Alternatives to Monetary Incentives for Employee Weight Loss Lenard I. Lesser, MD, MSHS, Rebecca M. Puhl, PhD
E
mployers are increasingly interested in improving employee health, with the goals of reducing health care costs and increasing productivity. As of 2010, 74% of employers who offered health insurance also offered a wellness program, and the prevalence is increasing.1 However, there is vigorous debate about whether employee wellness programs actually work to improve health. Although proponents assert that welldesigned programs can benefit employers and employees, many raise concerns about weak study designs (e.g., lack of control groups) in research on employee health programs and argue that their effectiveness is greatly overstated. Nonetheless, wellness programs have been given a boost by the Affordable Care Act (ACA). The ACA funds several programs to help companies initiate wellness programs, and allows employers to incentivize employees with monetary rewards and penalties.1 Previously, employers could entice employees to join a wellness program by offering as much as a 20% reduction in their health insurance premiums. With passage of the ACA, this incentive can be up to 30%. Wellness programs can take various forms, such as smoking-cessation groups, walking programs, or online programs that include setting and achieving personal health goals. One approach that is increasingly being used to incentivize employees is to pay employees (through insurance rebates) for achieving weight, cholesterol, or blood pressure goals. In response, concerns have been raised that these programs will result in unhealthy employees subsidizing healthy employees’ health care costs2 and may unfairly discriminate against people with obesity. In addition, this approach does little to effectively improve public health, given that such initiatives do not address the strong forces of the obesogenic environment: From the Palo Alto Medical Foundation Research Institute (Lesser), Palo Alto, California; and Rudd Center for Food Policy and Obesity (Puhl), Yale University, New Haven, Connecticut Address correspondence to: Lenard I. Lesser, MD, MSHS, Assistant Research Physician, Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Ames Building, Palo Alto CA 94301. E-mail: LesserL@ pamfri.org 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2013.11.017
& 2014 American Journal of Preventive Medicine
the marketing, pricing, and availability of unhealthy foods and an environment that promotes sedentary behaviors. Therefore, there are compelling clinical and ethical reasons not to incentivize employees to achieve a particular weight or biometric marker level.
Clinical Reasons Being overweight is not an automatic indicator that one is unhealthy, just as being normal weight is not an automatic indicator that one is healthy.3 For instance, individuals with excess weight who are physically active are likely to be healthier than normal-weight individuals who are not active. Individuals who eat a diet rich in vegetables are likely to be healthier than those who do not, regardless of weight. There is a range of body weights at which people may exhibit good health indices (such as cholesterol and blood pressure levels in a healthy range), and weight is only one risk factor for disease. Paying employees for achieving cholesterol or blood pressure goals may be similarly misguided, as checking cholesterol yearly is unlikely to change risk estimation for cardiovascular disease in low-risk individuals,4 and blood pressure varies considerably, making it difficult and potentially unfair to achieve a specific goal. BMI and other biometric markers of health such as blood pressure and cholesterol are also influenced by genetics and environmental determinants that do not exert equal effects across the population. Thus, incentivizing employees on the basis of these indices unfairly places the responsibility on individuals to change health indices that they may have little personal control over and disregards the multifactorial causes of body weight. There also seems to be an incorrect assumption made by employers that employees can simply lose weight with financial incentives. Research challenges this assumption, as previous studies evaluating monetary incentives for weight loss show high attrition rates of participants, indications that financial incentives lose their effectiveness over time, poor long-term sustainability of weight loss, and in some cases even extreme, unhealthy weightloss strategies among participants.5 Financial incentives are unlikely to be a “magic bullet,” as obesity is a complex condition that is not easily modified. Despite a multitude of conventional
Published by Elsevier Inc.
Am J Prev Med 2014;46(4):429–431
429
430
Lesser and Puhl / Am J Prev Med 2014;46(4):429–431
interventions and treatments available, rigorous science consistently demonstrates that only a small percentage of people can achieve long-term, significant weight loss.6 This evidence has led to a greater appreciation among expert medical panels of the biological factors that regulate body weight, as well as the difficulty of maintaining losses of more than 5%–15% of a person’s body weight. The legitimate challenges of achieving sustainable, significant weight loss may explain, in part, why adding financial incentives to lifestyle programs does not seem to lead to long-term weight loss.7 Weight, cholesterol, and blood pressure may seem like appropriate indices to measure, as we are accustomed to tracking them in the medical field. Although the field of medicine is accustomed to evaluating programs based on outcomes, this is an instance where process measures (i.e., behaviors) may be equally, if not more, important. Instead of paying employees for outcomes such as absolute BMI or blood pressure levels, why not pay all employees who practice the health behaviors we are actually trying to change, such as physical activity and eating behaviors? Mobile and web apps allow individuals to track their dietary intake, monitor their weight, and track their physical activity.8 Thousands of apps exist for these purposes, and 21% of Americans already track their health using such technology.9 Individuals who track their health behaviors are more likely to maintain healthy behaviors. Although employees may not want their employers to see what they are eating and when they are exercising, there are ways to incentivize the use of these trackers while maintaining privacy and confidentiality. For example, employers can simply measure an employee’s level of engagement or participation with a program or an app. Intermediaries can process the data and inform employers whether an individual employee has met an engagement benchmark.
Ethical Reasons Focusing on weight stigmatizes individuals who are already vulnerable to prejudice and discrimination in the employment setting. Considerable evidence spanning several decades consistently indicates that employees with excess weight or obesity face inequities in the workplace, including unfair hiring practices, prejudice from coworkers and employers, lower wages, and job termination, all because of their body weight.10 There are common societal stereotypes that obesity is simply a result of poor self-discipline and lack of willpower, and these stereotypes may be at the root of employer decisions to incentivize weight. When individuals feel blamed or stigmatized about their weight, they are more likely to engage in behaviors that impair weight-loss efforts and reinforce obesity, such as
increased food consumption, binge eating, and avoidance of physical activity.11,12 Thus, paying employees on the basis of weight may further reinforce weight stigma and actually have the unintended consequence of promoting unhealthy behaviors and reinforcing obesity. The opportunity costs of these programs may also direct funds away from where they are needed most. Implementing wellness programs to test employees’ biometrics is very costly and time consuming. Because laws prevent employers from obtaining biometrics directly from medical records, employers are required to set up clinics to weigh and take blood from employees. A more cost-effective approach would be to redirect the steep costs of these tests toward efforts that support social changes that can help reverse the conditions that have created obesity in the first place. For instance, employers could subsidize healthy meals for employees, provide standing workstations, provide time and space for physical activity, remove sugary beverages from the workplace, supply healthy snacks, and engage in community-wide efforts to limit the marketing of unhealthy food. Certainly, it is important for employees to take personal responsibility for their health, but expecting them to reach health goals through personal responsibility alone, in isolation of the environmental and biological forces that contribute to obesity, will not be sufficient or effective in efforts to achieve optimal weight-related health. Additionally, many of the tests that employers mandate in these programs are invasive and can lead to unnecessary worry on the part of low-risk participants. Testing weight correctly requires removal of clothes; this can lead to anxiety and embarrassment, especially for employees who know they are overweight. Testing cholesterol and blood sugar requires a blood draw, and many advocate for doing these tests while fasting. Even if these tests cause only minimal discomfort, it is unethical to force an employee (through lucrative financial incentives) to undergo these procedures when they will not change medical treatment.
Focus on Incentives for Behavior Financial incentives are not all bad. In fact, employers can use incentives to encourage a number of behaviors. Financial incentives are routinely used to reduce smoking rates, save for retirement, and use public transport to get to work. The difference between these incentives and those for weight or cholesterol is that the former are for modifiable behaviors. Paying for weight or cholesterol pays for an outcome without a direct line between a behavior and a condition. Paying for reduction of weight induces a range of problems; paying for employees to participate in physical www.ajpmonline.org
Lesser and Puhl / Am J Prev Med 2014;46(4):429–431
activity (a behavior) induces fewer problems. However, with any incentive program, we must be careful not to overly classify “good” and “bad” behaviors, which can inadvertently lead to unintended consequences.13 The reality is that poor diet and physical inactivity can impair health for all individuals, not just those with obesity. Incentive programs that instead reward healthy behaviors for all employees could offer a much broader umbrella under which people can be supported to become healthier, regardless of their body weight. Rather than just focusing on those employees who look unhealthy on the outside and emphasizing physical markers such as BMI, employers interested in participating in the ACA’s wellness incentives should incentivize healthy behaviors. They can achieve this through modern technologies, creating multiple opportunities for employees to engage in healthy behaviors in the workplace, and supporting broader policy initiatives that can improve the food environment and public health. These strategies prevent the stigmatization and ethical problems associated with incentivizing weight and provide ways to empower and support employees in their efforts to become healthier. Dr. Lesser is supported by institutional funds from the Palo Alto Medical Foundation Research Institute. He serves as an unpaid advisor to a company that integrates mobile tracking into employee health programs. Dr. Puhl has no financial disclosures.
April 2014
431
References 1. Mattke S, Schnyer C, Van Busum KR. A review of the U.S. workplace wellness market. Santa Monica CA: RAND Health, 2012. . 2. Horwitz JR, Kelly BD, DiNardo JE. Wellness incentives in the workplace: cost savings through cost shifting to unhealthy workers. Health Aff 2013;32(3):468–76. 3. Karelis AD, St-Pierre DH, Conus F, Rabasa-Lhoret R, Poehlman ET. Metabolic and body composition factors in subgroups of obesity: what do we know? J Clin Endocrinol Metab 2004;89(6):2569–75. 4. Bell KJL, Hayen A, Irwig Les, Takahashi O, Ohde S, Glasziou P. When to remeasure cardiovascular risk in untreated people at low and intermediate risk: observational study. BMJ 2013;346:f1895. 5. Cawley J, Price JA. A case study of a workplace wellness program that offers financial incentives for weight loss. J Health Econ 2013;32(5): 794–803. 6. Katan MB. Weight-loss diets for the prevention and treatment of obesity. N Engl J Med 2009;360(9):923–5. 7. John LK, Loewenstein G, Troxel AB, Norton L, Fassbender JE, Volpp KG. Financial incentives for extended weight loss: a randomized, controlled trial. J Gen Intern Med 2011;26(6):621–6. 8. Azar KMJ, Lesser LI, Laing BY, et al. Mobile applications for weight management. Am J Prev Med 2013;45(5):583–9. 9. Fox S, Duggan M. Tracking for health. Washington DC: Pew Internet & American Life Project, 2013. www.pewinternet.org/Reports/2013/ Tracking-for-Health.aspx. 10. Rudolph CW, Wells CL, Weller MD, Baltes BB. A meta-analysis of empirical studies of weight-based bias in the workplace. J Vocat Behav 2009;74(1):1–10. 11. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One 2013;8(7):e70048. 12. Wott CB, Carels RA. Overt weight stigma, psychological distress and weight loss treatment outcomes. J Health Psychol 2010;15(4): 608–14. 13. Fitzgerald FT. The tyranny of health. N Engl J Med 1994;331(3):196–8.
E
mployers are increasingly interested in improving employee health, with the goals of reducing health care costs and increasing productivity. As of 2010, 74% of employers who offered health insurance also offered a wellness program, and the prevalence is increasing.1 However, there is vigorous debate about whether employee wellness programs actually work to improve health. Although proponents assert that welldesigned programs can benefit employers and employees, many raise concerns about weak study designs (e.g., lack of control groups) in research on employee health programs and argue that their effectiveness is greatly overstated. Nonetheless, wellness programs have been given a boost by the Affordable Care Act (ACA). The ACA funds several programs to help companies initiate wellness programs, and allows employers to incentivize employees with monetary rewards and penalties.1 Previously, employers could entice employees to join a wellness program by offering as much as a 20% reduction in their health insurance premiums. With passage of the ACA, this incentive can be up to 30%. Wellness programs can take various forms, such as smoking-cessation groups, walking programs, or online programs that include setting and achieving personal health goals. One approach that is increasingly being used to incentivize employees is to pay employees (through insurance rebates) for achieving weight, cholesterol, or blood pressure goals. In response, concerns have been raised that these programs will result in unhealthy employees subsidizing healthy employees’ health care costs2 and may unfairly discriminate against people with obesity. In addition, this approach does little to effectively improve public health, given that such initiatives do not address the strong forces of the obesogenic environment: From the Palo Alto Medical Foundation Research Institute (Lesser), Palo Alto, California; and Rudd Center for Food Policy and Obesity (Puhl), Yale University, New Haven, Connecticut Address correspondence to: Lenard I. Lesser, MD, MSHS, Assistant Research Physician, Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Ames Building, Palo Alto CA 94301. E-mail: LesserL@ pamfri.org 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2013.11.017
& 2014 American Journal of Preventive Medicine
the marketing, pricing, and availability of unhealthy foods and an environment that promotes sedentary behaviors. Therefore, there are compelling clinical and ethical reasons not to incentivize employees to achieve a particular weight or biometric marker level.
Clinical Reasons Being overweight is not an automatic indicator that one is unhealthy, just as being normal weight is not an automatic indicator that one is healthy.3 For instance, individuals with excess weight who are physically active are likely to be healthier than normal-weight individuals who are not active. Individuals who eat a diet rich in vegetables are likely to be healthier than those who do not, regardless of weight. There is a range of body weights at which people may exhibit good health indices (such as cholesterol and blood pressure levels in a healthy range), and weight is only one risk factor for disease. Paying employees for achieving cholesterol or blood pressure goals may be similarly misguided, as checking cholesterol yearly is unlikely to change risk estimation for cardiovascular disease in low-risk individuals,4 and blood pressure varies considerably, making it difficult and potentially unfair to achieve a specific goal. BMI and other biometric markers of health such as blood pressure and cholesterol are also influenced by genetics and environmental determinants that do not exert equal effects across the population. Thus, incentivizing employees on the basis of these indices unfairly places the responsibility on individuals to change health indices that they may have little personal control over and disregards the multifactorial causes of body weight. There also seems to be an incorrect assumption made by employers that employees can simply lose weight with financial incentives. Research challenges this assumption, as previous studies evaluating monetary incentives for weight loss show high attrition rates of participants, indications that financial incentives lose their effectiveness over time, poor long-term sustainability of weight loss, and in some cases even extreme, unhealthy weightloss strategies among participants.5 Financial incentives are unlikely to be a “magic bullet,” as obesity is a complex condition that is not easily modified. Despite a multitude of conventional
Published by Elsevier Inc.
Am J Prev Med 2014;46(4):429–431
429
430
Lesser and Puhl / Am J Prev Med 2014;46(4):429–431
interventions and treatments available, rigorous science consistently demonstrates that only a small percentage of people can achieve long-term, significant weight loss.6 This evidence has led to a greater appreciation among expert medical panels of the biological factors that regulate body weight, as well as the difficulty of maintaining losses of more than 5%–15% of a person’s body weight. The legitimate challenges of achieving sustainable, significant weight loss may explain, in part, why adding financial incentives to lifestyle programs does not seem to lead to long-term weight loss.7 Weight, cholesterol, and blood pressure may seem like appropriate indices to measure, as we are accustomed to tracking them in the medical field. Although the field of medicine is accustomed to evaluating programs based on outcomes, this is an instance where process measures (i.e., behaviors) may be equally, if not more, important. Instead of paying employees for outcomes such as absolute BMI or blood pressure levels, why not pay all employees who practice the health behaviors we are actually trying to change, such as physical activity and eating behaviors? Mobile and web apps allow individuals to track their dietary intake, monitor their weight, and track their physical activity.8 Thousands of apps exist for these purposes, and 21% of Americans already track their health using such technology.9 Individuals who track their health behaviors are more likely to maintain healthy behaviors. Although employees may not want their employers to see what they are eating and when they are exercising, there are ways to incentivize the use of these trackers while maintaining privacy and confidentiality. For example, employers can simply measure an employee’s level of engagement or participation with a program or an app. Intermediaries can process the data and inform employers whether an individual employee has met an engagement benchmark.
Ethical Reasons Focusing on weight stigmatizes individuals who are already vulnerable to prejudice and discrimination in the employment setting. Considerable evidence spanning several decades consistently indicates that employees with excess weight or obesity face inequities in the workplace, including unfair hiring practices, prejudice from coworkers and employers, lower wages, and job termination, all because of their body weight.10 There are common societal stereotypes that obesity is simply a result of poor self-discipline and lack of willpower, and these stereotypes may be at the root of employer decisions to incentivize weight. When individuals feel blamed or stigmatized about their weight, they are more likely to engage in behaviors that impair weight-loss efforts and reinforce obesity, such as
increased food consumption, binge eating, and avoidance of physical activity.11,12 Thus, paying employees on the basis of weight may further reinforce weight stigma and actually have the unintended consequence of promoting unhealthy behaviors and reinforcing obesity. The opportunity costs of these programs may also direct funds away from where they are needed most. Implementing wellness programs to test employees’ biometrics is very costly and time consuming. Because laws prevent employers from obtaining biometrics directly from medical records, employers are required to set up clinics to weigh and take blood from employees. A more cost-effective approach would be to redirect the steep costs of these tests toward efforts that support social changes that can help reverse the conditions that have created obesity in the first place. For instance, employers could subsidize healthy meals for employees, provide standing workstations, provide time and space for physical activity, remove sugary beverages from the workplace, supply healthy snacks, and engage in community-wide efforts to limit the marketing of unhealthy food. Certainly, it is important for employees to take personal responsibility for their health, but expecting them to reach health goals through personal responsibility alone, in isolation of the environmental and biological forces that contribute to obesity, will not be sufficient or effective in efforts to achieve optimal weight-related health. Additionally, many of the tests that employers mandate in these programs are invasive and can lead to unnecessary worry on the part of low-risk participants. Testing weight correctly requires removal of clothes; this can lead to anxiety and embarrassment, especially for employees who know they are overweight. Testing cholesterol and blood sugar requires a blood draw, and many advocate for doing these tests while fasting. Even if these tests cause only minimal discomfort, it is unethical to force an employee (through lucrative financial incentives) to undergo these procedures when they will not change medical treatment.
Focus on Incentives for Behavior Financial incentives are not all bad. In fact, employers can use incentives to encourage a number of behaviors. Financial incentives are routinely used to reduce smoking rates, save for retirement, and use public transport to get to work. The difference between these incentives and those for weight or cholesterol is that the former are for modifiable behaviors. Paying for weight or cholesterol pays for an outcome without a direct line between a behavior and a condition. Paying for reduction of weight induces a range of problems; paying for employees to participate in physical www.ajpmonline.org
Lesser and Puhl / Am J Prev Med 2014;46(4):429–431
activity (a behavior) induces fewer problems. However, with any incentive program, we must be careful not to overly classify “good” and “bad” behaviors, which can inadvertently lead to unintended consequences.13 The reality is that poor diet and physical inactivity can impair health for all individuals, not just those with obesity. Incentive programs that instead reward healthy behaviors for all employees could offer a much broader umbrella under which people can be supported to become healthier, regardless of their body weight. Rather than just focusing on those employees who look unhealthy on the outside and emphasizing physical markers such as BMI, employers interested in participating in the ACA’s wellness incentives should incentivize healthy behaviors. They can achieve this through modern technologies, creating multiple opportunities for employees to engage in healthy behaviors in the workplace, and supporting broader policy initiatives that can improve the food environment and public health. These strategies prevent the stigmatization and ethical problems associated with incentivizing weight and provide ways to empower and support employees in their efforts to become healthier. Dr. Lesser is supported by institutional funds from the Palo Alto Medical Foundation Research Institute. He serves as an unpaid advisor to a company that integrates mobile tracking into employee health programs. Dr. Puhl has no financial disclosures.
April 2014
431
References 1. Mattke S, Schnyer C, Van Busum KR. A review of the U.S. workplace wellness market. Santa Monica CA: RAND Health, 2012. . 2. Horwitz JR, Kelly BD, DiNardo JE. Wellness incentives in the workplace: cost savings through cost shifting to unhealthy workers. Health Aff 2013;32(3):468–76. 3. Karelis AD, St-Pierre DH, Conus F, Rabasa-Lhoret R, Poehlman ET. Metabolic and body composition factors in subgroups of obesity: what do we know? J Clin Endocrinol Metab 2004;89(6):2569–75. 4. Bell KJL, Hayen A, Irwig Les, Takahashi O, Ohde S, Glasziou P. When to remeasure cardiovascular risk in untreated people at low and intermediate risk: observational study. BMJ 2013;346:f1895. 5. Cawley J, Price JA. A case study of a workplace wellness program that offers financial incentives for weight loss. J Health Econ 2013;32(5): 794–803. 6. Katan MB. Weight-loss diets for the prevention and treatment of obesity. N Engl J Med 2009;360(9):923–5. 7. John LK, Loewenstein G, Troxel AB, Norton L, Fassbender JE, Volpp KG. Financial incentives for extended weight loss: a randomized, controlled trial. J Gen Intern Med 2011;26(6):621–6. 8. Azar KMJ, Lesser LI, Laing BY, et al. Mobile applications for weight management. Am J Prev Med 2013;45(5):583–9. 9. Fox S, Duggan M. Tracking for health. Washington DC: Pew Internet & American Life Project, 2013. www.pewinternet.org/Reports/2013/ Tracking-for-Health.aspx. 10. Rudolph CW, Wells CL, Weller MD, Baltes BB. A meta-analysis of empirical studies of weight-based bias in the workplace. J Vocat Behav 2009;74(1):1–10. 11. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One 2013;8(7):e70048. 12. Wott CB, Carels RA. Overt weight stigma, psychological distress and weight loss treatment outcomes. J Health Psychol 2010;15(4): 608–14. 13. Fitzgerald FT. The tyranny of health. N Engl J Med 1994;331(3):196–8.
