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Real Life Case Study - Metabolic Syndrome Mar 3rd, 2014

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The following Case study is taken from Exercise is Medicine e-Newsletter.

 

James is a 52 year old academic, diagnosed with Metabolic Syndrome in 2013.  He has never smoked and consumes an average of six standard drinks a week.

As a participant of a University of Queensland study, The Effect of Exercise Intensity on Metabolic Syndrome, James was prescribed supervised high intensity interval training (HIIT) for 16 weeks (3 sessions per week) on a cycle ergometer.  Each training session consisted of 4 x 4 minutes of cycling exercise at 85-95% peak heart rate (HRpeak), alternated with 3 minutes of active recovery at 50-60% HRpeak.  A 10-minute warm-up at 60-70%HRpeak and a 3-min cool-down was also conducted within each session. Throughout all training sessions, speed was maintained at 60-70 revs per minute whilst the load was adjusted to ensure that the prescribed target heart rates were met.

James has now finished the HIIT program and is continuing the program at home three times per week.  He attends a monthly HIIT session as part of the study until the 12-month testing follow-up. 

Results

After the 16-week HIIT intervention, James no longer meets the criteria for metabolic syndrome as shown on the table below.  He is no longer on cholesterol treatment.

James’ measurements against the risk factors* for Metabolic Syndrome: 

*Risk factors according to the International Diabetes Federation (IDF) criteria

The evidence behind the intervention:

High intensity interval training (HIIT) has been shown by a recent meta-analysis (including 10 randomized studies) to be superior in enhancing cardiorespiratory fitness in patients with lifestyle-induced cardiometabolic diseases (HIIT Vs. MICT; 19.4% Vs. 10.3%) (Weston et al. 2013).  Given the ability of increased cardiorespiratory fitness in attenuating traditional risk factors of cardiovascular disease (CVD) (Blair et al. 1996; Warburton et al. 2007), this finding proves to be clinically significant.  More specifically, in 2008, a pilot study by Tjonna and colleagues showed a greater improvement in cardiorespiratory fitness (HIIT Vs. MICT; 35% Vs. 16%) and a reduction in the composite number of CVD risk factors following HIIT (4x4min at 90%HRmax, 3x/week, 16 weeks) compared to an isocaloric MICT (70%HRmax, 47 mins) in 32 patients with metabolic syndrome.  Interestingly, nearly half (45%) of the patients in the HIIT group were no longer diagnosed with the metabolic syndrome after the 16-week program compared to only 38% in the MICT group, with this change only significant in the HIIT group. Furthermore, this study also revealed HIIT to have a greater impact in other physiological measures such as insulin sensitivity, mitochondrial function, and endothelial function compared to the isocaloric MICT


Physical Activity and Happiness Mar 2nd, 2014
Happy

To investigate the associations among changes in leisure-time physical activity (LTPA) and changes in happiness over a  12 year period. 17 276 Canadians were followed from 1994 to 2009. People who were inactive at baseline were more likely to be unhappy after 2 years and 4 years of follow-up than those who were active. Leisure-time physical activity was associated with maintaining happiness and avoiding unhappiness. Changes from activity to inactivity status from one 2-years cycle to the next were associated with changes from happiness to unhappiness.

Although the same principles of physiologic adaptation to exercise apply to nonathletes, the “motivation” factor is very different. Human-centered design holds great promise for the development of prevention programs because it incorporates patient preferences and desires as the programs are being developed.

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Job Strain as a Risk Factor for Physical Inactivity Mar 2nd, 2014
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Low job control and too high or too low job demands, have been suggested to increase the likelihood of physical inactivity during leisure time. The authors examine the association between unfavorable work characteristics and leisure-time physical inactivity in a total of 170,162 employees (50% women; mean age, 43.5 years). The odds for physical inactivity were 26% higher for employees with high-strain jobs (low control/high demands) and 21% higher for those with passive jobs (low control/low demands) compared with employees in low-strain jobs (high control/low demands). This data suggest that unfavorable work characteristics may have a spillover effect on leisure-time physical activity.


Predictors of Work Absence Following a Work Injury Feb 27th, 2014
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This study examined if the factors associated with days of absence following a work-related injury are similar for mental health versus musculoskeletal (MSK) conditions. Mental health conditions were associated with a greater number of days of absence over the 2 years following first incapacity compared to MSK conditions. Differences were observed in employment, injury and industry variables on absence from work for mental claims compared to MSK claims. Predictors of days away from work in the 2 years following an injury differ for mental health versus MSK claims.

 

 

 


World Health Organisation - Physical Activity Feb 27th, 2014

logoKey facts



  • Physical inactivity is the fourth leading risk factor for death worldwide.

  • Approximately 3.2 million people die each year due to physical inactivity.

  • Physical inactivity is a key risk factor for noncommunicable diseases (NCDs) such as cardiovascular diseases, cancer and diabetes.

  • Physical activity has significant health benefits and contributes to prevent NCDs.

  • Globally, one in three adults is not active enough.

  • Policies to address physical inactivity are operational in 56% of WHO Member States.

  • WHO Member States have agreed to reduce physical inactivity by 10% by 2025.



Employee Physical and Psychosocial risk factors Feb 26th, 2014
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While in recent years there has been a growing awareness among mining companies of the need to address physical injuries and environmental issues, there remains a lack of knowledge about how psychosocial risks independently and in conjunction with physical risks affect the health, general well-being and quality of life of mine workers. Responses from 307 participants showed mining equipment, ambient conditions, and work demands and control as being significant predictors of quality of life and general well-being after controlling for demographics. Age as a demographic variable also had important implications, with older workers experiencing better well-being and quality of life. Implications of findings for the mining sector in Ghana and other developing countries are discussed as a starting point towards developing further initiatives in this area.

 

Glen dealing with Stress of pool championships (see all 5 parts on youtube)



 

 



How high heels harm and how to make it better Feb 25th, 2014
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High-heeled shoes are thought to characterise femininity and beauty, making the wearer feel self-assured and elegant. But they also alter alignment of the feet, legs, and back, and can have long-term effects on posture and health.

Feet suffer considerably inside high-heeled shoes. The higher the heel, the more the foot slides inside the shoe and the greater the pressure and friction under the heel, the ball of the foot, and the big toe.

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Mitigating harm


Women who love high-heeled shoes are unlikely to stop wearing them, even if they become aware of the problems they may cause. So here are some suggestions to reduce the harmful effects of high heels:

choose a shoe with moderate heel height, no higher than five centimetres, and a fastening over the instep;

wear high heels for short periods of time, and take a pair of flat shoes or runners to change into if you have to walk a long distance during the day;

choose a shoe with a wide heel base, or a wedge heel, to reduce the load under the front of your foot;

avoid running in high-heeled shoes as pressure under the foot increases considerably when running, even at low speed;

use a shoe insert to reduce pressure on the forefoot and heel; and

do calf muscle stretching exercises every day to maintain ankle flexibility.

Reference:


http://theconversation.com/health-check-how-high-heels-harm-and-how-to-make-it-better



Raise the conversation on rising weight Feb 25th, 2014
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SINCE the mid-1980s the weight status of Australian children has changed significantly, with the prevalence of overweight doubling and obesity trebling at the start of the 21st century. The latest data estimate that approximately one in four Australian children is currently overweight or obese. Translating the current prevalence into real numbers, there are approximately 736,000 Australian children aged 5—18 years who are classified as overweight/obese (of which 222,000 are obese).  Tertiary paediatric obesity services in Australia are inadequate to meet treatment requirements of these children.

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The foremost question is whether society would accept a prevalence rate of 25% in other preventable paediatric disorders (e.g. pertussis, poliomyelitis, diphtheria)? Given the clear evidence that obesity during childhood increases obesity risk across the life course and lays down the foundations for developing myriad metabolic chronic diseases, it is difficult to understand criticism of proponents calling for better child obesity prevention investments. The prevalence of overweight/obesity is approximately 6% points higher among children from lower compared with higher socioeconomic backgrounds (~26% vs 20%). Similarly the prevalence is higher among primary school aged children from Middle-Eastern (~36%) and Asian (~28%) backgrounds compared with English-speaking counterparts (~22%), and among Indigenous children (~28%). There is a double burden for children from non-English speaking backgrounds living in areas of social disadvantage.

 


Reference:


http://www.medicalobserver.com.au/news/raise-the-conversation-on-rising-weight



Where does exercise time come from? Feb 22nd, 2014
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When people undertake a new exercise program, the time spent in other domains, such as sleep or screen time, must be reduced to accommodate the new activity. If someone starts jogging at lunchtime, for example, they will need to find time not only for the jogging, but also for changing into exercise clothes, showering and changing back into work clothes after the run. Where does this time come from? Which “time reservoirs” are drawn upon? This study aimed to investigate how previously inactive adults modify their time budgets when they undertake a new physical activity program.

Participants who did significantly increase their Physical Activity levels appeared to increase Active Transport and spend less time watching television/videogames by the end of the intervention period. 


Next - Time out for exercise


 



Preventing work disability due to work injuries Feb 22nd, 2014
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The process of returning disabled workers to work presents numerous challenges. In spite of the growing evidence regarding work disability prevention, little uptake of this evidence has been observed. This literature review and collection of experts’ opinion presents the evidence for work disability prevention, and barriers to evidence implementation. Some clinical interventions (advice to return to modified work and graded activity programs) and some non-clinical interventions (at a service and policy/community level but not at a practice level) are effective in reducing work absenteeism. Implementation of evidence in work disability is a major challenge because intervention recommendations are often imprecise and not yet practical for immediate use, many barriers exist, and many stakeholders are involved. 

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Suitable Duties - Some Care needed Feb 21st, 2014

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In the section on Modified Duties, or suitable duties, as they are called in the workers’ compensation arena the point is made that employers need to ensure the documents and other discussions surrounding the initial and ongoing offer of modified duties should reflect they are temporary and time-limited pending a return to the agreed position ie in most cases the pre-injury role.  The authors also note the length of time the modified duties are offered needs to be carefully considered and regularly reviewed to avoid suggestions that since the worker has been doing them for so long, it is not a burden for the employer to continue offering the modified duties and it is unfair to withdraw them. Keeping the following 5 steps in mind should assist in controlling the above risk:



  1. Assessing The Suitable Duties

  2. Establishing The Prognosis

  3. Documenting The Path

  4. Monitoring The Plan

  5. Reviewing The Plan


Central West Health and Rehabilitation's Employer Services division offers an Injury Managements System online assessment to help you check you are meeting your obligations. Contact us to know more.



400 annual diabetes diagnoses in young Australians Feb 19th, 2014
 

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AROUND 400 new cases of type 2 diabetes are diagnosed each year in Australian children and young people. And although the rates of new cases have largely remained stable over the last decade (2002–03 to 2011–12), the emerging burden of type 2 diabetes is a cause for concern, according to a new report by the Australian Institute of Health and Welfare (AIHW). The report is the first to document incidence and prevalence estimates for type 2 diabetes in children and young people.

The increase in type 2 diabetes in children and young people was attributed in part to high rates of overweight and obesity in these age groups. The incidence was found to increase with age – from three new cases per 100,000 population in 10–14 year-olds to eight per 100,000 in 15–19-year-olds and 16 per 100,000 for those aged 20–24 years.

Between 2006–11, the age-specific rate of type 2 diabetes for Indigenous Australians was eight times higher than non-Indigenous among 10–14-year-olds. As of June 2012 there were around 2200 children and young people aged 10–24 years diagnosed with type 2 diabetes. But the AIHW believes these figures to be an under-estimate, due to limitations of data collection such as undiagnosed diabetes, misdiagnosis between type 1, type 2 and monogenic diabetes in this age group, and misreporting. However, the study found no evidence of a rise in the rate of new cases of type 2 diabetes in young people over 2002–03 to 2011–12 and rates fell in the 20–29 year group.

“Given that type 2 diabetes is largely preventable, there is considerable potential for health, social and economic gains through effective actions based on the best available evidence,” the report stated.

 

Reference:

http://www.medicalobserver.com.au/news/400-annual-diabetes-diagnoses-in-young-australians


Promoting Exercise in the Workplace Feb 18th, 2014
The "EIM Physical Activity in the Workplace: A Guide" supports organisations in the promotion of physical activity in the workplace and to reduce sedentary behaviour. It is a collation of current evidence and best practice, including a toolkit of resources and audit tools.

Topics covered include:

Recommended levels of physical activitySedentary behaviourBarriers to increasing physical activityPromoting active transportEmpowering employees, andMaking physical activity a cultural fit.

The target audience includes senior management, human resource units, health promotion units and workplace health committees. It’s content and recommendations are applicable to small, medium and large organisations.

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The Process of Change Feb 16th, 2014
When it comes to health recommendations, we mostly know the drill:

TTM ModelExercise most days of the week;

eat a varied and nutritious diet;

keep your body mass index less than 25;

get enough sleep;

keep up with medical screenings for blood pressure, cholesterol, and blood sugar;

don’t smoke;

and limit alcohol to seven drinks a week.

Reducing stress;

improving relationships;

Developing new interests or hobbies.

When trying to change non-constructive behaviour it is important to remember that behaviour change is rarely a discrete, single event. During the past decade, behaviour change has come to be understood as a process of identifiable stages through which people pass.

People who are trying to change an unwanted habit or behaviour are more successful if they approach this process in an appropriate way depending on which of the five stages of the stage of change model their actions most closely resemble.



What is an Employee Assistance Program? Feb 16th, 2014
An Employee Assistance Program (EAP) is a work-based intervention program designed to enhance the emotional, mental and general psychological wellbeing of all employees and includes services for immediate family members. The aim is to provide preventive and proactive interventions for the early detection, identification and/or resolution of both work and personal problems that may adversely affect performance and wellbeing. These problems and issues may include, but are not limited to, relationships, health, trauma, substance abuse, gambling and other addictions, financial problems, depression, anxiety disorders, psychiatric disorders, communication problems, legal and coping with change.

The Employee Assistance Professional Association of Australasia (Inc)


Is the Peak Australasian Body representing provider and user members that supply Employee Assistant Programs in the workplace. In co-operation with employees and management, EAPAA members' primary objective is to provide the most effective employee assistance services to individuals and their families suffering from personal or work related problems, which negatively affect their work and wellbeing.



Are you considering Ergonomics in your Workplace Feb 16th, 2014
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All this talk of sedentary workers and reducing the risks posed to them has reminded me of the other risks for workers who may sit in the same position for most of their working day: poor posture and repetitive movements. Work duties that involve poor posture and repetitive movements, such as typing, can cause muscle fatigue and injuries to other soft tissue. For example, people working at desks for extended periods often adopt postures that lead to discomfort and injury over time, such as carpal tunnel syndrome.

Ergonomic design in your workplaceStretches

Ergonomics is the process of designing workplaces, equipment and systems so that they are suited to the user. This approach can be applied to numerous aspects of a workplace such as chairs, tables, keyboards, computer screens and telephones.Incorporate the principles of ergonomic design into your workplace. This may include, for example, purchasing office chairs that provide a headrest, adjustable height and adequate lumbar support.It is really important to take a 'proactive' rather than a 'reactive' approach to these types of hazards. This means that rather than responding to an incident when it occurs, you should look for and address areas in your workplace that are in need of improvement.You can also do small things in the workplace to reduce poor ergonomics such as:

Position desks and chairs so that the elbow is level with or slightly higher than the keyboard.

Place computer screens at an appropriate distance from the worker (between 350mm to 750mm) and at an appropriate height (the top of the screen should be just below eye level).

Remember, there are also lots of exercises your workers can do at their workstations to help reduce posture and movement hazards. Train your workers in methods like this and don't forget to train workers who work from home in these practices as well. Consult them about their needs, and ensure that any equipment you provide is appropriate and they are aware of potential hazards related to sedentary work, poor posture and repetitive movements, how to identify the hazards, and how to avoid them. 


Select your Injury Management Coordinator Feb 15th, 2014

Injury Management GuideAll employers must nominate an employee to have day-to-day responsibility for the Injury Management System – usually referred to as the Injury Management Coordinator.

In small business the owner often fills this role. A medium-sized business may designate the role on a part or full-time basis. Large businesses may need to appoint a number of Injury Management Coordinators across many sites.

Choose an Injury Management Coordinator carefully. An ability to communicate and develop rapport with a range of different people are important skills to consider when selecting the person for this role.

The Injury Management Coordinator will need your support to perform their role effectively. You should ensure they have access to relevant training, resouces and any other assistance required to carry out their roles.


Contribution of Age and Workplace to Exercise and BMI Feb 15th, 2014
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The workplace is an important domain for adults, and many effective interventions targeting physical activity and weight reduction have been implemented in the workplace. This paper reports on the distribution of physical activity and BMI by age in a population of hospital-based healthcare workers and investigates the relationships among workplace characteristics, physical activity, and BMI. Workers reporting greater decision latitude and job flexibility reported greater physical activity. Overweight and obesity increased with age, even after adjusting for workplace  characteristics. Sleep deficiency and workplace harassment were also associated with obesity. These findings underscore the persistent impact of the work environment for workers of all ages. Based on these results, programs or policies aimed at improving the work environment, especially decision latitude, job flexibility, and workplace harassment should be included in the design of worksite-based health promotion interventions targeting physical activity or obesity.

 



Love boosts health Feb 14th, 2014

Medical Observer


AUSTRALIANS shot by Cupid's arrow are the happiest and healthiest in the land — until they get engaged. After that things tend to get a bit stressful, particularly for the bride-to-be. But the honeymoon glow lasts longer than most people think.

Couples with up to two children and people in same-sex relationships are among the happiest and healthiest, according to the Alere Wellness Index made up of scores for exercise, psychological wellbeing, nutritional health, alcohol, smoking, medical conditions and body mass.Couples with three or more children aged under 16 have increased stress, according to the index, which is based on 50,000 surveys a year conducted by Roy Morgan Research.Men in a same-sex relationship are prone to drinking too much and putting on weight.Separated and divorced people are the least healthy, with poor psychological scores and high rates of smoking.

Single people, particularly women aged 35 –49, do worst on a psychological level, according to the index. But things improve for single people aged 65 and older.In general, people who describe themselves as planning to get married do more exercise than others and are less likely to smoke or drink to excess. 

The people in the best psychological shape are those aged older than 65 who are planning to marry. Younger engaged men and women are slimmer than other groups, but husbands-to-be perform less exercise and have a less healthy diet than average. Younger women also have better than average overall health but score badly on psychological wellbeing, with more than four in 10 engaged women saying they feel stressed.

Young Couple


List of Approved Workers Compensation Insurers Feb 13th, 2014

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Insurers are integral to the workers’ compensation system in Western Australia. They have a role in assessing claims made by workers, and indemnifying employers of compensation for accepted claims.

Approved Insurers


Effective Injury Management System Feb 13th, 2014
Injury Management Guide

All employers must have an Injury Management System. An Injury Management System is a written description of the steps you will take when there is an injury in your workplace. An employer is also required to develop a formal (written) return to work program for a worker when the medical practitioner:

advises the employer in writing that a return to work program should be established for the worker

signs a medical certificate indicating that the worker has partial capacity to return to work

signs a medical certificate indicating that the worker has total capacity to return to work, but for some reason is not able to return to the position held immediately prior to injury.

Employers are encouraged to read WorkCover WA’s Injury Management: A Guide for Employers publication which provides information to assist employers to understand their legal obligations and contains a three step approach to effective injury management.



Five men’s issues to watch - Medical Observer Feb 12th, 2014


WHAT'S ahead for men’s health? Here are five issues to watch as the year unfolds.

A focus on men’s health in Australia has been reinvigorated in recent years with the launch of the 2010 National Men’s Health Policy. But new issues continue to emerge, so it is important to remain vigilant in addressing areas of need. In particular, health issues facing younger males — including drugs in sport and pressures around body image — have gained growing media attention.


Sport

Until recently most us of may have thought the major male health issue around sport was participation levels. But 2013 was the year that performance-enhancing drugs and ‘supplements’ came to the attention of the mainstream media.

The health consequences of drugs in sport can get lost within the media hoopla and the drama of high-profile sports people implicated in these activities, plus the associated legal and sporting regulatory issues. And let’s keep in mind that what takes place in the elite levels of sport often propagates throughout the amateur ranks as well. The use and abuse of ‘recreational’ drugs and alcohol also has a long but not particularly glorious history in Australian sport. It will be interesting to observe how the major sporting codes will approach the use of social and performance-enhancing drugs in 2014 and beyond.

Body image

Recent evidence suggests that body image concerns are more prevalent in boys than previously thought, and that boys may manifest these concerns in a different manner to girls.

The finding that boys tend to be concerned about muscularity (rather than concerns about thinness observed in females) has significant implications for diagnosis and treatment of eating disorders in men and boys.

Dads get the blues too

Becoming a parent for the first time marks a major life milestone, and is also a time of significant lifestyle upheaval. Health professionals are beginning to recognise that the mother and the father both share the emotional and psychological impacts of new parenthood. Postnatal depression in men is now on the health agenda with support services being developed, albeit in the early stages.

Prostate cancer

Several promising new approaches to the diagnosis of prostate cancer are under investigation. While the venerable PSA is not likely to fall into disuse any time soon, we can look forward to a future where more specific markers for prostate cancer may play a role in diagnosis and management.

In the meantime, the use of the PSA test will continue to be a contentious issue, as will recommended treatment and management practices. Careful analysis of quality evidence must remain the cornerstone of this debate.

Erectile dysfunction

Erectile dysfunction (ED) is more than just old blokes worrying about their sexual performance. Men who experience ED face a higher risk of developing cardiovascular disease compared to men who do not. The degree of risk for a cardiovascular event after developing ED is said to be similar to that of current smoking or a family history of ischaemic heart disease.

While specific treatments to promote erectile function, usually starting with options such as PDE5 inhibitors, are effective, management of any identified cardiovascular disease or risk factors should follow a diagnosis of ED. It is hoped that awareness of the role of a man’s penis as a barometer for his overall health will become more widespread in 2014.

 


Safety management for heavy vehicle transport Feb 12th, 2014
Mooren et al (2014)Safety management for heavy vehicle transport: A review of the literature. Safety Science 62: 79–89

Big TruckThis paper reviews the literature concerning safety management interventions, that have been effective in reducing injury outcomes in occupational health and safety (OHS) and road safety, and assesses their applicability to reducing crash and injury outcomes in heavy vehicle transport. The operational and management characteristics that were associated with reduced crash and injury risk included: safety training, management commitment, scheduling or journey planning, size of organisation or freight type, worker participation, incentives and safety or return to work policies. Other characteristics that might be associated with lower incident and injury rates were risk analysis/corrective actions, prior safety violations, crashes or incidents, vehicle conditions or physical work environment, vehicle technologies, recruitment and retention, pay and remuneration systems, communications/ support, safety or quality management accreditation, financial performance, and worker characteristics and attitudes. The review also highlighted gaps in the literature requiring further research.


Pilates training results in improved flexibility Feb 12th, 2014
Pilates ExercisesSegal et al (2004)The Effects of Pilates Training on Flexibility and Body Composition: An Observational Study. Archive of Physical Medicine and Rehabilitation 85:1977-1981

Pilates training may result in improved flexibility. However, its effects on body composition, health status, and posture are more limited and may be difficult to establish. Further study might involve larger sample sizes, comparison with an appropriate control group, and assessment of motor unit recruitment as well as strength of truncal stabilizers.

 

 


Workers Compensation Insurance Policies & Premiums Feb 12th, 2014
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Workers’ compensation insurance protects employers from financial costs when a worker sustains a work-related injury or disease. It also protects injured workers by providing weekly payments to cover loss of earning capacity, payment of reasonable medical and rehabilitation expenses, and other entitlements.

Take out insurance

You can obtain insurance cover from any of the insurers approved by the Minister to underwrite workers' compensation insurance. It is important to shop around to get the best policy for your business.

Standard workers' compensation policy

All insurers are required to issue workers' compensation policies in an approved form. WorkCover WA has issued a Standard Employer Indemnity Policy (PDF - 70kb) which is the basis of all workers' compensation policies.

How your insurance premium is calculated

WorkCover WA determines and applies recommended premium rates to each industry classification, and updates the rates annually. However, insurers can discount these rates or load (increase) them by up to 75%.

In determining the premium rate for your business, your insurer will:
Request a wages declaration as the recommended premium rate applies to the aggregate amount of wages, salaries or other remuneration paid to an employer's workers

Assign an industry classification to your business - all premiums for a particular industry are calculated on the same rate

Examine the risk factors (claims history, safety and injury management policies etc) associated with your business

Discount the recommended industry rate by any amount, or surcharge it by up to 75%, depending upon an employer's individual risk factor

Insurers may surcharge more than 75% with approval from WorkCover WA, dependent upon the claims experience and risk associated with the operation of an employer’s business

Apply your premium rate. Only one rate applies for each ‘establishment’ - defined as a unit covering all the operations of a company conducted at or from a single location. If an employer conducts more than one industry at the same single location, the classification of the employer's predominant industry (based on gross remuneration) applies.

Adjust your premium following the submission of your actual gross wages, depending on whether the actual wages were more or less than the estimate you first provided. If you wish to renew your policy with the same insurer, you need to submit (on the same declaration) an estimate of gross wages to be paid the following year.