Employers Should Disband Employee Weight Control Programs

ABSTRACT

American corporations continue to expand wellness programs, which now reach an estimated 90% of workers in large organizations, yet no study has demonstrated that the main focus of these programs—weight control—has any positive effect. There is no published evidence that large-scale corporate attempts to control employee body weight through financial incentives and penalties have generated savings from long-term weight loss, or a reduction in inpatient admissions associated with obesity or even long-term weight loss itself. Other evidence contradicts the hypothesis that population obesity rates meaningfully retard economic growth or manufacturing productivity. Quite the contrary, overscreening and crash dieting can impact employee morale and even harm employee health. Therefore, the authors believe that corporations should disband or significantly reconfigure weight-oriented wellness programs, and that the Affordable Care Act should be amended to require such programs to conform to accepted guidelines for harm avoidance.

Am J Manag Care. 2015;21(2):e91-e94

Corporate weight control programs are ineffective at reducing weight; in addition, the nexus between weight loss and savings/productivity improvement is weak. Especially given the costs and potential harms of these programs, the authors recommend phasing them out altogether and reallocating resources towards creating a healthier work environment for everyone.Wellness programs have become nearly ubiquitous in larger organizations following the passage of the Affordable Care Act (ACA), which allows corporations to tie up to 30% of total insurance premiums to participation in corporate wellness programs and/or achievement of positive health outcomes.¹ Along with smoking, the most common target of this tie-in is overweight status. However, we find that most corporate weight control programs (and wellness programs generally) fail—using valid metrics, none have reported savings, long-term weight loss, or reduction in medical events over a sizable population for 2 years or more, accounting for dropouts and nonparticipants. Further, these “wellness” programs can adversely impact the morale and even the health of employees.

Even the premise that excess weight hampers productivity lacks evidence. We found that the Organisation for Economic Co-operation and Development countries and US states with higher productivity and growth generally also had higher rates of obesity. We are not positing causality, but rather observing that factors other than successful weight management of the workforce drive economic prosperity.

Neither Savings nor Weight Loss Itself Is Achieved in Workplace Wellness/Weight Reduction Programs

Wellness programs and weight loss programs need to be considered together when measuring savings because weight is the major target (along with smoking cessation, which has a low success rate) of these programs. It is reasonable to assume that wellness savings and obesity reduction savings should correlate closely, but corporations have not found savings in wellness programs. Since 2010, Health Affairs articles about wellness programs have documented no savings²—even in 1 case, in an organization that reported a significant reduction in its extraordinarily high rates of hospital admissions logically avoidable through wellness programs, such as heart attacks.³ All known publicly claimed vendor savings claims have been prima facie invalidated on www.theysaidwhat.net.

All vendors were notified of the questions and offered an honorarium to respond, but responses from the vendors in question have not been forthcoming.^4-6 Organizations whose wellness programs have been analyzed by RAND or Health Affairs have shown losses.^2,7 The sponsors of 2012’s most lauded program and the recipient of numerous awards, the state of Nebraska, subsequently admitted data falsification.⁸

Weight loss itself is equally elusive. This conclusion can be reached on both micro and macro levels. On the micro level, no corporation has ever followed large numbers of employees over a long enough period to track recidivism. Moreover, only 1 published study, GEICO’s, has ever controlled for self-selection. Results over the company’s 18-week study period were sufficiently disappointing that GEICO declined to report actual weight changes, and rather reported just shifts in dietary composition, publishing the results in a European journal.⁹

Highmark Blue Cross’s ShapeUp program is more typical of the way weight loss programs are measured. The program did not report weight change for nonparticipants, dropouts, or employees who gained weight or regained the weight they lost. (As is typical in corporate weight-loss reporting, these study design limitations were not disclosed.) Despite counting only active participants who succeeded in short-term weight gain, ShapeUp’s program shifted only 163 of Highmark’s 19,000 employees (0.86%) into lower weight categories¹⁰—which is perhaps even a lower percentage than random weight variation or regression to the mean would account for on its own. Oddly, this modest improvement was nonetheless considered a newsworthy event by ShapeUp.

ShapeUp is not alone. The wellness “industry standard” modus operandi is to report only successes and not failures. Wellness Coaches USA reports: “The average employee who lost weight lost over 12.1 pounds,” without disclosing the percentage of employees who participated or the percentage of employees who lost weight and kept it off.¹¹ Cigna guarantees that some employees will lose weight (and reduce other risk factors), without offsetting this positive directional change with employees who gain weight.¹²

On the macro level, obesity and obesity-related medical events should be declining in the employer-insured population, if these programs

are working as advertised given the number of employees with access to them.¹³ However, to date, the only major population cohort to possibly show a reduction in obesity over the decade in which wellness programs exploded is young children—a cohort excluded from all corporate wellness programs.¹³ Likewise, as a percentage of total admissions, wellness-sensitive medical events requiring hospitalization have declined at higher rates in the Medicaid and Medicare populations, which have little if any access to corporate wellness programs, than in their commercially insured counterparts.¹⁵

Consistent with all prior research showing that sustained weight reduction on a large scale is not possible, the conclusion is that alleged successes misrepresent true outcomes and that corporations are no more successful at weight control than individuals.

Further, contradicting subjective polling data¹⁶ and a study of self-reported work limitations published in the American Journal of Health Promotion¹⁷ show there is no objective correlation between obesity and manufacturing productivity^18,19 or obesity and economic growth among the Group of Twenty (G20) nations.²⁰

Obesity-Focused and Other Wellness Programs Harm Morale and Corporate Culture

Weight reduction programs may also adversely affect morale. Employees usually resist corporate wellness programs that involve surveys, weigh-ins, and screens. This can be inferred by observing employee revolts against wellness programs,^21,22 documented in a Cornell study showing a revealed preference that people prefer to pay more for a health benefit without a wellness plan,²³ and by the increasing financial incentives—now averaging $594 per employee per year^24,25—needed to drive participation. There is also the impact on morale for the many people who drop out26 or who resent corporate intrusion.⁷

Next is the impact on corporate culture: wellness programs generally create obvious incentives to lie when answering such questions as, “How often do you drive drunk?” At Penn State, employees encouraged one another to lie.²⁷ Likewise, fitness tracking foments a surveillance-state mentality that encourages cheating,²⁸ and wellness vendors may also cheat to improve the appearance of their outcomes.²⁹ An e-book published in 2014 by wellness coordinators describes the pressure they feel to lie about results.³⁰ Instead of creating a culture of health, wellness programs can create a culture of deceit.

Obesity Programs Cause Health Hazards

Finally, and most importantly as a policy matter, there are health hazards in “wellness.” First, the possibilities of overdiagnosis and overtreatment exist.^31,32 While virtually every wellness program prescribes annual blood draws on all employees to screen for various conditions (and employees forfeit money by refusing to participate), there is no blood-based screen that the US Preventive Services Task Force recommends being done annually on all working-age adults, because overscreening can potentially cause harm through overdiagnosis and overtreatment—and it also increases cost. For some of the most common conditions, the appropriate screening is every 5 years.^33,34

Popular but ineffective³⁵ “biggest loser” contests, as well as pay-per-pound-lost programs,³⁶ create a direct and negative health impact by humiliating people and encouraging crash dieting.³⁷ In addition, it is easy to imagine that a participant in a corporate weight screening program could, to boost his “results,” binge before the initial weigh-in and crash diet before the follow-up weigh-in.

Put These Programs to Rest

It is time to end coercive or financially based wellness programs focused on weight issues. There is no evidence that these programs work, but ample evidence exists that they are a morale-reducing and expensive distraction from the business of business. To avoid such hazards, the ACA should be amended to require programs to operate consistent with established guidelines for weight control programs—meaning removing all express or implied incentives to crash diet.

Instead, employers could subsidize healthy food options in workplace cafeterias, give employees an extra break designated for taking a walk, or reimburse fitness memberships. Programs such as these may improve health, but most importantly, they do no harm, which would make them an improvement over the typical program now in operation.Author Affiliations: Disease Management Purchasing Consortium (AL), Waltham, MA; Vikram Khanna Health Consulting (VK), Chesterfield, MO; Independent consultant (SM).

Source of Funding: None.

Author Disclosures: Mr Lewis and Khanna report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Ms Montrose completed this research in 2014 as an independent consultant.

Authorship Information: Concept and design (VK, AL); acquisition of data (AL, SM); analysis and interpretation of data (VK, AL, SM); drafting of the manuscript (VK, AL); critical revision of the manuscript for important intellectual content (AL, SM); statistical analysis (AL); administrative, technical, or logistic support (VK); and supervision (AL).

Address correspondence to: Alfred Lewis, JD, Disease Management Purchasing Consortium, 890 Winter St, Waltham, MA 02451. E-mail: diseasmgmt@aol.com.REFERENCES

1. Final Rule. Internal Revenue Service, Department of the Treasury; Employee Benefits Security Administration, Department of Labor; CMS, HHS. Department of Labor website. http://www.dol.gov/ebsa/pdf/workplacewellnessstudyfinalrule.pdf. Accessed March 17, 2014.

2. Caloyeras JP, Liu H, Exum E, Broderick M, Mattke S. Managing manifest diseases, but not health risks, saved PepsiCo money over seven years. Health Aff (Millwood). 2014;33(1):124-131.

3. Gowrisankaran G, Norberg K, Kymes S, et al. A hospital system’s wellness program linked to health plan enrollment cut hospitalizations but not overall costs. Health Aff (Millwood). 2013;32(3):477-485.

4. Lewis A, Khanna V. Is it time to re-examine workplace wellness ‘get well quick’ schemes? Health Affairs Blog. http://healthaffairs.org/blog/2013/01/16/is-it-time-to-re-examine-workplace-wellness-get-wellquick-schemes. Published January 16, 2013. Accessed March 11, 2014.

5. Lewis A, Khanna V. Surviving workplace wellness. The Health Care Blog. http://thehealthcareblog.com/blog/tag/surviving-workplace-wellness/. Published 2014. Accessed March 11, 2014.

6. Lewis A. Company wellness programs don’t really save money. Harvard Business Review. http://blogs.hbr.org/2013/03/do-wellnessprograms-really-sa. Published March 8, 2013. Accessed March 7, 2014.

7. Mattke S, et al. Workplace wellness programs study: final report. RAND Health website. http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR254/RAND_RR254.pdf. Published 2013. Accessed March 7, 2014.

8. Stoddard M. Nebraska’s acclaimed wellness program under fire. Omaha.com website. http://www.omaha.com/article/20130715/LIVEWELL01/707159943/1707#nebraska-s-acclaimed-wellness-program-underfire. Published July 15, 2013. Accessed March 7, 2014.

9. Mishra S, Barnard ND, Gonzales J, Xu J, Agarwal U, Levin S. Nutrient intake in the GEICO multicenter trial: the effects of a multicomponent worksite intervention. Eur J Clin Nutr. 2013;67(10):1066-1071.

10. ShapeUp falls down trying to do math for Highmark. They Said What? website. http://theysaidwhat.net/2014/07/23/shapeup001/. Published July 2014. Accessed January 29, 2015.

11. Wellness Coaches USA 2012 Client Outcomes Report. Wellness Coaches USA website. http://www.wellnesscoachesusa.com/wp-content/uploads/2013/03/2012-Outcomes-Release-Summary.pdf. Published January 2013. Accessed March 17, 2014.

12. Cigna Better Health Guaranteed brochure. Cigna website. http://www.cigna.com/assets/docs/employers-and-organizations/Betterhealth-guaranteed.pdf. Accessed March 26, 2014.

13. Healthcare survey finds spending on corporate wellness incentives to increase 15 percent in 2014. National Business Group on Health website. http://www.businessgrouphealth.org/pressroom/pressRelease.cfm?ID=225. Published February 20, 2014. Accessed March 17, 2014.

14. Tavernise S. Obesity rate for young children plummets 43% in a decade. New York Times. http://www.nytimes.com/2014/02/26/health/obesity-rate-for-young-children-plummets-43-in-a-decade.html. Published February 25, 2014. Accessed March 10, 2014.

15. The Healthcare Cost and Utilization Project. AHRQ website. http://www.hcupnet.ahrq.gov/HCUPnet.jsp. Accessed March 15, 2014.

16. Berman J. Obesity costs U.S. companies billions in lost productivity: Gallup. The Huffington Post. http://www.huffingtonpost.com/2011/10/17/obesity-costs-us-companies-billions-in-lostproductivity_n_1015414.html. Published October 17, 2011. Accessed April 1, 2014.

17. Rodbard HW, Fox KM, Grandy S; Shield Study Group. Impact of obesity on work productivity and role disability in individuals with and at risk for diabetes mellitus. Am J Health Promot. 2009;23(5):353-360.

18. Prevalence of self-reported obesity among U.S. adults, BRFSS 2012. CDC website. http://www.cdc.gov/obesity/data/adult.html. Accessed March 20, 2014.

19. “Establishment Data State Employment Seasonally Adjusted. Table D-1. Employees on nonfarm payrolls by state and major industry seasonally adjusted.” Predicted growth rate from December 2012 to December 2013. Author’s calculations. Bureau of Labor Statistics website. http://www.bls.gov/sae/#tables. Accessed March 20, 2014.

20. Prometheus Unbound. Thanks, McDonald’s: obesity is killing America’s economic competitiveness by ballooning health care costs. http://santitafarella.wordpress.com/2012/04/21/thanks-mcdonalds-obesity-iskilling-americas-economic-competitiveness-by-ballooning-health-carecosts. Published April 21, 2012. Accessed March 11, 2014.

21. Jaspen B. Like CVS, more employers penalize workers that snub wellness exams. Forbes. http://www.forbes.com/sites/brucejapsen/2013/03/25/like-cvs-more-employers-penalize-workers-thatsnub-wellness-exams. Published March 25, 2013. Accessed March 17, 2014.

22. Singer N. On campus a faculty uprising over personal data. New York Times. http://www.nytimes.com/2013/09/15/business/on-campusa-faculty-uprising-over-personal-data.html. Published September 14, 2013. Accessed March 17, 2014.

23. Danagoulian S. The hassle of wellness programs: do peers and health status matter? Presented at the Population Association of America 2014 meeting. http://paa2014.princeton.edu/abstracts/141305. Accessed January 30, 2015.

24. Kruger J, Yore MM, Bauer DR, Kohl HW. Selected barriers and incentives for worksite health promotion services and policies. Am J Health Promot. 2007;21(5):439-447.

25. Delta GB and General Counsel. The big fat truth about use of incentives for wellness programs. The Institute for Healthcare Consumerism website. http://www.theihcc.com/en/communities/population_health_and_wellness/big-fat-truth-about-use-of-incentives-for-wellness_gl1os3yd.html. Accessed March 11, 2014.

26. Cawley J, Price JA. A case study of a workplace wellness program that offers financial incentives for weight loss. The University of Texas, Arlington website. http://www.uta.edu/economics/workshop/Financial%20Incentives%20for%20Weight%20Loss.pdf. Published March 21, 2013. Accessed March 17, 2014.

27. A call for action and civil resistance for Penn State employees. Wordpress website. http://pa-aaup.com/2013/07/30/the-penn-statehealthcare-mandate-and-a-call-for-civil-disobedience. Published July 30, 2013. Accessed March 17, 2014.

28. US Attorney’s Office of Western Missouri. KC employee pleads guilty to fraud scheme to cheat health insurance program. US Department of Justice website. http://www.justice.gov/usao/mow/news2013/king.ple.html. Published May 30, 2013. Accessed March 7, 2014

29. Lewis A, Khanna V. The strange case of the C. Everett Koop National Health Award. The Healthcare Blog. http://thehealthcareblog.com/blog/2013/08/08/the-strange-case-of-the-c-everett-koop-national-healthaward. Published August 8, 2013. Accessed March 14, 2014.

30. Wellness Underground. If you give a CEO a wellness program. http://static.squarespace.com/static/52cd84b3e4b08ddc00d460e7/t/52efbfaee4b07e7f0e7f24a1/1391443886785/If%20You%20Give%20a%20CFO%20a%20Wellness%20Program.pdf. Published 2014. Accessed March 17, 2014.

31. Krogsbøll LT, Jørgensen KJ, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. JAMA. 2013;309(23):2489-2490.

32. McCartney M. Patients deserve the truth: health screening can do more harm than good. The Guardian. http://www.theguardian.com/science/blog/2014/jan/03/patients-truth-health-screening-harm-good. Published January 3, 2014. Accessed March 20, 2014.

33. Screening for lipid disorders in adults. US Preventive Service Task Force website. http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm. Released June 2008. Accessed March 20, 2014.

34. Screening for colorectal cancer: recommendation statement. US Preventive Service Task Force website. http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm. Released October 2008. Accessed March 20, 2014.

35. Why ‘Biggest Loser’ wellness programs don’t work. LaCarte Wellness website. http://lacartewellness.com/why-biggest-loser-wellnessprograms-dont-work. Published May 20, 2011. Accessed March 7, 2014.

36. Barton County Memorial Hospital weigh down competition. Fourstateshomepage.com website. http://www.fourstateshomepage.com/story/d/story/barton-county-memorial-hospital-weigh-down-competi/77623/2iUHCkPS7EOu2PbqIZiw_w. Published March 18, 2014. Accessed March 18, 2014.

37. Pappas S. The ‘Biggest Loser’ has big problems, health experts say. LiveScience website. http://www.livescience.com/9820-biggestloser-big-problems-health-experts.html. Published February 21, 2010. Accessed March 7, 2014

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