region, and to develop and implement a lifestyle management program for them. This

cross-sectional study was carried out in seven BPOs among 415 calling level (21-30 years) and

61 managerial level (25-40 years) employees. Metabolic Syndrome, which is a disorder

characterized by presence of 3 or more of 5 the components viz. abdominal obesity, high blood

pressure, high triglyceride levels, low HDL levels and high fasting blood glucose, was assessed

using the Adult treatment panel III (ATPIII) criteria (ATPIII, 2001) and International Diabetes

Federation (IDF) criteria (specific for South Asian population) (IDF, 2005). The syndrome was

present among 11.8% employees at the calling and 21.3% employees at the managerial level

using ATPIII criteria; and 18.3% employees at the calling level and 31.1% employees at the

managerial level using IDF criteria. The syndrome’s prevalence was significantly higher in males

as compared to females at both calling and managerial levels. With the increase in number of

components of MetS in abnormal range, a significant increase was observed in the levels of

waist circumference, serum triglyceride and high sensitive C reactive protein, and a decrease in

the levels of HDL cholesterol. The syndrome was significantly associated with positive family

medical history of heart disease, high blood pressure, diabetes and/or thyroid disorders,

occasional alcohol drinking (≤ once a month; consumption of >5 standard drinks by men and >3

standard drinks by women at a time), skipping breakfast and lunch at the calling level, and with

current smoking (smoking cigarette/hookah at present) at the managerial level. Engaging in

moderate physical activity for 10 minutes continuously for 4 or more days in a week was

protective. Following assessment of MetS, a worksite lifestyle management program was

developed and implemented for BPO employees. Ecological model of health for behavior

change was used as the framework for program development which focused on promotion of

healthy eating habits and physical activity and discouraging harmful use of alcohol and tobacco

products among BPO employees. A total of 20 employees participated in the feasibility trial,

while 41 participated during program implementation in one BPO company. The program

strategy involved three steps – (i) designing of specific key messages, and goals and targets for

the employees, (ii) Development of sessions, communication material and activities to facilitate

achievement of goals and targets, and (iii) Program trial to assess its acceptability and feasibility.

Before program implementation, the employees were assessed on their knowledge levels,

dietary and lifestyle practices and self-efficacy level. The interactive educational and skill

enhancement sessions were followed by a 6 week follow up period during which the employees

were allotted goals and targets to be fulfilled. They were provided a tracking booklet to track

their progress. Besides sessions on nutrition and health promotion and prevention of MetS, the

program involved creation of peer groups of employees working in the same work process at

the BPO company, and changes in the physical-environment of the company (introduction of

curd and fresh fruit salad in the cafeteria, increase in aisle space on floors for walking while

attending calls, provision of foot exerciser at the desk and creation of badminton court in the

company compound). After 6 weeks of follow up, the program led to significant improvement in

the knowledge level, certain practices and self-efficacy level of the employees. However,

company policies limited radical changes in cafeteria menu and also rotational shifts which are

an integral part of the work policy of the industry. With 1/5 th of the BPO employees at the

calling level (21-30 years) and nearly one third at the managerial level (25-40 years) having

MetS, it is important to initiate appropriate screening and intervention strategies to prevent and

reverse the syndrome among them. Worksite nutrition and health education program to

promote healthy lifestyle is an acceptable and feasible intervention for this population group.

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prevalence and risk factors of metabolic syndrome … · prevalence and risk factors of metabolic...

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