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Obesity and Corporate America: Getting to Solutions

Pronk, Nico Ph.D., FACSM, FAWHP

doi: 10.1249/FIT.0000000000000145
COLUMNS: Worksite Health Promotion

This column discusses the consequences of obesity in the workplace and offers solutions on how to improve the health of the employee and the productivity of the company.

Nico Pronk, Ph.D., FACSM, FAWHP, is vice president and chief science officer at HealthPartners in Minneapolis, MN, where he also is a senior research investigator at the HealthPartners Research Foundation. Dr. Pronk is an adjunct professor of Social and Behavioral Sciences at the Harvard University School of Public Health, where he teaches and conducts research in worker health protection and promotion. He is past president of the International Association for Worksite Health Promotion (IAWHP), an ACSM Affiliate Society, coauthor of the IAWHP Online Certificate Course, editor of ACSM’s Worksite Health Handbook, 2nd Edition, and associate editor for ACSM’s Health & Fitness Journal®.

Disclosure: The author declares no conflict of interest and does not have any financial disclosures.

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The consequences of the ever-increasing numbers of people afflicted by obesity are continuing to emerge. They range from the impact on society through increasing health care costs and chronic illness burden to the ways individuals are affected by reduced function and quality of life. Business and industry are not shielded from these consequences either. For example, obesity is associated with lower productivity, higher absenteeism rates, higher disability rates, and higher health care costs (8). However, employee interests also are affected because obesity is associated with lower wages, lower family earnings, lower functional status, discrimination, and social stigma… all of which can have an enormous impact on a person’s life (8). In the context of the workplace and the workforce, obesity has been identified as a major threat to the economic productivity of a company, the local community, and the nation as a whole.

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OBESITY BY THE NUMBERS

The prevalence of obesity has increased dramatically during the past three to five decades. Globally, more than 2.1 billion people — approximately 30% of the global population — are overweight (defined as a body mass index (BMI) of ≥25 kg/m2 to <30 kg/m2) or obese (defined as a BMI of 30 kg/m2 or greater) today. Overweight and obesity place individuals at an elevated risk for the development of obesity-related disorders, such as type 2 diabetes, cardiovascular disease, stroke, certain cancers, orthopedic problems, and depression. However, the major risks are associated with obesity and severe obesity. According to the U.S. Centers for Disease Control and Prevention, between 1989 and 2008, prevalence of obesity in the United States increased from 12% to 27%. An increasingly urgent need exists to do something about this pervasive health problem because it comes at a huge personal, social, and economic cost. Obesity is responsible for approximately 5% of all global deaths; the global economic impact is estimated at $2 trillion or 2.8% of the global Gross Domestic Product, which approximates the impact of smoking or armed conflict (violence, war, and terrorism) (6). Obesity-related medical expenditures cost Americans $147 billion in 2008 (3) and has been projected to reach $344 billion by 2018, effectively imposing a “tax” of $1,425 for every person in the United States (10).

Obesity also exerts a heavy toll on employers. Obesity prevalence among workers seems to have doubled between 1985 and 2015 from approximately 15% to 30% (8). Estimated medical and absenteeism expenses for obese employees have been estimated to be between $400 and $2,000 per person per year higher than their nonobese counterparts (2). In addition, obese workers were noted to have 20% more doctor visits, 26% more emergency room visits, and 10% higher presenteeism rates than normal-weight workers, resulting in an increased cost of $644 per obese person per year compared with normal-weight workers (5).

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COMPLEXITY OF THE PROBLEM

Obesity is a complex problem, and attempts to treat or prevent it by considering it to be a simple problem have generally not been effective (e.g., by considering individual behavioral strategies alone). Cultural forces, such as social norms and environmental context, are powerful influences on the eating and activity habits of people. In an attempt to understand the various factors that are related to a causal model for obesity, the U.K. government Foresight research on obesity identified more than 100 variables (11). As such, obesity is identified as a systemic problem with causes that are complex, manifold, and interdependent. These causes are influenced by media, social, psychological, economic, biological, medical, activity, and food environments, as well as the larger developmental and macroeconomic infrastructures. More specifically, the Foresight complex causal model identifies clusters related to food production and consumption, biology, individual psychology, individual activity, societal influences, and the activity environment, along with the individual’s core. The interactive and interdependent properties of multiple factors generate an overall outcome that reflects the body weight of an individual or a population.

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An example of how complexity manifests itself in the context of the workplace across longer periods is provided by a recent analysis of the changes in the physical demands of work (1). The modern contemporary workplace does not require as much physical exertion to complete work tasks as was required half a century ago. Technology replaces the need for physical labor. The increasingly large number of sedentary jobs demands a more intentional approach to accumulating sufficient amounts of activity throughout the course of the day. Unfortunately, this is a difficult behavioral challenge that many people struggle to do well. As a result, daily occupation-related energy expenditure has reduced by 100 calories per person, and this change is purported to account for a large proportion of the concomitant increase in body weight among the workforce during the past 50 years (1,8).

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ARE THERE SOLUTIONS TO OBESITY THAT WORK?

A singular focus on interventions that asks obese individuals to change their behavior has been shown to initiate reasonable amounts of weight loss in the short-term. Unfortunately, these interventions struggle to sustain their impact, often showing weight regain during the ensuing 1 to 2 years by as much as 70% (4). The Figure shows the summary graph of a systematic review and meta-analysis of behavioral interventions and their associated weight loss trajectories. As noted, initial success is followed by a slow regain of weight lost. Despite this observation, it should be noted that programs such as those including exercise and a healthful weight-reducing diet certainly benefit the individual beyond weight loss alone, and these are therefore not without merit. However, the conclusion makes it clear that, for sustained weight loss success, a more comprehensive approach is needed that incorporates environmental and cultural solutions.

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Figure. Ave

Another review designed to identify a broad catalog of programs and interventions that may be used to reduce obesity identified 74 interventional approaches that are being discussed, piloted, or implemented all over the world (6). These 74 interventional approaches fall into 18 broad categories that are summarized in the Table 1. These 18 categories and their associated interventions can be implemented in the context of a behavioral framework designed to inform, enable, motivate, and/or influence the people, groups, or populations to which they are targeted. The information architecture can be enhanced to optimize the impact of information availability as well as the relevance of the message to the individual or group by using market segmentation techniques. Choice architecture and behavioral economics may be used to make change efforts easier through the options made available. Changing social norms is at least as important as changing behavior to accomplish broad-based success. Motivation to change and shift the social norm is related to personal goals and commitments as well as incentives or disincentives — much like the changes in the price of tobacco products and the shift in acceptability of smoking during the past 30 years. Influence exerted through campaigns added to other educational efforts is an important strategy to affect social norm shifts. Workplace wellness programs are identified as 1 specific category out of the 18 intervention groups; however, it is obvious that other categories overlap and interact with workplace wellness especially when considering that workers do not limit their time to the workplace alone.

TABLE 1

TABLE 1

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PRACTICAL APPLICATIONS

When it comes to taking action, certain solutions may be implemented at the workplace as part of the already existing processes associated with the workplace wellness program. Other actions will need more formal collaboration with other partners, and yet other solutions cannot be implemented without recognizing the cross-sectoral activities that position a company as a partner in the overall effort. In other words, it is important to realize that some things can be done relatively easily because the company has a large amount of control over the proposed actions. On the other hand, the farther away from the workplace, the less control a company has over what and how things will be done. In such circumstances, the company remains an important member of the collaborative effort with the ability to influence the activity but will need to recognize the appropriate role to play.

In addition, based on what has been learned so far about what works to address obesity, it is imperative that companies implement programs at sufficient scale to have an impact. Across the board, successful programs and interventions still have relatively small effect sizes and most workplaces have unique cultures — even within the same company, different sites or even departments may have unique needs. It is therefore highly unlikely that any single solution will work for all situations. Rather than prioritize programs and wait for perfect proof, companies should implement as many programs as possible simultaneously. Small experiments and pilot programs also will be useful to ensure a good fit for the local situation. Whereas Nicholas Negroponte, the famed head of MIT’s Media Lab, once said, “incrementalism is innovation’s worst enemy” (7), this author’s view is that, in the case of addressing obesity and getting to large-scale successes, “intentional incrementalism is innovation’s best friend.”

To ensure sufficient reach and scale, the activities should not only be limited to the workplace alone but also include the community setting. Companies should intentionally reach out to community partners and stakeholders and become part of multistakeholder cross-sectoral efforts to address obesity. No sector or stakeholder can address obesity effectively on its own; no single sector or stakeholder owns the problem, and no single sector or stakeholder owns the solution. It will take multipartner collaboratives to create systematic approaches with scalability and sustainability to drive solutions powerful enough to make a difference (9).

Finally, company leaders can make a real difference in addressing public health concerns that affect the corporation — such as obesity. Leader-to-leader engagement can be a powerful means of setting a corporate vision, creating community partnerships, mobilizing resources, and generating regional prosperity. Connecting the workplace to the community for such efforts represents an investment in the long-term viability of the company and the community alike.

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TAKEAWAY ACTION ITEMS

In summary, what can a company do to address obesity? Here are some action items to consider — the more the better:

  • Of all programs and interventions that are known to work for obesity, do as many as you can — don’t prioritize!
  • Be systematic, reach as many people as possible, implement for as long as possible.
  • Education and behavior change support are necessary but not sufficient. Ensure to modify the physical environment and change the culture so as to support health and well-being.
  • Partner with others to reach far beyond the workplace walls and support families, schools, and other community organizations in collaborative efforts to address obesity.
  • Look for relevant incentives aligned with collective action.
  • Try new ideas and pilot new programs — don’t wait for the perfect proof of effectiveness.
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References

1. Church TS, Thomas DM, Tudor-Locke C. Trends over 5 decades in U.S. occupation–related physical activity and their associations with obesity. PLoS ONE. 2011; 6 (5): e19657.
2. Finkelstein EA, Fiebelkorn IC, Wang G. The cost of obesity among full-time employees. Am J Health Promot. 2005; 20 (1): 45–51.
3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: Payer- and services-specific estimates. Health Aff. 2009; 28 (5): w822–31.
4. Franz MJ, VanWormer J, Crain L, et al Weight loss outcomes: A systematic review and meta-analysis of weight loss clinical trials with a minimum of 1-year follow-up. J Am Diet Assoc. 2007; 107 (10): 1755–67.
5. Goetzel RZ, Gibson T, Short ME, et al A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker productivity. J Occup Environ Med. 2010; 51 (1): S52–8.
7. Negroponte N. Being Digital. New York (NY): Vintage Books; 1995.
8. Pronk NP. Fitness of the U.S. workforce. Ann Rev Public Health. 2015; 36: 131–49.
9. Pronk NP, Baase C, Noyce J, Stevens DE. Corporate America and community health: Exploring the business case for investment. J Occup Environ Med. 2015; 57: 493–500.
10. Thorpe K. The future cost of obesity: National and state estimates of the impact of obesity on direct health care expenses 2009; [cited 2014 Apr 6]. Available from: http://www.nccor.org/downloads/CostofObesityReport-FINAL.pdf.
11. VandenBroeck P, Goossens J, Clemens M. 2007. Foresight Tackling Obesities: Future Choices — Building the Obesity Systems Map. London (UK): Government Office for Science.
© 2015 American College of Sports Medicine.