Do Workplace Wellness Programs Promote Discrimination?

The obesity epidemic is costing employers. Earlier this year, The Conference Board estimated that obesity-related health problems cost US companies an estimated $45 Billion each year in medical coverage and absenteeism - more than smoking or problem drinking.

Not surprisingly, employers and health care plans have long recognized the importance of promoting and perhaps even coddling employees into participating in "wellness" efforts. The idea is a no-brainer: healthier employees are more productive - a great investment for any company.

But with any good idea, the devil is in the details. The legal limits and potential for well-meant wellness programs (especially when promoted by health-care plans and payers) for promoting discrimination are discussed in a recent article by Michelle Mello and Meredith Rosenthal from the Harvard School of Public Health published in the July 10 issue of the New England Journal of Medicine.

In their analysis, Mello and Rosenthal focus on the impact of the nondiscriminatory provisions of the US Health Insurance Portability and Accountability Act (HIPPA) of 1996, which bars health plans and issuers of group health insurance from discriminating on the basis of a health factor.

The general rule is that no person can be denied or charged more for coverage than other "similarly situated" persons because of health status, genetic history, evidence of insurability, disability, or claims experience. In this context "similarly situated" refers only to an employment-based classification, such as full-time or part-time, not on health factors.

As a result of this, health plans can only opt not to provide coverage for particular health conditions, if this applies to all "similarly situated" individuals and is not based on whether or not people actually have that health condition.

While HIPAA is designed to prevent health discrimination, it does allow insurers and health plans to reward members for participating in health-promotion programs (e.g. reduced premiums, payouts, etc.) as long as the reward is open to all members (irrespective of whether or not they actually have a health problem). HIPAA, however, makes it particularly difficult for plans to tie these rewards to actually achieving an individual health target - i.e. it allow rewards for participation but not success.

In the rare cases that insurers do tie rewards to achieving health targets, there are important restrictions in place. In this regard, the provision that in cases where it is "unreasonably difficult" or "medically inadvisable" for a person to satisfy the health standard owing to a "medical condition" must be offered a reasonable alternative standard.

As pointed out by Mello and Rosenthal, the problem with this restriction is that no definition of "medical condition" is provided. So whether or not someone with overweight or obesity can be expected to achieve a target weight ultimately depends on whether or not the prior presence of excess weight is defined as being a "medical condition" or not - obviously, this leaves the room wide open for weight-based discrimination. It is certainly easier for someone with little excess weight to achieve an arbitrary "ideal weight" than for someone with a lot to lose - no matter that actually keeping the weight off becomes an exponentially bigger challenge the more you lose.

It is clear that whether or not excess weight in a given individual is caused by genetic predisposition, psychosocial factors, comorbidities or obesogenic medications, or, is simply a matter of poor "choices" and "sloth" will in most cases remain a matter of debate.

To me, the overall problem remains in the focus of employers, insurers and policy makers in general on the promotion of individual changes rather on than shifting society as a whole to a healthier lifestyle for everyone.

Given the multidimensional sociocultural, psychological and biomedical nature of obesity, answering "chicken and egg" questions or trying to pinpoint the primary causal factor is nigh impossible.

Perhaps one solution is to take "weight" out as a measure of health - either as a promoting factor or as a target.

As I have pointed out repeatedly, good health is possible over a surprisingly wide range of body weights and there is a wide variation in individual susceptibility to "weight-related" health problems. No one weight cuttoff will work for everyone - clearly, we have no idea what a good weight target should be, as our definitions of healthy weight are entirely defined on the presence or absence of comorbidites and/or functional limitations in a given individual or on actuarial morbidity and mortality statistics that, in turn, are simply not helpful when dealing with individuals.

I certainly do not envy the lawyers and policy makers who have to address this complex issue with "legalese". I am glad I am just a simple clinician helping patients conquer their obesity one step at a time.

Look forward to any comments on workplace wellness and its legal framework in Canada (or in Germany from my German readers).

AMS
Edmonton, Alberta

No Food For the Lazy!

Yesterday, newspapers reported widely about the UK conservative leader David Cameron calling on the obese, the idle, and even the poor to accept some responsibility for their plight.

According to Cameron, society has become "far too sensitive" to people's feelings, with no one prepared to say "what needs to be said." "We talk about people being 'at risk of obesity' instead of people who eat too much and take too little exercise".

Great stuff! So all fat people eat too much and are lazy - they deserve their plight! In other words, let's stop coddling them and let's certainly not bother providing them with any health services for their plight.

Perfect. Let's next stop providing services for all smokers who get heart attacks or cancer, no more trauma surgery for anyone who gets injured driving above the speed limit or, God forbid, gets run over jay walking. No more health services for anyone coming down with influenza who did not get his flu shot, no more medical freebies for people spraining their ankles at sports, and obviously definitely no more medical help with "lifestyle diseases" like diabetes, high cholesterol, hypertension, osteoporosis, osteoarthritis and back pain.

Everyone is the master of their own destiny.

Thank you Mr. Cameron for saying what needed to be said.

Anyone feeling depressed? Suck it up!

AMS
Edmonton, Alberta

The Pap Gap

Previous studies have shown that patients with obesity may not be receiving the same quality of health care as non-obese patients.

Reasons for this are likely to be complicated: yes, there is a provider bias - health professionals are likely to blame most complaints on the presence of obesity and perhaps not order the same tests that they may for the same complaints in a non-obese individual - on the other hand, patients with obesity may be more reluctant to go to their family physician because of embarrassment, frustrations about only being told again and again to simply lose weight, or fear of furniture or equipment that's too small.

How do these circumstances affect the rates of preventive screening?

This was addressed in a study by our own Rebecca Mitchell and colleagues from the University of Alberta, who examined the relationship between body weight and cancer screening in data from the 2003 Canadian Community Health Survey 2003. (The paper will appear in the August issue of the American Journal of Preventive Medicine).

Of the nearly 38,000 women participants, 82.6 percent reported having cervical cancer screening (Pap test) within the past three years. However, women with a BMI of 35 or higher, were nearly 40 percent less likely than others to have had a Pap test.

The findings were not explained by differences in socioeconomic status, health habits, chronic medical conditions or health care access. Reasons for less tests were more likely attributable to fear of pain, embarrassment or of finding something wrong.

Obesity did not alter mammogram or colorectal screening.

This study is only the latest in a number of studies that have looked at this issue before. Thus, Sarah S. Cohen and colleagues from the University of North Carolina in their review of 32 relevant published studies (10 breast cancer studies, 14 cervical cancer studies, and 8 colorectal cancer studies) found that in women obesity most likely is a barrier to screening for breast and cervical cancers whereas the evidence for colorectal cancer screening was inconclusive.

These finding certainly send a message to health care providers to be vigilant that their larger patients receive the same level of screening as their leaner patients - especially since obesity has been noted as a risk factor for both breast and cervical cancers.

AMS
Edmonton, Alberta

Employees' Obesity Costs Employers

This week, The US Conference Board released a report called "Weights and Measures: What Employers Should Know about Obesity" on the financial and ethical questions surrounding whether, and how, US companies should address the obesity epidemic.

Apparently employees' obesity-related health problems cost US companies an estimated $45 Billion each year in medical coverage and absenteeism - more than smoking or problem drinking.

Given the high costs of obesity, the report estimates the return on investment for employee wellness programs from zero to $5 per $1 invested. ROI aside, these programs may give companies an edge in recruiting and retaining desirable employees. The report also looks at the issue of awarding employees cash and prizes for weight loss rather than devoting resources to long-term wellness programs.

Interestingly the report also discusses the benefits of paying for employees' obesity surgeries. Apparently 9% of the US workforce would be eligible for such surgery, but because people often change jobs (e.g. in the retail industry), employers may not always recoup the full costs of supporting obesity surgery in their employees.

One big concern of course is how employers can address this issue without seeming intrusive or discriminatory. It is recommended that companies should involve employees in planning health initiatives, rather than working from the top-down, and should make sure personal privacy is protected.

While this report focuses on the US, and for obvious reasons cannot directly be transferred to the Canadian situation with its more or less universal health coverage, it is unlikely that obesity, at least with regard to absenteeism and early disability, is any less expensive to Canadian employers.

While preventive "wellness initiatives" may work for the 3/4 of the workforce, which does not yet have obesity, how do you provide effective obesity treatments to the employees who already have the problem?

Allow me to offer a few pointers:

1) Inform employees about evidence-based treatment options for this condition.

2) Encourage employees to seek treatments for obesity like they would seek treatments for any other chronic disease (e.g. diabetes, hypertension, etc.).

3) Supplement costs for evidence-based obesity treatments (including behavioural interventions, special diets, medications and surgery) as prescribed by qualified health professionals.

As I have blogged before - we may not have a cure for obesity - but we sure have treatments that work!

AMS
Edmonton, Alberta

How Far Will You Travel for Obesity Treatment?

One consequence of the rapid increase in obesity is that the vast majority of Canadians cannot rely on local facilities or expertise for obesity treatments. As a result, patients often have to travel long distances or even across borders to seek obesity treatments.

For example, our program has over 300 patients from other provinces awaiting assessment and hoping for treatment.

This throws up a number of logistical but also practical issues: how do you provide cross-border management for a chronic disease?

It is one thing to fly across the country to consult an expert for a diagnosis of a rare condition or a one-time specialized procedure. But what do you do for a common condition that requires on-going lifelong management? How do you provide education, counseling, monitoring and support across 1000s of kilometers?

Sure there are telephones, internet and telehealth but this does not entirely replace the need to actually see and examine a patient face-to-face.

Remember, obesity is a complex and heterogeneous condition - patients may require 10s of visits with a whole array of health professionals to determine the best treatment plan. Successful obesity management requires continued intervention and monitoring to keep the patient in remission. Early signs of relapse need to be recognized and dealt with to prevent weight regain. Surgical patients need band readjustments, dietary counseling and psychological support.

Much of this is theoretically possible across distances with modern communication technologies but in reality often impractical and inefficient.

On the other hand, how do you refuse to see patients who are clearly in dire straits for whom no local help is available or forthcoming any time soon?

Frankly, I see no alternative to rapidly ramping up obesity care across Canada - this will take both time and resources but most of all a change in attitude: ignoring obesity is no longer an option - limiting efforts to prevention is not helping the millions already struggling with this condition.

AMS

Obese Folks: on Your Feet!

One of the most common accusations faced by people with weight problems is that they are simply lazy and just lack the motivation to be active (the other one is that they simply eat too much!).

It turns out that some obese people may in fact be less active than lean individuals. For e.g., a recent study by Darcy Johannsen and colleagues from Iowa State University published in OBESITY, used state-of-the-art activity monitoring technology (IDEAA) to examine in detail the activity patterns of 20 free-living lean and obese women over 14 days. Total energy expenditure was measured using doubly labeled water, body composition was measured using dual energy X-ray absorptiometry.

The main finding was that even after correction for increased body mass, obese women on average expended around 300 KCal less in physical activity per day than their lean counterparts. Overall, obese women sat 2.5 hrs more each day and stood 2 hrs less than the lean women. They also spent only half the time being physically active compared to lean women.

This finding is not new. Previous studies have noted that obese individuals spend less time on their feet and expend less energy through non-exercise thermogenesis (fidgeting). Importantly, intervention studies have shown that this is not corrected by weight loss - rather, the tendency to be less active appears to be innate, i.e. not due to the excess weight.

Well, as usual, Johannson and colleagues conclude their paper with the profound insight that if only obese women adopted the activity pattern of lean women, they wouldn't be obese - and that is where the logic breaks down.

In fact, this is very much like saying that, "if only depressed people could be less sad and, like "normal" people, show more interest in things, they'd be so less depressed".

The issue is not whether or not obese people move less - the question is why they do so. If the tendency to be less physically active and spend less time on their feet is innate - i.e. a character trait that is determined largely by genetics, then trying to get someone with this trait to be more physically active is likely to be difficult.

Perhaps one way of thinking about this is to reverse the argument. If, for a moment, we assumed that being lean was really the problem, then we'd have to teach lean people to really try to sit down more and to focus on being less active, so that they could gain weight. Anyone who believes that it would probably be difficult to teach lean people to sit still, to stop fidgeting and to simply be less active, should realise that for exactly the same reasons it may be unreasonable to expect the opposite of people with excess weight.

Not to say it is impossible - but in both cases it would take a special focus, a lot of resolve and perhaps constant reminding as it goes against their "natural" disposition.

While in today's obesogenic environment the natural disposition to fidget and rush around works to the advantage of lean people, the natural disposition to sit down and not rush around (indeed a "sensible" behaviour in a calorically frugal environment) is a handicap.

Again, the results of such studies should not be interpreted in the sense of: "Aha, so now we know what is "wrong" with people who have obesity - they are indeed lazy!". Rather they should be interpreted in the sense of: "Aha, so that is why people with obesity have such a hard time keeping their weight off - they are simply "programmed" against a senseless waste of energy".

This of course is not an excuse to do nothing - it just means that we must appreciate the extra effort that is required.

In other words, when lean people run around - that's just their nature, they can't help it - it's not because they are extra smart or better people. In fact, now that we have seen this research we should realise that when people who have obesity run around (even a little) this is certainly highly commendable, as we now know that they have to consciously make this extra effort despite their innate tendency to preserve energy.

Creating an environment that fosters time on your feet will serve everyone - the lean people will love it (or not care), those with weight problems will benefit without having to make a conscious effort. Time for more stand-up meetings?

AMS

Don't Shoot the Messenger

Here is an interesting Editorial in the Globe and Mail on not being judgmental about people with obesity. The author is Irving Gold, Chairman of the Canadian Obesity Network's Board of Directors.

The editorial speaks for itself and there is little point in repeating it here.

The reason for my post is mainly to point out the interesting discussion with 100s of comments that were provoked by this Editorial. The range of comments very much reflects the nature of the current discussion on obesity by the general public and nicely shows how emotional people can get when discussing this subject (both on the pro and con side).

To me, the increase in obesity has always been just a symptom of living in an obesogenic environment.

The fact that this environment affects some people more than others is not different from other situations, where for the same level of exposure some suffer the consequences while others get home free.

Not every smoker gets a heart attack, not everyone who eats a ton of salt gets a stroke and not everyone who breathes in polluted air gets an asthma attack. But yes, more smoking means more heart attacks, more salt means more strokes, more pollution means more asthma.

Similarly, not everyone who indulges in junk food or lies on the couch becomes severely obese. In fact, we all know people (I call them the mutants), who can eat ridiculous amounts of food and never seem to gain a gram of fat. In fact, there is a whole "weight-gain" industry out there catering to young men who are tired of having sand kicked in their face by the jocks.

Obviously, the people likely to be affected most by our obesogenic environment are those that have familial, emotional, sociocultural or medical reasons for eating too much and not moving enough - the same people, who would have been the largest even 100 years ago. They are the magnifying glass through which we fully realise the profound impact of our environment on population weight.

The fact that we have more people with obesity is sending us a clear message: let's clean up our act and address the issues that are causing our obesogenic enviroment and provide help to those who are struggling the most.

Don't shoot the messenger!

AMS