After screening 3993 records (after deduplication), 19 publications were included in the systematic review (Fig. 1). These 19 publications could be assigned to 10 studies, since multiple publications existed for most trials. None of the included publications was a language copy. We chose the unit of studies (not publications) to report frequencies. Most studies were excluded because they were not full-length publications based on an RCT, the intervention was shorter than 6 months, or the outcomes were assessed after 6 months without further follow up. Some studies would have been eligible from a design and outcome assessment perspective, but the studied population was either mixed (i.e. Sinclair et al.28), or the choice of participants was based only on MMSE scores (i.e. Varela et al.29).

Figure 1 PRISMA flow diagram for systematic reviews30. Full size image

The characteristics of the included studies are summarized in Table 1 and Supplementary Table 1. Overall, 10 RCTs involving 1741 adults with MCI (64% female, mean age range 65–78) were included. Three studies31,32,33,34,35,36,37,38 were from North America., two from Australia39,40,41, two from Europe42,43,44, two from China45,46,47 and one from Japan48,49. The recruitment setting was generally community-based (50%), with most populations stemming from the outpatient clinic of a hospital (50%), followed by long-term care centers (30%). The majority of interventions lasted 12 months (80%) and employed aerobic exercises of moderate intensity with a mean overall exercise volume of 79 ± 32 h. The EXPA setting was mostly supervised training in groups, followed by a mix of group-based sessions and unsupervised home sessions. Six studies reported that training was tailored to the individual, however only four provided a detailed description of how tailoring was achieved (i.e. individualized intensity according to the participants aerobic capacity, individualized progression of exercises according to the participant’s exercise response). On average, participants were not regularly active before beginning the EXPA interventions, had a mean education of six years and a mean MMSE of 26. Included interventions were mostly tested against control groups that implemented stretching and toning activities that did not meet the criteria for physical activity20.

Table 1 Descriptive summary of included studies. Full size table

Figure 2 summarizes the RoB in the included studies. All but two studies46,47,48,49 described the methodology for random sequence generation, but only four32,33,39,40,41,42 reported allocation concealment. Selection bias was unclear for the remaining studies. In five studies no performance bias could be detected32,33,34,35,36,37,38,40,41,43,44,46,47 and was high in two studies because participants were unblinded42,48,49, in a further three because healthcare professionals were unblinded39,42,48,49 and unclear for two studies31,45. Detection bias was high in one study39 and unclear in another31. The risk of attrition bias was high in three studies39,43,44,46,47 because of missing data. Reporting bias was high in two studies40,41,45 and unclear in one study46,47.

Figure 2 Risk of bias in the included studies. Full size image

Progression to dementia and neuropsychiatric symptoms

Progression to dementia was evaluated by one study with mostly high and unclear RoB46,47. Although a trend towards lower risk development was seen in the ITT analysis, the differences between 12 months of Tai Chi and a stretching and toning group were not significant. The authors also used the Neuropsychiatric Inventory (NPI)50 to assess neuropsychiatric symptoms but found no significant differences between Tai Chi and Placebo Tai Chi.

Global cognitive function

Global cognitive function was measured in nine studies. Five moderate quality studies32,39,40,41,45,46,47 used the Alzheimer’s disease assessment scale–cognitive subscale (ADAS-Cog)51 to evaluate global cognitive status, three moderate quality studies39,45,46,47 used the clinical dementia rating sum of boxes (CDR SOB)52, one study with unclear RoB31 used the computerized assessment of mild cognitive impairment (CAMCI)53, four moderate quality studies43,44,45,46,47,48 the MMSE21, and two studies with high RoB arising from blinding procedures and selective reporting41,42 used an individual composite score for global cognition consisting of various domain-specific cognition tests.

The majority of these measures indicated that improvement in global cognition after 12 months was greater in the EXPA group than the sham-exercise group. Due to potential increase of detection bias because of the use of different procedures to detect global function no combined pooling of all studies were made. Analysing the studies assessing the outcome with the CDR SOB showed significant improvement in favour of the EXPA intervention in two of the three studies – an effect that was not obvious in any of the other tests of global cognition.

We performed a meta-analysis for ADAS-Cog (n = 587, MD = 0.40, 95% CI − 0.15 to 0.96), MMSE (n = 566, MD = – 0.02, 95% CI − 0.35 to 0.30) and CDR SOB measures, as shown in Fig. 3. The results show that participants in the EXPA group only showed significantly improved global cognitive ability in their CDR SOB scores (n = 478, MD = 0.34, 95% CI 0.03 to 0.66, p < 0.01, I2 = 82%; Fig. 3), however with considerable heterogeneity.

Figure 3 Meta-analyses of global cognition (ADAS-COG and CDR-SOB outcomes multiplied with − 1 so that higher scores reflect “better” results). Full size image

Executive functions

Executive domain was assessed in all studies with overall moderate quality. They used the Matrices and Similarities subtests of the Wechsler Adult Intelligence Scale, Third Edition (WAIS-III)54, as well as categorical and lexical verbal fluency tests. The latter included the Controlled oral words association test (COWAT)55, Kaplan executive function system (KEFS)56, Cambridge contextual reading test57, executive interview (EXIT25)58, stroop colour and word test (SCWT)59, trail making test (TMT)60 and individual composite scores.

We were able to perform meta-analyses including data from seven studies for the verbal fluency tests by including both verbal and lexical test scenarios (VFT), as well as three studies for SCWT (see Fig. 4). After 12 months, VFT (n = 755, MD = 0.33, 95% CI − 1.34 to 2.00; Fig. 4) and SCWT (n = 258, MD = 0.26, 95% CI − 1.01 to 1.52; Fig. 4) summary measures indicated a non-significant difference in executive function of EXPA interventions.

Figure 4 Meta-analyses of executive function (SCWT outcomes multiplied with − 1 so that higher scores reflect “better” results). Full size image

Memory function

Memory tests were performed in seven studies and involved both auditory and visual recall test scenarios and included the auditory logical memory I (immediate) and II (delayed) subtests of the Wechsler memory scale third edition (WMS-III)61, the list-learning subsection of the ADAS-Cog51, visual recall via the benton visual retention test—revised 5th edition (BVRT-R)62, the California verbal learning test—second edition (CVLT-II) total score and delayed free recall63, and the Consortium to establish a registry for Alzheimer’s disease (CERAD) word list64. We pooled the results of seven moderate quality studies reporting 12- or 18-month data on delayed recall tasks (see Fig. 5). The results indicate that in terms of improving and protecting memory function, in two studies EXPA interventions significantly performed worse than control groups that did not involve physical activity (n = 756, MD = – 0.75, 95% CI − 1.67 to 0.18; Fig. 5). The overall result showed no significant difference.

Figure 5 Meta-analysis of memory function. Full size image

Attention and speed

Attention and speed was assessed in six studies using individual digit and visual span tests, as well as the following digit symbol substitution tests: (DSST) Symbol digit modalities test65, digit symbol substitution test66, and digit symbol coding total67. It was possible to conduct a meta-analysis on DSST scores including data from four moderate quality studies (see Fig. 6). The summary measure indicated no significant difference between EXPA intervention and control groups in terms of improving executive function of speed and attention (n = 337, MD = 0.11, 95% CI − 1.65 to 1.88; Fig. 6).

Figure 6 Meta-analysis of attention and speed. Full size image

(Instrumental) activities of daily living

(Instrumental) activities of daily living (I)ADL were measured in four studies with overall moderate quality by the Chinese disability assessment for dementia (CDAD)68,45, by the Timed instrumental activities of daily living (TIADL)69,31, by the Alzheimer’s disease cooperative study-activities of daily living (ADCS-ADL)70,32, and by mental capacity to perform daily tasks by the Bayer activities of daily living (B-IADL)71,41. No significant changes were found in CDAD or TIADL. Small between-group differences were observed in ADCS-ADL, but they were not statistically significant. Functional status with B-IADL improved significantly after 18 months in favor of 6-month progressive resistance training, as compared with a stretching and video watching control group41. Since the reported outcome measures of (I)ADL could not be pooled meaningfully, a forest plot was published in the Zenodo repository for open access without a combined analysis of the individual studies22.

Health-related quality of life

Three studies with low-to-moderate quality assessed health-related quality of life. Two studies39,44 reported health-related quality of life by using the Medical Outcomes 36-Item Short Form (SF-36) and its even shorter form SF-1272 for both the mental and physical component summary. Furthermore, the health-related quality of life for people with dementia scale (DQOL)73,44 and the DEMQOL tool was reported42,74. There was no statistically significant effect in favour of EXPA interventions over sham-exercise controls 12 or 18 months after start of intervention. Due to high heterogeneity in terms of outcome measurements only a forest plot was published in the Zenodo repository for open access22.

Healthcare utilization

Healthcare utilization was not an outcome measured in any of the included studies.

Caregiver outcomes

None of the included studies measured caregiver outcomes.

Psychosocial functioning

Four low-to-moderate quality studies assessed psychosocial functioning. Three of the included studies39,45,47 used the Cornell scale for depression in dementia (CSDD)75 and the Beck depression inventory (BDI)76 to assess depressive symptoms. After 12 and 18 months, none of the studies showed either EXPA interventions or sham-exercise to have a significant effect on depressive symptoms. One study31 reported social functioning based on the Cognitive Self-Report Questionnaire (CSRQ) Social subscale77, but did not show significant effects of an interactive video gaming intervention versus a health education control group on self-rated social functioning. A forest plot was published in the Zenodo repository for open access22.

Physical functioning

Physical functioning was assessed in six studies with overall moderate quality. Lam et al.46,47, used the Berg balance scale (BBS)78 to assess functional balance. In an intention-to-treat analysis, the performance of the Tai Chi group was better than that of the stretching and toning exercise group. Peak oxygen consumption measurements (VO2peak) during treadmill stress tests were used in two studies34,42, and indicated that after 12 months, aerobic fitness had improved in the aerobic exercise intervention groups compared to the stretching and toning control groups, but the improvement was not significant. Hughes et al.31 used gait speed in seconds as a measure of physical functioning, but the results were not significantly different to those in the Wii and the health education control groups. Liu-Ambrose et al.32,33 used the physical activities scale for the elderly (PASE) questionnaire79 and the 6-min walking test (6MWT)80, but were unable to report significant within-group changes or between-group differences in either of the two measures between baseline and month 12. 6MWT was also reported by Uemura et al.49, but no significant difference could be demonstrated between combined aerobic, strength and balance training and an educational control group, after 12 months. A forest plot was published in the Zenodo repository for open access22.

Pain

Pain was not included as an outcome in any of the studies in this review.

Motivational parameters

Only Hughes et al. assessed motivation to participate, which was very high in both intervention and control groups31. Self-rated satisfaction as well as mental and social stimulation was very high among the majority of participants. However, the Wii and control groups did not significantly differ in terms of motivation in this study with mostly unclear RoB. No other motivational parameters were included as outcomes in any of the studies in this review.

Adverse events

Adverse events were assessed in eight studies32,35,36,39,41,42,43,44,45,46,47. Fiatarone Singh et al.41 reported seven adverse musculoskeletal events—three falls, three exacerbations of pre-existing arthritis, and one non-resolved exacerbation of an underlying rotator cuff tear in the strength training group but lacking report of adverse events in other intervention arms. Lautenschlager et al.39 reported 10 events across groups that were thought to be unrelated to the intervention with three events having occurred in the active phase of the exercise intervention. Tarumi et al.34,35 reported four adverse events across groups with half of them having occurred in the aerobic training group, including knee and ankle pain, as well as one fall from the treadmill. Liu-Ambrose et al.32 reported three study-related non-syncopal falls, of which two occurred in the aerobic training group and the other in the usual care plus education group. Zero adverse events across groups apart from falls unrelated to the exercise intervention occurred in four studies42,43,44,45,46,47.

Neurobiological outcomes

Neurobiological outcomes were reported in one good quality study in different publications. Tarumi et al.34 included measures such as a decrease in brain volume, and Aß plaque deposition in the brain that had increased over time, but did not differentiate between the aerobic training and the stretching and toning groups. In Tomoto et al.38, cardiovascular and cerebrovascular hemodynamics were measured using MRI measurements of brain tissue volume and white matter hyperintensity. In the aerobic group, the carotid ß-stiffness index and cerebral blood flow pulsatility decreased, while normalized cerebral blood flow increased, in comparison to the stretching and toning groups; these differences were statistically significant. Twelve months after the initiation of an exercise intervention, Broadhouse et al.40 reported the protective effect of high-intensity resistance training on the degeneration of hippocampal structures that are relevant in the pathology of Alzheimer’s Disease.

Compliance

All studies reported on adherence or attendance. In Fiatarone Singh et al.41, no significant group differences were observed regarding the median training duration (26 weeks), or the mean number of sessions (42 sessions). Average exercise compliance in the aerobic training group was 68% in the study by Liu-Ambrose et al.32 without having assessed this data for the control group. In Lautenschlager et al.39, adherence to the prescribed exercise over the 24-week period was 78%. At 12 and 18 months, a respective 29% and 19% in the physical activity group and 18% and 19% in the usual care group achieved the equivalent of 70,000 steps or more per week (complete-case analysis only). Adherence reported by Suzuki et al.48 was 79.2% in the exercise group without assessment of control group compliance. In van Uffelen et al.43,44, median adherence of 63% in the walking and the placebo activity programs did not differ between the two groups. Stuckenschneider et al.42 reported that 53% of participants reached the prescribed exercise frequency of 100 sessions over 12 months but did not differentiate between exercise and toning groups. Tarumi et al.34 reported a drop-out rate of 31% without differentiating between exercise and control group. Hughes et al.31 reported good attendance rates of 20 out of 24 sessions in the majority of participants for both the exercise and control group. Drop-out rates reported by Lam et al.46 showed that compliance was lower in the Tai Chi group than the stretching control group. Adherence in Lam et al.45 was rated as satisfactory, with 75% in the EXPA intervention and 71% in the control group attending social gatherings.

Consensus on exercise reporting

The studies did not provide sufficient information on the exercise interventions to enable patients and therapists to base exercise recommendations on them and put them into practice (Table 2). The studies particularly lacked information on the employed exercise equipment, the exercise program, and for what reason the decision was made to starting exercising. Furthermore, it was unclear whether participants were expected to exercise at home, whether the programs included relaxation measures, whether individual tailoring took place, and how adherence and treatment compliance were assessed.

Table 2 CERT outcomes. Full size table

Patient preferences

Table 3 provides an overview on the frequencies of outcome parameters reported in studies compared to outcomes preferred by patients based on the initial workshops involving eight patients with MCI. Psychosocial health goals were rated as the most important endpoints for patients. However, freedom from pain, freedom from stress, mood, motivation and self-efficacy were only addressed in one of the studies31. No studies were found on either the long-term effects of EXPA programs on the health of relatives or the use of health services. People with MCI also expressed concern that participation in EXPA programs put social pressure on them to stay young and fit. The extent to which EXPA programs adequately addressed this concern in their design and delivery was not described in the studies and should be considered when therapists recommend physical activity and exercise.

Table 3 Reported outcomes and outcomes preferred by patients with MCI. Full size table

Table 3 compares the frequencies of outcome parameters reported in studies with those preferred by patients.

Study design

LETHE (ClinicalTrials.gov NCT05565170) is a two-year pilot RCT conducted at four European sites: Medical University of Vienna (Austria), Finnish Institute for Health and Welfare (Finland), University of Perugia (Italy), and Karolinska Institutet (Sweden). At each site, eligible participants were randomized in a 1:1 ratio in blocks of four (centralized computer-based allocation performed by project partner FH Joanneum) to either a 1) structured digitally supported multimodal lifestyle program (= intervention; scheduled program designed and led by professionals) or 2) a self-guided multimodal lifestyle program (= control; regular health advice).

The structured LETHE intervention follows a hybrid approach where in-person intervention activities (on-site and remote; adopted from the original FINGER program) are supported by independent activities in the Android smartphone application designed by the LETHE Consortium (the LETHE App). The LETHE App includes personalized features and dynamic content supporting engagement in the lifestyle program and risk factor self-management. The self-guided group is encouraged to implement general health/lifestyle advice independently; this group has access to a simplified version (view) of the LETHE App including educational material selected by the study teams but no personalized content. All participants have the possibility to contact the study staff throughout the study, and they also receive support from so-called digital coaches (dedicated study staff members) who help with any technical questions and problems in person or by email/phone.

Like in FINGER, blinding is pursued such that cognitive outcome evaluators are blinded to randomization and not involved in the intervention. Group allocation is not actively disclosed to participants. The main study visits, including clinical and cognitive assessments, take place at baseline and at 6, 12, and 24 months; additional data are collected digitally (actively via outcome-related questionnaires in the LETHE App and passively via monitoring through smart devices). During the second year, a subset of intervention group participants will be invited to join a two-month sub-study exploring novel interactive technology and its feasibility in the context of the LETHE intervention (audio smart glasses paired with a voice interaction app, a social robot). The overview of the study is presented in Fig. 1.

Fig. 1 Overview of the LETHE trial design Full size image

Participants

Participants were recruited using a local social media (Facebook) advertisement in Sweden, Finland, and Austria. In Italy, local associations for older people were utilized, as well as printed posters which were distributed in the hospital/memory clinic. The study population in LETHE is similar as in FINGER: older adults (age 60–77 years) at risk of dementia based on the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) Dementia risk score [21] and cognitive performance, but without any substantial cognitive impairment. LETHE participants were additionally required to have sufficient digital readiness to follow the intervention. The full inclusion and exclusion criteria are shown in Table 1.

Table 1 Participant inclusion and exclusion criteria Full size table

Study procedures and data collection

During recruitment, individuals expressing their interest to join the study were first pre-screened over the phone to check basic inclusion criteria to reduce screening failures (age, digital readiness/skills, and CAIDE score). Digital readiness was assessed by interviewing the participant about their prior use of digital devices (which device, how often and for which purposes, and if the participant is comfortable with using Internet and email (e.g., search for information online, read and send emails)), about their current internet access, and willingness to use a phone that is compatible with the LETHE App. Potentially eligible persons were invited to full screening for detailed eligibility assessment, including cognitive testing and interview to confirm absence of medical exclusion criteria (Table 1). Screening was conducted on-site (Austria, Italy, Sweden) or online (Finland).

At baseline, in addition to conducting clinical, cognitive, and other assessments, the study staff installed the LETHE App on participants’ smartphones (a new smartphone was provided if participant’s existing phone was not compatible with the technical requirements of LETHE). Participants were requested to complete a set of questionnaires (e.g., lifestyle-related) in the App within two weeks from the baseline visit. Once completed, participants were randomized, and the full version of the App was activated (different view and content for the intervention and control groups). Successively, an extra visit with the digital coach was arranged to introduce the entire App content to the participants, and to hand out a smartwatch (intervention group: Fitbit Sense; control group: Fitbit Charge 5) and a tablet computer for those intervention group participants who did not yet own one.

After baseline, the main study visits take place at 6, 12, and 24 months, to collect clinical and cognitive outcome data. At these timepoints, participants in both groups also complete outcome-related questionnaires in the LETHE App. Other digital data collection takes place continuously throughout the trial, i.e., passive monitoring through the phone, LETHE App, and smartwatch. Table 2 summarizes the data collected at different timepoints. The trial also includes biomarker studies: at baseline and end of study, blood samples are collected for e.g. analysis of Alzheimer’s disease (AD) blood markers and MRI is conducted (in a subsample) across all sites.

Table 2 Overview of assessments conducted for all participants Full size table

Outcome assessments

Primary outcomes

The primary outcomes are: 1) feasibility of the digitally supported multimodal lifestyle intervention and 2) change in dementia risk based on validated risk scores.

Feasibility is assessed based on retention rate (proportion of randomized participants completing the trial in each group) and adherence to the intervention. A retention of 65% (max. 35% drop-out) is considered successful. Reasons for discontinuation are recorded. In terms of adherence, both digital and non-digital intervention activities will be considered. The following will be assessed: usage of and engagement with the LETHE App and smartwatch (e.g., frequency and duration of logins, wear time), and participation in study visits and intervention-related activities/meetings. Feasibility is further explored by investigating participants’ opinions on the intervention and the usability of the LETHE App / digital tools (quantitative assessment with the System Usability Scale [22] and qualitative interviews in a subsample).

Change in dementia risk is assessed based on two scales, CAIDE [21] and LIfestyle for BRAin health (LIBRA) index [23]. Both are validated tools to estimate risk of late-life dementia [24, 25], and findings from FINGER suggest that they can be useful in quantifying risk reduction and prevention potential in an at-risk population and trial context [8, 9]. CAIDE considers non-modifiable and modifiable risk factors: age, education, sex, systolic blood pressure (BP), body mass index (BMI), total cholesterol, and physical activity. Total score is the sum of the points assigned for each factor (range 0–15; higher scores indicate higher risk). LIBRA consists of a weighted sum score of modifiable risk and protective factors; factors in the original version include coronary heart disease, diabetes, hypercholesterolemia, hypertension, depression, obesity, smoking, physical activity, renal disease, alcohol use, cognitive activity, and diet (theoretical range from –5.9 to + 12.7; higher scores indicate higher risk).

Secondary outcomes

Secondary outcomes include changes in lifestyle/adherence to healthy lifestyle, stress-related symptoms, sleep problems, health-related quality of life, health literacy, and cognition (composite z-score of 14 tests in the extended Neuropsychological Test Battery, NTB [26], adapted from the FINGER [6] and MET-FINGER [27] RCTs). The assessment methods and scales are summarized in Table 3.

Table 3 Methods and scales to assess secondary outcomes Full size table

Exploratory/other outcomes

Exploratory outcomes include changes in individual lifestyle domains and risk factors, mood/depressive symptoms, sleep quality/duration, physical performance, and cognitive and functional measures. Changes in AD/dementia-related biomarkers will also be explored. The assessment methods and scales are summarized in Table 4.

Table 4 Methods and scales to assess exploratory/other outcomes Full size table

Intervention

Structured multimodal lifestyle program (intervention group)

The LETHE intervention is a digitally supported, structured multimodal lifestyle program delivered partly in-person and partly digitally using the LETHE App and other digital tools (tablet, smartwatch). The intervention domains are 1) Dietary guidance, 2) Physical activity, 3) Cognitive training, 4) Monitoring and management of vascular and metabolic risk factors, 5) Social stimulation, and 6) Sleep and stress management (only digital). The in-person intervention activities are organized both face-to-face and remotely as online meetings. The activities are aligned with the original FINGER and the more recent FINGER-based RCTs [27, 28].

The design and development of the multimodal lifestyle intervention program are centrally coordinated and harmonized. The intervention activities at the four sites share common key principles and similar schedules to ensure comparable intervention content and intensity. Detailed staff manuals guarantee harmonized intervention delivery across all study sites. Certain local adaptations, as well as tailoring to individual participant needs are nevertheless allowed to optimize feasibility and efficacy. Also, each site designs the detailed intervention delivery (e.g., balance between face-to-face and online meetings) depending on local arrangements and feasibility, as well as participant preferences.

To support adherence, the different intervention domains were introduced gradually during the first six months of the trial, starting with individual vascular risk factor and dietary consultations which were followed by cognitive and finally exercise group sessions. Participants gained access to all the intervention content in the LETHE App directly after randomization and the digital introduction visit.

Dietary guidance

The dietary intervention aligns closely with the principles of FINGER [29] and is based on general dietary recommendations with special attention on nutritional issues common among older adults. Local adjustments are allowed to align with national dietary recommendations. The key dietary intervention goals in nutrient and food intake levels are summarized in Supplementary Table 1 (Additional file 1). The intervention is delivered through individual consultations (1–2 sessions, approx. 30–45 min each) and small group sessions (3–4 sessions, approx. 45–60 min each) with a trained nutritionist. Individual consultations include a thorough assessment of the participant’s current dietary habits and provide tailored, practical advice on how to improve diet and implement changes in daily routines. All recommendations are adjusted according to individual needs considering e.g., health status and weight. Group sessions provide more information and support the implementation of relevant dietary changes. Group support is exploited through joint discussions. Participants are encouraged to invite their spouse/partner to join the sessions.

Physical activity

The physical activity intervention is based on FINGER and the international guidelines for older adults [30]. The program combines aerobic, strength, and balance training, with progressively increasing intensity and frequency. It is tailored to meet individual needs, e.g., fitness level, health status, and personal preferences. The goal is to make permanent changes to include physical activity into everyday life. Participants are encouraged to lead a more active and less sedentary life and provided with practical advice on how to incorporate activity in their daily routines.

The exercise program is led by a physiotherapist or trained professional experienced in working with older adults, and consists of the following components: an initial motivational consultation and muscle strength testing to define the optimal training load; group sessions on strength training (at least one weekly 30–60 min session at the gym and/or online); and independent aerobic exercise (planned together with the professional based on participants’ needs and preferences). The progression pattern for the training is shown in Supplementary Table 2 (Additional file 1). Participants are advised to use the on-demand video material in the LETHE App to reach the goal of two weekly strength training sessions. To track their activities and self-monitor exertion level to ensure right intensity level, participants are encouraged to utilize their smartwatches.

Group sessions on strength training follow a similar structure and concept regardless of whether they take place on-site or online (e.g., duration, targeted muscle groups). Remote sessions rely on bodyweight exercises, resistance bands, and exercises utilizing everyday tools at home (e.g., chairs, bottles). Even if most group sessions were remote, all sites organize a few on-site sessions at the beginning and end of the intervention, as well as in-between, to ensure safety and proper exercise techniques, and to facilitate grouping, support motivation, and monitor progression.

Cognitive training

The cognitive intervention is delivered through group sessions (3 sessions, approx. 60 min each) with a psychologist or other trained professional, and independent cognitive training with a web application available via the LETHE App (cTRAIN, provided by Combinostics Ltd and adapted from the program used in FINGER [31]). The group session topics are cognitive abilities, aging-related changes in cognition, brain plasticity, factors affecting cognition (e.g., sleep, stress, mood), and tips to stay mentally fit. The first group session is dedicated to introducing the cTRAIN program; after that the participants have access to the program for the whole trial duration. cTRAIN includes six games to train working memory (visuo-spatial span task), executive functions (two working memory updating tasks, spatial and verbal), mental speed (set-shifting task), and episodic memory (word associate task i.e., word triplets and a classic memory-game). The software introduces automatically different tasks in a sequential order (two games available at a time for each two-week period). With improving performance, the difficulty of the games increases, and more advanced levels are unlocked. Participants are recommended to train three times per week for 10–15 min/session, but they can train more if they wish. Activity and performance are registered automatically, and participants can monitor selected statistics (completed sessions, high scores).

Monitoring and management of vascular/metabolic risk factors

Risk factor monitoring and management is based on country-specific evidence-based guidelines. The goal is to identify risk factors and motivate participants to take action by giving tailored, targeted counselling and personalized feedback taking into account individual situation and motivation. Risk factors/conditions to cover include BP/hypertension, dyslipidemia, diabetes/ glucose levels, smoking, alcohol consumption, weight management (acknowledging the complex role of weight changes in old age and risk of frailty/malnutrition), and other relevant lifestyle factors. The intervention includes 1–2 individual consultations with a nurse and physician, respectively (in total 2–4 sessions, approx. 45–60 min each). Extra measurements of e.g., BP or waist circumference can be conducted to support the consultation. If medication initiation or adjustment is needed, the study physician writes a prescription, or the participant is recommended to contact (or referred to) the regular health care provider.

Social stimulation

In previous multimodal prevention RCTs, social engagement was crucial to support motivation and intervention adherence [10, 32]. In LETHE, social activities are therefore strongly supported and stimulated through regular group meetings. Group sessions are designed to facilitate open discussions and social interaction among participants. This interaction is also encouraged outside the scheduled sessions, e.g., via local WhatsApp group chats.

Sleep and stress management

Stress and sleep are acknowledged as relevant factors for brain health, although more evidence is needed of their potential causal role as risk factors [33, 34]. Stress and sleep problems can nevertheless interfere with health as a whole and prevent from making sustained lifestyle changes. No separate in-person activities are organized in this domain, but the topics are addressed as part of other consultations as applicable. Participants can independently monitor sleep with the smartwatch and access relaxation videos in the LETHE App.

Self-guided multimodal lifestyle program (control group)

Participants in the control group are advised to build their own healthy lifestyle program based on the standard advice they receive at the main study visits and through the simplified LETHE App. Participants are encouraged to independently implement relevant changes in their daily routine. The simplified LETHE App includes a library of educational material selected by the local study teams, but none of the personalized features or notifications (see next section and Fig. 1). The smartwatch worn by the control group is a simpler model than the one worn by the intervention group (serves mostly passive data collection, yet allows e.g. physical activity tracking). Like the intervention group, the control group receives the results of routine blood tests (e.g., lipids), information about their meaning, and if needed, advice to seek medical care.

LETHE App

Given the lack of existing apps that are appropriate for the LETHE target group and aligned with the principles of the FINGER intervention model, a new app was in the project to support the intervention delivery and trial data collection. The LETHE App is an Android native app; the development process and technical implementation are described elsewhere (Hilberger et al., in preparation). In brief, the LETHE App features two different views (full view with all functionalities for the intervention group; simplified view with selected functionalities for the control group). Figure 2 shows the two different overviews (dashboards) of the LETHE App. All content is available in English and the four trial languages (Finnish, German, Italian, Swedish). Translations were provided and checked by the local study teams.

Fig. 2 Overview (front page) of the different LETHE App views (full view for the intervention group, simplified view for the control group) Full size image

The key features of the LETHE App are summarized in Fig. 1. Features for both study groups include: a calendar (to view and keep track of study appointments and join online meetings if applicable), questionnaires (for outcome-related assessments at timepoints shown in Table 2), option to record current mood (by selecting emoticons), and a library of educational content covering all domains of the lifestyle program (external websites). This material was selected by the study teams to ensure it is appropriate for this target group, evidence-based, reliable, and aligned with the principles of the lifestyle intervention as well as local guidelines. The full App includes several additional features designed to support the delivery of the multimodal lifestyle intervention and encourage independent engagement in healthy activities. Some of the features and activities can be viewed and modified by the study staff on a web portal (LETHE Clinical Trial Management System, CTMS) which helps deliver the intervention in a more personalized way.

For diet, a short questionnaire is available in the App for simple self-monitoring of healthy diet adherence (e.g., consumption of fish, processed meat, and fruit and vegetables). The questionnaire is divided into three blocks, each of which appears weekly (Additional file 1, Supplementary Table 3). For physical activity, on-demand exercise videos focusing on strength and balance training are available (selected or filmed by the local study teams to accommodate different fitness levels). These videos complement the in-person group sessions. To relax or help fall asleep, YouTube videos with soothing melodies and breathing exercises are available (selected by the study teams). For cognitive training, participants have access to the cTRAIN program through the LETHE App. cTRAIN, as well as all videos in the LETHE App, can also be opened on a tablet or computer, by scanning a QR code or sending the link by e-mail. For social stimulation, participants are offered the possibility to connect with each other in a local WhatsApp group chat. For vascular risk factor control, the App includes a diary for self-monitoring of smoking, alcohol consumption, and BP. The professionals can view the entries in the CTMS, and results can be discussed at the individual consultations.

The full LETHE App also includes a feature for personal goals. The goals are discussed and set together with the professional to ensure they are relevant and follow the SMART principles (specific, measurable, achievable, realistic, time-bound). Goals are displayed in the App as items on a to-do list, and they can be ticked off once reached. The full App also includes a library of practical everyday tips and behavioral suggestions to help individuals implement healthy habits into the daily routine (so called tiny habits, based on habit formation theory [35, 36]). The library was originally created for a large Finnish type 2 diabetes online prevention RCT [37] (library publicly available in Finnish under CC BY 4.0 license [38]). Lifestyle domains covered were diet, exercise and sedentary lifestyle, mental wellbeing, sleep, smoking, and social interaction. For LETHE, the library was reviewed, translated, and partly adapted and expanded by the study teams to ensure appropriateness for our context. For example, the dietary and exercise advice was aligned with the principles of FINGER, and a new section was developed for cognitive stimulation. Participants can choose new habits and unselect old ones as often as they wish (total number of available habits > 500; examples in Additional file 1, Supplementary Table 4). Participants can indicate regularly if the habits were successfully implemented or not. Finally, a feature for personalized semi-automated feedback is currently under development. Based on data from the smart devices, motivational feedback messages will be sent, and a weekly performance/adherence score will be calculated and shown in the App (Fig. 2).

Exploring novel interactive technology (sub-study)

A subset of intervention group participants will be invited to test novel interactive technology as a complementary way to engage with the LETHE App. Two different technologies are tested: a social robot (Temi) and audio smart glasses (FAUNA Spiro) (Fig. 1). The robot can navigate around the house and display LETHE App content on a touch display. It can also assist by reminding about intervention-related tasks. The audio glasses have a Bluetooth microphone and headphones. In combination with a voice interaction app, glasses enable hands-free interaction with the LETHE App functionalities. Instead of reading on the screen and typing answers to questions as done with the smartphone, participants can listen to App contents and enter information through voice interaction. Both devices are CE-certified.

Statistical considerations

LETHE is an RCT assessing primarily feasibility. In line with CONSORT extension guidelines for such RCTs [39], no formal sample size calculations were conducted. Sample size is in line with other feasibility RCTs testing multimodal preventive lifestyle interventions in similar populations [28, 40,41,42], and many ongoing studies assessing digital brain health interventions [43]. The two study groups will be compared to assess differences in the trial outcomes, as applicable.

Ethical and safety aspects

Trial was approved by local ethical committees in all four countries. All participants provided a written informed consent prior to enrollment. Separate consents were obtained for screening and the full trial; an additional consent will be obtained for the sub-study. A verbal informed consent was allowed for remote screening. Participants’ study partners/informants provided their own consent (involving a partner e.g., family member is recommended but not mandatory).

The multimodal lifestyle intervention is not expected to cause harm or involve major health risks [6]. No interim safety analysis is therefore planned. Information about adverse events is collected at the study visits and with a brief digital questionnaire every three months. All participants are informed about the results of their routine health examinations, blood tests, and any other relevant findings concerning their health. If needed, participants are either referred to medical care or advised to contact their regular health care provider. Participants are covered by local insurance.

Data protection and privacy

All study documentation collected at the sites is stored securely in local premises, labeled with a unique participant ID, and kept apart from identifying information. All data collected via the LETHE App, CTMS (including electronic case report forms), smartwatch, and phone sensors are stored on a secure cloud-based server with restricted access (hosted by EGI Foundation in the Netherlands). In addition to the participant ID, participants have unique dummy Google accounts to login the LETHE App and the other web applications used in the RCT (e.g., cognitive training program). Dummy accounts enable the linkage of data from different sources on the server. After the end of the LETHE project, data are transferred to the study sites and stored locally. Third parties e.g., Fitbit, collect and process certain data for their own purposes via their products (e.g., usage of smartwatch and related app); this is explained to the participants in the informed consent form. Third parties do not have access to the trial data.

Public involvement

An Advisory Board (AB) including members of the public with an interest in or affected by cognitive impairment was set up at the beginning of the project (work led by Alzheimer Europe in collaboration with other partners). The AB consists of seven members from Austria, Finland, Italy, and Sweden. The AB has provided feedback on the trial design and intervention concept, participant materials, digital devices, and issues concerning recruitment, ethical aspects, and data protection. The AB contribution is described in detail elsewhere (Rosenberg et al., in preparation).

Methodology

An English-language literature search was conducted using medical databases (MEDLINE via PubMed and SCOPUS, through November 29th, 2024) and keywords such as “multidomain”, “intervention”, “dementia”, “prevention” and “cognitive decline”. Additional studies were identified through the reference lists of selected publications and the researchers’ expertise on WW-FINGERS studies. The search strategy, screening process, and data selection adhered to PRISMA guidelines [16]. The following criteria were used to select relevant studies, including both randomized controlled trials (RCTs) and protocols: nonpharmacological multimodal interventions (defined as combining three or more intervention domains) with a duration of at least 6 months, a target population including individuals without dementia at baseline, and cognitive performance and/or incident mild cognitive impairment (MCI) or dementia as primary or secondary outcomes. This review was not registered in the International Prospective Register of Systematic Reviews (PROSPERO).

During the screening process, two independent reviewers (NS-D and AA-G) assessed eligibility based on titles and abstracts. Data extraction for the narrative review was conducted by one researcher (NS-D), capturing details on study design, multimodal intervention characteristics (e.g., dose, duration, adherence), and primary outcome measures. Quality assessment of the studies included was not conducted.

The database search identified 417 unique articles, with an additional 13 articles retrieved from other sources (Supplementary Fig. 1). After screening, 45 articles were selected for full-text review of clinical trials. Of these, 24 completed clinical trials met the inclusion criteria for analysis, and were distributed geographically as follows: 12 from Asia, 10 from Europe, and 2 from America. Among the excluded articles, 25 protocols of ongoing clinical trials were identified and included in the data synthesis of adherence reporting and assessment of the expected intensity of the multimodal intervention. These protocols were distributed geographically as follows: 8 from Europe, 7 from Asia, 5 from America, 4 from Australia, and 1 from Africa.

Adherence definition in multimodal studies

Adherence is defined as the degree to which the person’s behavior corresponds with the agreed-upon recommendations from a healthcare provider [8]. It differs from compliance, which is the extent to which a patient’s behavior matches the prescriber’s advice, emphasizing obedience rather than actively choosing to make lifestyle changes. Adherence to multimodal interventions should encompass participation in intervention activities and lifestyle change, as both aspects impact cognitive change and are not directly interrelated [10]. Nonetheless, most studies thus far have focused solely on participation in intervention activities as a measure of adherence [9, 11,12,13,14]. Accordingly, good adherence has often been defined as completing at least 66% of prescribed interventions [9], a benchmark often used in behavioral interventions [17]. However, an arbitrary cutoff such as a simple percentage of 66% might not be informative of high adherence, as it depends on the overall amount of the intervention offered.

Adherence reporting in multimodal studies

As shown in Table 1, there was significant heterogeneity in the reporting of adherence across the completed multimodal intervention studies. Adherence is commonly reported by intervention domain; however, certain studies, such as the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) [9] and the GOIZ-ZAINDU [18], have also assessed simultaneous adherence to all assigned components, albeit with the use of cut-offs. This diversity in adherence reporting makes cross-trial comparisons of adherence to multimodal interventions difficult. This challenge could be improved by reporting average participation (mean (SD), in percentage units) to each intervention component.

Table 1 Reporting of adherence to multimodal interventions for preventing cognitive decline Full size table

On the other hand, ensuring consistency in reporting lifestyle changes across multimodal interventions can be challenging due to the considerable heterogeneity of the assessment tools used to measure lifestyle changes. A solution to this harmonization challenge could be the use of dementia risk scores such as The Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) risk score or the Lifestyle for Brain Health (LIBRA) index [19]. These scores can be calculated uniformly across studies irrespective of the various measurement instruments used to evaluate lifestyle or cardiovascular risk factors [20, 21]. Moreover, they have been suggested as surrogate outcomes for lifestyle-based multimodal prevention trials because they may register changes in dementia risk before detectable cognitive changes [22, 23]. However, risk scores often attribute points using categorical scoring systems, which might reduce responsiveness, as large changes in individual risk factors may not be registered if these changes do not cross the categorical cutoff points [22]. To improve their performance, it has been proposed to use continuous scoring systems (crude and weighted z-score versions), taking into account all changes in risk factors, not only those crossing specific cutoff values [22]. Using this approach, the LIBRA index demonstrated greater responsiveness to change, than did the CAIDE dementia risk score, as it includes a larger number of modifiable risk factors and a broader range of scores [22]. However, risk scores often put very limited weight on the lifestyle changes most frequently targeted in multimodal interventions (e.g., CAIDE has physical activity only, and LIBRA has physical activity, cognitive activity and diet) and contain many factors that cannot be changed (the effect of multimodal interventions on cardiovascular risk factors is modest, particularly when medications are not a part of the program).

Intensity of multimodal interventions

A measure of the intensity of the intervention that combines the dose delivered (i.e., total number of sessions) and the length of the intervention may be more useful for comparing adherence to different multimodal interventions. Among large multimodal intervention studies, the FINGER is the only one that demonstrated benefits on cognition [24]. The Multimodal Alzheimer Preventive Trial (MAPT) [9] and the Prevention of Dementia by Intensive Vascular Care (PreDIVA) [14], for example, reported no intervention effect on their primary cognitive outcomes. In addition to differences in the target population (at-risk individuals in the FINGER, frail individuals with subjective cognitive impairment in the MAPT, and the general population in the PreDIVA), these three studies differed substantially in terms of intervention intensity and delivery mode (structured intervention programs in the FINGER and MAPT, and mainly self-guided intervention in the PreDIVA). The expected intensity of the FINGER study, calculated as the ratio between the prescribed dose (number of prespecified sessions) and the length (months), was 10.6 points. In contrast, the MAPT had an intensity of 1.2 points, and the PreDIVA had an even lower intensity of 0.3 points (Table 2).

Table 2 Intensity of multimodal intervention studies Full size table

As shown in Fig. 1A, structured multimodal intervention programs with expected intensities greater than 10 points are more likely to succeed in terms of improving cognitive performance or meeting primary cognitive outcomes. In turn, mainly self-guided or remote interventions should probably need greater intensities to impact cognition (Fig. 1B), because participants might be less likely to adhere, as evidenced by the AgeWell.de or HATICE results [25, 26]. On the other hand, ongoing studies are mainly framed within the WW-FINGERS network and thus follow the FINGER model of structured multimodal intervention, with expected intensities over 10 points (Fig. 1C). Specifically, the expected intensities ranged from 32 points in the US POINTER [27, 28], 31.8 points in the AU-ARROW [29], 30.3 points in the LatAm-FINGERs [30], 22.2 points in the LETHE trial [31], 20.4 points in the PENSA Study [32], 15.0 points in the Africa-FINGERS [33], 14.1 points in the CITA GO-ON [34], 12.9 points in the J-MINT and MET-FINGER trials [35, 36], 10.5 points in the SINGER [37], 9.2 points in the FINOMAIN [38], and 4.7 points in the FINGER-NL [39, 40]. Other ongoing multimodal intervention studies that are not members of the WW-FINGERS network usually have lower intensity scores ranging from 0.3 to 6.5 points, except for the MINE trial, which has an expected intensity of 29.3 points [41]. However, it is important to note that the intensity of the intervention is closely affected by the adherence and the content/quality of the intervention (although difficult to quantify). For instance, the observed intensity in the PENSA study after adjusting the expected dose by the average adherence to each intervention component was 14.5 points instead of 20.4 points (30% lower than expected by the design). Similarly, the observed intensity of the MAPT study was 33% lower than that expected by the design [9, 42], and this number was 36% in the GOIZ-ZAINDU study [18], and 55% in the HATICE study [26, 43]. However, the reporting of adherence or participation in intervention activities using cutoffs (e.g., percentage of participants with at least 66% adherence) prevents the assessment of the observed intensity, which requires adjusting the expected intensity by the average adherence to each intervention component. Moreover, information on the duration of cognitive or physical training sessions could allow a more accurate estimation of the intensity, as it could be equivalent to performing, for example, a 60-minute cognitive training session once a week and a 30-minute cognitive training session twice a week. Another aspect that could influence the estimation of the intensity is that the score proposed gives the same weight to all intervention components, although typically cognitive training or physical activity interventions have higher doses (e.g., weekly sessions) than nutrition or cardiovascular risk monitoring interventions (e.g., (bi)monthly visits).

Fig. 1 Intensity of multimodal intervention (MI) studies aimed at preventing cognitive decline, including (A) completed structured intervention programs (A, B) completed predominantly self-guided intervention programs, and (C) ongoing intervention programs categorized by WW-FINGERS network membership. Details of each study are provided in Table 2 Full size image

While there is a strong rationale for delivering intensive, high-dose multimodal interventions to promote cognitive improvement or delay the onset of cognitive decline, it is equally crucial to address the challenge of achieving a sustained pattern of lifestyle modification. Striking a balance between intervention intensity, feasibility, cost-effectiveness, and long-term engagement is essential for the success and real-world applicability of these interventions. One potential approach involves a gradual increase in the intervention dose during the first 12–18 months, maintaining this heightened dose until the 2-year mark (in alignment with evidence of efficacy observed in the FINGER study), and thereafter gradually reducing the intervention dose so that the participants are likely to maintain the activities on their own after the intervention period is over. Another approach is to offer part of the program in a semistructured manner, for example, by using a hybrid intervention design. This approach is currently being tested in FINGER-NL, where part of the intervention program for all lifestyle domains is offered through a digital intervention platform. For example, online exercise instruction videos are made available with options for adapting the intensity of the work-out.

Determinants of adherence

Understanding why individuals engage (or do not engage) in a particular behavior is vital in the context of behavior modification [44]. Moreover, the identification of determinants of adherence is linked to the mechanisms of an intervention as described in, for example, the Medical Research Council guidance regarding complex interventions [45]. Evidence suggests that baseline social and health conditions matter for adherence and efficacy, and interventions that consider psychosocial factors for engaging in a healthy lifestyle (e.g., motivation, environmental adjustment) may achieve better results [46].

To identify determinants of global adherence to multimodal interventions, we conducted a systematic search on PubMed (see details in the introduction section) and employed snowball methods, involving the pursuit of references within references and electronic citation tracking. Table 3 provides a summary of the evidence on the determinants of global adherence in multimodal interventions.

Table 3 Overview of determinants of global adherence to multimodal interventions identified in previous studies Full size table

In the recent years, numerous theories, frameworks, and models have emerged within the field of implementation science; however, their application in aging research has been limited [47]. An example of this is the Health Belief Model (HBM), which serves as a framework to explain and predict adherence to health and medical care recommendations. Its main premise lies in the notion that identifying beliefs and motivations related to health behaviors can inform the development of interventions aimed at increasing desirable health behaviors. This model defines key factors that explain health behaviors, including health knowledge, perceived susceptibility, perceived severity, perceived benefits of action, perceived barriers to action, cues to action, and self-efficacy. Notably, the HBM has been identified as the best-suited model for the development and evaluation of dementia prevention interventions [48]. In the context of the HBM, some studies have investigated the barriers and facilitators to participating in or implementing lifestyle interventions for dementia prevention using qualitative methods, targeting participants [49, 50], healthcare professionals [51] or the general public [52]. Experience with cognitive disorders (through family history or indirectly), motivated attitudes toward prevention and willingness to participate in a prevention trial were found to be facilitators, while beliefs that dementia is part of normal aging and not preventable were found to be barriers to participation. However, barriers to and facilitators of dementia prevention may differ, for example, between different socioeconomic groups, cultures, and genders [53]. Barriers and facilitators of overall participation in a trial may also differ from factors associated with adherence, and they can also differ between the intervention domains.

While HBM factors provide insight into the determinants of adherence, it is unlikely that a single intervention strategy can universally enhance adherence among all participants. The success of lifestyle interventions may depend upon tailoring interventions to the individual characteristics of participants. This is especially relevant in the context of multimodal interventions, which can be burdensome and not universally accepted. Participants may require different focuses on different domains, so tailoring is needed within the intervention. It has been proposed that some people (for example those who are frail or have a lower cognitive reserve) may benefit from higher dose of intervention, while for other people a lower dose might be sufficient [42]. Other factors related to the design of multimodal interventions such as the type, intensity and delivery method, or context (e.g., population, setting, community) may also influence adherence [9]. The adaptation of evidence-based programs to particular settings or populations is thus essential for maximizing their effectiveness [54]. Addressing this evidence-to-practice gap can be facilitated by incorporating implementation science approaches such as Intervention Mapping [55, 56]. These methodologies emphasize the evaluation of context and integrate social determinants of health in the development of interventions. Moreover, they involve program users (implementers, adopters, and maintainers) in the evaluation process [56]. The use of Intervention Mapping or similar methodologies in the design of dementia prevention studies can enhance their relevance in diverse populations. For instance, the LatAM-FINGERS and the AFRICA-FINGERS initiatives adopted the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to assess a project’s effectiveness, feasibility, and sustainability [30, 33]. This approach has the potential to narrow the gap in dementia prevention research between low and middle-income countries and high-income countries [30, 33].

It is a matter of social justice that accessibility to health services is provided with the principle of equity. Populations with low socioeconomic status (SES) are known to be less likely to access health care and, more importantly, may be more likely to have less healthier lifestyles. Moreover, previous literature has shown a clear relationship between the prevalence of dementia and low SES, measured as annual income, educational level, occupation, and even neighborhood income levels [57]. Another important social determinant of health associated with dementia development is gender. Both a higher prevalence and incidence of dementia have been reported in women than in men, with two-thirds of individuals living with dementia and AD being women [58]. Risk factors associated with gender, which are all interrelated, range from lifestyle and psychosocial factors to cognitive reserve and may also affect participation in and adherence to multimodal interventions [59].

The results point to potential intervention paths to help people with early dementia or interventions to possibly prevent dementia.

In a 20-week intervention, researchers found that combining lifestyle interventions like following a plant-based diet, exercising, managing stress, and attending group support meetings may help improve cognitive function.

A recent study published in Alzheimer’s Research & Therapy examined how intensive lifestyle interventions can help people in the early stages of Alzheimer’s disease.

Receiving a dementia diagnosis can be devastating and discouraging. However, experts are determined to figure out how to best help people with Alzheimer’s disease, and recent research in this area is hopeful.

There are medications that help people with Alzheimer’s disease, but experts are also interested in how lifestyle interventions can also help. These lifestyle interventions were the focus of the current study.

“Over time, Alzheimer’s disease leads to declines in physical health, reducing mobility and increasing the risk of falls. Overall, these effects result in social isolation and substantial caregiver burden, further impacting the individual and caregivers’ quality of life,” Elhelou said.

“Alzheimer’s disease significantly impacts quality of life and function through progressive declines in memory, cognitive functioning (attention, processing speed, problem-solving, word finding), tasks of daily living (managing finances, driving, medication management, household duties), as well as changes in mood (increased irritability, anxiety, depression, or apathy).”

Shannel Kassis Elhelou, Psy.D. , geropsychology and neuropsychology fellow at Pacific Neuroscience Institute’s Brain Wellness and Lifestyle Programs in Santa Monica, CA, who was not involved in the study, noted the following about Alzheimer’s disease to Medical News Today:

People with Alzheimer’s disease often experience a progressive decline in their cognitive function and memory. They may struggle with memory loss, personality changes, and declines in judgment. Alzheimer’s disease is also the most common dementia type, making it a particularly important area for research focus.

Alzheimer’s disease is a condition that results in brain changes and impacts over six million people in the United States alone.

For the current study, researchers wanted to examine if a combination of non-medication interventions could help people in the early stages of Alzheimer’s disease.

This study was a randomized, controlled clinical trial that included fifty-one participants. All participants had mild cognitive impairment or early dementia from Alzheimer’s disease. The average age for participants was 73.5 years. Researchers excluded participants who had moderate or severe dementia and those who could not participate in regular exercise.

Researchers divided participants into two groups. The control group received standard care, and the intervention group received standard care and took part in four key lifestyle interventions:

Implementation of a whole-foods, minimally processed plant-based diet with specific supplements and low levels of harmful fats and refined carbohydrates, Moderate exercise for at least thirty minutes daily and mild strength training three times a week or more, Stress management techniques like meditation, yoga, and breathing exercises, Regular use of support groups three times a week.

Overall, the intervention period lasted 20 weeks, and two participants from the intervention group withdrew. Researchers provided intervention participants with food, assistance with exercise, supervision of stress management techniques, and access to support group meetings.

Researchers used several measurements to assess the success of the interventions, including four assessment tools: the AD assessment Scale—cognitive Subscale, Clinical Global Impression of Change, Clinical Dementia Rating Sum of Boxes, and Clinical Dementia Rating Global. They also examined certain biomarkers and microbiome taxa.

The control group showed declines in all four assessments of cognition and function. In contrast, the intervention group showed improvement in three of the assessments. In the last assessment, the intervention group showed less progression than the control group.

In addition, the intervention group showed improvement in microbiome configuration and improvement in clinically relevant biomarkers compared to controls.

Study author Dean Ornish, founder and president of the nonprofit Preventive Medicine Research Institute and clinical professor of medicine at the University of California, San Francisco, noted the following highlights of the research to Medical News Today:

“What makes our research unique is that it’s the first time a randomized controlled clinical trial has demonstrated that an intensive lifestyle intervention, without drugs, significantly improved cognition and function after 20 weeks in many patients with mild cognitive impairment or early dementia due to Alzheimer’s disease.”

“There was a statistically significant dose-response correlation between the degree of lifestyle changes in both groups and the degree of change in most measures of cognition and function testing. In short, the more these patients changed their lifestyle in the prescribed ways, the greater was the beneficial impact on their cognition and function.”

— Dean Ornish, study author

While the results don’t mean that everyone in the intervention group experienced an improvement in cognition, they do mark superior outcomes to standard care interventions. Ornish noted that “Not all patients in the intervention group improved; in the CGIC test, 71% improved or were unchanged. In contrast, none of the patients in the control group improved, eight were unchanged, and 17 (68%) worsened.”

Thriving workplaces: How employers can improve productivity and change lives (43 pages)

As the world grapples with rapid technological advancements, demographic shifts, and evolving work paradigms, it is vital to invest in employee health.

Why prioritize workforce health? Investing in employee health can substantially increase economic returns. Research by the McKinsey Health Institute in collaboration with the World Economic Forum indicates that enhanced employee health and well-being could generate up to $11.7 trillion in global economic value. Organizations that prioritize health often see marked improvements in productivity, reduced absenteeism, lower healthcare costs, and heightened employee engagement and retention. They are better placed to adapt to increased regulatory pressures on workplace health and safety standards and withstand greater focus from investors and the public on how organizations are meeting environmental, social, and governance (ESG) criteria. Moreover, a healthier workforce is a more resilient and adaptive workforce, more capable of navigating the uncertainties and challenges of a rapidly changing world.

What is the current state of workforce health? Work can and should enhance health, yet it is not doing so for a sizeable proportion of employees. In a McKinsey Health Institute survey of more than 30,000 employees worldwide, only 57 percent reported good holistic health (an integrated view of an individual’s mental, physical, spiritual, and social functioning), with important differences in holistic health and burnout symptoms found across different industries and demographics. For example, employees who are women, LGBTQI+, younger, or neurodivergent, or who report lower education levels or poor financial status, tended to report poorer employee health outcomes than their counterparts in the survey. This underscores the need for tailored interventions to address and prevent health challenges and tackle the workplace factors that contribute to them.

How can organizations address workforce health? Although there is no one-size-fits-all approach, given that each organization is different and employees have varying needs, there are six “evergreen,” evidence-based principles for employers seeking to make a positive impact: understand the baseline health status of employees and the value at stake, develop initiatives for a sustainable healthy workforce, pilot interventions to test and learn, track three to five metrics to measure success, ensure leadership commitment and sponsorship, and embed employee health into organizational culture.

These actions seem simple but are often hard to put into practice. Today, many organizations do not see or cannot measure the benefits of their current investments in employee health. They also don’t allocate resources in the most effective way—often, the issue is not how much is being invested but the type of investment being made. Rather than solely addressing the poor health of individual employees, developing a healthy workforce means taking a portfolio approach: addressing ill health and promoting good health, supporting individuals, and creating healthier teams, jobs, and organizational environments.

By making work a place that improves health, organizations can build a strong, productive, and engaged workforce and release greater individual and organizational potential. The choice to demand a healthy workplace is one every employee and investor can make.

There is an urgent need to improve employee health. Stakeholders who take immediate action will reap substantial benefits.

Health is “more than the absence of disease or infirmity,” as the World Health Organization (WHO) puts it. Modern concepts of health include mental, physical, spiritual, and social function. Today, more than 3.5 billion working adults each spend roughly 90,000 hours (or about 45 years) of their lives at work. This underscores the workplace’s potential to profoundly influence health—not just for the benefit of employees but also for their families and the communities in which they live.

Several trends are impossible to ignore: more people working than ever, an aging population living and working longer, and escalating levels of burnout. The current state of the workforce, coupled with these trends, demands a rethink of employee health to avoid a potential crisis for health and business. A healthy workforce is not just a matter of corporate and societal responsibility; it is a strategic necessity and a substantial business opportunity.

The reality that leaders face is stark: failing to prioritize employee health risks creating a sicker, unhappier, and less productive workforce, burdened with higher healthcare costs and diminished productivity. The good news is that, conversely, the path to a healthier workforce can yield substantial returns for executives, investors, policy makers, and other stakeholders, including more robust organizations, vibrant communities, and, ultimately, a healthier society.

Guidance for developing a healthy workforce

This report is a call to action for leaders to recognize that the health and well-being of their employees is critical to the future success and sustainability of their organizations. While small actions taken today can build towards substantial impact tomorrow, many stakeholders are uncertain how to make the required changes in the most effective way.

This report is structured to guide stakeholders on this journey, with the aim of helping them feel empowered and enabled to act. The first chapter outlines the case for investing in a healthy workforce, while the second delves into the current state of employee health and well-being globally, looking at how health varies by industry and by demographic group. The final chapters focus on measurement and first steps, and are particularly geared towards executives, providing leaders with the tools and strategies necessary to implement effective health initiatives.

1: The case for investing in employee health

Investing in a healthy workforce delivers measurable performance gains and benefits for organizations and communities.

The workplace needs to foster holistic employee health. Companies of all sizes are entering a period in which it is essential to manage human capital with the same level of discipline as financial capital as part of their total business strategy. Globally, more than 3.5 billion people will each spend approximately 90,000 hours, or about 45 years, of their lives at work, representing a major opportunity for employers to nurture the good health of a substantial proportion of the world’s population. Improved health benefits individuals, their families, and broader society, as well as the organizations for which they work.

This briefing describes why investing in workforce health can boost organizational performance, enhance employee outcomes, and offer a substantial return on investment.

There is a clear investment case for improving employee health and well-being

The world is changing. People are living and working longer, and their roles are evolving due to shifts in demography, advances in technology, globalization, and geopolitical and climate risks. For example, non-communicable diseases (NCDs), such as cardiometabolic diseases, cancers, substance use, and mental and neurological conditions account for 69 percent of today’s global disease burden. In the next 15 years, most of the disease categories predicted to rise will be NCDs, with age-related diseases such as kidney diseases increasing the most. Furthermore, the COVID-19 pandemic created a shift in working trends, launching many organizations into the world of remote work. It also accelerated and exacerbated long-standing corporate challenges to employee health and well-being, in particular employee mental health, with reports of burnout rising to almost one in four.  Many employers started to actively support and promote brain health—not only to address burnout but also because analytical thinking, a key marker of positive brain health, is one of the most sought-after skills by employers.

The evolution in lifespan, age-related diseases, what we work on, and how we work will require people to be in better physical and mental health for longer and be more resilient and adaptable to change. The McKinsey Health Institute estimates that investing in holistic employee health could generate between $3.7 trillion and $11.7 trillion in global economic value. This equates to approximately $1,100 to $3,500 per person, or 17 to 55 percent of average annual pay. This estimate includes the impact of reduced attrition, absenteeism, and presenteeism, as well as improved employee productivity, attraction, and retention. The direct costs of medical treatments have been excluded because public, private, and employer-sponsored insurance options vary by country.

The biggest potential benefits come from enhancing productivity and reducing presenteeism, estimated to be worth $2 trillion to $9 trillion. This is between 54 and 77 percent of the total opportunity identified (Exhibit 1). Many organizations substantially underestimate these potential benefits. For example, companies may struggle to quantify the costs of presenteeism, whereby employees are not working at their full potential, and instead focus their investment cases on reducing direct costs, such as attrition and absenteeism, which are more easily measurable. Yet attrition and absenteeism are estimated to account for only between an eighth and a quarter of the total opportunity.

All economies benefit from improving the health of workforces, but the distribution of value varies

The case for investing in employee health and well-being applies beyond high-income countries. Investment in employee health could boost global GDP by between 4 and 12 percent, with high- and middle-income countries each contributing roughly half of that total (2 to 5 percent) (Exhibit 2).

However, average salaries are lower in middle-income countries, so analysis suggests these countries have up to four times as many employees who would benefit: an estimated 2.5 billion employees compared to 636 million employees in high-income countries.

The data on low-income countries was insufficient to reliably estimate the value at stake or the total number of employees potentially affected, but there is little doubt that employees in these economies would also benefit from workplace investment in health.

Within low- and middle-income countries (LMIC), non-communicable diseases (such as cancer, cardiovascular disease, and diabetes) meaningfully influence employee health, well-being, and productivity. Premature deaths due to non-communicable diseases account for 80 percent of deaths in LMICs. With limited financial security provided by the state and greater pressure on workers to maintain a stable income and afford healthcare, workplaces in LMICs have a significant opportunity to support good employee health.

Several factors directly contribute to the investment case for employee health and well-being within an individual organization

Benefits for an organization can vary widely depending on the number, sector, and location of their employees (Exhibit 3). Consequently, when organizations evaluate their investment cases, they need to calculate all the potential benefits, including costs that can be avoided.

Major factors which organizations need to consider as part of their investment case include the following:

1. Direct healthcare costs: Healthier workforces correlate to lower healthcare costs and reduced absenteeism

Although not included in the calculation of the economic value at stake globally, healthcare claims often account for the majority of an organization’s total employee health and well-being costs in countries such as the United States where employee health claims are subsidized by employers. In the United States, employers face an estimated $226 billion annually in absenteeism costs (approximately $1,695 per employee), largely driven by chronic health conditions that could be mitigated through preventive care and health programs. Conditions such as hypertension, heart disease, and depression cause substantial on-the-job productivity losses, exceeding $300 per US employee annually. Cardiovascular disease leads to the loss of $156 billion in productivity annually. US employees with untreated insomnia cost employers approximately $2,280 more per year than those without insomnia because of factors such as absenteeism, presenteeism, diminished performance, and higher rates of accidents and injuries.

A survey of more than 1,600 employer benefits decision makers in the United States (including C-level executives and human resources/benefits leaders) revealed that employers are preparing for medical inflation, with more than two-thirds budgeting for healthcare costs to grow at three times the rate of inflation.

Globally, total healthcare costs are expected to continue growing because of cost pressures such as those related to an aging population. In countries with universal healthcare, organizations currently avoid most of the direct costs of poor health, but this could change with increasing pressure on healthcare budgets and the tightening of fiscal wallets. For these countries, the goal will likely be to maintain quality and accessibility across health systems while controlling costs. Consequently, companies may be asked to pay for their employees’ healthcare, especially if the workplace is found to be a cause of ill health. For example, Japan introduced the Stress Check Program in 2015 to tackle an increasing number of work-related mental health disorders. The program requires workplaces with more than 50 employees to offer an annual stress survey and to facilitate consultations with a physician for those with high stress levels.

Many people with mental illness can continue working without relapse with appropriate support for their resilience. They can live their lives, support family, disperse stigma among colleagues, and contribute to [their] corporation and society. Society needs to realize that people with mental illness are an asset and not a cost. Tsuyoshi Akiyama, president, World Federation of Mental Health

More recently, the Chilean government introduced a mandatory evaluation of workplace environments and mental health in 2024 to promote the accountability of employers for their employees’ health. The Chilean Safety Association has taken a leadership role in this policy change by developing preventive medicine, launching affordable mental health for communities, and convening local organizations and leaders to collaborate on mental health (including the development of an annual Mental Health Thermometer).

At ACHS, we are committed to making Chile the country that best cares for its workers and their families. A critical part of this is addressing the mental health challenges that our country faces. We are deploying diverse mental health initiatives to care for the three million workers that we cover. In addition, we have extended access to mental healthcare for individuals in the communities that we serve. We hope that in doing so, we can create healthier communities with healthier families and, ultimately, healthier workers, improving companies’ climate and productivity. Juan Luis Moreno, CEO, Chilean Safety Association (ACHS)

Supporting employee health does not need to rest on employers alone and can be a joint public and private effort. There is no need for employers to reinvent the wheel: they can benefit from the expertise, infrastructure, and goals of public health stakeholders through partnerships, especially as these stakeholders may offer referral pathways. For example, employers may consider partnering with a private, non-profit, or public healthcare provider to offer on-site employee health clinics with a focus on preventive care. This could include cardiovascular, diabetes, cervical cancer, or mental health screenings that give employees easier access to care without taking paid time off. Employers can also consider one-off events, such as a day of optional flu or COVID-19 shots, eye examinations, or specialist training to prevent back injuries.

2. Productivity and presenteeism: There is growing evidence of a potential causal link between employee well-being and increased productivity and reduced presenteeism

While the global investment case for improved productivity and reduced presenteeism offers clear value, calculating the gain or ROI for a specific program within an individual organization can be more complex. The literature demonstrates, however, a correlation between employee well-being interventions and productivity improvements of between 10 and 21 percent. Research by the University of Warwick found that happier employees are more productive, while a recent University of Oxford study found that happier employees in a call center were 13 percent more productive. More high-quality research on the causal links is needed, but these early insights are promising.

3. Talent management: A focus on health can improve employee attraction and retention

Investing in employee health and well-being can boost employee retention. Mercer research shows that companies which foster a “culture of health” experience employee turnover rates 11 percentage points lower than those that do not.

Moreover, investing in employee health and well-being is increasingly important for attracting talent. Research from Saïd Business School finds that for many employees, factors contributing to their well-being—such as mental and physical health, work-life balance, and job satisfaction—are as crucial as traditional incentives such as salary. This is especially important for younger generations in the workforce, born between 1996 and 2010 (also referred to as Generation Z). A McKinsey Health Institute survey of more than 42,000 respondents found that at least a third consider physical, mental, social, and spiritual health resources when choosing an employer, with Gen Z respondents and those with lower mental health scores giving particular consideration to mental health benefits.

Employers may also wish to consider how to promote the health of older employees. Increases in life expectancy and advances in healthcare will extend working lives: by 2050, about 30 percent of the global workforce will be over 50 years old. Governments may raise the retirement age or rethink pension structures in response. Consequently, both public and private sector organizations should expect an increasingly multigenerational workforce and tailor their health and well-being programs accordingly.

Employers’ actions are ever more visible to stakeholders. Platforms such as Glassdoor, Indeed, Fishbowl, and Reddit offer employee insights into how organizations treat employees and support their well-being, potentially influencing the decisions of recruits, customers, and investors. Data from these platforms can be harvested to find out how employees may feel and why they quit. For example, a recent MIT study identified toxic culture at the top of a workplace as a meaningful factor in employee resignations.

Additional factors which employers may choose to include in the investment case for employee health and well-being:

4. Performance: A healthier, happier, and more engaged workforce boosts company performance and resilience

Research from the University of Oxford shows a direct correlation between employee well-being and an organization’s financial success. Companies with higher well-being scores consistently achieve greater valuations, higher profits, and superior returns on assets. For example, a one-point increase in employee happiness scores was shown to be associated with a $1.39 billion to $2.29 billion increase in annual profits. A hypothetical “Wellbeing 100” stock portfolio, based on data from Indeed, comprising the top 100 companies in employee well-being, has significantly outperformed major stock market indexes since the start of 2021, demonstrating that high well-being scores are linked to stock performance (Exhibit 4).

Moreover, today’s workforce needs to adjust to new roles and technologies in a shifting job landscape. The rapid pace of technological change can be overwhelming. It can contribute to job insecurity and require employees to continuously upskill and adapt by, for example, focusing more on creativity, problem-solving, cognitive flexibility, and emotional intelligence. The rise of remote working has blurred the lines between personal and professional life, creating a workplace culture that can enhance or harm employees’ well-being and productivity. A healthier workforce is a more resilient and adaptive workforce, better capable of navigating the uncertainties and challenges of a rapidly changing world.

5. ESG: Investors are increasingly seeing employee health and well-being as an important component of the ‘S’

Some employers may assess the impact on suppliers and partners when deciding how to invest in employee health and well-being. Prioritizing holistic health is not a task to be undertaken alone, not least because long-term health investment benefits business, the workforce, and society. Healthy individuals are more likely to contribute actively to their local communities—volunteering at the food bank, running for city council, coaching their child’s sports team, or shoveling a neighbor’s driveway.

ESG criteria are becoming important aspects of delivering business value. They help to enhance revenue growth, reduce risks, minimize regulatory intervention, and increase loyalty and productivity among employees. According to a 2020 McKinsey global survey, a majority of executives and investment professionals believe ESG programs deliver greater shareholder value and would pay a premium to acquire companies with a strong ESG track record.

To date, environmental and corporate governance issues have dominated the ESG agenda, but the social pillar—which guides how companies manage relationships with customers, suppliers, communities, and employees—is gaining consideration. Investors are increasingly paying attention to how companies manage employee health and well-being, recognizing their criticality to long-term organizational success. Also, there is growing scrutiny on labor practices, employee satisfaction, support for employees’ mental health, and thinking around workforce stability. Companies listed on benchmarks such as the S&P 500 index are now assessed not only on financial metrics but also on employee factors, such as job satisfaction, happiness, stress, and purpose at work. Similarly, stock exchanges, including the Hong Kong Stock Exchange, are developing ESG reporting guidelines that mandate disclosures on employee health and well-being metrics, such as working hours, rest periods, and equal opportunities.

6. Regulation and compliance: Regulatory environments may become more stringent, forcing employers to act

Around the world, governing bodies increasingly recognize the importance of employee health and well-being, and regulatory pressures are mounting. For example, the European Union has introduced stricter standards for workplace well-being, such as the European Framework Directive on Safety and Health at Work, the Strategic Framework on Health and Safety at Work 2021–2027, the Work-Life Balance Directive and the European Framework Agreement on Telework. EU regulations state that risk management within the workplace should encompass stress, thereby requiring psychological risk assessments and appropriate prevention methods. In the United States, the Occupational Safety and Health Administration (OSHA) increased penalties for workplace health and safety violations to $15,624 per violation in 2023, with non-compliance leading to hefty fines, lawsuits, and reputational damage.

Adherence to these regulations reduces compliance risks and enhances a company’s reputation as a socially responsible entity. There is increasing expectation from consumers, employees, and communities that organizations should be transparent about labor practices, diversity and inclusion, mental health support, and work-life balance. Companies that fail to meet these expectations risk losing their reputation and trust among employees and customers alike.

The time to act is now

By prioritizing employee and health well-being, employers can unlock substantial performance gains, achieve a healthier, more adaptable and more resilient workforce, and drive positive change in their organizations and communities. Employers should not wait. Decisive action taken today can secure a healthier, more productive future.

Well-being is the ultimate productivity multiplier. And when companies invest in their people’s well-being, it’s a win-win—creating workplace cultures where individuals can maximize their productivity and creativity, which in turn enables businesses to grow and maximize their impact. Arianna Huffington, author of “Thrive” and “The Sleep Revolution”

2: Current status of healthy workforces

No industry or demographic group is immune to employee burnout, exhaustion or poor health—though some are more affected than others.

With more than half of the working population reporting suboptimal employee health, change is imperative. Today’s workers face unprecedented challenges across sectors and geographies. Contemporary threats to health include a rise in mental health disorders and obesity; unmet needs from conditions such as diabetes, cancers, brain health disorders, and cardiovascular conditions; and concerns about how climate change will affect food security, infectious diseases, and access to healthcare.

A 2023 McKinsey Health Institute survey of more than 30,000 employees across 30 countries found that 57 percent of employees globally reported good holistic health (physical, social, spiritual, and mental health), while a fifth of people reported burnout symptoms. Only 49 percent of employees were “faring well” —meaning they had positive scores on holistic health and no symptoms of burnout. There are multiple drivers of negative and positive health, but it is clear that the current state of health in workplaces is associated with the choices that employers and societies make. It is within the power of executives to build both healthier workforces and healthier societies. Change is necessary and achievable, with many ways to improve health within employers’ control.

All industries need to improve workforce health—but some industries have surprising results

Based on the 2023 McKinsey Health Institute survey, this report reveals, for the first time, the state of holistic health across more than 35 industries (Exhibit 5). Encouragingly, in only 10 percent of the industries surveyed did more than a third of employees report burnout symptoms. In two-thirds of the industries, however, more than 20 percent of employees said they were burned out, while in no industry did more than 75 percent of employees say they were healthy overall.

What was measured From April to June 2023, the McKinsey Health Institute conducted a global survey of more than 30,000 employees in 30 countries (Argentina, Australia, Brazil, Cameroon, Canada, Chile, China, Colombia, Egypt, France, Germany, India, Indonesia, Italy, Japan, Mexico, Netherlands, New Zealand, Nigeria, Poland, Saudi Arabia, Singapore, South Africa, South Korea, Sweden, Switzerland, Türkiye, the United Arab Emirates, the United Kingdom, and the United States). The dimensions assessed in the survey included toxic workplace behavior, interpersonal conflict, workload, work hours, time pressure, work pressure, physical demands, role conflict, role ambiguity, job insecurity, self-efficacy, adaptability, access to health resources, leadership commitment, career opportunities, career customization, psychological safety, supervisor support, coworker support, authenticity, belonging, meaning, job autonomy, remuneration, person–job fit, learning and growth. Individual self-efficacy and adaptability were also assessed.

Employees reported higher rates of burnout symptoms and lower rates of holistic health in five industries (reported on their percentage of faring well): accounting, retail, agriculture/forestry/fishing/livestock, shipping/distribution, and arts/media/entertainment/recreation. Conversely, industries reporting good holistic health and low burnout symptoms (reported on their percentage of faring well) included human resources, construction, administrative and support services, education, and engineering/architecture. These results reflect a global snapshot of a specific point in time and should be interpreted as a potential opportunity for improvement (see sidebar, “What was measured”). They do not mean every farmer or artist struggles with health, and neither do they negate any of the hardships a carpenter or human resources executive faces. Instead, this research offers new data points for employers seeking ways to improve employee health.

The data analysis did not reveal clear global trends explaining why certain industries outperform others. Nor did any single aspect of health drag down the average of low-performing industries, such as may be expected of jobs that are physically or emotionally demanding. Instead, scores were generally low or high for all four dimensions of health.

The data also returned some examples that run counter to global trends. For example, while the health of front-line workers is generally worse than that of managers, people working in construction report high holistic health. In education and administrative support services, employees report low burnout symptoms with high job security, possibly offsetting higher financial instability.

The absence of consistent patterns across industries suggests that for both highly and poorly performing sectors, the drivers of workplace health are multifaceted and not easily attributable to specific roles.

Minority demographic groups form the majority and are scoring worse on overall employee health

A much clearer story emerges from an analysis of demographic data, such as gender, sexual orientation, neurodivergence, age, education, and income. Responses were not assessed for ethnic diversity because of restrictions in certain countries. This report reflects survey responses only; further contextual research is required to understand the underlying causes.

Respondents who self-identified as women, LGBTQI+, lacking a high school diploma, neurodivergent, or low-income reported lower holistic health and higher burnout symptoms compared to other respondents. Notably, these groups make up most of the sample, not the minority. Only 20 percent of the employees surveyed did not identify with at least one of these groups—groups that are often underrepresented on executive leadership teams. This report can only report outcomes; more research is needed to understand the reasons behind those outcomes.

Specific demographic findings include the following (Exhibit 6):

Exhibit 6

In the research model analyzed for both those aged 61 and over and the youngest working generation, the top two predictors for holistic health are self-efficacy and meaning. Drivers of burnout differ slightly: in this research, role ambiguity affects older workers most strongly, while a toxic workplace environment affects younger employees and the overall global cohort most strongly (Exhibit 7).

These disparities highlight the importance of understanding differences across age groups to support longevity in the workplace, because older employees bring valuable experience, stability, and institutional knowledge. Employers play a crucial role in helping employees adapt to longer lifespans by fostering age-diverse workplaces and developing products that meet the needs of younger and older employees. Research suggests that innovative workforce planning, including retaining older employees and making the most of their experience, can enhance organizational performance, while creating age-friendly jobs can help maintain a talented and diverse workforce.

Educational level: College or graduate-level education correlates with reported higher holistic health and reported lower burnout symptoms. Individuals without a high school diploma were 20 percentage points less likely to report good holistic health compared to those with graduate degrees (50 percent versus 70 percent). Research underscores the critical role of continuous learning and development in promoting overall well-being. Learning, development, adaptability, and self-efficacy are core predictors of holistic employee health and vice versa in the underlying research model.

Financial situation: The survey assessed employees’ financial situations based on financial status, financial stability, and remuneration. Only 41 percent of individuals with poor financial status reported good holistic health, compared to 76 percent of those with good financial status. Those reporting low financial stability reported 27 percentage points lower holistic health (47 percent versus 74 percent for financially stable) and more than 30 percentage points more burnout symptoms (38 percent versus 5 percent for financially stable). Remuneration is positively correlated with holistic health. People reporting positively on remuneration were 30 percentage points more likely to report higher holistic health than those reporting less positively on remuneration (70 percent versus 40 percent for lower scores on remuneration), and they also reported fewer symptoms of burnout.

Job insecurity: 45 percent of respondents with high job insecurity reported burnout symptoms compared to the global average of 22 percent. Research shows job insecurity leads to adverse effects in mental health (depression, anxiety, burnout) and physical health (back pain, headaches, high blood pressure).

Job type: Being a member of upper management seems to be both a blessing and a curse: 80 percent of these individuals reported good holistic health, but 24 percent reported burnout symptoms, which is higher than the global average of 22 percent. Front-line workers also reported higher burnout rates (26 percent), driven by exhaustion. The top three factors associated with positive holistic health for managers in this study are self-efficacy, meaning, and belonging. For non-managers, the top three are self-efficacy, adaptability, and belonging.

Caregiving can boost holistic health but is associated with more burnout symptoms

More people are working while raising children, and more workers are taking care of adults who require care. Globally, the survey found that 10 percent of employees care for someone with a mental or physical illness in addition to their paid jobs. As the number of caregivers in the workforce grows, their role in organizations becomes increasingly important. Employers can benefit by understanding how caring for others affects overall holistic health and burnout.

Caregivers were more likely to report higher holistic health (61 percent versus the global average of 57 percent), driven by experiencing better social and spiritual health (Exhibit 8). However, caregivers were also 17 percentage points more likely to report higher burnout symptoms (37 percent versus 20 percent for non-caregivers), primarily driven by exhaustion.

Exhibit 9

The opportunity is maximized by helping all employees across diverse demographics achieve good health

There is no one-size-fits-all solution; leaders must recognize and address the varying needs of different groups. By doing so, they can develop targeted interventions that enhance holistic health and reduce burnout. This approach may involve greater autonomy and empowerment for teams and individuals to manage their work and resources effectively.

Employers and employees need to work in partnership to improve health, as neither can realize the full benefits on their own. Employers who are not helping every member of their workforce achieve their full potential risk affecting the health and well-being of their employees, limiting their societal and economic contributions, and missing substantial value creation for their organization.

3a: Measuring the impact of investing

The return on investment in employee health can be measured with tailored metrics that go beyond traditional sickness absence, safety, and injury statistics.

Taking action: How executives can build the investment case for a healthy workforce

Many organizations offer multiple employee health and well-being programs, but the organizational value and ROI of these programs are often overlooked. Executives regularly struggle to answer the question, “Is our investment in employee health driving sustainable improvements in performance?”

This briefing provides frameworks and approaches to help organizations develop investment cases, strategies, and tailored action plans for successful health and well-being programs and highlights opportunities to use data and analytics.

No single KPI can measure the impact of employee health and well-being investment

Every industry or organization has its own unique characteristics, meaning there is no single KPI for measuring success. Metrics should be tailored to each organization’s specific needs. However, a tried-and-tested approach based on the principles described in Briefing 3B should work for most organizations, whatever their context.

1. Understand the status of employees’ health and well-being and the value at stake

Conducting comprehensive health and well-being surveys can diagnose workforce health needs

An S&P Global Corporate Sustainability Assessment shows that only 2.2 percent of assessed companies conduct employee surveys with a core focus on health and well-being. Smaller organizations can overcome potential funding barriers through free tools and training available from not-for-profit providers.

Ideally, employers measure aspects of direct health as experienced by employees (mental, physical, social and spiritual health, and burnout symptoms), their associated work experience outcomes (for example, engagement and satisfaction), and core work experiences (such as job demands and resources). These measurements identify both immediate outcomes and root causes. Employers can assess employee health using quick pulse checks, health assessments, automated text analyses of comments within annual people surveys, focus groups, or anonymized voluntary health data.

Calculate the investment case opportunity for the organization

Good-quality, evidence-based data on employee health and well-being should be combined with an investment case to guide the development of strategic health interventions (see Briefing 3B). Organizations can build an investment case for employee health and well-being by focusing on the value drivers identified in Briefing 1. Those sources of value for the global economy have been adapted into four drivers which can be used by any organization to calculate their investment case opportunity: employee output, talent management optimization, healthcare cost savings, and ability to attract investment (Exhibit 10).

Employee output: Employee output can be calculated as a combination of productivity, absenteeism, and presenteeism. Example metrics for each include efficiency of completing tasks, innovation rates, sales increase, and customer service sentiment (productivity), number of workdays lost to sickness (absenteeism), and lost time caused by physically present employees working at reduced levels (presenteeism). For example, offering free flu shots can give employers a potential immediate result in lower absentee rates. A 2021 cost-benefit analysis of employer-funded influenza vaccinations found that employers could have saved €10 ($10.82) per vaccinated employee per year between 2011 and 2018. Talent management optimization: Developing a strong employee value proposition can enhance talent attraction and retention and minimize employee turnover. This not only enriches company culture but also boosts business performance, as employees with longer tenure have between 12 percent and 30 percent higher output than newer employees.  Example metrics include average tenure (retention), days required from job posting to hire (attraction), and involuntary attrition (turnover). For example, industries that have a high number of workers in their first job, who are likely to leave because of burnout symptoms or exhaustion, may focus on digital mental health applications or other solutions geared to develop immediate resilience and track involuntary attrition. In contrast, for employees who are likely to stay a long time, virtual employee assistance options or chronic disease management programs may be more important. In either case, organizations may choose to measure ROI.

Additional elements

Major factors which organizations need to consider as part of their investment case include the following:

Direct healthcare costs: These include what an employee pays when seeking healthcare, what the employer covers under any employer-sponsored insurance, and any costs associated with work-related injuries. These costs are often major for organizations that have employees in economies with private healthcare systems. ESG premium: An organization that highlights good employee health and well-being as part of its culture and value proposition may make itself more attractive to investors, customers, and partners. Investment case for contractors and suppliers: Some organizations may also choose to include the impact on contractors and suppliers within their investment cases. Employers can also consider how to expand interventions in ways that benefit employees both within their organizations and within the broader local community. For example, executives in organizations with a global presence may consider how to invest in widescale health education outreach. One example is Bayer’s support for smallholder farmers, who represent 11 percent of their Crop Science’s divisional sales. The company is introducing access to health and nutrition education for members of their value chain (including farmers) in India, Indonesia, and Mexico. This initiative aims to improve health outcomes and productivity by directly supporting farmers and their associated communities.

Overall, to build the investment case effectively, estimates need to assess the value of making the investment (costs avoided and benefits gained) versus the cost of the intervention required to address the issue.

Exhibit 11 provides sample metrics that can be used to gather data on each of the drivers of employee output and talent management optimization, as these two elements are at the core of any business case.

Case study: Novo Nordisk provides support and targeted interventions to teams reporting high stress levels

Healthcare company Novo Nordisk regularly deploys a global survey to measure employee stress levels and mental health using validated screening questions. About 14 percent of the company’s 64,000 employees reported symptoms of stress in the 2023 survey. Managers of highly stressed teams receive support from organizational psychologists and are trained to use well-being tools effectively, adhering to the IGLO (individual, group, leaders, and organization) model. Stronger support interventions generally demonstrate a 20 to 30 percent decline in the number of employees reporting symptoms of stress one to two years after the intervention. Novo is now implementing a similar survey focusing on physical health, particularly pain.

Case study: On achieved 11.6x ROI annually ($2.9 million) through employee health intervention

Sportswear company On implemented an employee health intervention, via Kyan Health, to over 2,500 employees within the organization. The intervention gave employees access to a self-care library (including mediation, relaxation, and breathing practices), 12 coaching sessions, and internal well-being workshops. Since its launch in 2022, 1,240 employees have created accounts, representing approximately a 50 percent uptake. The intervention has gained the company $2.9 million annually (11.6xROI). This consists of $1.3 million in productivity gains due to a 5 percent improvement in presenteeism-related productivity loss, $1.1 million driven by a 30 percent reduction in voluntary attrition, and a $0.5 million reduction in HR costs to manage mental health cases globally.

2. Develop initiatives for a sustainable healthy workforce

Executives may consider how to use the baseline and investment case created using the above principle to develop a targeted intervention strategy aligned with the overall organizational strategy. When developing an initiative portfolio, organizations should consider their current initiatives to understand how much is currently spent on employee health and well-being, how effective they are, and where there is room for growth. The initiatives can be focused on direct employees or include suppliers and the wider communities from which the workforce is drawn.

Case study: Swiss Re’s metabolic health program targeted interventions based on an onboarding survey

Reinsurance provider Swiss Re partnered with Combe Grove (a metabolic health center) and Gro Health (a digital well-being platform) to deliver a pilot program focused on optimizing the metabolic health of its 1,100 UK employees. The intervention began with a survey on risk factors for metabolic ill health—the primary cause of many chronic diseases which today contribute to the majority of global ill health and deaths (including heart disease, diabetes, certain cancers, musculoskeletal diseases, and mental ill health). It asked employees about their motivations to participate. More than 220 employees participated in the survey, and many more have since accessed the diverse resource offerings, including a digital well-being platform focusing on nutrition, sleep, exercise, and mental well-being. Forty individuals (identified from the risk factor survey) participated in one-on-one health planning sessions and a further five completed a seven-day residential program with virtual follow-up support for 12 months.

With full pilot outcomes expected in May 2025, interim results indicate that the program is very relevant (59 percent of surveyed employees showed some degree of metabolic ill health and were highly motivated to improve this), and that the intervention is effective. High-risk participants achieved an average of 6 percent body weight loss, 20 percent improvement in blood fat profile, and 50 percent improvement in well-being, sleep, and diet quality. As well as these clinical improvements, wider program rollout post-pilot will aim to demonstrate on a broader scale the day-to-day impact many colleagues have noted: “My energy has increased;” “I’m sleeping better;” “I’m more focused at work.”

Case study: Novartis Foundation funded cardiovascular health interventions in Senegal

The Novartis Foundation funded the Better Hearts Better Cities initiative, which was designed to improve cardiovascular health in Dakar, Senegal. The program provided education about healthy lifestyles, including information about blood pressure, diet, physical activity, stress, and tobacco use and was delivered in collaboration with 18 companies, reaching 36,000 employees. Outcomes included hypertension screening of 21,000 employees and improved blood pressure for 34 to 39 percent of employees in six months.

3. Use pilots to test the effectiveness of an intervention

Pilots help organizations test interventions on a small scale before full implementation, helping to justify investments and refine interventions. They can compare intervention and non-intervention groups or assess pre- and post-intervention outcomes within specific employee subgroups or locations. Metrics such as adoption rate, direct impact on employee health and well-being (for example, anonymous and voluntary data on health scores), distress levels and burnout symptoms, cost analysis, and ROI can all be used to measure success. Investment returns can be measured by comparing the cost of the intervention with outcomes. Some companies also look at cultural ROI, such as improvements in employee sentiment or scores from experience surveys.

Case study: ASICS piloted a Movement for Mind intervention

To address the potential inactivity of desk-bound employees, often caused by insufficient time, facilities, or motivation to be active, sportswear company ASICS developed the Movement for Mind initiative. The program is an audio series with movement instructions for all fitness levels, aimed at improving mental health through a range of techniques. Participants listened to two 30-minute sessions per week for eight weeks. Initially piloted with 189 people (including but not limited to ASICS staff), the program showed clinically significant improvements in mental well-being (Warwick-Edinburgh Mental Well-being scale and WHO-5), low mood (PHQ-2 scale), and anxiety (GAD-2 scale). Of those taking part in the pilot, 71 percent said they felt happier and 70 percent reported being more active after completing the program. Following this successful pilot, the initiative recruited nearly 3,000 additional participants worldwide over an 18-month period.

4. Monitor employee health and well-being improvements over time

Regular, ongoing monitoring helps ensure that interventions are effective, identifies areas for adjustment, and helps organizations track progress and assess the impact of employee health and well-being programs. Depending on their starting point, organizations can tailor their approach. Those starting on this journey can begin with a few data points and refine measurement over time, while advanced organizations may be able to use advanced analytics and modeling, depending on their resource levels.

Case study: Wellhub shows that interventions become self-reinforcing when adoption rates are more than 20 to 25 percent

Wellhub, a wellness platform, connects clients’ employees to physical, mental, and nutritional interventions, such as local gyms and meditation apps. Tracking more than 15,000 employees over time, Wellhub found an average adoption rate of 15 to 25 percent, but clients in the top quartile achieved a 40 to 70 percent adoption rate and an average year-on-year adoption rate growth of approximately 42 percent. Wellhub’s study suggests that fostering a healthy workforce culture could increase the adoption of employee health and well-being interventions by up to 12 times compared to simply offering the intervention. The platform finds that interventions surpassing an adoption rate of 20 to 25 percent tend to be self-reinforcing. One possible explanation is that when at least one in five employees participate, a microsociety of participants forms, which starts changing the organization to become healthier. Practically, this means colleagues influence each other, share recommendations on helpful interventions, or invite each other to attend workout classes together—all of which help foster a thriving, healthy workforce culture.

Case study: Audi introduces Checkup program, reaching 10,000 employees

Audi, a German automotive manufacturer, began its Audi Checkup program in 2006 to enable employees to identify their health risks and help prevent chronic illnesses. More than 90 percent of employees opt in to the voluntary examination and preventive program. The 75-minute check-up includes blood tests, an electrocardiogram, biometry, tissue analysis, a lung test, an eye test, a hearing test, and the SF-12® Health Survey. Since 2006, more than 10,000 employees have taken part.

People and organization analytics are an important enabler of successful employee health and well-being strategies

Integrating employee health and well-being into core organizational strategies is crucial. Robust information management and people and organization analytics approaches help achieve this. Organizations often track financial and supply chain metrics, but many overlook comprehensive health and well-being data. However, rapid advancements in data infrastructure, analytics, and AI are helping to bridge this gap. A recent McKinsey global survey of more than 1,200 respondents found that 12 percent are regularly using generative AI in HR and seeing meaningful cost reductions. “Big data” can be collected and, provided it is of good quality and appropriate privacy standards are in place, can be used for predictive analysis. This could help guide decision making on effective interventions by providing a view of upstream drivers, real-time indicators, and key enablers to improve employee health and well-being. As data analytics evolve, now is the time to incorporate health metrics into organizational measurements.

Beyond analytics, high-quality AI-enabled systems can enhance employees’ understanding of health benefits, streamline onboarding and scheduling, and increase flexibility. They can even assist leaders in improving workplace interactions and provide real-time feedback to employees. Participation could be boosted by allowing employees to track their health status through innovative tools such as opt-in wearables. This not only promotes well-being but also fosters a culture of health within the organization.

Case study: Experian reduces global attrition, saving $14 million over two years, by using predictive workforce analytics

Experian, a data analytics and consumer credit reporting company, faced resignation rates 4 percent above the industry benchmark, creating a strain on growth and innovation. Initially, Experian looked to tackle this by focusing on recruitment and simply managing the high resignation rates, resulting in decreased attention to workplace initiatives for the existing workforce.

Subsequently, Experian turned to data analytics. By using HR data and in-house analytics capabilities, the company developed a solution that equipped global HR teams with advanced insights into employee needs and motivation, enabling tailored approaches to support employee health and well-being. The platform analyzes up to 200 employee attributes (including core HR and people data) to create a comprehensive assessment of the risk that employees will leave. HR teams can now make informed decisions on the most effective support for employees, reducing global attrition by 4 percent and saving Experian $14 million over two years.

Lack of data is not a constraint to acting

Lack of data should not be an excuse for inaction by executives. Organizations can tailor metrics to meet their unique needs much like individuals tackle improving their own health. They may start by measuring how much physical activity they do in a week, how many hours they spend on social media, or how much water they consume in a day. Any journey to improvement must start with a baseline. Executives have an exciting opportunity to leverage health metrics to improve sustainable performance, enhance employee well-being, and foster a thriving organizational culture.

3b: Developing an action plan

A portfolio of investments that address poor health and promote good health can unlock full workforce potential.

By taking decisive steps towards building a healthy workforce, organizations will not only benefit employees but also enhance performance. Executives often view employee health and well-being programs as a cost rather than a strategic opportunity with a positive ROI. This report aims to change that. But many executives would not know where to begin even if they were convinced of the need for change.

Where to start? Six principles to address employee health

Each organization has unique needs and opportunities to address employee health and well-being, based on size, organizational set-up, geographic spread, and level of resources. Here we suggest six simple principles each organization could follow to create a successful employee health and well-being intervention portfolio.

Understand the baseline and value at stake: As described in Briefing 3A, start by assessing the baseline health status of employees through surveys. Alongside the baseline, it is important for each organization to understand the potential value of revising a workforce strategy and the risks associated with doing nothing. Develop initiatives for a sustainable healthy workforce: One-off efforts will not build a healthy workforce. Achieving sustainable results requires a long-term, systemic approach with high-quality, evidence-based interventions. This should be complemented by a clear vision of what the organization is attempting to solve, leading to a targeted approach to improving health, in alignment with the overall organizational strategy. Short-term projects may yield immediate benefits, but real change comes from a complete plan that includes clear leadership behaviors and effective tools. The updated strategy can then build on current efforts, such as programs focused on diversity and inclusion and psychological well-being. This strategy should be sponsored by the board and empower lower-level teams to drive autonomous, aligned interventions. Pilot interventions to test and learn: Deploy, test, and learn. Set up pilot programs to try out and refine strategies. This allows for targeted testing, continuous improvement, learning from failures, and ensuring that only the most effective interventions are scaled. Begin with small, manageable programs addressing immediate needs to start building momentum and create longer-term impact. Interventions do not need to be complicated—simple actions, such as encouraging employees to take “movement breaks” during work or training managers to discuss mental health with their teams, can be highly effective. Shift away from offering reactive interventions at an individual level in favor of implementing more proactive interventions, especially those aimed at teams. Track three to five metrics to measure success: Start with three to five KPIs that drive workforce health and organizational performance, ideally ones already tracked or easy to implement. Refine these KPIs for optimal insights. Assess broader effects by updating the investment case and resurveying employee health. Use these insights to steer the strategy—whether that means stopping, redirecting, or scaling interventions. Systematic measurement validates the investment in a healthy workforce. Ensure leadership commitment and sponsorship: Real change starts in the boardroom with executives making employee health and well-being a strategic priority. Executives need to set the vision, hold themselves accountable, and integrate health and well-being into the core organizational strategy. They should also nominate an executive-team sponsor and a board sponsor as a signal of leadership commitment. The sponsor does not need to be the chief HR, people, or medical officer; it can be very powerful if another executive takes the sponsor role. Executives will need to be transparent in their communication and authentic in how they role model. They also need to participate in health initiatives to create a supportive environment where employees feel encouraged to engage and be open about their health challenges. Embed employee health into organizational culture: Creating a sustainable and healthy workforce is a long-term journey requiring a systemic shift in organizational mindset and culture. Employee health must be integral to everyday work life and embedded in daily practices, management analytics, leadership behaviors, the deployment of digital tools, policies, and values. This cultural shift demands continuous engagement, regular evaluation, and flexible interventions to meet needs as they evolve. This approach will help break down some barriers, such as privacy concerns from employees or stigma about mental health. Fostering a culture of health and well-being is not just about immediate outcomes; it is about building resilience and long-term sustainability in the organization.

As the executive sponsor of the well-being agenda at Standard Chartered, I believe that well-being at work is at the core of employee engagement and productivity. We want our people to feel able to bring their best selves to work and deliver sustainable high performance. I am passionate about using my role to help create a positive and healthy work environment. This means listening to colleagues about their needs and supporting them to build well-being-related skills such as resilience and adaptability, empathy, and personal energy management. Having an executive sponsor outside of the traditional HR setting demonstrates that well-being is for everyone and it’s a shared responsibility. Diego De Giorgi, Group Chief Financial Officer, Standard Chartered

Case study: Ikea Canada implements Wellness Days, reducing turnover from 35.0 to 24.5 percent

Furniture and home-goods company Ikea Canada found through its 2019 annual employee engagement survey that employees flagged up family obligations, personal illness, and stress, and they wanted a healthier lifestyle. In 2020, the company introduced Wellness Days, allowing employees to take 12 days off per year for personal illness or injury, supporting a family member with an illness or injury, taking care of a personal emergency, participating in a community event, volunteering at a not-for-profit organization, self-care, inclement weather, or spending time with loved ones or a new pet. In response to the COVID-19 pandemic, it partnered with the Mental Health Commission of Canada to introduce training and a digital program that develops self-care, self-leadership, resilience, and mindfulness practice. Executives have credited the focus on mental health with contributing to a drop in employee turnover from 35.0 to 24.5 percent.

Create a portfolio of evidence-based interventions for a sustainable healthy workforce

Many employers care deeply about their employees’ health and well-being, introducing interventions designed to help, including yoga classes, meditation apps, wellness days, and awareness campaigns. Often, however, the portfolio of interventions is not a coherent whole that significantly moves the needle to address specific workforce needs. To make interventions effective, employers need to understand and proactively address employees’ needs at the individual, team, and organizational level. Companies often provide ways to help individual employees, but mental health apps and gym access alone are not enough if systemic problems remain.

So where does a CEO, CHRO/CPO, CFO, or chief medical/health officer start to create a portfolio of effective interventions? How can leaders select the right evidence-based employee health and well-being interventions?

The ideal portfolio aims to address both immediate needs (reactive) and root causes (proactive) and is made up of a complementary mix of interventions, some of which are designed to help individuals and teams, some to reshape jobs, and some to change the organization (Exhibit 12 ).

The reason a portfolio approach is important is that work and health-related outcomes are influenced by both enablers and drivers. Enablers are the aspects that can provide positive energy, such as meaningful work and psychological safety. In comparison, demands are challenges at work that require sustained cognitive, physical, or emotional effort, such as toxic workplace behavior and role ambiguity.

Holistic health is most strongly influenced by enablers, such as the employee experience of having self-efficacy, adaptability, feelings of belonging, meaningful work, and psychological safety. Interventions that address these drivers include self-efficacy and adaptability training, purpose workshops, and psychological-safety leadership and team training. Other interventions to support holistic health include workplace nutrition programs, peer mentoring, job crafting, and physical-activity nudges.

In contrast, burnout symptoms are more strongly associated with demands, such as the employee experience of toxic workplace behavior, role ambiguity and role conflict. Interventions related to these drivers focus on eliminating toxic behaviors, making roles clearer, and helping teams and team leaders reduce confusion and role conflict. Additional interventions include offering high-quality mental health awareness training, managing teams’ ways of working, creating space for recovery, and adjusting roles to enhance control and autonomy.

The best place for an organization to start addressing demands and building enablers for employees is at the team and job levels. Notably, team-level drivers are predictive of both holistic health and burnout symptoms. Middle managers are crucial to team health and well-being, serving as the link between leadership and employees. Their engagement is vital for the successful implementation of employee health and well-being interventions. Empowering and training middle managers to prioritize the health and well-being of their teams can unlock employee growth and productivity. Investing in middle management pays off: research shows that organizations with top-performing middle managers generate three to 21 times more in total shareholder returns. Additionally, including employees in the decision-making process through surveys, focus groups, and well-being committees ensures that subsequent actions meet their needs and realities.

Case study: Vitality provides personalized health interventions to create a healthier workforce

Vitality is a health and life insurer whose well-being strategy for employees comprises five pillars—physical, mental, social, financial, and lifestyle—and features on-site health checks, mental health counseling, mental health awareness training for managers, lunchtime leadership walks, and life-stage-specific medical support. The Vitality Programme provides incentives and rewards for employees to take actions that support healthier living, and 72 percent of participants report that the program inspired them to make positive lifestyle changes. Vitality’s Next Best Action feature alerts members and employees to the one action that would have the biggest impact on their health, based on the results of their annual online health review, and directs them in how to make this change.

The organization’s focus on employee well-being has delivered a healthier, happier, more productive workforce, reflected in employee experience survey outcomes. Vitality research shows that employees who are highly engaged with the Vitality Programme lost 50 percent fewer days to presenteeism, recorded 28 percent fewer absences, and took 46 percent less time to recover from sickness.

Each organization is unique, and tailoring interventions accordingly is crucial for improving overall employee well-being. The good news is that this often involves investing smarter rather than more. To realize the full potential of their workforce, organizations should develop a strategic portfolio of health investments that address poor health and promote well-being. Leaders should commit to long-term, systemic approaches, supported by evidence-based interventions and proactive involvement at all organizational levels. True progress requires smart investment that tackles both symptoms and root causes, fostering a healthier and more productive workforce.

Conclusion

Employers should invest in and improve employee health to benefit their organizations and society.

Work is a cornerstone of many people’s lives. However, it should not leave people less happy, less healthy, or less fulfilled. Physical, mental, social, and spiritual well-being are intricately tied to work, productivity, and performance. Investing in employee health and well-being is both an ethical obligation and a strategic organizational imperative with tangible returns.

This report offers a plan that goes beyond the behavior of individuals. It sets out the mechanism for changing a company’s culture, addressing specific workplace requirements, and improving health and well-being at every level of the organization—thereby developing a healthier, more productive workforce. It shows why prioritizing a healthy workforce is essential and beneficial, as well as providing practical guidance that will help employers feel enabled and empowered to seize the opportunity.

Firstly, the case for investing in holistic employee health is substantial. With more than 3.5 billion people dedicating a substantial portion of their lives to work, the workplace plays a crucial role in fostering holistic health. Investing in health presents a global economic value opportunity worth 17 to 55 percent of average annual pay per employee. Organizations that invest are likely to reduce healthcare costs, enhance productivity, improve talent management, boost company performance, and strengthen organizational resilience. Increasingly, investors are emphasizing employee health and well-being as a crucial component of the social element of ESG criteria, recognizing its impact on long-term organizational success and shareholder value. Regulatory pressures are also mounting globally, with stricter standards and compliance requirements being introduced to ensure workplace well-being, such as those from the European Union and the United States’ OSHA. Applying these rules not only reduces the risk of breaking them but also improves a company’s reputation as socially responsible. This helps meet growing demands for transparency made by consumers, employees, and communities.

Good health is good work and good work is good health. Professor Sir Cary Cooper, CBE, Professor of Organizational Psychology and Health at the ALLIANCE Manchester Business School, United Kingdom

Secondly, disparities in holistic health and burnout symptoms across various industries and demographics underscore the need for tailored interventions. Employees who identify as women, LGBTQI+, younger, neurodivergent, or with lower levels of education or income report poorer health outcomes than their counterparts. It is therefore important to understand the root causes of poorer health and create inclusive workplaces. A one-size-fits-all approach will not reap the full rewards; leaders must recognize and address the needs of different demographic groups and develop targeted interventions that enhance holistic health and reduce burnout. Employers and employees need to work in partnership to improve health, as neither can achieve the best results on their own. Unless employers help all employees achieve their full potential, they risk limiting the health and well-being of their workforce, restricting their societal and economic contributions, and missing out on substantial value creation for their organization.

Finally, leaders should address workforce health by taking a strategic approach, committing to making smart investments that tackle both symptoms and root causes and measuring the impact of those investments over time.

Returns on investment can be evaluated using customized metrics that extend beyond the traditional markers of sickness, absence, disease, safety, and injury. A four-step approach to building an investment case requires employers to understand the status of employee health and well-being within the organization, calculate the investment case opportunity, use pilot programs to measure intervention effectiveness, and monitor improvements over time. Advances in data analytics and artificial intelligence (AI) offer substantial opportunities to integrate health metrics into core organizational strategies. For example, AI could be used to translate specific workplace safety information, customize health-emergency protocols for a building, or aggregate reputably sourced health tips and links into an employee newsletter.

Overall, leaders can benefit their organizations by recognizing that creating a healthier workforce is not an isolated goal but a foundation of organizational performance and resilience. By prioritizing employee health, organizations can transform work into a source of life enhancement, unlock human potential, and reap financial benefits. This report provides the evidence and tools for leaders to feel empowered and enabled to take those crucial steps today.