The one way to make you slim, fit and healthy?

That your fattening lifestyle drives health insurance costs up is nothing but a fat lie. That much I have told you in the previous post. With Marlboro Man and Ronald McDonald doing better for your health insurer's balance sheet than Healthy Living, you might think that public health should look beyond economics as an argument for health.  In this post I will tell you why they shouldn't. 

 And why economics may well turn out to be the one and only way to getting you to exercise and reduce your weight. And, no, with economics I don't mean punishing you with penalty premiums on your health insurance and punitive taxes on your fast food. Let's leave such uninspired nonsense to the politicians. We can do better than that. Before I get to that point, let's pick up the thread from where we left it in the previous post. 

There I introduced you to the fact that the amazing arithmetic of sicker-equals-cheaper has been introduced by economists working in the employment of public health agencies. They are interested in the financial health of their government, not of a health insurance company. From that point of view, convincing smokers to quit and obese people to slim down doesn't seem to make much sense either. Here is why:

When smokers quit, their near-term health care costs may go down, but in the long run they will be offset by higher medical bills for causes unrelated to smoking but related to a longer life [1]. This longer life hurts the government twice. First, when smokers stop lighting up they also stop paying tobacco taxes to the government. Second, with longer lives come longer pension payments. In fact, if all smokers would quit today, we would have very unhappy finance ministers. Ours, here in Germany, would have his tax revenues reduced by € 14.5 Billion per annum. 

What goes for smoking goes for obesity, too. So, how sincere are our politicians with their professed concerns for our health? Is this a pretext for soon taxing your consumption of sugar and fast food? Well, they certainly have the backing of the World Health Organization. The WHO recommended the introduction of punitive taxes in their 2010 Global status report on noncommunicable diseases. What our politicians apparently don't have is the ingenuity to come up with a more innovative solution, for once. Which is why we have to find it. By looking a little closer at the economics of health.  

So, I'm asking you: aside from you personally, who benefits from your health so much, that promoting it makes economic sense? Your employer, for instance. Not only is a healthy employee less often absent from work, he is also more productive while he is at work. The costs related to work absence have been appropriately termed absenteeism, which makes you immediately understand what is meant with its twin, presenteeism. It describes the costs of being less productive while at work. 

As it turns out, presenteeism clobbers companies' profits much more than absenteeism. In fact, for cardiovascular disease and diabetes, the costs of reduced productivity, while at work, exceed those of absenteeism by a factor of 10 [2]. Admittedly, the calculation of presenteeism is not an exact science. But all available evidence points to a substantial return on employers' investments into preventing those chronic diseases, which produce chronically less productive workers. Across companies and nations, the overall cost:benefit ratio has been found to be in the region of 1:2.2 [3]. Which means, for every dollar spent on corporate health promotion, 2.2 dollars are gained. Not bad. But it could be a lot better if you really did prevent those chronic diseases.

Only, you don't. How do I know? By looking at the trends for the 7 metrics used by the American Heart Association (AHA) as the Strategic Impact Goals for improving cardiovascular health. By 2020 cardiovascular health shall be improved by 20%. That doesn't sound very ambitious. But in all likelihood it is way too ambitious. Here is why: Let's look at obesity, which the IOM has just branded a "catastrophic" problem in the U.S.
Instead of falling, the percentage of obese people has been on the rise, again, over the past 10 years, with now 34% of women and 32% of men being obese [4]. Physical activity levels have not improved significantly, neither did dietary habits. Blood sugar control has actually worsened, and blood pressure control has only slightly improved in men. Based on these data the improvements of cardiovascular health in 2020 will be around 6%, not 20%.

That's how I know that you aren't following your employer's corporate health program. Why would you when you don't follow public health's promotions and recommendations in the first place? Unless, of course, your employer makes you an offer you can't refuse. What would you do if your employer rewarded your participation in his health promotion program with hard cash, additional leave, or a tangible good you desire? What if he tied those benefits to your effort (e.g. your participation rate), or your measurable outcome (e.g. kgs of weight lost, or weight maintenance), or any mixture of effort and result? Would that entice you to pick up healthier habits?

As I have pointed out before, the argument that people who live healthy generate less health care costs than their unhealthily living peers is unsubstantiated. But that should not make us eliminate economics as a metric when it comes to promoting health. On the contrary. By making health an economic good we bring to the table what motivates people most: tangible rewards. The question is, would it get you to pick up exercise, if you didn't do it already, and would it get you to lose weight, if you needed to?

The reason why I'm asking you is, because as a public health scientist, I'm utterly disillusioned with the success rate of our preventive efforts. On one hand, we have this wonderfully simple and enormously effective preventive tool called exercise and weight loss. And on the other hand we have 4 out of 5 people not using this tool. On one hand, we have the new guidelines for the treatment of diabetes [5] and for the prevention of cardiovascular disease  [6], both of which have been released over the past few weeks. Both guidelines acknowledge lifestyle change as the first line of defense against those diseases. But on the other hand we have less than 2% of the population achieving the 7 simple health metrics of the AHA. Guidelines won't change that. So, how can we make the remaining 98% of the population achieve the 7 metrics? Obviously not with the same song and dance that didn't get the job done in the past.

Which is why we need to explore new ways. Taxing your consumption of the foods you enjoy isn't new. Making health an investment good, that's new. But without attracting those people who we haven't reached in the past, it won't work either. Now what do you think?

Will tangible rewards make employees exercise and lose weight?

1.          Temple, N.J., Why prevention can increase health-care spending. The European Journal of Public Health, 2011.

2.          Collins, J.J., et al., The assessment of chronic health conditions on work performance, absence, and total economic impact for employers. J Occup Environ Med, 2005. 47(6): p. 547-57.

3.          Dietmar Bräunig and T. Kohstall, The return on prevention: Calculating the costs and benefits of investments in occupational safety and health in companies, 2012, ISSA: Geneva, Switzerland.

4.          Huffman, M.D., et al., Cardiovascular Health Behavior and Health Factor Changes (1988-2008) and Projections to 2020: Results from the National Health and Nutrition Examination Surveys (NHANES). Circulation, 2012.

5.           Inzucchi, S.E., et al., Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diab tologia, 2012.

6.           Perk, J., et al., European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts) * Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal, 2012.

Temple, N. (2011). Why prevention can increase health-care spending The European Journal of Public Health DOI: 10.1093/eurpub/ckr139
 
Collins, J., Baase, C., Sharda, C., Ozminkowski, R., Nicholson, S., Billotti, G., Turpin, R., Olson, M., & Berger, M. (2005). The Assessment of Chronic Health Conditions on Work Performance, Absence, and Total Economic Impact for Employers Journal of Occupational and Environmental Medicine, 47 (6), 547-557 DOI: 10.1097/01.jom.0000166864.58664.29
 
Huffman MD, Capewell S, Ning H, Shay CM, Ford ES, & Lloyd-Jones DM (2012). Cardiovascular Health Behavior and Health Factor Changes (1988-2008) and Projections to 2020: Results from the National Health and Nutrition Examination Surveys (NHANES). Circulation PMID: 22547667
Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, & Matthews DR (2012). Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 55 (6), 1577-96 PMID: 22526604
 
Authors/Task Force Members:, Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, Albus C, Benlian P, Boysen G, Cifkova R, Deaton C, Ebrahim S, Fisher M, Germano G, Hobbs R, Hoes A, Karadeniz S, Mezzani A, Prescott E, Ryden L, Scherer M, Syvänne M, Scholte Op Reimer WJ, Vrints C, Wood D, Zamorano JL, Zannad F, Other experts who contributed to parts of the guidelines:, Cooney MT, ESC Committee for Practice Guidelines (CPG):, Bax J, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Document Reviewers:, Funck-Brentano C, Sirnes PA, Aboyans V, Ezquerra EA, Baigent C, Brotons C, Burell G, Ceriello A, De Sutter J, Deckers J, Del Prato S, Diener HC, Fitzsimons D, Fras Z, Hambrecht R, Jankowski P, Keil U, Kirby M, Larsen ML, Mancia G, Manolis AJ, McMurray J, Pajak A, Parkhomenko A, Rallidis L, Rigo F, Rocha E, Ruilope LM, van der Velde E, Vanuzzo D, Viigimaa M, Volpe M, Wiklund O, & Wolpert C (2012). European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by re European heart journal PMID: 22555213 PrintPDF