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Addressing Obesity at the Workplace Promising Approaches HERO Forum for Employee Health Management Solutions September 18-20, 2006 Chicago, IL Nico Pronk, Ph.D., FACSM, FAWHP Vice President, Health & Disease Management Executive Director, HealthPartners Health Behavior Group

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Addressing Obesity at the WorkplacePromising ApproachesHERO Forum for Employee Health Management SolutionsSeptember 18-20, 2006Chicago, IL

Nico Pronk, Ph.D., FACSM, FAWHP

Vice President, Health & Disease Management

Executive Director, HealthPartners Health Behavior Group

Senior Research Investigator, HealthPartners Research Foundation


Minneapolis, Minnesota

  • Background and context related to excess weight
  • What do we know works?
    • Systematic review of weight loss strategies
  • Promising approaches to address excess weight for employed populations
excess weight
Excess Weight
  • Overweight prevalence in the U.S. exceeds 65% of the population
  • Excess weight is associated with a variety of diseases, disorders, disability, function, quality of life, musculoskeletal pain, diminished social functioning, and premature death

Optimal, best possible performance, fully present

Fully absent, no work or duties performed

Worst possible performance, fully present



















Performance Quality Units (%)

Hours-on-Task (%)

The Work Loss Continuum

Work Performance Scale

Source: Pronk, NP. ACSM’s Health & Fitness Journal 2003;7(3):31-33

the total cost of illness defined
The Total Cost of Illness Defined

Medical and



Direct Medical Costs

Indirect Medical Costs











Short-term Disability


Source: Hemp, P. Harvard Business Review, October, 2004

excess weight6
Excess Weight
  • Excess weight impacts on both direct costs and indirect costs for employers

Medical and Absenteeism Expenditures Attributable to Excess Weight

Source: Finkelstein, et al. Am J Health Promot 2005;20(1):45-51.

health is more than the absence of disease
Health is more than the absence of disease…
  • Despite proclamations to the value of health, morbidity and mortality are what counts and gets counted (i.e., measured)
  • Evaluations are primarily based on reductions in mortality and morbidity, and their known behavioral risk factors, such as PA and diet
  • Do individuals characterized as being in “complete health” incur less health care costs and are they more productive than those characterized as being in “incomplete health” or “complete ill health”?
does health as a complete state add benefit to the bottom line
Does Health as a Complete State add Benefit to the Bottom Line?








* All p-values < 0.001

Source: Keyes, Grzywacz. JOEM 2005;47:523-532.

productivity and health risks obesity and work limitations
Productivity and Health RisksObesity and Work Limitations
  • Obesity impact on work limitations
  • NHANES III and NHANES 1999-2000 data
  • Obese workers, regardless of gender, are more likely than normal weight workers to report being limited in the amount or type of work they can do because of physical, mental or emotional problems (6.9% vs. 3.0%, respectively)

Impact of obesity on work limitations is akin to 20 years of aging

Source: Hertz, et al. JOEM 2004; 46:1196-1203.

weight related factors and productivity
Weight-related Factors and Productivity

Dep. Var. Effect on PROD

PA moderate Quality Improvement

Work rate Improvement

PA vigorous Work rate Improvement

Cardiorespiratory Fitness Quantity Improvement

Cardiorespiratory fitness Extra effort Improvement

BMI obese Getting along Decrement

BMI morbid Work loss days Decrement

Physical inactivity Absenteeism Decrement

No HPDP program participation Absenteeism Decrement

Physical inactivity Presenteeism Decrement

Poor diet Presenteeism Decrement

High Stress Presenteeism Decrement

Lack of emotional fulfillment Presenteeism Decrement

Sources: Pronk, et al., JOEM, 2004; 46(1): 19-25; NBGH Issue Brief Dec. 2005.

what do we know works
What do we know works?
  • Basing decisions on evidence is a good idea
  • By and large, the best evidence for many decisions comes from a systematic review of all the evidence
  • Systematic reviews currently provide the best, least biased, and rational way to organize, cull, evaluate, and integrate the available research evidence

HealthPartners Systematic Review on Obesity

  • Study question:
    • “What lifestyle strategies and/or treatment components contribute to successful weight management defined as 5% to 7% of starting (baseline) body weight, 5% loss maintained for 1 year or longer?”
  • Studies published after January 1997
    • Randomized controlled trials 12 months in duration
    • Observational studies 5 years in duration
    • Meta-analysis of studies meeting study criteria
  • Results presented by intervention type
    • Advice-only; diet-only; diet plus PA; exercise-only; meal replacements; VLCD; anti-obesity medications
literature review
Literature Review
  • Diet advice only
    • 16 studies with diet advice alone as 1 arm: 3,786; 3,418 completers
  • Exercise alone
    • 4 studies; 6 studies with exercise alone as 1 arm: 325; 260 completers
  • Diet the primary therapy
    • 8 studies; 39 studies with diet alone as 1 arm: 7,798; 4,979 completers
  • Diet plus exercise
    • 13 studies; n=2,183; 1,950 completers
  • Meal replacements
    • 8 studies; n=470; 376 completers
  • Anti-obesity medications
    • 21studies; n=6,634; 4.241 completers
  • Very-low calorie diets
    • 11studies; n=925; 551 completers

Total: 80 studies; N=24,698; 16,823 completers (68%)


Systematic Review of Weight Loss StudiesAverage Weight Loss of Subjects Completing a Minimum 1-Yr Weight Management Intervention80 Studies, 24, 698 Subjects, 16,823 Completers (68%)

task force on community preventive services
Task Force on Community Preventive Services
  • Obesity-related systematic review for worksite setting
    • Multi-component interventions aimed at diet, physical activity, and cognitive change
    • Single component interventions aimed at diet, physical activity, or cognitive change alone


Optimizing Practice through Research

The application of “evidence-based” recommendations



and summaries

Logic Framework Depicting the Conceptual Approach to Development of an Adult Weight Management Protocol

Height and Weight

(Body Mass Index)

  • Structure
  • Intervention components
    • Individual
    • Correspondence
    • Multi-component
    • Group-based
    • Technology use
  • Providers
  • Clinical care guidelines
  • Platforms of operations
  • Program design






Comorbid Conditions



(age 18

and over)

  • Process
  • Delivery methods
  • Integration
  • Referral patterns
  • Provider role
  • Intervention processes
  • Process improvement


health promotion


Demographic Variations

Prevalence and


Financial Impact

  • Outcomes
  • Participation
  • Weight change
  • Behavior change
  • Quality of life
  • New disease diagnoses
  • Satisfaction
  • Clinical management

Social Ecology

  • Worksite-based
  • Clinic-based
  • Health plan-based
  • Community-based
  • other settings

Design and

Process Improvement

Source: HealthPartners Health Behavior Group, 2004

promising approaches
Promising Approaches
  • Program strategy and design elements
    • Clear goals and objectives
    • Strong leadership
    • Socio-ecological approach recognizing both individual-level and organizational-level program characteristics
    • Program intensity and cost
    • Communications and incentives
    • Inter-relatedness of all elements
program elements to consider
Program Elements to Consider
  • Program intent
  • Intervention target level
  • Intervention design features
  • Program intensity and cost
  • Target population
  • Program approaches (tactics; options)
program components related to successful outcomes
Program Components Related to Successful Outcomes
  • Behavioral weight loss strategies:
    • Calorie reduction
    • Fat reduction
    • Increased fruit/vegetable intake
    • Increased exercise/physical activity
    • Elimination of sweets
    • Consumption of less food
  • Any use of strategies (singly or in combination) is associated with weight loss
  • Use of these strategies is related to better weight loss in a dose-response fashion

Source: Linde, et al Int J Behav Nutr Phys Act 2006, 3(3) [access online].

program components related to successful outcomes21
Program Components Related to Successful Outcomes
  • Successful weight loss maintenance
    • Dietary composition – moderately low fat diet consumption and total caloric intake monitoring
    • Breakfast – 7 days per week
    • Self-monitoring – daily or weekly monitoring of body weight
    • Physical activity – regular PA; 1 hour of moderate intensity PA daily (or ~28 miles of walking per week)

Source: Wyatt, et al Obesity Management 2005;1(2):56-61.

addressing obesity at the worksite
Addressing Obesity at the Worksite

Assess Organizational


Environmental Risks

Physical environment

(physical surroundings)

Social environment

(policies, norms, etc.)

Health education programming

(learning resources)

Management support

(leadership support, resources)

Organizational foundations

(supporting structure incl.

health benefits)


Measurement and Evaluation









Stratify Population

by BMI Risks





Maintain Health

High cost

High intensity

Moderate cost

Moderate intensity

Low cost

Low intensity

Severely obese


Population Size

Program Cost


Healthy weight