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

Who says being fat is bad?

Would you have guessed that, one fine day, health insurers will regret the demise of big tobacco and its contribution to health care costs? Would you have guessed that, when that day arrives, health insurers would also learn to love other frowned-upon-vices of their policy holders, such as getting fat and lazy? Your answer is probably "no, I wouldn't have guessed that in my dreams.". 

And also very probably this answer is based on what you typically read in the media, such as this piece of news titled "Obesity Adds More to Health Care Costs Than Smoking, Study Suggests." released on April 3, 2012, on sciencenews.com. The article text wraps the title message into a substantially larger amount of unsubstantial words, before it concludes what you would probably subscribe to blindfolded: the  "...study [1] provides new insights into the long-term costs of obesity and smoking, showing that both risk factors lead to persistently higher health costs throughout a seven-year follow-up period.". Dah, what else is news?

Well, for one, that the Joe Camels and the lardbuckets, with all their vices, cost their health insurers actually LESS money than Mr. and Mrs Healthy. For one simple reason: the "vice guys" die earlier.

But let's hold that thought for a moment and let's look at the figures. In a Dutch study performed by Pieter van Baal and colleagues, the authors compared the annual and lifetime health care costs of three cohorts, namely the obese, the smokers, and the healthy living people [2]. As the basis of their calculations they used the Dutch National Institute's of Public Health and the Environment (RIVM) chronic disease model, which, the authors assure us, has been widely used and validated in disease and cost projection analyses.

To make their results more comparable internationally, they ran their analyses with altogether 7 different scenarios, to account for different health care systems and for different mortality risk estimates. The latter had been drawn from observations in the U.S. published by Flegal and colleagues [3] who had found declining mortality risks in the obese cohorts. I mention this because I don't want you to suspect that the Dutch authors had based their calculations on an unrealistically high keeling-over rate for the obese. Now, fast forward to the astonishing results.

In all 7 models, as well as in the unadjusted base case scenario, the financially most attractive "villains" to health insurers are the smokers. The most expensive are always the goody-two-shoes healthy-living people. Somewhere in-between are the fat ones. In the model which assumed a yearly 1% increase in health care costs, the lifetime costs for an obese person amounted to € 399,000, compared to which the smoker comes at a 14% discount of € 341,000, but the healthy living person with a 17% premium at € 468,000.

How can that be? The answer is not where you and I would have looked first: The diseases which directly associate with smoking and obesity (heart disease, cancer, diabetes, pulmonary diseases, musculoskeletal disorders). They account only for 20% of total disease costs. The remaining 80% are for ailments and conditions, which come with age. But when that age doesn't come, because you die earlier, then those costs don't come either. And Joe Camel and Ronald McDonald are rather effective in cutting years out of your life, and thereby costs out of your health insurers balance sheet. For 7 and 5 years respectively, to be precise.   

So, where are the premium discounts for the obese and the smoking policy holders? Why are the healthy living people permanently miffed about not getting premium discounts, when they actually cost more? I have to admit, I belong to the latter, too. But recently, after having listened to one of my talks at a conference, a friend of mine, the CEO of a German health insurer, took me aside and told me, that my indignation about the healthy people having to share the cost burden of their willfully negligent peers, was unfounded.

As much as I wanted to disbelieve, I also knew that these insurance guys do one thing very well: calculating risk and premiums. So I had to give him the benefit of the doubt. Which is why I began to check. And by checking, I came to know about quite a number of studies confirming my friend's argument. One of those studies was van Baal's, which I chose to quote from because he is actually working for the Dutch National Institute of Public Health and the Environment. Not that I'm biased in favor of the Dutch. I'm biased in favor of anyone who articulates a viewpoint which is in stark contrast to what I would expect merely on the basis of his association. I mean, here you have someone telling you to NOT confuse health with health care cost savings, when his employer is actually trying to make everyone with a cigarette or a burger in his mouth feel guilty about sending health care costs sky high.  

So what now? Shall we promote the vices and lower our health care costs in a decade-long smoking and feeding frenzy? Well, it's your choice, but I'm not convinced that we have got the reasoning or the arguments right just yet. We need to do a little more detective work to solve this case.

Now, you know how the French, at least in their novels, dish out that piece of advice to the detective: Cherchez la femme (look for the woman)? Maybe it works in the French universe. In mine, I have always found this one to work better: "Cherchez l'argent" (look for the money).

Which will lead us to another few surprising discoveries in the next post. And, of course, a couple more reasons to believe that there are quite some powerful players around who yearn for the good old times when Marlboro Man and Ronald McDonald delivered us from the risk of a costly long life.

PS: To meaningfully pass the time until the next post, watch this video on the calorie cartel

1.           Moriarty, J.P., et al., The effects of incremental costs of smoking and obesity on health care costs among adults: a 7-year longitudinal study. Journal of Occupational and Environmental Medicine, 2012. 54(3): p. 286-91.

2.           van Baal, P.H.M., et al., Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure.PLoS Med, 2008. 5(2): p. e29.

3.           Flegal, K.M., et al., Excess deaths associated with underweight, overweight, and obesity. Jama, 2005. 293(15): p. 1861-7.

Moriarty, J., Branda, M., Olsen, K., Shah, N., Borah, B., Wagie, A., Egginton, J., & Naessens, J. (2012). The Effects of Incremental Costs of Smoking and Obesity on Health Care Costs Among Adults Journal of Occupational and Environmental Medicine, 54 (3), 286-291 DOI: 10.1097/JOM.0b013e318246f1f4
van Baal PH, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, Boshuizen HC, Engelfriet PM, & Brouwer WB (2008). Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS medicine, 5 (2) PMID: 18254654
Flegal, K. (2005). Excess Deaths Associated With Underweight, Overweight, and Obesity JAMA: The Journal of the American Medical Association, 293 (15), 1861-1867 DOI: 10.1001/jama.293.15.1861