A Review of the Financial and Productivity Implications of NOT Managing Cardiometabolic Risk

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A Review of the Financial and Productivity
Implications of NOT Managing Cardiometabolic Risk
George C. Carpenter IVPresident CEOWorkWell
Systems Inc.

• Midwest Business Group on Health
• November 15, 2006

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Obesity Trends in U.S. Population
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Sources CDC, NHANES, National Center for Health
Statistics
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The diagnosis is simple

• 3500 kcal 1 pound
• Average calorie surplus per person 150 kcal/day

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The prescription is simple

• Eat less
• Exercise more

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The prescription is simple ... and WRONG
Weight of evidencewhat works/what doesnt
results not statistically significant
Sources compiled from Eliosoff 1997, Sjostrom
2000
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So why blame the victim?
Ron Barrett, New York Times -- Health, October
29, 2006
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Why its a C-suite issueWorkforce of the
future
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Workforce of the future Older
45 and over working population
Fastest growing population 55
Source U.S. Bureau of Labor Statistics, 2005
Source RAND Corporation, 21st Century
Workforce, 2004
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Workforce of the future Older...and feeling it
Obesity increases chronic disease as much as
aging 20 years
Source Sturm Wells, RAND Corporation, The
Health Risks of Obesity, 2005
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Workforce of the future Fatter
The new minoritynormal weight active
employees
1987 2001 2010
Sources K. Thorpe et. al., Health Affairs
W4-480 10-20-04 Tom Gilliam, PhD,
HealthyBodyWeight.com, 2005
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Workforce of the future sleepier
Probability of obesity based on average hours
slept/night vs. 7 hour/night baseline
Source James Gangwisch, Columbia University,
11/16/04
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...and paying more in health care costs
Medical costs for obese employees outweigh those
of healthy weight employees by 77, according to
a new white paper by Michigan-based health
coaching company Leade Health. Medical costs
associated with obesity cost U.S. businesses
about 8,720 per patient per year.
Source Medical Expenditure Panel Survey, 1998
Source BenefitNews Connect, April 18, 2006
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The problem moral weakness or biochemistry?
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Three control points for obesity
Body Weight
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Caloric Restriction Lifespan
Remarkable studies of chronic disease reduction
Animal studies 25-35 caloric reduction
eliminated cancer risk Significant reductions in
cardiac disease, signs of aging Human trials
(bio-markers of aging) 6 month trial
findings Contributes greater health benefit than
exercise--reduced fasting insulin, core temp, dna
damage from free radicals 2-year randomized
trial begins soon
Source Dr. Eric Rovisen, Pennington Biomedical
Research Center, 2006, in NPR Science Friday
4/14/06
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Werent we hungrier in the 70s?
Number of large-size fast food portionsby year
of introduction
Source Young Nestle, American Journal of
Public Health, 2002. Vol.92 pp.246-249.
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The supply side biggest factor in obesity
Since 1980, calories consumed per day for the
average American have increased by at least
150kcal/day, with most of these excess calories
consumed outside the home and outside of regular
mealtimes. -- Cutler, Harvard University,
2003 The increase in the per capita number of
restaurants makes the largest contribution to
trends in weight outcomes, accounting for 69 of
the growth in BMI. For example, a 10 increase
in the number of restaurants in a given area
increases the number of obese residents by 9.
-- Shin-Yi Chou et.al., An Economic Analysis of
Adult Obesity, Working Paper 9427, 2002 Were
not competing with the other fast-food companies.
Were competing with your refrigerator. --
Steve Reinemund, Pepsico, 1988.
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Emerging clinical researchthe biochemistry of
fat

• Why food makes us hungry and fat makes us
  fatter

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Why do you think they call it Dopamine?

• Active hormones which mediate this exchange
• Serotonin
• Ghrelin
• Adiponectin
• Dopamine
• GABA
• Glutamate

Hypothalamus
I want to look great, feel great, and live forever
I want that chocolate cake NOW!
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Food makes you hungry The pharmacological
properties of food

• Predictable dose-response
• Can regulate or disregulate brain chemistry
  (and behavior)
• Powerful mood-altering effects
• Disregulating effects stress hormones increase
  appetite
• Mediated by specific hormones
• Toxic at certain threshold
• Quitting cold turkey is not an option

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The hedonic response omnipresence of food
--even dieting-- stimulates appetite
Homeostasis is the state of being in balance --
e.g. the point where one is satisfied with a
neutral energy balance (calories ingested minus
calories expended 0). When the body perceives
a net calorie deficit, it stimulates
appetite. Ever try the See-Food Diet? Hedonic
compensation one promising area of
investigation is now looking at how visual,
aural, and olfactory messages about food affect
our consumption. PET scan research is making the
brain chemistry more evident similar regions of
the brain are activated when subjects are simply
discussing, thinking about, or being near food as
are stimulated when actually consuming it.
Seeing food without eating it creates a
perceived deprivation -- as we see/hear/smell
food being consumed by others, even on TV, our
appetites are genuinely stimulated to catch up.

Source Lowe Levine, Obesity Research, 2005
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Visceral fat is biologically activeFat makes
you fatter

• Visceral fat now considered the bodys biggest
  endocrine organ
• Activates hormones which suppress immunity,
  stimulate appetite and fat storage
• Major contributor to acceleration of morbid
  or super-obesity

• Eating is largely driven by signals from fat
  tissue, from the gastrointestinal tract, to the
  liver. All those organs are sending information
  to the brain to eat or not to eat. So, saying to
  an obese person who wants to lose weight, All
  you have to do is eat less, is like saying to a
  person suffering from asthma, All you have to do
  is breathe better. -- Dr. Arthur Frank, GW
  University
• This is not debatable. Once people gain
  weight, then these biological mechanisms which
  were beginning to understand, develop to prevent
  people from losing weight. Its not someone
  fighting willpower. The body resists weight
  loss. -- Dr. Lou Aronne, Chairman of NAASO
• Source Dr. Arthur Frank, Director of GW
  University Weight Management Program Dr. Lou
  Aronne, Chairman NAASO, 2004

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The cost corporate performance

• How cardiometabolic syndrome impacts employers

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The cost to companies
Cathy Guisewite, October 28, 2006

• Obese workers have the highest prevalence of
  work limitations (6.9 vs. 3 among normal-weight
  workers), hypertension (35.3 vs. 8.8),
  dyslipidemia (36.4 vs. 22.1), type 2 diabetes
  (11.9 vs. 3.2) and the metabolic syndrome
  (53.6 vs. 5.7).
• Overweight and obesity also have been linked to
  increases in healthcare costs. In 1998,
  overweight and obesity-attributable healthcare
  spending accounted for 78.5 billion, or 9 of
  total medical expenditures. Among adults younger
  than 65, healthcare expenditures were 36 higher
  among obese as compared with normal-weight
  persons.

Source Robin Hertz, Ph.D. et.al., The Impact of
Obesity on Work Limitations and Cardiovascular
Risk Factors in the U.S. Workforce, JOEM vol. 46,
No. 12, Dec 2004
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Workplace impacts

• beyond health care costs

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Excess health risk excess cost
Excess Cost () 36 38 29 24 41
Total Medical Rx Absence Workers
Compensation Short Term Disability
0 625 1,250 1,875 2,500
Base Excess Cost
Sources Wright, Beard, Eddington. JOEM 44(12)
1126-1134, 2002
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Productivity losses per employee --selected
conditions
Obesity is associated with 39 million lost work
days and 239 million restricted activity days
Additional Absence Short Term Disability
costs per employee
Sources MedStat, Inc., Institute for Health and
Productivity Management, and Lynch Consulting,
2004
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Obesity, fatigue drivingHigh BMI drivers have
over twice as many accidents
Trucking Accidents/10,000 miles
Source R.A. Stoohs et.al., Stanford University,
Traffic Accidents in Commercial Long-Haul Truck
Drivers The Influence of
Sleep-Disordered Breathing and Obesity, 1994.
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Obesity and workplace performanceadvancement
and pay discrimination?
Prior studies generally have found that obese
workers have lower wages that cannot be explained
by variation in worker productivity. The
underlying implication is that obese workers,
particularly women, face significant labor market
discrimination. NBER, Why Obesity Lowers Wages,
2005 Self-report studies show substantial
changes in perceived discrimination after
bariatric surgery. In one, 87 of pre-surgical
patients reported that their weight prevented
them from being hired for a job, 90 reported
being stigmatized by coworkers, 84 avoided being
in public places because of their weight, and 77
reported daily depression. Fourteen months after
surgery, every patient reported reduced
discrimination, most reported rarely or never
perceiving prejudice after surgery, and 90
reported substantially increased cheerfulness and
confidence.
On average, wages of mildly obese women were 6
lower than standard weight counterparts, 24
lower for morbidly obese women. Its
understandably tough to get companies to study or
admit to discrimination issue regarding obesity,
so one group of researchers flipped the question,
quantifying bariatric surgery patients
experience with workplace discrimination before
and after major weight loss
Source Kelly Brownell, PhD., Stigma and
Discrimination in Weight Management and Obesity,
The Permanente Journal, 2003
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Withdrawal behaviors Obesity, Absence and
Disability

• The absenteeism measure in this study was the
  number of work-loss days. This measure was
  significantly associated with severe obesity,
  corroborating other previously reported findings.
• Interpersonal relationship problems could be
  related to decreased motivation for individuals
  to spend time at work. When obesity extends into
  severe obesity, the associated social stigma and
  reduced quality of peer interactions could
  produce higher levels of absenteeism.

Source Nicolaas Pronk, Ph.D. et.al., The
Association Between Work Performance and Physical
Activity, Cardiorespiratory Fitness, and Obesity,
JOEM vol. 46, No. 1, January 2004 p. 23
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What can be done about cardiometabolic risk -- as
individuals?

• (1) Treat the symptoms diabetes, hypertension,
  high cholesterol, etc.
• (2) Treat obesity as root cause of metabolic
  syndrome -- design benefits accordingly

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Diet, exercise and adherence decay
12 month adherence decay formost popular
commercial weight loss programs
Source Michael Dansinger, MD, JAMA, January 5,
2005 Vol. 293, No.1 p.47
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Behavioral approaches to obesity management the
true cost to the workplace
Fat people are more reviled than ever,
researchers find, even as more people become fat.
When smokers and heavy drinkers turned pariah,
rates of smoking and drinking went down. Wont
fat people, in time, follow suit? Research
suggests that the stigma of being fat leads to
more eating, not less... Once weight is due to a
personal failing, a lot of things follow.
Theres the attitude that if you are fat, you
deserve to be stigmatized. Maybe it will
motivate you to lose weight. The opposite
happens. In a paper published October 10th in
Obesity, Dr. Brownell and his colleages studied
more than 3,000 fat people, asking them about
their experiences of stigmatization and
discrimination and how they responded. Almost
everyone said they ate more.
Source New York Times -- Health, October 29,
2006
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Drug therapies for weight loss
Currently approved weight-loss medications
Weight loss pharmaceutical pipeline
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Explosive growth in bariatric surgeries
U.S. Bariatric Surgery Trend1992-2003
Source American Society for Bariatric Surgery,
Health Plans Emerging, 2005
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Corporate approaches to cardiometabolic risk
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One solution Retreat!finding a healthier
workforce
Wal-Mart Internal Board MemoOctober, 2005
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Another solution Engage!making a healthier
workforce
Best performing firms invest more in
lifestyle/obesity management programs
Source 10th Annual National Business Group on
Health/Watson Wyatt Survey Report, 2005
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Conflicting evidence
Wellness doesnt matter - Limited impact on
large employers with high turnover and/or mobile
populations - Virtually no impact on small
employers (the largest part of the U.S.
economy)
Wellness matters - ONLY way to maintain body
mass over long term - ONLY way to scalably deploy
prevention (risk profile gt budget allocation)
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Prevailing solutions to cardio-metabolic syndrome
in the workplace
Questions we have to ask 1. Are these
approaches truly promoting a healthier workplace?
(both physical and mental health?)2. Are they
consistent with Evidence Based Medicine?
Value-Based Purchasing?
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The Good News about management of
cardio-metabolic syndrome

• Most of what we know is wrong
• Health care cost inflation is structurally
  inherent -- requires structural change

• Obesity is not a moral weakness, it is a
  progressive disease
• It requires significant personal resources
  (time, , support of family work) and
  constant attention to combat
• In an obesogenic (food-rich/exercise poor)
  environment, obesity is inevitable
• The coming demand wave meets fee-for-service
  medicine -- inflation is inevitable
• Many solutions exacerbate the problem -- e.g.
  corp-sponsored weight loss

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The Good News about management of
cardio-metabolic syndrome

• And why, again, is this GOOD news?
• Bad solutions crowd out research, investment in
  good ones
• Good solutions are coming six sigma, EBM, and
  Freakanomics
• the future is already here, its just not
  evenly distributed -- Paul Saffo,
  Institute for the Future

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Good solutions are coming
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Evidence-based solutions
Best prevent overweight Next best aggressively
deal with obesity

• Controlled environment it works for the
  Biggest Loser
• limit access to poor food choices -- e.g.
  Pitney Bowes, CA schools, junk food taxes
• for aerobics lovers build exercise facilities
  into worksite design, staffing/scheduling
  policies
• for everyone else Non-Exercise Activity
  Thermogenesis (e.g. Sprint, CDC)
• Human Resource policies
• choose your workforce carefully _at_hire
• offer health promotion incentives in Group
  Health pricing
• Early intervention hiring, periodic HRAs --
  provide health coaching for all high risk
  employees
• Benefit design medically supervised weight
  loss, medication coverage, gastric procedures as
  last resort
• Controlled environment NEAT, on-site
  cafeteria pricing, workout-friendly schedules
• Management
• clear health risk factor metrics and rewards
  for management (MBOs)
• include obesity factors in critical facility,
  workhour and labor decisions
• banish formal behavioral anti-obesity programs,
  or informal discrimination

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Good solutions are coming

• In medicine
• ?EBM, IOM --gt Wennberg/Eddy/Berwick on improving
  healthcare value, adoption rates, and delivery
  quality
• ? Promising medication pipeline
• From payors CMS, Pay4Performance,
  consumer-directed HSAs pass the baton to
  consumers
• From employers Six Sigma, BTE/Leapfrog, AIAG,
  supply-chain healthcare
• From academia Behavioral economics, new
  prospective payment tools

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Incentives at work IBM
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Summary

• Obesity and the clinical pathway to metabolic
  disease
• Traditional approaches focus on behavior
• weve moralized a problem which is an inevitable,
  biochemical response to the explosive growth in
  food availability
• well-intentioned bad ideas can crowd out research
  and investment in good ones
• Significant consequences for corporate health and
  productivity
• Good solutions are coming
• Call to action need to apply EBM and
  value-purchasing principles

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For presentation copies additional
informationgcarpenter4_at_mac.com
Thank you!

• Published in 2006 from LRP Publications
• http//www.shoplrp.com/product/p-8000.SHAPE.html

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APPENDIX
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The emergence of metabolic disease a direct
clinical pathway from obesity
Visceral Obesity
Insulin Resistance Hyperinsulinemia
Triglycerides
Dense LDL
HDL Cholesterol
Heart Disease, Stroke Risk
Source NAASO, 2005
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Increasing Risk of Serious Illnessas Body Mass
Index Rises
Cancer60 higher risk of death from cancer
HypertensionAdults with a BMI gt30 are twice as
likely to have high blood pressure
DiabetesAdults with a BMI gt30 comprise over 50
of diabetics
Coronary Heart DiseaseAdults with a BMI gt30 are
3 times more likely to die from CHD
Source Magellan Health Care, 2005
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Visceral fat (internal) vs. subcutaneous fat
(love handles)
2 patients with similar BMI but very different
fat deposition
Source Wajchenberg, BL. Endocrinology Rev 2000
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NIH guidelines for obesity treatment x stage
BMI Category
Treatment
25-26.9 27-29.9
30-34.9 35-39.9 gt40
Yes
Yes
Yes
Yes withcomorbidities
Yes withcomorbidities
Diet, physicalactivity, behaviortherapy
Yes withcomorbidities
Yes
Yes
Yes
Pharmaco-therapy
Yes withcomorbidities
Yes
Bariatricsurgery
Yes alone indicates that the treatment is
indicated regardless of the presence or absence
of comorbidities. The solid arrow signifies
the point at which therapy is initiated.
Source NIH/NHLBI/NAASO NIH Publication No.
00-4084, October 2000