Lifestyle behaviors and stress are risk factors for overweight and obesity in healthcare workers: a cross-sectional survey | BMC Public Health

Study design

Taking all Chinese HCWs as the study population, this study is based on a cross-sectional random-sample online survey using a structured self-administered questionnaire developed by the research group. The respondents’ relevant data were collected, including socio-demographics, health status, height and weight, persistent stress and/or recurrent anxiety/depressed mood, and lifestyle behaviors.

Sampling strategy and eligibility criteria

A multi-staged clustered random sampling method was employed. First, 5 provincial administrative regions were selected at random from 32 provinces/autonomous regions/municipalities of China. Second, considering the inter-provincial difference and intra-provincial homogeneity, 20 healthcare institutions from each of the 5 provincial administrative regions were selected using a random systematic sampling method. Third, all HCWs of the selected institutions were surveyed as respondents. In total, 100 healthcare institutions were sampled.

The inclusion criteria of subjects were as follows: (1) age ≥ 24 years; (2) working in present healthcare institutions for at least 3 years from 2019 to 2022; (3) possessing and using a smartphone; and (4) providing informed consent and voluntarily participating in the survey.

Survey tools

The survey questionnaire was developed by the study group. First, we conducted item pooling based on literature research and expert interviews. Second, a nominal group discussion with 10 senior experts in lifestyle/mental health was organized, and items (questions) with a face validity ≥ 0.8 were included. Third, we invited 10 HCWs to conduct a pre-test using the initial questionnaire to validate all the items. The weak items were removed or revised.

The final questionnaire comprises modules: informed consent, answering guide, socio-demographics, health status (Self-rated in the past three years (improving/worsening)), chronic diseases (with diagnosed hypertension, cardiovascular and cerebrovascular diseases, cancer, diabetes, COPD, osteoporosis, etc. [22] (Yes/No)) and control in the three past years (improving/worsening), height (m) and weight (kg) (based on latest annual physical examination records), and lifestyle behaviors (eating behaviors, regularly exercising, habitually staying up late (not falling asleep after midnight due to specific activities, voluntarily or involuntarily [23]. (Yes/No)), smoking (Yes/No) and alcohol consumption (Yes/No)). The socio-demographic variables included gender, age, education, and working and living locations (urban/rural). This study determined overweight and obesity based on BMI values (BMI = (Weight (kg))/(Height (m))², and overweight was defined as 24.0 kg/m² ≤ BMI < 28.0 kg/m², and obese as BMI ≥ 28.0 kg/m² [24].

To measure persistent stress, we used the following question: “During the past 3 years, have you frequently experienced feelings of being under too much mental or emotional pressure that made you angry/irritated/moody/frustrated, worried, or unable to sleep for at least 6 months?” Recurrent anxiety was measured by the following question: “During the past 3 years, have you experienced recurrent feelings of being nervous or restless or a sense of impending danger, panic or doom with increased heart rate/sweating/ accelerated breathing /trembling for at least 6 months?” To measure depression, we used the following question: “During the past 3 years, have you experienced persistent feelings of sadness, tearfulness, emptiness or hopelessness, and loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports, with angry outbursts, irritability or frustration, even over small matters for at least 6 months?” We collected data on eating and lifestyle behaviors such as consumption of take-out food (“Often”: 4–6 times/week), vegetables and fruits (“Regularly”: ≥ 4–6 times/week), breakfast (“Regularly”: 3–7 times/week), fried food (“Often”: ≥ 4–6 times/week), snacks or desserts (“Often”: ≥ 4–6 times/week), sugary drinks (“Regularly”: 4–6 times/week) and exercising (“Regularly”: ≥ 150 min/week), staying up late (“Habitually”: ≥ 4 times/week), smoking (Continuously or cumulatively for 6 months or more during their lifetime [25]), and alcohol drinking (At least once a week in the past year, including liquor, wine, beer, rice wine, etc. [26]).

The Cronbach’s α of the final questionnaire was 0.82, with three factors explaining 63.55% of the total variance between the items based on exploratory factorial analysis (EFA).

Data collection

The Wenjuanxing^Ⓡ Web Survey System [27] was used to generate a QR code of the electronic questionnaire. The investigators from each province contacted the liaison of each selected healthcare institution and sent the QR code to all the HCWs in the institution. The respondents were required to scan or press the QR code through WeChat to fill out the electronic questionnaire and submit it to the Wenjuanxing^Ⓡ backstage after completion. The WeChat ID was used to ensure that each respondent could only submit the questionnaire once. Every participant could obtain some daily necessities as a reward upon submission, such as napkins, towels, soap, hand sanitizer, etc..

Participants’ responses were anonymous and confidential and declared at the beginning of the electronic questionnaire. The respondents were also informed that data would be used for research purposes only. Participants completed the questionnaire directly connected to the Wenjuanxing^Ⓡ platform. Each submitted questionnaire was reviewed, and questionnaires with incomplete/missing items, incorrect completion, and obvious logical errors were regarded as invalid.

Statistical analysis

Statistical analysis was performed using SPSS 25.0 software. The socio-demographic characteristics were analysed using descriptive statistics, and the quantitative data were represented by \(\overline\mathrm x\) ± s. The chi-square test was used to assess the association between categorical variables and trends within a categorical variable. Analyses of variance (ANOVA) were performed to compare continuous variables between two or more groups. Univariate analyses were used to assess the influence of self-reporteded persistent stress and/or recurrent anxiety/depressed mood on lifestyle behaviors. The forced introduction method was used for binary logistic analyses, with overweight and obesity as dependent variables and socio-demographic characteristics and lifestyle behaviors as independent variables. P < 0.05 was considered to indicate statistical significance.

Ethical declarations

This study was conducted in compliance with the Declaration of Helsinki. The Ethics Committee of the Chinese Academy of Medical Sciences Fuwai Hospital reviewed and approved the study procedures (No: 2021–1559). Informed consent of participants was obtained in accordance with ethical guidelines. This study abided by the principles of scientific research ethics, clearly stated the purpose of this survey in the preface of the electronic questionnaire, and strictly protected the privacy of all respondents. All respondents were required to be honest in their responses. The respondents were able to stop answering and leave the questionnaire at any stage before the end of the process, with no answers being saved. Respondents’ answers were saved by clicking on the “submit” button provided. Upon completing the survey, participants acknowledged their voluntary consent to participate in this anonymous study.