Do Change in Life Style Improve Work Ability? A Controlled Study of the Effect of Changes in Lifestyle on Work Participation.
Phase: NA
Conditions: Obesity, Morbid, Sick-leave, Work Related Illnesses, Life Style
Sponsor: Molde University College

0 
 
 
 
 
Will change in lifestyle have a correlation 
with ability to work?  
Life style factors that affect work 
participation 
Occupational rehabilitation for people with body mass index 
above 30 
Anita Dyb Linge 
Anita.linge@hivolda.no 
Summary 
This trial will follow up a group of people with BMI above 30 and who have 
participated in an occupational rehabilitation program at Muritunet. The aim of this 
study is to gather information about how life style changes affect the ability to work.  
Ver.2.0, 24.7.2017 

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1 Introduction 
Numbers from Statisk Norway indicate that one out of three has overweight (BMI >25) or obesity 
(BMI >30) in the population in the age of 16 to 74 [1].  Development of overweight and obesity have 
the latest years dramatically increased. In Norway, the consequences of this development is an 
epidemic situation with an increase in life style diseases and work absence. Central Norway Regional 
Health Authority (HMN RHF) has initiated action to reduce work absence and consequence of obesity 
by introducing a work related rehabilitation program for people with BMI above 30. Combination of 
weight loss programs and work related intervention is new in Norway. Outcomes of this intervention 
are so far are not known.  
The trial can be used to improve the quality of occupational rehabilitation in Norway in the 
Specialised Health Care services. Others who work with life style changes and with work related 
rehabilitation can also use the collected information. This study is a Cohort clinical trial with a Pseudo 
prospective design. 
1.1 Status of knowledge  
Development of overweight and obesity is one of the three biggest health challenges in Norway.  
Overweight and obesity influence the person's life quality, psychiatric and physical health and social 
life [2].  Overweight and obesity associates with high comorbidity and illnesses such as muscular and 
skeletal problems, lung diseases, cancer, social isolation, stress, psychiatric diagnoses and early death 
[3-6]. Higher BMI gives more complications [7]. The reason for obesity is complicated since many 
factors affect. Individual factors as the personal life style, society, culture, socio-economic status, 
genetic and biological factors influence the development [8].   
High BMI and the consequence of obesity gives challenges for the individual, for the society and the 
occupational. Studies in the latest years indicate that high BMI is increasing longer periods with work 
absence [9] and that there is directly context between high BMI and long-term sick leave above 
seven days [3, 10]. Obesity contributes to independent factor to work absence and indirect thru 
lifestyle related illnesses.  
Long-term sick leave also affects the society with cost cause reduced work productivity and 
increasing Social Security benefits [10]. A study from Denmark refers to that obesity contribute to 
yearly 1,8 million extra days of work absence and closely to 1.100 cases of disability pension related 
to obesity [11]. In a study on Swedish women concludes that overweight and obesity cause ten 
present of the total cost regarding social security. A rapport from OECD through Statisk Norway 
shows that persons in the age between 50 to 59 with obesity have three times as much work 
absence than those that don't have obesity [12]. The reasons for work absence is complexed. Factors 
that contribute is disease and symptom from the muscular and skeletal system, mental disorders, 
relation at the workplace, family relationship and socioeconomic issues.  
A person with a long-term sick leave in Norway can participate in an institutional work related 
rehabilitation stay. The aim for such stay is to increase function and work ability to prevent the 
individuals permanent to fall out of working life [13]. The intervention in occupational rehabilitation 
builds on physical activity, cognitive therapy, and cooperation with Norwegian Labour and Welfare 
Administration (NAV), employer and others that can contribute to deal with the health challenge and 
to increase work ability. The intervention based on the World Health Organisation's classification of 
health and health-related domains, known as The International Classification of Functioning, 
Disability, and Health, ICF.  ICF is the WHO framework for measuring health and disability at both 
individual and population levels, known as a bio-physio-social framework [14-16]. Many studies 

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indicate that occupational rehabilitation can be an effective intervention to reduce sick leave and 
disability benefit [13].    
People with high BMI needs beside work rehabilitation also focus on life style changes to reduce 
consequences of obesity. The basic treatment of obesity is a focus on cognitive treatment that helps 
people changing diet and increasing activity. 
In Norway, there is entirely 340.000 humans with overweight and obesity in the age between of 20 
to 76.  Obesity cost yearly for the western countries 2 to 7 present of the national health budget [17]. 
In Norway, people with obesity can participate in weight loss programs in specialized institutions that 
focus on life style treatment.  
1.2 Knowledge challenge    
Occupational rehabilitation with a focus on weight loss program is new in Norway, and just a few 
institutions offer this kind of intervention. The consequence of this extent is little knowledge, 
experience, and few studies were done in the crossing fields between occupational rehabilitation and 
rehabilitation generally [18] and in work related rehabilitation individually [19].  
Life style changes take time. The weight loss program needs to focus on changes in diets, physical 
activity, and cognitive therapy [20]. The primary challenge with weight loss programs is that the body 
weight gain with a third of the total weight loss within a year. Studies show that about fifty present 
of those who participate in weight loss programs going back to their original weight after five years 
[21]. There is a lack of documentation on what kind of life style treatment that gives a good effect, 
both in and outstay [22]. Therefor life style treatment is often given without proper documentation 
for what intervention that works or not [23].  
Today many unknown factors affect in between obesity and sick leave. The challenge is that 
traditional occupational rehabilitation does not include weight loss programs, and weight loss 
programs don`t include the focus on work participation. There is also in the field of work related 
rehabilitation lack of knowledge about effect full interventions that can reduce sick leave and 
disability pension in people with nonspecific muscular and skeletal problems, obesity and physiatric 
disorder [24]. Besides lack of information on the effect of occupational rehabilitation, few studies 
have focused on the mechanism that can be effect full between obesity and sick leave [10], on 
individual factors that generate changes in life style [8, 25] and what will make work participation 
[26].     
1.3 Background 
In 2015 established HMN RHF an occupational rehabilitation program for people with BMI above 30 
who might be or is on sick leave directly or indirect cause obesity. This program combines work 
participation and life style changes and exists only in two institutions in Norway. The goal of the 
program is to increase function and work ability and weight loss. The program is new, and few 
documents exist on the effect and the correlation between life style changes and work ability.  There 
is also need to question whether obesity is the reason for work absence or is there other factors that 
affect work ability. This study wants to follow up a group of people who have been participating 
occupational rehabilitation at Muritunet.    
1.4 Research fields meaning for patient treatment and disciplines 
This trial can contribute to improving the quality of work related rehabilitation in the specialized 
health care services and for other institutions who work with obesity and occupational rehabilitation.  
The study can also contribute to: 

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1. Participants in this trial might get the opportunity to increase their knowledge about their 
health and function that affect their everyday living. 
2. New research-based knowledge and professional development in the crossing field between 
obesity and work participation.  
3. New insights about effective interventions that can contribute to reducing the number of sick 
leave and long lasting weight loss.  
4. Documentation of result over time for the group that has participated in the professional 
program for people with BMI above 30. 
5. Developing the program for people with BMI above 30. 
6. Increasing political focus on a fast growing group.  
7. Indirect social-economic and individual benefits.  
2 The research question and goal 
Lifestyle is a field that contains several areas. It tells us about how persons live their life measured in 
physical activity, diets, inactivity, intoxication, smoking, alcohol, circadian rhythm, sleep behavior and 
stress. The focus for people in life style changes is weight loss through reducing energy consumption 
and increasing energy consumption through physical activity [27] with the help of cognitive methods. 
One of the goals is to reduce the weight with 5 to 10 percent. This reduction will accumulate health 
benefits as better life quality, reducing life style diseases and better mental and physical health and 
this health benefits will gain the society. Several studies indicate that there is an association between 
high BMI and sick leave [3, 10, 28]. The question is what correlation is there between life style 
changing and work participation. What motivates people to work and what happens with the sick 
leave when BMI is decreasing?  
The purpose of this trial is to get more information about how life style changes affect work 
participation for people with BMI above 30. The information can contribute to improving the quality 
of occupational rehabilitation programs in the specialized health care services and for others who 
work with weight loss programs and work related rehabilitation programs. 
The primary goal of this trial: What correlation is there between life style changing and work 
participation after participating in occupational rehabilitation on Muritunet? 
Aims of the trial are:  
1. Will changes in physical activity, diets, and life quality correlate with work participation? 
2. Will changes in physical activity, diets, and return to work self-efficacy correlate with life 
quality? 
3. Will changes in work participation, life quality, and diets correlate with weight changes? 
4. What experience the participants as important factors to achieve lifestyle changes and work 
participation? 
Work participation defined in this study is working full time or partial with an employer, permanent 
or temporary or as a student. The employee has to work coherently in 28 days without to receive 
social benefits. 
Life quality defines in either in a subjective or an objective perspective [29]. In this study, the 
subjective perspective emphasizes the individual’s positive, negative, cognitive and emotional 
experience that concern life quality.    
Diet in this study is the intake of food and liquid that shall ensure a satisfying amount of calories, 
nutrient and prevent life style diseases.  

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Physical activity in this study is action made by musculature in a way that it results in increased 
energy consumption higher than resting. 
3 Implementation  
3.1 Design, methods and analyze 
This study will follow-up a group of people with BMI above 30 over a period of one to four years. 
Study with a Pseudo prospective design that includes collecting data through both qualitative and 
quantitative methods. Both methods will take place at the same time, Parallel mixed Methods. The 
data is linked to each other in the different stages in the study, and the methods will confirm, cross-
validate or confirm findings in one method with another result in another process. Creswell uses the 
Current concept Triangulation [30]. The purpose of this plan is to make one method stronger with 
using the strength of another method. 
The definition of Mixed Method research in this study is; Approach to gathering data through 
quantitative and qualitative methods with the use of designs that involve both philosophical and 
ethical theory [31].  
Collecting data through forms, physical test, journal, interviewing, from national register from the 
Norwegian Labour and Welfare Administration and National 
Education Data Base. Using registry data will be useful because there might be a link between 
different variables that might contribute to clarify the association between health and work 
participation. It then can be specified whether the participant is on sick leave because of obesity 
related issues or if there are other reasons for the sick leave. Another example is the connection 
between education and work participation because the level of education may have importance for 
choice of profession and sick leave. There are several links in this study that can strengthen the 
findings in the data collection. 
Data collected at four different stages.  
1. Baseline (BL). From the beginning of the stay at Muritunet. Data gathered from the journal, from 
self-reported forms, and from a physical test. The particular data package is; in and out date for the 
stay, age, sex, diagnosis, education level, health problems, work status, social benefits, changing in 
work status, work place, expected work time pr. Week and occupation code, work motivation, 
income, diet, physical capacity and activity, life quality and overeating behaviour.  
2. T1, six months after the first stay at Muritunet. Data gathered from the journal, from self-reported 
forms, and from a physical test. The particular data package is; in and out date for the stay, diagnosis, 
health problems, work status, social benefits, changing in work status, work place, expected work 
time pr. Week and occupation code, work motivation, income, diet, physical capacity and activity, life 
quality and overeating behaviour.    
3. T2, 12 months after the first stay at Muritunet. Data gathered from the journal, from self-reported 
forms, and from a physical test. The particular data package is; in and out date for the stay, diagnosis, 
health problems, work status, social benefits, changing in work status, work place, expected work 
time pr. Week and occupation code, work motivation, income, diet, physical capacity and activity, life 
quality and overeating behaviour.    
4. T3, Focus group interview, one to four years after the participants finishing their stay at Muritunet. 

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5. T4, Data collecting from Norwegian patient register (NPR) and National Education database 
(NUDB). Will be collected once. Data collected are social benefits as sick leave, work assessment 
allowance, disability benefits, unemployment benefits, diagnosis for sick leave, changing in work 
employment, work place and expected work time pr. A week and occupation code. 
Some participants will return to their work, but some will not. It will lead to variation for my chose of 
how to design methods and analyze the data material. Different ways will complete each other, and 
today it is common to use several methods and models in the same study.   
Data analysis is chosen on the background of design and approaches. BL, T1, and T2 is a typical 
quantitative approach and will be analyzed both on its own, but also compared with data collected in 
T3 and T4. The qualitative interview will have open-ended questions, and the participants will get the 
opportunity to reflect on themes defined from the data collection earlier in the study.    
3.2 Inclusion and excluding criteria  
Participant inclusion criteria; the participants have to be on sick leave or be in danger to be on sick 
leave because and obesity related problems. The participants have to have a real opportunity for 
returning to work, full time or part time. The participants have to have a BMI above 30 and be in age 
between 18 to 67 years old. 
Participants excluding criteria;  
1. People with a severe eating disorder.  
2. People who cannot consent.  
3. People with a severe alcohol and drug abuse.   
4. People with a severe psychiatric disease.  
5. Pregnancy 
6. People with a health condition that contraindicates physical activity.  
7. People who receive work assessment allowance. 
8. People with or wants so seek for disability benefits.   
9. People with permanently organized work.    
3.3 Recruiting of participants 
Recruiting participants in this study are as followed:  
1. Before the first stay at Muritunet. The patients will receive an envelope with written 
information by post a month before their stay. In the envelope, there are two letters. One 
with detailed information about the study and one letter with a request to consent to the 
research.  After the participants arrive Muritunet, they will receive information about the 
study, attachment one, given by project secretary. Those who want to participate in the 
study gives written consent. The project secretary registers the written consents in SPSS at 
Muritunet. SPSS is a comprehensive software package for statistical analysis and data 
management.  
2. For participants who participate or are finished with the stay at Muritunet. The participants 
receive by post a written letter with detailed information about the study and two letters 
with a request to consent in the study. In addition to the letters, there is a prepaid envelope 
with the address to Muritunet, attachment one. If the person approves to participate in the 
study, he or she signs the consent and returning it to Muritunet. The project secretary 
registers the agreement in SPSS. This registration goes to the researcher who can call the 
participant regarding interview.   

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3.4 The content of the occupational rehabilitation stay at Muritunet 
The participants report data while they are at Muritunet. The rehabilitation stay is as followed with 
the moment for data collection: 
1. Four weeks with an institutional stay at Muritunet (BL) 
2. Follow-up: 
a. Eight weeks, telephone contact between therapist at Muritunet and the participant. 
b. 16 weeks, video conference on SKYPE between all the participants and a therapist. 
Lecture on diets.  
c. 28 weeks, Outpatient stay at Muritunet. Central themes that day is education, 
conversation, physical test, and forms. (T1) 
d. 40 weeks, telephone contact between therapist at Muritunet and the participant.  
e. 52 weeks, Outpatient stay at Muritunet. Central themes that day is education, 
conversation, physical test, and forms. (T2) 
The participants in the occupational rehabilitation program get both practical and theoretical 
intervention, in groups and individual. Four main themes; cognitive therapy, physical activity, diets 
and focus on work-oriented approach. The table under shows both groups based activity and 
personal follow-up. 
Group based intervention 
In stay 
Time 
Follow- up 
Time 
Cognitive approaches in groups 
- Expectation clarification 
- Sleep 
- Cognitive methods 
- Values, will and choice 
- Goals setting 
- Motivation 
- To come home/ what next/ home 
- Acceptance and commitment 
therapy 
 
11t 
2x 1,5 t 
Exchange of experience (by 
16, 28 and 52 weeks) 
 
 
 
 
 
 
Acceptance and 
commitment therapy 
(by 28 and 52 weeks) 
2x 1,5 t 
2x 1,5 t 
Physical activity in groups 
Education- how to exercise Physical 
activity in a group 
1 t 
23,5 t 
 
 
Diet 
Education 
- Diets 
- Food knowledge 
Making food in practice 
2t 
2,5 t 
5 t 
Diet, lecture- SKYPE (by 16 
weeks) 
 
2 t 
Work-oriented approach  
Education  
- Rights and duties at work 
- Work and health. 
Individual follow-up 
1 t 
1,5 t 
>1 t 
 
Education, knowledge about 
obesity 
Education  
- Facts about obesity part one 
- Facts about obesity part two 
1 t 
1 t 
 
Data-collection 
Foams 
Weight and waist circumference 
Physical test 
Skype 
1 t 
2 t 
2 t 
1 t 
Foams (by 28 and 52 week) 
Weight and waist 
circumference (by 28 and 52 
weeks)  
Physical test (by 28 and 52 
weeks) 
2 t 
2 t 
2 t 
Interdisciplinary intervention 
(when needed) 
Labour consultant, Psychiatric nurse, Physiotherapist, Nutritionist, General Practitioner, Senior 
Registrar Consultant, Sports Educator, Psychologist, Cognitive Therapist and Occupational 
Therapist.  
Individual intervention 
Phase one 
Time 
Phase two 
Time 
Personal approach 
Therapeutic contact with:  
Primary contact person for the stay 
ACT conversation 
Labour consultant  
Nutritionist  
4x 0,75 t 
6x 0,5t 
4x 1t 
3x 1t 
 
Prim.contact- conversation 
(by 4, 28, 40 and 52 weeks) 
4 x 0,5t 
2 t 

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Physiotherapist 
4x 1t 
Conservation after request 
with nutrition (by 28 and 52 
weeks) 
 
Contact with  work place, NAV 
or other 
Individual after need  
Individual after need ( by 28 
and 52 weeks) 
3.5 Data 
This study will use several sources for data to measure changing among the participants. Data from 
baseline, T1 and T2 will be the foundation to see if there is a correlation between the different 
factors, as well as to substantiate or to find new findings.  
3.6 Quantitative data collection  
Foams register and explain changing in life style factors and work participation. The physical test may 
say something about the participant’s physical capacity. In this study foams and a test will measure 
conditions that affect socio- economic, demographic and individual factors, their expectation of 
returning to work, the motivation for working and sick-leave, physical activity, physical and mental 
health, diet and nutrition, and life quality. Information about the date of the stay, diagnoses, and 
activity is in the journal at Muritunet.  
Areas  
Time of data 
collection  
Foams 
 
Employment 
data 
BL 
 
BL, T1 and T2 
ARR foam, socio-demographic data and work status (Nasjonal 
kompetansetjenseste for arbeidsretta rehabilitering) 
Short ARR foam  
BL 
Return to work self- efficacy (RTWSE 19) [31]  
Health data 
BL 
BL, T1, and T2 
   High, waist circumference, body fat percentage and  
   fat-free mass kg 
Weight, BMI 
BL 
BL 
Diagnoses 
Subjective Health Complaints (SCH 25) [32].  
Physical 
capacity  
BL 
Step-test with Borg scale CR 10  
BL, T1, and T2 
Registration of level of physical activity(Health Directorate) 
Quality of life 
BL, T1, and T2 
Quality of life (15D) [33]. 
Food habits 
 
BL 
Thoughts and feelings about food, body and eating behavior. Survey about 
Binge eating disorder (EDO)[34].  
BL, T1, and T2 
Food behavior registration (Health Directorate)  
 
 
3.7 Register data 
NAV and NUDB have reliable information about work participation and education data. The data will 
contain information about social benefits as sick leave, work assessment allowance, if the participant 
is registered as a job seeker, changing in work employment, income, about the work place and 
expected work time pr. Week, occupation code and about education. Collecting data at the end of 
the study and correlating with data from the foams, journal and qualitative interview.  
3.8 Qualitative interview 
Participants who complete 12 months of treatment on Muritunet will receive an invitation to 
participate in a focus group interview. The interview is carried in the T3 phase one to four years after 
finishing the stay at Muritunet. The interview will focus on health, life style changes, life quality and 
work participation. Each interview will last about one and a half to two hours. The group interview 
will consist of 6 to 8 people. The primary purpose is to get a complete picture of the complexity of 
returning to work, and how life style changes influence the process. The data collection has a 

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particular focus on the participants experience on what promotes and inhibits the process returning 
to work in due to their health, physical activity, life quality, workplace, diets and other factors that 
can contribute.  
3.9 Analyse 
The goal of this study is to explore the correlation between life style changing and work participation. 
Four secondary issues will result in using different ways of analyzing the data material. In this way, 
each issue can be investigated on their own, but also analyzed with each other.    
The primary analyzing approach for this study is multivariate logistics regression analysis with a focus 
on the correlation between several independent variables (X) and dependent variables (Y).  In the 
main issue Y= work, and X= physical activity (x1), diets (x2) and life quality (x3). Work divides into 
three categories; a) full time working, b) part time working, c) not working. In the secondary issue, is 
Y= life quality and X= physical activity (x1), diets (x2), and the belief in managing (x3). 
In the quality research, thematic methods will be used to analyze the interviews. This method can 
catch the significant complexity in the text and is the most usual way to analyze a text in qualitative 
research. This way of analyzing consist of six steps. 1. Transcribing data, 2. Reading and re-reading 
the data, 3. Coding, 4. Search after subjects, 5. Define and give a name to the subjects, and 6. Choose 
to illustrate examples of different issues.  
3.10 Calculation of sample size 
The calculation of the sample size on a group basing on previously participated in a similar 
occupational rehabilitation intervention for people with a BMI above 30 at Muritunet. Tre research 
question is leading for the sample size. The calculation is based on the time for data collection 
baseline and at the end of the intervention at Muritunet T3. The calculation is basing on apriority 
effect size, p value =0,05 and 80 percent statistical strength.  
 
Goal of changing 
1. Work; With a statistical power of 80,4 percent to achieve a clinical and a statistically 
significant change in 25 percent increasing work participation this study has to have 51 
participants with two end point. The calculation is made out of 95 percent confidence 
interval (95% CL=18,05-31,95). 
2. Weight reduction; With a statistical power of 80,2 percent to achieve a clinical and a 
statistically significant change in 11 kg weight reduction this study has to have 59 participants 
with two end point. The calculation is made out of 95 percent confidence interval (95% 
CL=6,82-15,18). 
3. Quality of life; With a statistical power of 80,7 percent to achieve a clinical and a statistically 
significant change on 0,02 this study has to have 55 participants with two end point. The 
calculation is made out of 95 percent confidence interval (95% CL=0,025- 0,045). In the foam 
Quality of Life 15D, the SMR is the smallest clinical relevant change 0,015. 
This calculation is done with the use of SPSS Sample Power program.  
3.11 Organization and cooperation 
Volda University College is responsible for this study. Anita Dyb Linge is the project manager and the 
Ph.D. student. This study is a partnership between Volda UC and Muritunet. The participants are 
collected from an occupational rehabilitation program for people with a BMI above 30. Data from 

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baseline, T1, and T2 is from the participants stay at Muritunet. T3 happens where the participants 
live. T4 is from two different registers. The Ph.D. student is a full-time employee with Volda UC, but 
work 25 percent at Muritunet.  
This study links to Regional Centre for Obesity Research and Innovation at St.Olavs Hospital in 
Trondheim, and the National Competence Centre for Work-Based Rehabilitation in Rauland.  
3.12 User involvement 
The user's voice in the project shall contribute to better planning and implementation of the 
intervention in the study. The user can participate in his or her experience, illuminate challenges, and 
share their own history. The project manager wishes to seek advice with the user about focus areas 
and questioners in the quality interview. It can also be useful to use the users to test the questions 
before the process with interviewing the participants. Muritunet does have other patients with 
similar challenges who can contribute in the process of quality assurance of the questions. Central 
Norway Regional Health Authority does also have professional users that can participate in this 
study. 
3.13 Budget 
The Central Norway Regional Health Authority is financing the occupational rehabilitation stays at 
Muritunet.  
Volda UC. is funding the Ph.D. student.   
 
3.14 Plan for the progress 
 
2016 
2017 
2018 
2019 
2020 
Application Regional 
Committees for Medical and 
Health Research Ethics (REC)  
 
X 
 
 
 
Application for finances 
X 
 
 
 
 
Recruiting participants 
 
X 
 
 
 
Data collection/ questioners 
 
X 
X 
X 
 
Data collection/ journal 
 
X 
 
 
 
Data collection/ register data 
 
 
 
X 
 
Status report 
Årleg 
 
Articles 
 
 
X 
X 
X 
Results of the study are publishing in three articles. 
3.15 Ethics 
Regional Committees for Medical and Health Research Ethics (REC) has approved the study. It has its 
foundations in laws and guidelines for proper health research and the laws that apply to treatment in 
the Specialised Health Care services in Norway. Collected data shall be stored anonymous and locked 
after guidelines from the Personal Data Act, the Health Research Act and the Research Ethics Law. 
The participants give written consent before participating in the study.  
Inconvenience 
The participants may experience to fill the foams as bothersome. Individual follow-up of participants 
has reading and writing difficulties, challenges with the language or concentration problem.   
Benefits 

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1. Participants in the study may increase self-efficacy, get more insight into own health and 
physical and mental disability through personnel in the Specialised Health Care services.  
2. During the interview, participants can improve their understanding of their situation, 
perspective on their own possible to increase work activity and self-efficacy to returning or 
continuing to work.     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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