Project Abstract:

Lifestyle changes have been known to improve an individuals overall health. There is
evidence to support that lifestyle change has reduced the risk of heart disease in Americans. Your
Guide to Improved Health is going to implement nutrition and fitness in the target audience of
<55 year olds. The program will target employees of one of the largest employers in Keene and
Cheshire County. C&S Wholesale Grocers has agreed to work with this project to reduce the
risk among 500 employees. Participants will undergo labs to see if they are at risk and eligible
for the program. Labs will measure BMI, LDL, HDL, TC, and blood pressure. These lab values
can indicate the level of risk. The goal for the overall program is to lower the participants risk of
heart disease. To reach this goal the participants will be involved in a six month program. During
this six month program they will be introduced new nutrition and fitness regimens. The regimens
will be introduced week by week. Each participant will get a personalized blueprint that will
have everything recorded for example their lab values, their projected nutrition and fitness
regimens. Dietitians and life coaches will help guide the participants through the program. The
participants will receive individual guidance from the coaches via telephone meetings and
information via email. Dietitians and life coaches will have the same cliental to make sure the
participant is getting optimal care. Participants are expected to attend biweekly meetings at the
C&S location. The budget will include wages for the dietitians and life coaches, marketing, and
supplies. At the end of the six months, the participants that have completed the full program will
have the labs completed again for comparison. The participants will also receive a cash bonus
from C&S Wholesale Grocers.

Introduction:
As generations age there is increased risk of disease. Five out of the ten chronic health
disorders in the United States can be linked to life style. 1 One of the five is coronary artery
disease or heart disease is at an increase in Cheshire County. Looking at the total populations and
the prevalence of heart disease, it is clear that there is an increase. In Cheshire County 4.1% of
citizens have coronary artery disease, while 3.7% of New Hampshire citizens had coronary
artery disease (Appendix A, Table one).4Five percent of Cheshire County citizen have had a
heart attack, while 3.5% of New Hampshire citizens have had a heart attack. According to the
Center for Disease Control, 3.5% of US citizens have been diagnosed with coronary artery
disease and/or have had a heart attack.5 With these statistics, it is clear that there is a need to
address this health issue. With nutrition and wellness intervention it is possible to reduce the risk
of heart disease among the Cheshire County population.
The proposed program is called Your Guide to Improved Health. This program will run
for six months starting in April and ending in September. It will be implemented within one of
the largest employers in Keene. This program will focus on a specific audience. The audience
will be employees of C&S Wholesale Grocers. C&S Wholesale Grocers has around 1,200
employees.6 The employees there have a large age group but the participants will those of<55
and or already at risk for heart disease. It is stated that the employed population and blue collar
workers are more likely than those in white collar jobs to report a history of heart disease.7 From
a previous program it was noted that the National Health Interview Survey in 2008-2012
estimated the prevalence of a history of coronary heart disease among adults age <55. In this age
group, there is an increase of disease. However, as stated in a similar program, age is the
strongest predictor of coronary heart disease; it cannot be modified. There have been other

successful programs similar to this one. The programs target employees that have or are at risk of
heart disease. The target audience in this program and the others are the same.
A similar program was completed and studied by Bennet et al. The program included 145
managers from eight organizations.8 The program lasted six months, the same time frame being
proposed. The program was designed around convenience, with that said the program was
internet based with flexible webinars and telephone support. The participants were asked to fill
out a comprehensive survey that measure demographic background, diet and exercise habits. The
participants were split into either a control group with no intervention or the program group.
After completing the survey the managers were mailed a measuring kit to record height,
weight, and other measures. The proposed program will not have a measurement tools. In the
new program, participants will be asked in a survey the same questions but blood labs including
anthropometric measurements will be done by medical staff at Cheshire County Medical. The
internet-based program was a tool to modify attitudes and behaviors. The program outcome was
positive in that it helped improve the health of the managers (Appendix A, Table 2).
Colkesen and colleagues tailored a health program to reduce the risk of cardiovascular
disease. Through a web-based questionnaire, biometrics and laboratory evaluation they were able
to tailor motivational and educational health advice to each participant. This program was
implemented all online. Having an actual person behind the given advice may have a positive
effect on the clients. Although this program was all online, it did have successful results. They
were able to reduce the risk of cardiovascular disease by 18% among the participants. 9
Your Guide to Improved Health is designed for convenience of the clients. Successful
programs have noted that computer-based interventions offer many opportunities for distributing
health information and skills for populations with a risk of heart disease. Colkesen and

colleagues also state that computer-based interventions are low cost and are shown to be
effective.10
With the available research, Your Guide to Improved Health will be able to appropriately
address the risk factors related to heart disease. The program length of six months has worked
best for target group. Having the telephone meetings and biweekly meetings will help keep
participants on track.
Goals and objective:
The objective is to have volunteer participants from C&S Wholesale Grocers involved in
a six month life style program. The volunteer participants from C&S will receive a bonus from
the company. The company encourages healthy lifestyles among their employees. Having
healthier employees helps increase efficient work and reduces health insurance cost for the
company. The overall goal for this program is to reduce the risk of heart disease among the 500
employees at C&S. As stated before this is a large population group within Cheshire County.
Using the Framingham Risk Score, the goal is to reduce an individuals score by at least one
point in at least two areas (Appendix B, Figure One). Areas that can change within the time
frame of six months could be cholesterol levels or blood pressure. The outcomes that are
expected of this program are broken down to short, medium and long term. In the short term
outcome the participants will become aware of their immediate health status. In the beginning
program the participants should develop personal motivation and a change in belief. A change in
belief can be a positive outlook on the program.
The participants at this point should be active in the program and have changed their
belief completely. A healthier life style will begin to evolve at this part that has the potential of
reducing the risk of heart disease. If the participants make it through the six month program, they

hopefully have been able to reduce the risk of heart disease. It is noted that age cannot be
modified. However, modifications in life styles can reduce risk. By life style modifications, the
program will have implemented healthier life styles choices, new diets, and exercise. The long
term outcome of this program will hopefully continue in C&S employees and encourage others
to evaluate their life styles. C&S will hopefully join the positivity and change some of the work
environment at their facility. C&S Wholesale Grocers should also see a reduction in the medical
care costs for employees. It has been stated that life style risk factors that can be modified cost
employers 228% more in medical costs. Twenty- eight to 56% of the total medical costs are
related to treating clinical disorders like heart disease.11
Methods:
To begin the program employees for Your Guide to Improved Health will need to be
hired. The employees of this program will be trained for three weeks before the program begins.
Expectation and roles will be explained. A total of twenty dietitians or nutritionist will be hired
as well as twenty certified life coaches. These are health coaches. Your Guide to Improved
Health will begin in the month of April and end in September. This six month program is
designed to target a majority group at risk for heart disease.
C&S Wholesale Grocers is one of the largest employers in Keene and Cheshire County.
The majority of employees at C&S Wholesale Grocers are within the target population of <55.
As stated before populations at the age of <55 are at the highest risk of heart disease. C&S
Wholesale Grocers has caped the participant total at 500. Five hundred participants is a third of
C&S total employees. With the expectations of 500 participants, each dietitian and coach will get
50 clients. Each participant will receive one dietitian and one life coach. These instructors will
have the same cliental to make sure that the program is thorough for the participant.

An email will go out to all employees to introduce the program. C&S has also caped the
participant enrollment to 500 employees because if a participant completes the whole program
they will receive a cash bonus.
The interested participants will be asked to complete labs at Cheshire medical. Labs
include lipid profiles; total blood cholesterol (TC), high density lipoprotein (HDL), and low
density lipoprotein (LDL). Blood pressure will also be taken. Body mass index will be measured.
Eligibility is based on lab values. A participant would be considered ineligible if they had history
of myocardial infraction, stroke, cancer, or diabetes, currently pregnant or plan to become
pregnant within six months. Theses ineligibilities are to ensure that the participant will not
further be at risk. Framingham Risk Scores will be used to measure who is at most risk for heart
disease.
After the initial screening, those whom are at risk for heart disease and are eligible will
be asked if they would like to participate. If they agree, they will be assigned a dietitian and a life
coach. Telephone interviews will begin the first week to introduce coaches. Telephone meetings
will be twice a week, one day for nutrition and one for life coaching. The meetings will last
about an hour each. During these meetings either a dietitian or a life coach will consult the client.
The client is encouraged to ask questions. These meetings are there to interpret what the
customized blueprint states.
Each coach will have the results of the client and begin to make a customized blueprint
for their client. This blueprint will outline nutrition, fitness, and life style advice based on their
level of risk. Level of risk was determined by the lab values previously completed. The
blueprints are designed to shape each week. They are in digital form both clients and coaches
will have access to them. The nutrition advice will be coming from the registered dietitian.

Fitness and life style advice will be encouraged by the life coaches. This blueprint will be used
for the entire program length of six months. There will be opportunities to change and adjust the
blueprint to properly fit the client. The participants have about 24 weeks with this blueprint. The
blueprint is used as a guide. The clients themselves will be able to check their progress and read
the notes of the coaches. The nutrition and fitness portions will be introduce each Monday of the
week, giving the clients a full week.
The nutrition portion is important and its expected that the client will be hesitant to alter
their eating habits. After the initial introduction, the nutrition will be broken down into weeks.
Each week the nutrition portion will change. Depending on the client, the client may be asked to
incorporate more fruits and vegetables, reduce the amount of fat, or reduce the amount of sugar.
Nutritional information published by the American Heart Association supports the nutritional
portion of our program. AHA states to eat a variety of fresh, frozen and canned vegetables and
fruits without sauces or added salt and sugar. Eat more whole grains with fiber, chicken and fish,
avoid hydrogenated oils, and limiting sodium to 2,400miligrams.12 Each of these diet changes
will be introduced each week and the clients are expected to be continuously implement each
diet. Twenty-four hour recalls will be asked during each telephone meeting with the dietitian.
The twenty-four hour recall will is just an estimate of what the client is eating. It will be used as
a tool to measure how well the client is doing with their customized blueprint.
Fitness is expected to be an easier change in a participants lifestyle. Fitness has been
seen to directly affect the risk of heart disease. US Department of Health and Human Services
has stated that physical fitness for 150 minutes a week has been shown to lower risk of heart
disease.11 Your Guide to Improved Health will increase the intensity of each regimen. US
Department of Health and Human Services notes that health benefits may not happen at 150

minutes a week, that an increase to 300 minutes will show additional benefits.13 One hundred
fifty minutes per week (seven days) is only two hours each day. The idea is to have each fitness
portion that is introduced will become a routine. The weeks will rotate between cardiovascular
training and strength. One week an individual may be asked to walk a mile a day. The next week
they may be asked to do weight training. The demographic location of Keene allows for many
recreational opportunities. There are many trails, mountains, and state parks available and
individuals in the program are encouraged to use them. (Appendix B, Figure Two) Many of the
participants will be doing the same routines because there is more fluidity in fitness than
nutrition. Coworkers are encouraged to work together on the fitness portion. An idea given will
be to walk during breaks; here the coworkers can create a group to walk together. Keene also has
a YMCA in the middle of town that the participants can use with a membership.14 The grant will
not being using money for memberships.
Biweekly meetings will be held at C&S Wholesale Grocers after hours. They are held
biweekly so that clients will not be overwhelmed and have time to comprehend the new material
given. Since dietitians and life coaches have the same cliental, only those clients will meet
together. All 500 participants will not meet altogether. Smaller groups will help clients feel
comfortable talking and asking questions. Clients will also have the ability to talk to their
coworkers on how their doing and even ask them for advice. Dietitians and life coaches will have
prepared information for the meetings incorporating each part of the program.
Twenty dietitians and twenty life coaches will be hired. They will be paid for the time
that they spend on the phone with clients, gathering data to provide to the client, and biweekly
meetings. Telephone meetings will last an hour. All forty employees will receive a prepaid phone
with the expected hours for the meetings all six months. There will be about 600 prepaid

minutes on the phone. Gathering information and creating webinars should take no longer than
four hours each day. Dietitians and life coaches will be also paid for the three week training. To
reduce the cost of materials, everything will be digital. Webinars and gathered advice will be
sent to the clients over email. Access to the blueprint templates will be purchased through online
companies who have designed them for these types of programs. There will be biweekly
meetings that last an hour and half that the dietitians and life coaches head. The dietitians and
life coaches will not have to work on the weekends. This gives each employee in the program
about forty hours a week. The program will be using Cheshire County Medical Center to conduct
labs. Lab fees will be covered or reimbursed in their entirety. The bonus that the participants will
receive at the end of the program will be given by C&S Wholesale Grocers and will be separate
from the grant budget. There will be a minimal budget for marketing with flyers.
Marketing:
C&S Wholesale Grocers will send out an email to all employees at their Keene location.
In the email, the program will be introduced. It will also have the expected outcomes for the
participants. It will state the methods and how the program will work. There will be flyers that
will be posted at C&S Wholesale Grocers. The flyers will be printed and sent to the managers of
the facility to be hung. Emails of the hired coaches will be provided in the flyers and in the initial
email. The employees can email the coaches for further questions. The coaches will be asked to
make phone calls to individuals that expressed interest. The phone call will help promote the
program and to ask individuals to encourage coworkers to participate. It is expected that with a
large employee population a huge marketing strategy is word of mouth. Since this is an
independent project there will be no social media and that will also reduce the cost of someone
making a social media website.

Evaluation:
During each telephone meeting with the clients the dietitian and life coach will be able to
evaluate the participants progress. Twenty-four hour recalls will be asked during the telephone
meeting and a recap on fitness regimens will be recorded. Evaluation will be completed after the
six months. To be eligible for the bonus participants must have made it to the end of the
program. Total numbers will be gathered for those who have completed.
To compare the progress of the client and the program, the beginning labs will be
completed again at the end. Labs include lipid profiles; blood cholesterol, high density
lipoprotein (HDL), and low density lipoprotein (LDL). Blood pressure will also be taken. Body
mass index will be measured as well. These levels should have been reduced at the end of the
program. If only a few labs were reduced, it still lowers the risk. Individual blueprints will
collected by coaches to evaluate and compare the beginning labs to the ending labs. All of the
blueprints will be compiled together to get an overall total of reduction. It will be reported to the
company as it was also their goal to reduce risk. The goals of the program were to lower the risk
of heart disease amongst individuals and the end results will conclude if the goal was met.

Concluding Remarks:
Heart disease is a chronic illness which the risk factors can be reduced through diet and
exercise. The program is designed to guide employees who are in the target group<55 year olds.
This age group has seen to have the highest risk of heart disease. Having a program to help give
advice and guide participants will be beneficial for the individual and the company. It has the
potential to reduce the risk of heart disease. The company will benefit from a program like this
because the cost of health insurance should go down as their employees get better.
This program is easy to access and the only involvement is personal. The client can
complete this program within their comfort zone. The telephone meetings are designed for their
convenience. The customized blueprints are also designed for convenience. The clients are able
to login and access the personal blueprint online.
The program is low cost and has achievable goals. It is desirable for those who are
looking for a personal program that will be easy and within the comfort of their home. It is also
desirable for companies who are looking to cut down on health care cost. It doesnt take much
for the companys involvement. C&S Wholesale Grocers decided that they wanted to implement
the program with a cash bonus for the participants who completed the program. It is totally up to
the company and how they want to get their employees involved. Your Guide to Improved
Health is a program that a company can easily hire to come in and improve the overall health of
their employees.

References:
1. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention
2012. Available at: http://www.cdc.gov/pcd/issues/2012/11_0169.htm. Accessed April 6,
2016.
2. United States Census. State & County QuickFacts. Keene, New Hampshire.
http://quickfacts.census.gov/qfd/states/33/3339300.html. Revised December 2, 2015.
Accessed March 30, 2016.
3. Population estimates, July 1, 2015, (V2015). UNITED STATES QuickFacts from the US
Census Bureau. Available at: https://www.census.gov/quickfacts/table/pst045215/00.
Accessed April 6, 2016.
4. New Hampshire Division of Public Health Services. Diabetes in New Hampshire.
http://www.dhhs.state.nh.us/data/documents/brief10.pdf. Published July 2010. Accessed
March 30, 2016.
5. Cadet JA. New Hampshire Department of Health and Human Services WebSite.
http://www.dhhs.nh.gov/dphs/cdpc/documents/2013-hdsp-report.pdf. Published 2013.
Accessed February 8, 2016
6. New Hampshire Employment Security. Keene,
NH. http://www.nhes.nh.gov/elmi/products/cp/profiles-htm/keene.htm. Published
January 2016. Accessed February 8, 2016.
7. Prevalence of Coronary Heart Disease or Stroke Among Workers Aged <55 Years
United States, 20082012. Centers for Disease Control and Prevention 2014. Available
at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6330a1.htm. Accessed April 6,
2016.
8. Bennett JB, Broome KM, Schwab-Pilley A, Gilmore P (2011) A web-based approach to
address cardiovascular risks in managers: results of a randomized trial. J Occup Environ
Med 53: 911918. doi: 10.1097/JOM.0b013e3182258bd8. Accessed April 6, 2016.
9. Colkesen EB, Ferket BS, Tijssen JG, Kraaijenhagen RA, van Kalken CK, Peters RJ.
Effects on cardiovascular disease risk of a web-based health risk assessment with tailored
health advice: a follow-up study. Vascular Health and Risk Management. 2011;7:67-74.
doi:10.2147/VHRM.S16340. Accessed April 6, 2016.
10. Deitz D, Cook RF, Hersch RK, Leaf S. Heart Healthy Online. J Occup Environ Med.
2014;56(5):547553. Accessed April 6, 2016.
11. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention
2012. Available at: http://www.cdc.gov/pcd/issues/2012/11_0169.htm. Accessed April 6,
2016.
12. The American Heart Association's Diet and Lifestyle Recommendations. The American
Heart Association's Diet and Lifestyle Recommendations. Available at:
http://www.heart.org/heartorg/healthyliving/healthyeating/nutrition/the-american-heartassociations-diet-and-lifestyle-recommendations_ucm_305855_article.jsp#.vwvdnpkrliu.
Accessed April 6, 2016.
13. US Department of Health and Human Services. 2008 Physical Activity Guidelines for
Americans. http://health.gov/paguidelines/pdf/paguide.pdf. Accessed April 6, 2016.
14. Keene Family YMCA - For Youth Development, Healthy Living, and Social
Responsibility. Keene Family YMCA. Available at: http://keeneymca.org/. Published:
date unknown. Accessed April 6, 2016.

Appendix A:
Table One:

https://www.guidelinesinpractice.co.uk/november_98_archer_framingham_nov98

Table Two:

Experimental

Control

Baseline

6
Months

Baseline

6
Months

Intervention
Effect

Attitude
toward healthy
a
diet

3.45
(0.06)

3.68
(0.08)

3.58
(0.06)

3.56
(0.06)

0.25 (0.08)

F(1,93.69) =
10.65, p = .00

Dietary selfefficacy

3.63
(0.09)

4.08
(0.11)

3.82
(0.09)

3.85
(0.10)

0.43 (0.14)

F(1,111.08) =
9.23, p = .00

Dietary stage
of change

3.84
(0.13)

4.10
(0.16)

3.64
(0.13)

3.72
(0.14)

0.17 (0.19)

F(1,115.17) =
0.86, p = .36

Leisure time
exercise

40.67
(3.41)

51.85
(4.12)

41.47
(3.30)

43.78
(3.47)

8.87 (4.82)

F(1,106.46) =
3.38, p = .07

Exercise stage
of change

4.05
(0.14)

4.43
(0.17)

3.78
(0.14)

3.94
(0.15)

0.22 (0.22)

F(1,108.94) =
0.93, p = .34

Test Statistic

Diet

Exercise

Bennett JB, Broome KM, Schwab-Pilley A, Gilmore P (2011) A web-based approach to

address cardiovascular risks in managers: results of a randomized trial. J Occup Environ
Med 53: 911918. doi: 10.1097/JOM.0b013e3182258bd8. Accessed April 6, 2016.

Appendix B:
Figure one:

http://www.dhhs.nh.gov/dphs/cdpc/documents/2013-hdsp-report.pdf.
Figure Two:

https://www.ci.keene.nh.us/departments/parks-recreation/trails-info-0