ACHIEVING AND

PEAK ENERGY REDUCED STRESSA Guide for the 21st Century Workplace

Business and industry are faced with an energy and stress

crisis some 40 years in the making. A confluence of personal

choices and work culture practices has produced unprecedented

workplace stress and a drain on personal energy that must be

reversed if organizations are to achieve sustainable health

and productivity. And while the current global recession

intensifies the challenges, when the economy does turn up,

stress will remain high and energy low — unless organizations provide the

tools to educate and inspire employees at all levels to take control. It won’t

be easy.

Individual habits ingrained over years or decades are hard to change.

And longstanding formal or informal policies that contribute to anything

but a health culture — inactivity, poor food choices, a skewed sense of

work/life balance, and ignoring the larger issue of purpose or meaning —

make the challenges even greater.

This paper is a guide for organizations that are serious about reversing

soaring stress levels and putting employees in position to regain energy. The

goal: enabling employees to perform their best at work, with the physical

and mental stamina to pursue personal interests outside of work. We detail

specific actions individuals can take and the organization can support —

backed by 55+ studies — to achieve peak energy while minimizing stress.

A Guide for the 21st Century Workplace

ACHIEVING AND

PEAK ENERGY REDUCED STRESS

1 Peak Energy/Reduced Stress

Stress ImpactHealthcare costs for employees with high stress levels are nearly 50% higher than for those who report low stress.1

Stress-related problems precipitate an estimated 75%-90% of all doctor visits.2

Low energy and high stress among employees can be devastating to the bottom line. Employees who aren’t functioning at their best can have considerable decreases in productivity. This is especially true for employees with high stress.3

Stress is our body’s response to a given event or situation, and it can be positive or negative. What is stressful for one person isn’t necessarily stressful for the next, but too much can wreak havoc.

In addition to sapping energy, regular high stress creates increased risk for physical and mental concerns, including:

n Depression/anxiety4 n Job dissatisfactionn Difficulty concentrating n Low moralen Digestive problems5 n Short tempern Headaches n Sleep disturbancesn High blood pressure n Type 2 diabetesn High heart rate n Upset stomach.2

Many of the chronic diseases that account for about 70% of all healthcare costs6 result from the same poor lifestyle habits that feed stress and deplete energy.

The good news is that simple changes can mean dramatic improvements. The result: lower healthcare costs and employees who have more energy as well as less stress, for higher productivity. The primary areas for improvement follow, with a focus on specific advantages and disadvantages, as shown in numerous studies.

Impact on Health and Productivity

2Copyright ©2009 Health Enhancement Systems

Lifestyle Improvementsfor Decreasing Stress and Increasing Energy

The Cost of InactivityIn a Minnesota study, 1.5 million participants accrued an additional $86.3 million in healthcare expenditures due to lack of physical activity.7

30 MinutesA model developed to determine the best amount of exercise for 40-80 year olds concludes that 30 minutes a day, 6 days/week reduces the risk of sudden cardiac death and provides health benefits.8

3 Peak Energy/Reduced Stress

Exercisen Boosts energy levels. After 6 weeks of exercise,

participants experience a 20% increase in energy and a 65% decrease in fatigue.9

n Reduces blood pressure. Physical activity can lower blood pressure levels at rest and during typically stressful situations. The positive effect increases with weight loss.10

n Improves mood and decreases fatigue. After an 8-week exercise program, participants have less fatigue and better moods (including improved vigor as well as decreased depression and tension).11

n Lowers mortality. Physically active study participants show a 32% lower risk of all causes of death compared to inactive participants.12

n Enhances sleep quantity and quality. After a regular exercise program, participants awake fewer times, have deeper sleep, and feel more rested.13

Morning WorkoutsWhile few studies on AM exercise have been conducted, many individuals report being more consistent with physical activity, getting better sleep, and feeling energized for the day. Exercising first thing can make it easier to commit to a regular routine, before other responsibilities get in the way.

Other benefits also are reported. In Zero Hour, a program among high school freshmen, reading and comprehension rose 17% in those exercising before school, compared to a 10.7% increase in students with typical schedules.14

Regular Work BreaksThe human body goes through cycles of differing alertness levels. These cycles vary by person, but can range from 75-125 minutes.15 Taking breaks during the day when experiencing a cycle’s low energy levels can help the body recover, while improving performance.16

Not getting up and moving around also increases your risk of developing venous clots.17

NutritionOf the 10 leading causes of death, 4 are associated with not eating a proper diet. Resulting decreased productivity and medical expenses for heart disease, stroke, some cancers, and type 2 diabetes cost the US over $200 billion each year.18

Meal Timing — Breakfast n Matches energy needs. Our energy expenditure

increases after each meal, with the largest increase in the morning and the smallest at night.19 So, when you eat more of your calories earlier in the day, you burn more off.

n Decreases calorie intake throughout the day. Those who eat breakfast consume fewer overall calories and impulse snacks as well as less fat compared to those who skip breakfast.20

n Increases alertness. People who have a high-fiber, complex carbohydrate-rich breakfast feel fuller and more alert throughout the morning.21 Eating breakfast also can enhance memory.22

n Controls weight. Those who have breakfast maintain lower body mass indexes compared to those who don’t eat breakfast.23

Vegetables, Whole Grains, Fruitn Manages appetite. Grain fiber is shown to reduce

appetite and lower food intake.24

n Lowers risk of heart disease. Each daily serving of vegetables or fruit results in a 4% risk reduction for heart disease. The largest effect came from green leafy vegetables and produce rich in vitamin C.25

Watern Reduces calorie intake. Drinking water before a meal

decreases calories consumed by 13% in overweight and obese older adults.26

4

BalanceStructured Planning/Goal Setting n Encourages good nutrition. A study of military

personnel who wanted to improve eating habits included a Goal-Setting/Goal Attainment (GSGA) group who learned about setting goals, getting fit, and developing skills; a Goal-Setting (GS) group who received information only about setting goals; and a control group who received no information. In the GSGA group, 84% improved their diets, compared to 64% of the GS group and only 37% of the control group.27

n Decreases depression symptoms. When used as therapy, a focus on goals produces declines in all depression measures, with the mean decreasing to a level associated with remission.28

Social Connectionsn Increases overall health. Frequent contact with friends

is linked to having complete health (optimal physical and mental health, including 1 or no chronic conditions and consistent energy levels).29

n Boosts feelings of happiness. Those who are more connected with others in their social network, directly or indirectly, are more likely to be happier, in the short and long term.30

Active Relaxationn Reduces stress and anxiety; changes hunger trends.

Performing a 20-minute muscle relaxation exercise can reduce stress, anxiety, fatigue, anger, and depression. Participants in this study also ate more in the morning and less at night.31

n Lessens pain. Relaxation techniques can decrease pain intensity as well as pain-related distress and increase perceived control over pain.32

Copyright ©2009 Health Enhancement Systems

The High Cost of Too Little SleepThe annual medical and reduced productivity costs associated with insomnia among US workers is estimated at $92.5 billion– $107.5 billion.42

Lifestyle Improvements continued…

PurposeHaving a sense of meaning or purpose is associated with higher quality of life.33

Personal Mission Statementn Increases life satisfaction. Having important life

goals is associated with increased purpose in life (satisfaction in daily activities, feeling useful).34

Meditationn Supports mental health. Meditation practice can

decrease mood disturbance and stress levels as well as anxiety, anger, and confusion, while enhancing well-being and quality of life.35,36 It has also been shown to promote a sense of peace, relaxation, health awareness, self-care concern, self-management, responsibility, and giving.37

n Decreases medical costs. A similar study found that a meditation program leads to fewer reported medical symptoms.38

n Lowers stress. A meditation program results in decreases in stress (including feelings of control, not being overwhelmed).39

Keeping a Journaln Leads to fewer doctor visits. Writing for 15

minutes each day can mean fewer doctor visits, with the most benefit derived from using many positive emotion words and only a moderate number of negative emotion words.40

n Improves mental function. Another study finds increases in working memory capacity (based on words recalled) as a result of writing about thoughts and feelings.41

Getting Sufficient Sleep

74% of American adults experience

a sleeping problem at least a few

nights each week, and sleepiness

interferes with daily activities in

37% of American adults.43

Adults typically need 7-9 hours of sleep;43 the consequences of not getting enough include an increased likelihood of these health conditions:

n Cardiovascular diseasen Depressionn Diabetesn Obesity.44

Other effects of not getting enough sleep follow:

n Difficulty getting along with othersn Diminished work performancen Increased injury riskn Poorer health.43

Related Activities to Increase Energy and Reduce Stress

5 Peak Energy/Reduced Stress

Respondents in the 2009 National Sleep Foundation poll who sleep less than 6 hours, vs. 8 hours or longer, are less likely to carry out various healthy activities due to sleepiness:

n Eat healthy (23% vs. 7%)n Engage in leisure activities (30% vs. 7%)n Exercise (28% vs. 8%)n Work well and efficiently (21% vs. 9%).45

...and are more likely to:

n Drink caffeinated beverages (48% very likely vs. 31%; 2.67 cups/cans a day vs. 1.83)

n Eat foods high in sugar or carbohydrates (19% very likely vs. 12%)n Smoke a cigarette or use tobacco (18% very likely vs. 7%) n Use prescription or over-the-counter medicines to stay alert and

get through the day (11% at least somewhat likely vs. 4%).45

On the other hand, getting sufficient sleep has several benefits:

n Enhances performance. This includes neural processing for insights, perceptions, and motor skills.46

n Decreases risk of heart disease. More sleep is associated with less likelihood of coronary artery calcification.47

n Controls appetite and weight. Sleep duration is linked to lower levels of leptin and higher levels of ghrelin (hormones that affect appetite). When subjects slept for less than 8 hours, increased body mass was proportional to decreased time spent sleeping.48

n Improves response time. After 17-19 hours without sleep, cognitive and motor responses can be up to 50% slower as well as inaccurate, with some performance worse than when study participants had a blood alcohol concentration of 0.05%. After longer sleep deprivation, performance can equal a blood alcohol concentration of 0.1%.49

n Reduces errors. At an intensive care unit, interns who work extended shifts made 35.9% more serious medical errors than during a reduced work hour schedule.50

Expressing Gratituden Improves sleep. Those who express

gratitude have more positive thoughts prior to sleep, resulting in better sleep quality and duration. Study participants fell asleep faster and were more functional throughout the day.51

n Increases feelings of well-being. Those who express gratitude experience higher levels of joy and happiness, life satisfaction, and optimism.52

Volunteeringn Benefits physical and emotional

health. Increased physical health as well as happiness, life satisfaction, self-esteem, and other benefits are associated with volunteering.53

n Diminishes physical pain and improves mental health. As a result of volunteering as peers for individuals with chronic pain, those with chronic pain experience less pain intensity, a decrease in disability due to the pain, higher self-efficacy, and fewer depression symptoms.54

6Copyright ©2009 Health Enhancement Systems

7

Too Much Television/Computer Timen Increases body mass index. Watching more

than 4 hours of TV a day is associated with higher waist circumferences and body mass indexes.55

n Boosts negative biological markers. As adolescents’ screen time increases, prevalence of metabolic syndrome increases.56

Too Much or Late-Day Caffeinen Does not enhance performance. Caffeine

merely restores performance that has decreased due to sleepiness, rather than enhancing performance.57

n Lowers sleep quality. Caffeine abstinence is associated with longer sleep duration, better sleep quality, and falling asleep faster.58

n Increases blood pressure and blood glucose levels. Caffeine can raise systolic and diastolic

blood pressure. In addition, it can reduce insulin sensitivity, resulting in higher

blood glucose levels,59 which can be harmful especially to those with

diabetes.

Habits With Negative ImpactWhile the previous behaviors increase energy and reduce stress, the following will diminish energy and amplify stress. These behaviors will decrease productivity and make your healthcare costs swell.

Peak Energy/Reduced Stress

High Sugar/Refined Carbohydrate Foodn Raises glucose/insulin and fatigue levels.

Men who eat a breakfast high in complex carbohydrates show lower levels of glucose and insulin 30 minutes after breakfast as well as lower free fatty acids at 180 and 240 minutes, compared to a breakfast high in simple carbohydrates. Those consuming the breakfast high in simple carbohydrates report more fatigue and feeling less full.60

Late-Night Snackingn Causes diabetes complications and affects

quality of sleep. Among those with diabetes, individuals who eat at night are less likely to engage in healthy behaviors such as diet, exercise, and glucose monitoring. They report more sleep disturbances as well, and are more likely to be obese and have 2 or more diabetes complications.61

n Raises body mass index. Night eating is associated with higher body mass index.62

Multitaskingn Decreases performance. When performing

multiple tasks simultaneously, studies show a drop in performance.63

n Reduces accuracy. There is a significant decrease in accuracy when performing 2 tasks simultaneously.64

Conclusionsn High stress and low energy levels can severely

compromise employee health and productivity.

n Employer-sponsored initiatives focusing on exercise, nutrition, stress reduction, and individual goals/values will result in reduced healthcare costs, improved productivity, and better quality of life for employees.

n Organizations that implement these effective stress management and energy-improving programs will have the best chances of surviving and thriving in today’s economy.

n Energy improvement and stress management are most effective and long-lasting when the workplace fosters a culture of health.

8Copyright ©2009 Health Enhancement Systems

Resourcesn Advances in Physiology Education

advan.physiology.org

n Agency for Healthcare Research and Quality www.ahrq.gov

n American Institute of Stress www.stress.org

n American Journal of Clinical Nutrition www.ajcn.org

n American Journal of Health Behavior www.ajhb.org

n American Journal of Preventive Medicine www.ajpm-online.net

n Annals of Internal Medicine www.annals.org

n BioMed Central Public Health www.biomedcentral.com/bmcpublichealth

n British Journal of Nutrition www.nutritionsociety.org/node/236

n British Medical Journal www.bmj.com

n Centers for Disease Control and Prevention www.cdc.gov/Features/Sleep

n Diabetes Care care.diabetesjournals.org

n Harvard Business Review hbr.harvardbusiness.org

n International Journal of Epidemiology ije.oxfordjournals.org

n International Journal of Obesity www.nature.com/ijo

n Journal of Alternative and Complementary Medicine www.liebertonline.com/acm

n Journal of the American Dietetic Association www.adajournal.org

n Journal of the American Medical Association jama.ama-assn.org

n Journal of Occupational and Environmental Medicine www.joem.org

n Journal of Personality and Social Psychology www.apa.org/journals/psp.html

n Medicina Sportiva www.medicinasportiva.pl

n Medicine & Science in Sports & Exercise www.ms-se.com

n National Sleep Foundation www.sleepfoundation.org

n Neurology www.neurology.org

n The New England Journal of Medicine content.nejm.org

n Pain Management Nursing www.painmanagementnursing.org

n Psychosomatic Medicine www.psychosomaticmedicine.org

n Public Library of Science Medicine Journal medicine.plosjournals.org

n US Department of Health and Human Services www.hhs.gov

Where to Go From HereDecreasing stress levels while increasing energy levels of your employees may seem daunting. However, clear information and enjoyable, engaging tools can help the healthy habits stick.

Health Enhancement Systems has developed Feel Like A Million, a fun, interactive, game show inspired program that addresses all of the health behaviors described here. Not only does it encourage habits conducive to more energy and less stress, but it also helps employees avoid negative habits — and learn more about themselves along the way.

The health improvement program to maximize energy while limiting stress.

By focusing simple actions in 4 core areas — fitness, nutrition, balance, purpose — participants experience how daily rituals contribute to improved energy, enhanced focus, and greater resilience.

Register for a demo at www.iFeelLikeaMillion.com.

9

Stress Reducing.Energy Boosting!

Peak Energy/Reduced Stress

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2 The American Institute of Stress. America’s no. 1 Health Problem 2009. 3 Boles M, Pelletier B, Lynch W. The Relationship Between Health Risks and Work Productivity.

Journal of Occupational and Environmental Medicine 2004;46(7):737-745. 4 Godin I, Kittel F, Coppieters Y, Siegrist J. A Prospective Study of Cumulative Job Stress in Relation

to Mental Health. BioMed Central (BMC) Public Health 2005;5:67. 5 Morse DR, Schacterle GR, Furst L, Zaydenberg M, Pollack RL. Oral Digestion of a Complex-

Carbohydrate Cereal: Effects of Stress and Relaxation on Physiological and Salivary Measures. American Journal of Clinical Nutrition 1989;49:97-105.

6 US Department of Health and Human Services, Agency for Healthcare Research and Quality. Health Care Costs Fact Sheet 2002.

7 Garrett NA, Brasure M, Schmitz KH, Schultz MM, Huber MR. Physical Inactivity: Direct Cost to a Health Plan. American Journal of Preventive Medicine 2004;27(4):304-309.

8 Fahey TD, Swanson GD. A Model for Defining the Optimal Amount of Exercise Contributing to Health and Avoiding Sudden Cardiac Death. Medicina Sportiva 2008;12(4):124-128.

9 Puetz TW, Flowers SS, O’Connor PJ. A Randomized Controlled Trial of the Effect of Aerobic Exercise Training on Feelings of Energy and Fatigue in Sedentary Young Adults With Persistent Fatigue. Psychotherapy and Psychosomatics 2008;77:167-174.

10 Steffen PR, Sherwood A, Gullette ECD, Georgiades A, Hinderliter A, Blumenthal JA. Effects of Exercise and Weight Loss on Blood Pressure During Daily Life. Medicine & Science in Sports & Exercise 2001;33(10)1635-1640.

11 Hanna LR, Avila PF, Meteer JD, Nicholas DR, Kaminsky LA. The Effects of a Comprehensive Exercise Program on Physical Function, Fatigue, and Mood in Patients With Various Types of Cancer. Oncology Nursing Forum 2008;35(3):461-469.

12 Khaw K, Jakes R, Bingham S, Welch A, Luben R, Day N, Wareham N. Work and Leisure Time Physical Activity Assessed Using a Simple, Pragmatic, Validated Questionnaire and Incident Cardiovascular Disease and All-Cause Mortality in Men and Women: the European Prospective Investigation Into Cancer in Norfolk Prospective Population Study. International Journal of Epidemiology 2006;35: 1034-1043.

13 King AC, Pruitt LA, Woo S, Castro CM, Ahn DK, Vitiello MV, Woodward SH, Bliwise DL. Effects of Moderate-Intensity Exercise on Polysomnographic and Subjective Sleep Quality in Older Adults with Mild to Moderate Sleep Complaints. The Journals of Gerontology 2008;63A(9):997-1004.

14 Ratey JJ, Hagerman E. Spark: The Revolutionary New Science of Exercise and the Brain. New York, NY: Little, Brown and Company, 2008.

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16 Schwartz T, McCarthy C. Manage Your Energy, Not Your Time. Harvard Business Review October 2007.

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18 US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Steps to a Healthier US: Prevention Report 2003;17(4).

19 Romon M, Edme JL, Boulenguez C, Lescroart JL, Frimat P. Circadian Variation of Diet-Induced Thermogenesis. American Journal of Clinical Nutrition 1993;57:476-480.

20 Schlundt DG, Hill JO, Sbrocco T, Pope-Cordle J, Sharp T. The Role of Breakfast in the Treatment of Obesity: a Randomized Clinical Trial. American Journal of Clinical Nutrition 1992;55:645-651.

21 Holt SHA, Delargy HJ, Lawton CL, Blundell JE. The Effects of High-Carbohydrate vs. High-Fat Breakfasts on Feelings of Fullness and Alertness, and Subsequent Food Intake. International Journal of Food Sciences & Nutrition 1999;50(1):13-28.

22 Benton D, Parker PY. Breakfast, Blood Glucose, and Cognition. American Journal of Clinical Nutrition 1998;67:772S-778S.

23 Song WO, Chun OK, Obayashi S, Cho S, Chung CE. Is Consumption of Breakfast Associated With Body Mass Index in US Adults? Journal of the American Dietetic Association 2005;105(9): 1373-1382.

24 Samra RA, Anderson GH. Insoluble Cereal Fiber Reduces Appetite and Short-Term Food Intake and Glycemic Response to Food Consumed 75 Min Later by Healthy Men. American Journal of Clinical Nutrition 2007;86:972-979.

25 Joshipura KJ, Hu FB, Manson JE, Stampfer MJ, Rimm EB, Speizer FE, Colditz G, Ascherio A, Rosner B, Spiegelman D, Willett WC. The Effect of Fruit and Vegetable Intake on Risk for Coronary Heart Disease. Annals of Internal Medicine, 2001;134(12):1106-1114.

26 Davy BM, Dennis EA, Dengo AL, Wilson KL, Davy KP. Water Consumption Reduces Energy Intake at a Breakfast Meal in Obese Older Adults. Journal of the American Dietetic Association 2008;108(7):1236-1239.

27 Berry MW, Danish SJ, Rinke WJ, Smiciklas-Wright H. Work-Site Health Promotion: the Effects of a Goal-Setting Program on Nutrition-Related Behaviors. Journal of the American Dietetic Association 1989;89(7):914-933.

28 Klausner EJ, Clarkin JF, Spielman L, Pupo C, Abrams R, Alexopoulos GS. Late-Life Depression and Functional Disability: the Role of Goal-Focused Group Psychotherapy. International Journal of Geriatric Psychiatry 1998;13(10):707-716.

29 Grzywacz JG, Keyes CLM. Toward Health Promotion: Physical and Social Behaviors in Complete Health. American Journal of Health Behavior 2004;28(2):99-111.

30 Fowler JH, Christakis NA. Dynamic Spread of Happiness in a Large Social Network: Longitudinal Analysis Over 20 Years in the Framingham Heart Study. British Medical Journal 2008;337:a2338.

31 Pawlow LA, O’Neil PM, Malcolm RJ. Night Eating Syndrome: Effects of Brief Relaxation Training on Stress, Mood, Hunger, and Eating Patterns. International Journal of Obesity 2003;27(8):970-978.

32 Kwekkeboom KL, Wanta B, Bumpus M. Individual Difference Variables and the Effects of Progressive Muscle Relaxation and Analgesic Imagery Interventions on Cancer Pain. Journal of Pain and Symptom Management 2008;36(6):604-615.

33 Harrison TC, Stuifbergen AK. Life Purpose: Effect on Functional Decline and Quality of Life in Polio Survivors. Rehabilitation Nursing 2006;31(4):149-154.

34 Pinquart M, Silbereisen RK, Fröhlich C. Life Goals and Purpose in Life in Cancer Patients. Support Care Cancer 2009;17(3):253-259.

35 Speca M, Carlson LE, Goodey E, Angen M. A Randomized, Wait-List Controlled Clinical Trial: the Effect of a Mindfulness Meditation-Based Stress Reduction Program on Mood and Symptoms of Stress in Cancer Outpatients. Psychosomatic Medicine 2000;62(5):613-622.

36 Majumdar M, Grossman P, Dietz-Waschkowski B, Kersig S, Walach H. Does Mindfulness Meditation Contribute to Health? Outcome Evaluation of a German Sample. The Journal of Alternative and Complementary Medicine 2002;8(6):719-730.

37 Matchim Y, Armer JM, Stewart BR. A Qualitative Study of Participants’ Perceptions of the Effect of Mindfulness Meditation Practice on Self-Care and Overall Well-Being. Self-Care, Dependent-Care & Nursing 2008;16(2):46-53.

38 Carmody J, Reed G, Kristeller J, & Merriam P. Mindfulness, Spirituality, and Health-Related Symptoms. Journal of Psychosomatic Research 2008;64(4):393-403.

39 Oman D, Shapiro SL, Thoresen CE, Plante TG, Flinders T. Meditation Lowers Stress and Supports Forgiveness Among College Students: a Randomized Controlled Trial. Journal of American College Health 2008;56(5):569-578.

40 Pennebaker JW, Seagal JD. Forming a Story: the Health Benefits of Narrative. Journal of Clinical Psychology 1999;55(10):1243-1254.

41 Klein K, Boals A. Expressive Writing Can Increase Working Memory Capacity. Journal of Experimental Psychology: General 2001;130(3):520-533.

42 Smith MD, McGhan W. Insomnia: Costs to Lose Sleep Over. Business & Health 1997;15(6):57-61.43 National Sleep Foundation. 2002 Sleep in America poll.44 Centers for Disease Control and Prevention. Sleep and Sleep Disorders 2008.45 National Sleep Foundation. 2009 Sleep in America poll: Summary of Findings.46 Ellenbogen JM. Cognitive Benefits of Sleep and Their Loss Due to Sleep Deprivation.

Neurology 2005;64:E25-E27.47 King CR, Knutson KL, Rathouz PJ, Sidney S, Liu K, Lauderdale DS. Short Sleep Duration and

Incident Coronary Artery Calcification. Journal of the American Medical Association 2008;300(24): 2859-2866.

48 Taheri S, Lin L, Austin D, Young T, Mignot E. Short Sleep Duration Is Associated With Reduced Leptin, Elevated Ghrelin, and Increased Body Mass Index. Public Library of Science (PLoS): Medicine 2004;1(3):210-217.

49 Williamson AM, Feyer AM. Moderate Sleep Deprivation Produces Impairments in Cognitive and Motor Performance Equivalent to Legally Prescribed Levels of Alcohol Intoxication. Occupational and Environmental Medicine 2000;57(10):649-655.

50 Landrigan CP, Rothschild JM, Cronin JW, Kaushal R. Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units. The New England Journal of Medicine 2004;351(18):1838-1848.

51 Wood AM, Joseph S, Lloyd J, Atkins S. Gratitude Influences Sleep Through the Mechanism of Pre-Sleep Cognitions. Journal of Psychosomatic Research 2009;66(1):43-48.

52 Emmons RA, McCullough ME. Counting Blessings Versus Burdens: an Experimental Investigation of Gratitude and Subjective Well-Being in Daily Life. Journal of Personality and Social Psychology 2003;84(2):377-389.

53 Thoits PA, Hewitt LN. Volunteer Work and Well-Being. Journal of Health & Social Behavior 2001;42(2):115-131.

54 Arnstein P, Vidal M, Wells-Federman C, Morgan B, Caudill M. From Chronic Pain Patient to Peer: Benefits and Risks of Volunteering. Pain Management Nursing 2002;3(3):94-103.

55 Stamatakis E, Hirani V, Rennie K. Moderate-to-Vigorous Physical Activity and Sedentary Behaviors in Relation to Body Mass Index-Defined and Waist Circumference-Defined Obesity. British Journal of Nutrition 2009;101(5):765-773.

56 Mark AE, Janssen I. Relationship Between Screen Time and Metabolic Syndrome in Adolescents. Journal of Public Health 2008;30(2):153-160.

57 Roehrs T and Roth T. Caffeine: Sleep and Daytime Sleepiness. Sleep Medicine Reviews 2008;12(2):153-162.

58 Sin CWM, Ho JSC, and Chung JWY. Systematic Review on the Effectiveness of Caffeine Abstinence on the Quality of Sleep. Journal of Clinical Nursing 2009;18(1):13-21.

59 Keijzers GB, De Galan BE, Tack CJ, Smits P. Caffeine Can Decrease Insulin Sensitivity in Humans. Diabetes Care 2002;25(2):364-369.

60 Pasman WJ, Blokdijk VM, Bertina FM, Hopman WPM, Hendriks HFJ. Effect of Two Breakfasts, Different in Carbohydrate Composition, on Hunger and Satiety and Mood in Healthy Men. International Journal of Obesity 2003;27(6):663-668.

61 Morse SA, Ciechanowski PS, Katon WJ, Hirsch IB. Isn’t This Just Bedtime Snacking? The Potential Adverse Effects of Night-Eating Symptoms on Treatment Adherence and Outcomes in Patients With Diabetes. Diabetes Care 2006;29(8):1800-1804.

62 Colles SL, Dixon JB, O’Brien PE. Night Eating Syndrome and Nocturnal Snacking: Association With Obesity, Binge Eating and Psychological Distress. International Journal of Obesity 2007;31(11): 1722-1730.

63 Law AS, Logie RH, Pearson DG. The Impact of Secondary Tasks on Multitasking in a Virtual Environment. Acta Psychologica 2006;122(1):27-44.

64 Lozito JP, Mulligan NW. Exploring the Role of Attention During Memory Retrieval: Effects of Semantic Encoding and Divided Attention. Memory & Cognition 2006;34(5):986-998.

Resourcesn Advances in Physiology Education

advan.physiology.org

n Agency for Healthcare Research and Quality www.ahrq.gov

n American Institute of Stress www.stress.org

n American Journal of Clinical Nutrition www.ajcn.org

n American Journal of Health Behavior www.ajhb.org

n American Journal of Preventive Medicine www.ajpm-online.net

n Annals of Internal Medicine www.annals.org

n BioMed Central Public Health www.biomedcentral.com/bmcpublichealth

n British Journal of Nutrition www.nutritionsociety.org/node/236

n British Medical Journal www.bmj.com

n Centers for Disease Control and Prevention www.cdc.gov/Features/Sleep

n Diabetes Care care.diabetesjournals.org

n Harvard Business Review hbr.harvardbusiness.org

n International Journal of Epidemiology ije.oxfordjournals.org

n International Journal of Obesity www.nature.com/ijo

n Journal of Alternative and Complementary Medicine www.liebertonline.com/acm

n Journal of the American Dietetic Association www.adajournal.org

n Journal of the American Medical Association jama.ama-assn.org

n Journal of Occupational and Environmental Medicine www.joem.org

n Journal of Personality and Social Psychology www.apa.org/journals/psp.html

n Medicina Sportiva www.medicinasportiva.pl

n Medicine & Science in Sports & Exercise www.ms-se.com

n National Sleep Foundation www.sleepfoundation.org

n Neurology www.neurology.org

n The New England Journal of Medicine content.nejm.org

n Pain Management Nursing www.painmanagementnursing.org

n Psychosomatic Medicine www.psychosomaticmedicine.org

n Public Library of Science Medicine Journal medicine.plosjournals.org

n US Department of Health and Human Services www.hhs.gov

10Copyright ©2009 Health Enhancement Systems

ACHIEVING AND

PEAK ENERGY REDUCED STRESSA Guide for the 21st Century Workplace

Health Enhancement Systems

712 Cambridge Street

Midland MI 48642

800.326.2317

www.HealthEnhancementSystems.com

Copyright © 2011, Health Enhancement Systems. No part of this document may be distributed, reproduced, or posted without written permission from Health Enhancement Systems.

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