Worksite Health Promotion and Obesity Donald D. Hensrud, M.D., M.P.H. Chair, Division of Preventive,...

Worksite Health Promotion and ObesityWorksite Health Promotion and Obesity

Donald D. Hensrud, M.D., M.P.H.Donald D. Hensrud, M.D., M.P.H.

Chair, Division of Preventive, Occupational, & Aerospace MedicineChair, Division of Preventive, Occupational, & Aerospace Medicine

Associate Professor of Preventive Medicine and NutritionAssociate Professor of Preventive Medicine and Nutrition

Chair, Health Promotion CommitteeChair, Health Promotion Committee

Mayo Clinic College of MedicineMayo Clinic College of Medicine

Rochester, MNRochester, MN

DisclosureDisclosure

Obesity,Obesity,Risk Assessment and ClassificationRisk Assessment and Classification

*An increased waist circumference can denote increased disease risk even in persons of normal weight.*An increased waist circumference can denote increased disease risk even in persons of normal weight.

BMIBMIMen Men 40 in40 in

Women Women 35 in35 in

UnderweightUnderweight

Normal*Normal*

OverweightOverweight

ObesityObesity

Extreme obesityExtreme obesity

——

——

IncreasedIncreased

HighHighVery highVery high

Extremely highExtremely high

<18.5<18.5

18.5-24.918.5-24.9

25.0-29.925.0-29.9

30.0-34.930.0-34.935.0-39.935.0-39.9

4040

CategoryCategoryMen >40 inMen >40 in

Women >35 in Women >35 in

——

——

HighHigh

Very highVery highVery highVery high

Extremely highExtremely high

Disease Risk Relative to NormalDisease Risk Relative to NormalWeight and Waist CircumferenceWeight and Waist Circumference

Adapted fromAdapted from Clinical guidelines on Obesity Clinical guidelines on Obesity. National Heart, Lung, and Blood Institute Web site.. National Heart, Lung, and Blood Institute Web site.Available at: Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

Obesity, Health ComplicationsObesity, Health Complications

• Type 2 diabetes mellitusType 2 diabetes mellitus• HypertensionHypertension• DyslipidemiaDyslipidemia

high triglycerideshigh triglycerideslow HDL cholesterollow HDL cholesterolsmall, dense LDL cholesterolsmall, dense LDL cholesterol

• Coronary artery diseaseCoronary artery disease• StrokeStroke• Overall mortalityOverall mortality


• Most cancersMost cancers• Respiratory diseasesRespiratory diseases

obstructive sleep apneaobstructive sleep apnearestrictive lung diseaserestrictive lung diseaseobesity hypoventilation syndromeobesity hypoventilation syndromeasthmaasthma

• OsteoarthritisOsteoarthritis• CholelithiasisCholelithiasis• Gastroesophageal reflux disease (GERD)Gastroesophageal reflux disease (GERD)• Nonalcoholic fatty liver disease (NAFLD)Nonalcoholic fatty liver disease (NAFLD)


• Gynecologic abnormalitiesGynecologic abnormalitiesabnormal mensesabnormal mensesinfertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome

• Venous stasisVenous stasis• Skin problemsSkin problems

intertrigointertrigocellulitiscellulitis

• Increased risk of complications during surgery or Increased risk of complications during surgery or pregnancypregnancy

N/AN/A

<10%<10%

10-15%10-15%

>15%>15%

CP999299-17

Prevalence of Obesity Among U.S. Adults Prevalence of Obesity Among U.S. Adults BRFSS, 1990BRFSS, 1990

Approximately 30 pounds overweight

Mokdad AH JAMA 2000;282:15Mokdad AH JAMA 2000;282:15

N/AN/A

<10%<10%

10-15%10-15%

15-19%15-19%

CP999299-26




>20%>20%

<10%<10%

10-14%10-14%

15-19%15-19%

CP999299-26



20-24%20-24%

>>30%30%

25-29%25-29%

N/AN/A

Mokdad AH Diabetes Care 2000;23:1278Mokdad AH Diabetes Care 2000;23:1278

N/AN/A

Prevalence of Diabetes Among U.S. Prevalence of Diabetes Among U.S. Adults BRFSS, 1990Adults BRFSS, 1990

CP999299-29

<4%<4%

4-6%4-6%

>6%>6%

N/AN/A

<4%<4%

4-6%4-6%

>6%>6%

CP999299-33

Prevalence of Diabetes Among U.S. Prevalence of Diabetes Among U.S. Adults BRFSS, 2000Adults BRFSS, 2000


Prevalence of Overweight Prevalence of Overweight and Obesity, NHANES 2003-4and Obesity, NHANES 2003-4

AllAll MenMen WomenWomen

>>Overweight Overweight 66.3% 70.8% 61.8%66.3% 70.8% 61.8%

ObeseObese 32.232.2 31.1 31.1 33.2 33.2

Extreme ObeseExtreme Obese 4.8 4.8 2.8 2.8 6.9 6.9

JAMA 2006;295;1549JAMA 2006;295;1549

Prevalence of Obesity, by Sex and RacePrevalence of Obesity, by Sex and Race

MenMen WomenWomen

WhiteWhite 31.1%31.1% 30.2%30.2%

BlackBlack 34.034.0 53.9*53.9*

HispanicHispanic 31.631.6 42.342.3*Black females – 14.7% extreme *Black females – 14.7% extreme

obesityobesity

Data from NHANES 2003-4 JAMA 2006;295;1549Data from NHANES 2003-4 JAMA 2006;295;1549

Obesity, Physical ActivityObesity, Physical Activity

• Changes in activityChanges in activitycars, buses, trainscars, buses, trainselevatorselevatorssedentary jobssedentary jobsstep-saving activitiesstep-saving activitiestechnologytechnology

computerscomputersremote controlsremote controls

Obesity, Dietary FactorsObesity, Dietary Factors

• Past couple decadesPast couple decadesslight increase in caloriesslight increase in caloriesdecrease in fat, increase in sugar intakedecrease in fat, increase in sugar intake

• Increased calorie intakeIncreased calorie intakeeating outeating out portion sizeportion size variety of most foods variety of most foods refined carbohydraterefined carbohydrate intake of snacks, soft drinks, and pizzaintake of snacks, soft drinks, and pizza

Curr Opin Gastroenterol 2004;20:119Curr Opin Gastroenterol 2004;20:119

Obesity, the Sobering FactsObesity, the Sobering Facts

• The cost of obesity has been estimated at up to The cost of obesity has been estimated at up to $117 B (cost to business - $13 B), and is greater $117 B (cost to business - $13 B), and is greater than smoking or problem drinkingthan smoking or problem drinking1,2,3,4,5,61,2,3,4,5,6

• Obese employees have 36% greater health care Obese employees have 36% greater health care costscosts

11Obes Res 1998;6:173Obes Res 1998;6:173 44Surgeon’s General Report 2001Surgeon’s General Report 200122Health Affairs 2003;Suppl:W3-219Health Affairs 2003;Suppl:W3-219 55Am J Health Promot 1998;13:120Am J Health Promot 1998;13:12033Obes Res 2004;12:18Obes Res 2004;12:18 66Am J Health Promot 2003;17:183Am J Health Promot 2003;17:183

Barriers to Clinical Treatment of ObesityBarriers to Clinical Treatment of Obesity

• Public health problemPublic health problem

• Behavioral change difficultBehavioral change difficult

• Physician education and trainingPhysician education and training

• TimeTime

• Reimbursement – BCBS of NCReimbursement – BCBS of NC

• ResourcesResources

• Available programs with ongoing followupAvailable programs with ongoing followup

Disincentives for Employers to Cover Disincentives for Employers to Cover ObesityObesity

• Lack of good efficacy dataLack of good efficacy data

• Long term return on investment of Long term return on investment of prevention/treatmentprevention/treatment

Mobile work forceMobile work force

• Young employees haven’t developed Young employees haven’t developed complicationscomplications

• Medicare assumes costs at age 65Medicare assumes costs at age 65

• 66% Overweight, 32% obese66% Overweight, 32% obese• 60% Sedentary60% Sedentary• 8% Diabetes mellitus*8% Diabetes mellitus*• 35% Hyperlipidemia35% Hyperlipidemia• 24% Hypertension24% Hypertension• 21% Smoking21% Smoking• 23% Prevalent cardiovascular disease23% Prevalent cardiovascular disease

Among all cancers, 1/3 are related to tobacco and 1/3 related to Among all cancers, 1/3 are related to tobacco and 1/3 related to dietdiet

Prevalence of Risk Factors, U.S.Prevalence of Risk Factors, U.S.

$840 $1,261

$3,321

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Low Risk (0-2 Risks)

HRA Non-Participant

Medium Risk (3-4 Risks)

High Risk (5+ Risks)

Excess Costs

Base Cost

More Risk Factors = Higher CostsMore Risk Factors = Higher Costs

$2,199

$3,039$3,460

$5,520

Edington, AJHP 2001; 15:341Edington, AJHP 2001; 15:341

More Risk Factors = Less ProductivityMore Risk Factors = Less Productivity

Mayo Clinic/Tufts University, 2006Mayo Clinic/Tufts University, 2006

$3,753

$3,182$3,184

$2,801

$2,388$2,225

$0

$1,000

$2,000

$3,000

$4,000

Underweight

Normal Overweight

Obesity I Obesity II ExtremeObesity

Median of Annual Medical Costs

Greater Weight = Higher Medical/Drug CostsGreater Weight = Higher Medical/Drug Costs

Wang, AJHP 2003;17:183Wang, AJHP 2003;17:183

Key Findings in Worksite Health Key Findings in Worksite Health ManagementManagement

• High risk = high costHigh risk = high cost

• High risk = decreased productivityHigh risk = decreased productivity

• Participation and % low risk are the most Participation and % low risk are the most important metrics to predict success of important metrics to predict success of worksite health managementworksite health management

Low-risk maintenance programs importantLow-risk maintenance programs important

U of MI HMRC, Cost Benefit Analysis and Report 2006 U of MI HMRC, Cost Benefit Analysis and Report 2006

Healthcare TrendsHealthcare Trends

• Increasing costsIncreasing costs

• QualityQuality

• Population health managementPopulation health management

Disease managementDisease management

Health promotion/risk reductionHealth promotion/risk reduction

• For each $1 invested in prevention, return of For each $1 invested in prevention, return of approximately $2 – $4approximately $2 – $4

• 44%-56% of companies offering health promotion 44%-56% of companies offering health promotion activities report:activities report:Decreased healthcare costsDecreased healthcare costsDecreased absenteeismDecreased absenteeismIncreased productivityIncreased productivity

• Should be comprehensive and include all Should be comprehensive and include all employeesemployees

• Opportunities to add to this literatureOpportunities to add to this literature

Evidence For Worksite Health PromotionEvidence For Worksite Health Promotion

U of MI HMRC, Cost Benefit Analysis and Report 2006U of MI HMRC, Cost Benefit Analysis and Report 2006

Worksite Health PromotionWorksite Health Promotion

• 66% of companies provide wellness programs66% of companies provide wellness programs

• Should be based on needs assessmentShould be based on needs assessment

• Support at all management levels crucialSupport at all management levels crucial

• Branding under a title and logo commonBranding under a title and logo common

• To control overweight and obesity, worksite To control overweight and obesity, worksite interventions should be multicomponent interventions should be multicomponent (nutrition, physical activity, etc.)(nutrition, physical activity, etc.)

National Business Group on Health National Business Group on Health www.benefitnews.com, 9/1/06, 9/1/06Task Force on Community Preventive Services MMWR 2005;54(RR-10):1-12Task Force on Community Preventive Services MMWR 2005;54(RR-10):1-12

http://www.benefitnews.com/

Employer Health Plan ComponentsEmployer Health Plan Components

• Health awareness tools (newsletters)Health awareness tools (newsletters)• Healthy lifestyle programs (HRA, behavior change Healthy lifestyle programs (HRA, behavior change

programs)programs)• Disease management programs (diabetes)Disease management programs (diabetes)• Demand management programs (self-care books)Demand management programs (self-care books)• Decision support tools (selecting MD, plan)Decision support tools (selecting MD, plan)• Onsite offerings (fitness center)Onsite offerings (fitness center)• Health advocacy programs (help to negotiate)Health advocacy programs (help to negotiate)• Outcomes researchOutcomes research

Employer Health Promotion InitiativesEmployer Health Promotion Initiatives

• Define strategies, goals, measuresDefine strategies, goals, measures• Communicate to employees (simple messages, Communicate to employees (simple messages,

win-win)win-win)• Provide tools and incentives (HRA)Provide tools and incentives (HRA)• Create supportive work environmentCreate supportive work environment• Develop benefit plan to include health promotionDevelop benefit plan to include health promotion• Onsite fitness facility or health club reimbursement Onsite fitness facility or health club reimbursement

importantimportant

Worksite Health Promotion OutcomesWorksite Health Promotion Outcomes

• Track, if possible:Track, if possible:• Wellness program enrollment and participationWellness program enrollment and participation• Fitness center participationFitness center participation• HRA dataHRA data• Medical and pharmacy claimsMedical and pharmacy claims• Disability and workers comp dataDisability and workers comp data• AbsenteeismAbsenteeism• Dining room purchasesDining room purchases• Financial impactFinancial impact

Industry, Best PracticesIndustry, Best Practices

• Aetna, Inc.Aetna, Inc.• Baptist Health South FloridaBaptist Health South Florida• FPL GroupFPL Group• Johnson & JohnsonJohnson & Johnson• Medical Mutual of OhioMedical Mutual of Ohio• Pitney BowesPitney Bowes• Texas Instruments Inc.Texas Instruments Inc.• Union Pacific RailroadUnion Pacific Railroad

Platinum Winners, National Business Group on Health www.businessgrouphealth.orgPlatinum Winners, National Business Group on Health www.businessgrouphealth.org

Worksite Health Promotion ProgramsWorksite Health Promotion Programs

• Johnson & JohnsonJohnson & Johnson$225/person/year reduction in health care $225/person/year reduction in health care

expenditures, with most benefit occurring in expenditures, with most benefit occurring in years 3 & 4years 3 & 4

• BCBS Indiana HP programBCBS Indiana HP program24% lower health care costs24% lower health care costs

• Procter & GambleProcter & Gamble29% decrease in health care expenditures in year 29% decrease in health care expenditures in year

3 of the program3 of the program

Mayo Health Promotion CommitteeMayo Health Promotion Committee

• Established by Board of Governors 2004Established by Board of Governors 2004

• Directly engaged with various areas involved with Directly engaged with various areas involved with health promotionshealth promotions

• Catalogued and coordinating health and wellness Catalogued and coordinating health and wellness programs at Mayoprograms at Mayo

• Developed 6 key health objectives to focus efforts Developed 6 key health objectives to focus efforts with communications planwith communications plan

1.1. Encourage employees to maintain a healthy weightEncourage employees to maintain a healthy weight

2.2. Promote opportunities to increase physical activity Promote opportunities to increase physical activity

3.3. Educate employees about the importance of nutrition and Educate employees about the importance of nutrition and healthy food choiceshealthy food choices

4.4. Direct employees to resources to manage emotional and Direct employees to resources to manage emotional and behavioral health issuesbehavioral health issues

5.5. Promote resources to help employees become tobacco freePromote resources to help employees become tobacco free

6.6. Increase overall employee awareness on the importance Increase overall employee awareness on the importance wellness and preventive serviceswellness and preventive services

Mayo Health Promotion CommitteeMayo Health Promotion CommitteeKey Health ObjectivesKey Health Objectives


• Established by BOG 2004Established by BOG 2004

• Directly engaged with various areas involved with Directly engaged with various areas involved with health promotionshealth promotions

• Catalogued and coordinating health and wellness Catalogued and coordinating health and wellness programs at Mayoprograms at Mayo

• Developed 6 key health objectives to focus efforts Developed 6 key health objectives to focus efforts with communications planwith communications plan

• Created “LiveWell” name and new graphic identity Created “LiveWell” name and new graphic identity to connect future effortsto connect future efforts


• Nutrition Committee established wellness meal Nutrition Committee established wellness meal criteria, put nutrition information on cash register criteria, put nutrition information on cash register receipts, and improved employee cafeteria, receipts, and improved employee cafeteria, committee meal, and vending machine optionscommittee meal, and vending machine options

• Applied for and received 2.5 FTE and modest budgetApplied for and received 2.5 FTE and modest budget

• Received approval for research position to document Received approval for research position to document return on investment of health promotion activitiesreturn on investment of health promotion activities

• Vision is to establish a premier medical center model Vision is to establish a premier medical center model for wellness for wellness

Employer Health Promotion InitiativesEmployer Health Promotion Initiatives

• Define strategies, goals, measuresDefine strategies, goals, measures• Communicate to employees (simple messages, Communicate to employees (simple messages,

win-win)win-win)• Provide tools and incentives (HRA)Provide tools and incentives (HRA)• Create supportive work environmentCreate supportive work environment• Develop benefit plan to include health promotionDevelop benefit plan to include health promotion• Onsite fitness facility or health club reimbursement Onsite fitness facility or health club reimbursement

importantimportant

SummarySummary

• Increasing health risks, including obesity, Increasing health risks, including obesity, are associated with increased health care are associated with increased health care costscosts

• Increasing evidence that comprehensive Increasing evidence that comprehensive worksite health promotion programs can worksite health promotion programs can decrease health risks and health care costsdecrease health risks and health care costs

ReferencesReferences• The Practical Guide to the Identification, Evaluation, and Treatment of The Practical Guide to the Identification, Evaluation, and Treatment of

Overweight and Obesity in Adults. Overweight and Obesity in Adults. http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

• Hensrud DD, ed. Mayo Clinic Healthy Weight for Everybody. Mayo Clinic, Hensrud DD, ed. Mayo Clinic Healthy Weight for Everybody. Mayo Clinic, Rochester, MN, 2005.Rochester, MN, 2005.

• Health Management Research Center. Cost Benefit Analysis and Report 2006. Health Management Research Center. Cost Benefit Analysis and Report 2006. University of Michigan, Ann Arbor, MI, 2006.University of Michigan, Ann Arbor, MI, 2006.

• Chapman LS, et al. Population health management as a strategy for creation Chapman LS, et al. Population health management as a strategy for creation of optimal healing environments in worksite and corporate settings. J Alt Comp of optimal healing environments in worksite and corporate settings. J Alt Comp Med 2004;10(Suppl 1):S127-S140. Med 2004;10(Suppl 1):S127-S140.

• Pelletier KR. A review and analysis of the clinical and cost-effectiveness Pelletier KR. A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management studies of comprehensive health promotion and disease management programs at the worksite: update VI 2000-2004. J Occup Environ Med programs at the worksite: update VI 2000-2004. J Occup Environ Med 2005;47:1051-8.2005;47:1051-8.

ReferencesReferences• Anderson DR, et al. Conceptual framework, critical questions, and Anderson DR, et al. Conceptual framework, critical questions, and

practical challenges in conducting research on the financial impact of practical challenges in conducting research on the financial impact of worksite health promotion. Am J Health Prom 2001;15:281-8.worksite health promotion. Am J Health Prom 2001;15:281-8.

• Hensrud DD, ed. The Mayo Clinic Plan: 10 Essential Steps to a Better Hensrud DD, ed. The Mayo Clinic Plan: 10 Essential Steps to a Better Body & Healthier Life. Time, New York, NY, 2006.Body & Healthier Life. Time, New York, NY, 2006.

• Supplement on Bariatric Surgery in Extreme Obesity. Mayo Clin Proc Supplement on Bariatric Surgery in Extreme Obesity. Mayo Clin Proc Oct 1, 2006. Available online at: Oct 1, 2006. Available online at: http://www.mayoclinicproceedings.com/supplements.asphttp://www.mayoclinicproceedings.com/supplements.asp

• Lang RS, Hensrud DD, eds. Clinical Preventive Medicine, 2Lang RS, Hensrud DD, eds. Clinical Preventive Medicine, 2ndnd ed. ed. AMA, Chicago, IL, 2004.AMA, Chicago, IL, 2004.

Worksite Health Promotion and Obesity Donald D. Hensrud, M.D., M.P.H. Chair, Division of Preventive,...

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