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By Adrian Wieland PUBA 601: Exam #1 February 21, 2007
ABSTRACT The purpose of this summary report is to evaluate the potential need, options and applicability of action by the City of Charleston that would encourage the reduction in number and an increase in overall health of overweight and obese persons in its employ and to consider areas in which HR policy changes may positively benefit both the City of Charleston and its workforce.
I. Introduction 1 Wieland
There is no question that excess weight carries significant negative health risks and can have substantial impacts on employers in both direct expenditures for healthcare and indirect costs in terms of loss of productivity. Innumerable studies1 have been done relating increases in Body Mass Index (BMI)2 to heightened risk of many of the largest health concerns in the US including: diabetes, heart disease, stroke, hypertension, high blood cholesterol, gallbladder disease, osteoarthritis, sleep disorders, some cancers, stress and psychological disorders, and increased mortality. It is well documented3 that the ill health associated with increased BMI has considerable impact upon employer healthcare expenditures compared to those whose BMI falls within the normal weight range, reaching $75 billion in US obesity-attributable medical expenditures by 2003.4 Furthermore, while certainly once can conclude that other variables besides of excessive BMI can reduce productivity, the negative indirect costs to employers have been extensively researched5 and have been found to be significant in affecting a wide range of
Fontaine, KR et al. “Years of Life Lost Due to Obesity.” JAMA. 2003. Vol. 289: 187193. Freedman, David S. PhD et al. “ Trends and Correlates of Class 3 Obesity in the United States from 1990-2000.’ JAMA. 2002. Vol. 288: 1758-1761. Mokdad, Ali H. PhD et al. “Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, 2001.” JAMA. 2003. Vol. 289: 76-79. Stein, Cynthia J. and Graham A. Colditz. “The Epidemic of Obesity.” The Journal of Clinical Endocrinology and Metabolism. 2004. Vol. 89, No. 6: 2522-2525. 2 As defined by the World Health Organization: BMI is an index of weight adjusted for the height of an individual (irregardless of gender) calculated as “weight (kg)/height (m2). Statistical ranges are grouped into the following categories: underweight (BMI ≤18.5); healthy weight (BMI 18.5 to 24.9); overweight (BMI 25 to 29.9); obese (BMI ≥30). Accessed online: February 20, 2007. http://www.who.int/bmi/index.jsp? introPage=intro_3.html 3 Burton, Wayne P. MD et al. “Measuring the Relationship between Employees’ Health Risk Factors and Corporate Pharmaceutical Expenditures.” Journal of Occupational and Environmental Medicine. 2003. Vol. 45, No. 8: 793-802. Goetzel, Ron Z. PhD et al. “The Relationship between Modifiable Health Risks and Health Care Expenditures: An analysis of the Multi-Employer HERO Health Risk and Cost Database.” Journal of Occupational and Environmental Medicine. 1998. Vol. 40, No. 10: 843-854. Raebel, Marsha A. PharmD et al. “Health Services Use and Health Care Costs of Obese and Nonobese Individuals.” Archives of Internal Medicine. 2004. Vol. 164, No. 19: 2135-2140. Wang, Feifei PhD et al. “Relationship of Body Mass Index and Physical Activity to Health Care Costs among Employees.” Journal of Occupational and Environmental Medicine. 2004. Vol. 46, No. 5: 428-436. 4 Finkelstein, Eric A. et al. “State-level Estimates of Annual Medical Expenditures Attributable to Obesity.” Obesity Research. 2004. Vol. 12, No. 1: 18-24. p. 18. 5 Arena, Vincent C. PhD et al. “The Impact of Body Mass Index on Short-Term Disability in the Workplace.” Journal of Occupational and Environmental Medicine. 2006. Vol. 48, No. 11: 1118-1124. 2 Wieland
productivity-related measures including absenteeism/presenteeism, psychological demands (i.e., job strain, depressed mood), decision latitude, quality and quantity of work performed, job-related injuries (i.e., workers’ compensation) and short-term disability. In order to best evaluate the considerable bulk of information related to obesity and wellness as it relates to the City of Charleston’s workplace, this report is organized in the following manner. Part II compares U.S. and S.C. obesity demographic information and City of Charleston employee demographics and extrapolates potential areas of significance. Part III reviews three areas of impact that may promote increased workforce wellness, and concomitantly reduce related expenditures and increase productivity measures. Part IV provides a summary of the political and cultural climate concerning governmental behavioral regulation as well as a brief overview of current health and wellness initiatives at the state, county and city level. This report will conclude with a presentation of proposed “Next Steps” and recommendations for potential areas of impact and improvement. II. Obesity Demographics According to the National Institute of Health (NIH), “the prevalence of overweight and obese [20 – 74 year olds] has increased steadily…from 1960 to 2002…from 44.8% to 65.2% and 13.3% to 30.5%” respectively6. The American Obesity Association (AOA) further demonstrates a dramatic prevalence increase among minority groups (Black, Hispanic) and across gender (prevalence among white men and African-American women).7 These trends can also be seen at the state level with some notable distinctions. The Trust for America’s Health has ranked S.C. as the 8th heaviest in the country, 3rd in diabetes and 6th in hypertension.8 As compared to national averages, the rates of obesity Burton, Wayne N. MD et al. “The Role of Health Risk Factors and Disease on Worker Productivity.” Journal of Occupational and Environmental Medicine. 1999. Vol. 41, No. 10: 863-877. Pronk, Nicolas P. PhD et al. “The Association Between Work Performance and Physical Activity, Cardiorespiratory Fitness, and Obesity.” Journal of Occupational and Environmental Medicine. 2004. Vol. 45, No. 1: 19-25. Ricci, Judith A. ScD, MS and Elisabeth Chee, ScD. “Lost Productive Time Associated with Excess Weight in the U.S. Workforce.” Journal of Occupational and Environmental Medicine. 2005. Vol. 47, No. 12: 1227-1234. Wright, Douglas W. PhD et al. “Association of Health Risk with the Cost of Time Away from Work.” Journal of Occupational and Environmental Medicine. 2002. Vol. 44, No. 12: 1126-1134. 6 National Institute of Health. Statistics Related to Overweight and Obesity. Accessed online: February 15, 2007. http://win.niddk.nih.gov/statistics/, p. 2. 7 American Obesity Association. AOA Fact Sheets: Obesity in Minority Populations. Accessed online: February 15, 2007. http://www.obesity.org/subs/fastfacts/Obesity_Minority_Pop.shtml 8 Trust for America’s Health. Obesity Report in South Carolina 2006. Accessed online: February 16, 2007. http://healthyamericans.org/reports/obesity2006/release.php?StateID=SC 3 Wieland
(and rates of diabetes) are higher in S.C. among Blacks and Hispanics and present similar variances along gender lines.9 This presents particular areas of concern within the context of the City of Charleston’s workforce composition: 45.3% of employees are Black or Hispanic (17% are Black females) and nearly 70% of the employees are male (38.7% are white males)10 and extrapolations can be made concerning the need for closer examination and rigorous study of the City’s employees’ overweight and obesity risk factors. III. Areas of Impact There are three main areas of influence that present repeatedly in the available literature: nutrition, physical activity and ‘targeted’ programs. 1. Nutrition. There is a demonstrable change in the eating patterns of Americans that has had a negative impact on waistlines.11 As what we eat has been proven to have a significant impact upon our weight and overall wellness, it is an important consideration in the context of this report. Through various initiatives and programs employers can attempt to manipulate workforce behavior and attitudes relating to food consumption. Nutrition programs can range widely from food regulation (i.e., application of pricing incentives/disincentives on foods sold at worksites) to nutrition education (i.e. counteradvertising).12 2. Physical Activity. As lifestyles in developed countries have become increasingly sedentary, including pronounced decreases in worksite exertion, efforts to encourage
Trust for America’s Health. Health Disparities: South Carolina. Accessed online: February 16, 2007. http://healthyamericans.org/state/disparities/index.php? StateID=SC 10 Jones, Miranda. Human Resource Specialist, Department of Human Resource and Development, City of Charleston. By Phone: February 20, 2007. 11 Close, Rachel N. BS and Dale A. Schoeller, PhD. “The Financial Reality of Overeating.” Journal of the American College of Nutrition. 2006. Vol. 25, No. 3: 203-209. 12 [No author specified] “The Elephant in the Room: Evolution, Behavioralism, and Counter-advertising in the Coming War against Obesity.” Harvard Law Review. 2003. Vol. 116, No. 4: 1161-1184. Kim, Daniel MD, MPH, MSc and Ichiro Kawachi MD, PhD. “Food Taxation and Pricing Strategies to ‘Thin Out’ the Obesity Epidemic.” American Journal of Preventive Medicine. 2006. Vol. 30, No. 5: 430-437. Wanjek, Christopher. Food at Work: Workplace Solutions for Malnutrition, Obesity and Chronic Diseases. International Labour Office: Geneva, 2005. Segments Accessed online: February 13, 2007. http://books.google.com/books? vid=ISBN9221170152&id=f7RD7e9NH5oC&pg =PP1&lpg=PP1&ots=JTMtSNTd8l&dq=Wanjek,+Christopher.+Food+at+Work: +Workplace+Solutions+for+Malnutrition,+Obesity+and+Chronic+Diseases&sig= sm6RyFPMrDtRkGuHyLHJWseqDm4#PPR8,M1 4 Wieland
physical activity by employers are beneficial in evaluating workplace wellness strategies.13 Initiatives and programs in this area can also range from more aggressive strategies such as workplace environment manipulation (i.e. restructuring the built environment or workflow processes to avoid occupational sitting time) to less intrusive, and optional provisions like fitness incentives (i.e. gym membership subsidy or benefits for distance parking).14 3.‘Targeted’ Programs. There is also a visible trend by employers to specifically address issues of obesity, or obesity-related conditions like diabetes, in the context of their overall healthcare provisions and worksite accessibility compliances. Many of these programs are prompted by federal regulations regarding disability and new tax rules;15 others consult with outside providers on behalf of affected employees that cover a wide range of activities that might include incorporating more comprehensive coverage for treatments like gastric bypass to sponsoring health screenings.16 IV. Overview of Current Conditions There are cultural and political barriers to paternalistic government action that make more aggressive action difficult and potentially damaging to not only the public confidence, but also to employee morale. It is widely debated to what extent the government can and should be involved in moralistic legislation, as well as whether there even exists an
Brownson, Ross C. et al. “Declining Rates of Physical Activity in the United States: What are the Contributors?” Annual Review of Public Health. 2005. Vol. 26: 421-443. 14 Aldana, Steven G. PhD and Nicolas P. Pronk PhD. “Health Promotion Programs, Modifiable Health Risks, and Employee Absenteeism.” Journal of Occupational and Environmental Medicine. 2001. Vol. 434, No. 1: 36-46. Burton, Wayne N. MD et al. “The Association of Health Status, Worksite Fitness Center Participation, and Two Measures of Productivity.” Journal of Occupational and Environmental Medicine. 2005. Vol. 47, No. 4: 343-351. Taylor, Wendell C. PhD, MPH. “Transforming Work Breaks to Promote Health.” American Journal of Preventive Medicine. 2005. Vol 29, Issue 5: 461-465. Thigpen, Kimberly G. “Fighting Obesity Through the Built Environment.” Environmental health Perspectives. 2004. Vol. 112, No. 11: A616-A619. Chenoweth, David PhD. “Obesity and the Built Environment: Worksites, Employers and Employees.” Sponsored by National Institute of Environmental Health. For Presentation at the Marriott Wardman Park Hotel: Washington, DC: May 24-26, 2004. Accessed online: February 15, 2007. http://www.niehs.nih.gov/drcpt/beoconf/agenda.htm 15 AOA. Accessed online: February 10, 2007. http://www.obesity.org/subs/tax/taxbreak.shtml AOA. Accessed online: February 10, 2007. http://www.obesity.org/subs/disability/ 16 Empire Blue Cross Blue Shield. Inside Benefits: Getting the most from Empire BlueCross BlueShield. 2004. Accessed online: February 10, 2007. http://www.empireblue.com/pdf/gba_newsletter_fall_04.pdf 5 Wieland
public interest in discourse about the subject, much less political action.17 Further, research suggests that the public at large is more comfortable with policy aimed at childhood obesity prevention than those attempting to regulate adult behavior, though decisive public interest is still largely absent.18 The City of Charleston has certainly developed an historical record in recent decades related to behavioral legislation (i.e., 2am bar closing ordinance, no smoking ordinance) that may indicate deference to municipal expertise; however, it would be foolish to make such an inference without more concrete data. Further complicating the issue are recent legislative and cultural developments that while currently marginal, may be indicative of a trend towards ‘acceptance’ and accommodation of obesity rather than prevention and correction of contributing behavioral or attitudinal factors. The addition of ‘weight’ to anti-discrimination laws in San Francisco, Santa Cruz, Washington, DC and Michigan19 and the growth of organizations like the National Association for the Advancement of Fat Acceptance (NAAFA)20 are two such examples. Additionally, there is considerable research considering ‘fat’ bias, discrimination and stigmatization in employment environments that should be evaluated and controlled for in any research done by the City of Charleston as these issues have also been shown to negatively affect performance and productivity measures.21 As of the issuance of this report, there are several relevant initiatives at the state, regional and city levels that should be considered in developing an overview of the current climate.
At the State-level: ● Snack and Soda Taxes – enacted, but later repealed.22
Kersh, Rogan and James Morone. “The politics of Obesity: Seven Steps to Government Action.” Health Affairs. 2002. Vol. 21, No. 6: 142-153. Oliver, J. Eric and Taeku Lee. “Public Opinion and the Politics of Obesity in America.” Journal of Health Politics, Policy and Law. 2005. Vol. 30, No. 5: 923-954. 18 Mello, Michelle M. JD, PhD et al. “Obesity – The New Frontier of Public Health Law.” The New England Journal of Medicine. 2006. Vol. 354, No. 24: 26012610. 19 Tolerance.org. “Tolerance in the News: Sizing up Weight-Based Discrimination.” Accessed online: February 16, 2007. http://www.tolerance.org/news/article_tol.jsp?id=505 20 National Association for the Advancement of Fat Acceptance. http://www.naafa.org 21 Puhl, Rebecca and Kelly D. Brownell. “Bias, Discrimination, and Obesity.” Obesity Research. 2001. Vol. 9, No. 12: 788-805. AOA. “Discrimination: Employment.” Accessed online: February 10, 2007. http://www.obesity.org/discrimination/employment.shtml 22 Healthy States Initiative. “Trends in State Public Health Legislation: January 1, 2006December 31, 2006.” Issued January 12, 2007. Accessed online: February 10, 2007. http://www.healthystates.csg.org, p.19. 6 Wieland
Medicaid Benefits and Services to Treat Overweight and Obese Individuals and Insurance Coverage for Treatment and Prevention of Obesity and Chronic Illnesses23
At the Regional-level: ● The Berkeley-Charleston-Dorchester council of Governments’ Regional Pedestrian and Bicycle Action Plan to encourage Lowcountry workforce physical fitness24 ● SCDHEC Region 7 Public Health Office promotes several health and wellness programs: Workout @ Work (to promote healthy lifestyles in the workplace), health risk screenings for various obesity-related risk factors, Reach 2010 (to determine disparity-reduction potential for African-Americans with diabetes), Stepping out in Charleston (to promote walking as exercise), and Chronic Disease Prevention Education.25 At the City-level:26 ● Weight Watchers program – free to all city employees ● Gym membership reimbursement program – at least 3 times per week; city employees can be reimbursed up to $20 each month ● “10 Cities Challenge” – free diabetes medicine program for city employees, partnered with Piggly Wiggly and Eckerd Pharmacies
V. Conclusion - Proposed Next Steps The preponderance of evidence suggests that there is sufficient cause for concern about obesity as it relates to overall wellness and its social and economic impacts on the City of Charleston. However, in consideration of the current political climate, and general apathy of the public, it wouldn’t be politically advisable to take actions that were too intrusive, paternalistic or had the appearance of the government supplanting personal autonomy. As such, there are many other ways to work within the three areas of impact using a non-intrusive, and optionally participatory approach that wouldn’t conflict with individual choice regarding health and wellness. It is arguable that the City of Charleston, through initiatives of its own, combined with the efforts at the regional and state level already has been proactive in its designing and implementing such efforts at mitigating the impact of overweight and obesity in the workplace. What is unclear is whether these programs have been successful (or ever been evaluated) in reducing the direct and indirect costs associated with elevated BMI.
Ibid, p.20-25. Quick, Dennis. “Council pushes community health improvement.” Charleston Regional Business Journal. Published May 15, 2006. Accessed online: February 16, 2007. http://www.charlestonbusiness.com/pub/12_11/news/6571-1.html 25 SCDHEC. Accessed online: February 10, 2007. http://www.scdhec.gov 26 Jones, Miranda. HR&D, City of Charleston. By Phone: February 20, 2007. 7 Wieland
While certainly, recommendations can be made regarding areas of expansion, it should first be determined if the current efforts have a positive impact. Program studies using focus groups and employee surveys or questionnaires would be helpful in measuring knowledge/awareness of and perceived access to programs, qualitative attitudes about these programs (i.e., efficacy, ease of use, availability), as well as provide feedback regarding any adjustments that may make the programs more accessible or user-friendly. Regression models would be most used in comparing current and archived data sets providing before- versus after-program implementation results, using variables like healthcare expenditures, average number of absences/per employee, number of reported job-related injuries and associated workers compensation costs, number of and duration of short-term disability claims, number of program participants as compares to total workforce, and rate and constancy of participation. Additionally, it may be relevant to look at participation by City departments, as variables such as demographic breakdown of participants, participation rates, attitudes, potential for on the job injury of the Fire, Police, Parks and Recreation, administrative and other departments may differ significantly from each other statistically. Lastly, in light of the significance of minority groups and gender variances among overweight and obese individuals, determining if these national and state statistics are in line with City of Charleston employee demographics would be instrumental in ensuring that city government is maximizing its potential with regard to these higher-risk groups.
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