Worksite Health Promotion and Obesity

1. Donald D. Hensrud, M.D., M.P.H. Chair, Division of Preventive, Occupational, & Aerospace Medicine Associate Professor of Preventive Medicine and Nutrition Chair, Health Promotion Committee Mayo Clinic College of Medicine Rochester, MN Worksite Health Promotion and Obesity

2. Disclosure Speaker Discloses he is a speaker for Blue Cross Blue Shield of North Carolina and receives an honorarium for his speaking services.

3. Obesity,Risk Assessment and Classification Disease Risk Relative to NormalWeight and Waist Circumference Men 40 inWomen 35 in Men >40 in Women >35 in Category BMI Underweight Normal* Overweight Obesity Extreme obesity <18.5 18.5-24.9 25.0-29.9 30.0-34.935.0-39.9 40 — — Increased HighVery high Extremely high — — High Very highVery high Extremely high *An increased waist circumference can denote increased disease risk even in persons of normal weight. Adapted from Clinical guidelines on Obesity. National Heart, Lung, and Blood Institute Web site. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

4. Obesity, Health Complications • Type 2 diabetes mellitus • Hypertension • Dyslipidemia • high triglycerides • low HDL cholesterol • small, dense LDL cholesterol • Coronary artery disease • Stroke • Overall mortality

5. Obesity, Health Complications • Most cancers • Respiratory diseases • obstructive sleep apnea • restrictive lung disease • obesity hypoventilation syndrome • asthma • Osteoarthritis • Cholelithiasis • Gastroesophageal reflux disease (GERD) • Nonalcoholic fatty liver disease (NAFLD)

6. Obesity, Health Complications • Gynecologic abnormalities • abnormal menses • infertility • polycystic ovarian syndrome • Venous stasis • Skin problems • intertrigo • cellulitis • Increased risk of complications during surgery or pregnancy

7. <10% 10-15% Prevalence of Obesity Among U.S. Adults BRFSS, 1990 Approximately 30 pounds overweight N/A >15% Mokdad AH JAMA 2000;282:15 CP999299-17

8. 10-15% Prevalence of Obesity Among U.S. Adults BRFSS, 2000 Approximately 30 pounds overweight N/A <10% 15-19% >20% Mokdad AH JAMA 2001;286:1195 CP999299-26

9. 10-14% Prevalence of Obesity Among U.S. Adults BRFSS, 2005 Approximately 30 pounds overweight N/A <10% 15-19% 20-24% 25-29% >30% CP999299-26

10. Prevalence of Diabetes Among U.S. Adults BRFSS, 1990 N/A <4% 4-6% >6% Mokdad AH Diabetes Care 2000;23:1278 CP999299-29

11. Prevalence of Diabetes Among U.S. Adults BRFSS, 2000 N/A <4% 4-6% >6% Mokdad AH JAMA 2001;286:1195 CP999299-33

12. Prevalence of Overweight and Obesity, NHANES 2003-4 AllMenWomen >Overweight 66.3% 70.8% 61.8% Obese 32.2 31.1 33.2 Extreme Obese 4.8 2.8 6.9 JAMA 2006;295;1549

13. Prevalence of Obesity, by Sex and Race MenWomen White 31.1% 30.2% Black 34.0 53.9* Hispanic 31.6 42.3 *Black females – 14.7% extreme obesity Data from NHANES 2003-4 JAMA 2006;295;1549

15. Obesity, Physical Activity Changes in activity cars, buses, trains elevators sedentary jobs step-saving activities technology computers remote controls

16. Past couple decades slight increase in calories decrease in fat, increase in sugar intake Increased calorie intake  eating out  portion size  variety of most foods  refined carbohydrate  intake of snacks, soft drinks, and pizza Obesity, Dietary Factors Curr Opin Gastroenterol 2004;20:119

17. Obesity, the Sobering Facts • The cost of obesity has been estimated at up to $117 B (cost to business - $13 B), and is greater than smoking or problem drinking1,2,3,4,5,6 • Obese employees have 36% greater health care costs 1Obes Res 1998;6:173 4Surgeon’s General Report 2001 2Health Affairs 2003;Suppl:W3-219 5Am J Health Promot 1998;13:120 3Obes Res 2004;12:18 6Am J Health Promot 2003;17:183

18. Barriers to Clinical Treatment of Obesity • Public health problem • Behavioral change difficult • Physician education and training • Time • Reimbursement – BCBS of NC • Resources • Available programs with ongoing followup

19. Disincentives for Employers to Cover Obesity • Lack of good efficacy data • Long term return on investment of prevention/treatment • Mobile work force • Young employees haven’t developed complications • Medicare assumes costs at age 65

20. Prevalence of Risk Factors, U.S. • 66% Overweight, 32% obese • 60% Sedentary • 8% Diabetes mellitus* • 35% Hyperlipidemia • 24% Hypertension • 21% Smoking • 23% Prevalent cardiovascular disease Among all cancers, 1/3 are related to tobacco and 1/3 related to diet

21. More Risk Factors = Higher Costs $5,520 $3,460 $3,039 $2,199 Edington, AJHP 2001; 15:341

22. Medical/Drug Costs by Weight Group Wang, AJHP 2003;17:183

23. Key Findings in Worksite Health Management • High risk = high cost • High risk = decreased productivity • Participation and % low risk are the most important metrics to predict success of worksite health management • Low-risk maintenance programs important U of MI HMRC, Cost Benefit Analysis and Report 2006

24. Healthcare Trends • Increasing costs • Quality • Population health management • Disease management • Health promotion/risk reduction

25. Evidence For Worksite Health Promotion • For each $1 invested in prevention, return of approximately $2 – $4 • 44%-56% of companies offering health promotion activities report: Decreased healthcare costs Decreased absenteeism Increased productivity • Should be comprehensive and include all employees • Opportunities to add to this literature

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

27. Worksite Health Promotion • 66% of companies provide wellness programs • Should be based on needs assessment • Support at all management levels crucial • Branding under a title and logo common • To control overweight and obesity, worksite interventions should be multicomponent (nutrition, physical activity, etc.) National Business Group on Health www.benefitnews.com, 9/1/06 Task Force on Community Preventive Services MMWR 2005;54(RR-10):1-12

28. Employer Health Plan Components • Health awareness tools (newsletters) • Healthy lifestyle programs (HRA, behavior change programs) • Disease management programs (diabetes) • Demand management programs (self-care books) • Decision support tools (selecting MD, plan) • Onsite offerings (fitness center) • Health advocacy programs (help to negotiate) • Outcomes research

29. Employer Health Promotion Initiatives • Define strategies, goals, measures • Communicate to employees (simple messages, win-win) • Provide tools and incentives (HRA) • Create supportive work environment • Develop benefit plan to include health promotion • Onsite fitness facility or health club reimbursement important

30. Worksite Health Promotion Outcomes • Track, if possible: • Wellness program enrollment and participation • Fitness center participation • HRA data • Medical and pharmacy claims • Disability and workers comp data • Absenteeism • Dining room purchases • Financial impact

31. Industry, Best Practices • Aetna, Inc. • Baptist Health South Florida • FPL Group • Johnson & Johnson • Medical Mutual of Ohio • Pitney Bowes • Texas Instruments Inc. • Union Pacific Railroad Platinum Winners, National Business Group on Health www.businessgrouphealth.org

32. Worksite Health Promotion Programs • Johnson & Johnson • $225/person/year reduction in health care expenditures, with most benefit occurring in years 3 & 4 • BCBS Indiana HP program • 24% lower health care costs • Procter & Gamble • 29% decrease in health care expenditures in year 3 of the program

33. Mayo Health Promotion Committee • Established by Board of Governors 2004 • Directly engaged with various areas involved with health promotions • Catalogued and coordinating health and wellness programs at Mayo • Developed 6 key health objectives to focus efforts with communications plan

34. Mayo Health Promotion CommitteeKey Health Objectives • Encourage employees to maintain a healthy weight • Promote opportunities to increase physical activity • Educate employees about the importance of nutrition and healthy food choices • Direct employees to resources to manage emotional and behavioral health issues • Promote resources to help employees become tobacco free • Increase overall employee awareness on the importance wellness and preventive services

35. Mayo Health Promotion Committee • Established by BOG 2004 • Directly engaged with various areas involved with health promotions • Catalogued and coordinating health and wellness programs at Mayo • Developed 6 key health objectives to focus efforts with communications plan • Created “LiveWell” name and new graphic identity to connect future efforts

37. Mayo Health Promotion Committee • Nutrition Committee established wellness meal criteria, put nutrition information on cash register receipts, and improved employee cafeteria, committee meal, and vending machine options • Applied for and received 2.5 FTE and modest budget • Received approval for research position to document return on investment of health promotion activities • Vision is to establish a premier medical center model for wellness

38. Employer Health Promotion Initiatives • Define strategies, goals, measures • Communicate to employees (simple messages, win-win) • Provide tools and incentives (HRA) • Create supportive work environment • Develop benefit plan to include health promotion • Onsite fitness facility or health club reimbursement important

42. Summary • Increasing health risks, including obesity, are associated with increased health care costs • Increasing evidence that comprehensive worksite health promotion programs can decrease health risks and health care costs

43. The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Hensrud DD, ed. Mayo Clinic Healthy Weight for Everybody. Mayo Clinic, Rochester, MN, 2005. Health Management Research Center. Cost Benefit Analysis and Report 2006. University of Michigan, Ann Arbor, MI, 2006. Chapman LS, et al. Population health management as a strategy for creation of optimal healing environments in worksite and corporate settings. J Alt Comp Med 2004;10(Suppl 1):S127-S140. Pelletier KR. A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: update VI 2000-2004. J Occup Environ Med 2005;47:1051-8. References

44. Anderson DR, et al. Conceptual framework, critical questions, and practical challenges in conducting research on the financial impact of worksite health promotion. Am J Health Prom 2001;15:281-8. Hensrud DD, ed. The Mayo Clinic Plan: 10 Essential Steps to a Better Body & Healthier Life. Time, New York, NY, 2006. Supplement on Bariatric Surgery in Extreme Obesity. Mayo Clin Proc Oct 1, 2006. Available online at: http://www.mayoclinicproceedings.com/supplements.asp Lang RS, Hensrud DD, eds. Clinical Preventive Medicine, 2nd ed. AMA, Chicago, IL, 2004. References