The scientific evidence behind health care benefit and employer wellness programs
© Sandy Szwarc 2006
The National Business Group on Health (NBGH) has just released their “Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage,” funded by a grant from the Robert Wood Johnson Foundation. It is “designed to help employers offer coverage for 46 clinical preventive services proven to be effective in preventing illness and premature death of their employers and families and potentially reduce their healthcare costs.”
“This is public health science research in action — a guide to provide employers with advice on how to have a healthier, more productive workforce,” said CDC Director Julie Gerberding, M.D.
The Guide promises its recommendations are based on scientific evidence of clinical effectiveness, but a close examination reveals they aren’t.
Although you may not be familiar with the NBGH, your employer certainly is. This group has been the forerunner of the “costs of obesity” claims and one of the most vocal proponents of employer-mandated “wellness programs,” health screenings and obesity interventions. NBGH is also the group promoting incentives to compel compliance with wellness and health guidelines for people receiving private or federal health insurance (for instance, premiums billed according to participation in wellness and weight loss programs); Health Savings Accounts; third-party payer “evidence-based benefit designs” to compel compliance with insurer guidelines among physicians and healthcare providers; and informational technology to develop national databases of health records. Since 2003, this organization has had an entire Institute on the Costs and Health Effects of Obesity devoted to its agendas. NBGH Founding Board members, as well as their current Institute Board members, include the country’s largest employers, insurance companies, pharmaceutical companies, weight loss programs, bariatric surgery companies, for-profit hospitals, Health and Human Services officials and other interests. They recommend employers cover obesity screening for ages 2 and up; as well as counseling and weight loss treatments, including weight loss drugs and surgery as indicated, for ages 18 and older. They state successful treatment “can be expected to produce significant health benefits.” Support for their recommendations relies primarily on the U.S. Preventive Services Task Force recommendations. The USPSTF is sponsored by the Agency for Healthcare Research and Quality, the Federal government’s lead agency under the U.S. Health and Services Department (a NBGH Board member) for research on health care quality, costs, outcomes and patient safety. It is charged with issuing careful, evidence-based findings that are used to develop clinical guidelines for healthcare providers and justify all aspects of government healthcare spending and HHS health policies. As their 2006 Congressional budget report says, they have made “significant improvements in realigning the work we do with our strategic goals and those of the Department.” So not surprisingly, the very first reference listed in the USPSTF’s “Screening and Interventions to Prevent Obesity in Adults” used in the NBGH Guide was the HHS’ 2001 “Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity.” [See: The Emperor’s New Crisis.] The other selected references were similarly weighted, which makes their unenthusiastic conclusions about the evidence in support of obesity screening and interventions especially remarkable and commendable. Even so, the NBGH Guide found them sufficient to support their recommendations, stating: The U.S. Preventive Services Task Force recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults....There is fair to good evidence that high-intensity counseling — about diet, exercise, or both — together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3 to 5 kg for 1 year or more in adults who are obese. Nevertheless, the Guide left out key sentences from the actual USPSTF report: The evidence is insufficient to recommend the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults...The relevant studies were of fair to good quality but showed mixed results....studies were limited by small sample sizes, high drop -out rates, potential for selection bias, and reporting the average weight change instead of the frequency of response to the intervention. As a result, the USPSTF could not determine the balance of benefits and potential harms of these types of interventions. Despite no evidence for long-term success of any program, the NBGH Guide goes on to recommend interventions for obesity, combining diet and exercise counseling and behavioral strategies to help obese patients acquire the skills they need to change their habits. Concerning the benefits of weight loss among adults, the NBGH Guide states: Although the USPSTF did not find direct evidence that behavioral interventions lower mortality or morbidity from obesity, the USPSTF concluded that changes in intermediate outcomes, such as improved glucose metabolism, lipid levels, and blood pressure, from modest weight loss provide indirect evidence of health benefits. The Guide goes on to make their case for benefits of weight loss: For adults, losing excess weight has positive effects on overall health status. A 5% to 7% reduction in body weight decreases the risk of type 2 diabetes, reduces blood pressures, and improves lipid profiles...The USPSTF found limited data on the positive effect that weight loss may have on overall mortality, mental health, and daily functioning. In 1992, the National Institutes of Health held what is still the most pivotal conference on Methods for Voluntary Weight Loss and Control, in which the country’s top experts reviewed nearly half a century of evidence on voluntary weight loss. It concluded that most studies, and the strongest evidence, show voluntary weight loss regardless of the method, although seemingly to reduce risk factors, is actually strongly associated with increased rates of premature deaths, heart disease, stroke, type 2 diabetes and cancers — by as much as several hundred percent. What is rarely mentioned is that in short-term studies claiming dieting improves health, they all use intermediate measures — those indirect measures have been shown to initially improve with any caloric deficit but quickly take a dramatic turn around and rebound, often surpassing pre-weight loss levels. And more importantly, the weight loss actually shortens lives. Dr. Reubin Andres of the National Institute on Aging admitted that weight loss can improve blood sugar levels, blood pressure and cholesterol in the short term. “The only problem is that when you look at mortality rates,” he said, “they don’t look good. Fat people who are subject to weight loss have a higher mortality rate than those who remain fat.” But the Guide is especially troubling in its failure to discuss the risks surrounding their proposed interventions. While giving a cursory nod to the USPSTF’s mention of potential harm of weight cycling and the stigma of labeling people as “obese,” and of pharmacological and surgical interventions, the Guide states: The USPSTF was unable to find studies that suggested harms associated with screening or counseling obese patients....The USPSTF concluded that the benefits of screening and behavioral interventions outweigh potential harms. Since then NIH review, research has continued to indicate potential harm from weight loss endeavors, among adults of all sizes. And the evidence of harm for growing children is considerably greater. In studies this writer has outlined previously, women losing just 1-19 pounds had 70% higher rates for premature deaths, 62% increase in death from cancer, 167% increase in death for heart disease and stroke. Studies of men with intentional weight loss of a mere 10 pounds increased their mortality from heart disease by 60-242%. Other potential dangers from dieting that have been documented in clinical studies include: · reduced bone mass · cardiac arrhythmias · eating disorders · diminished brain function, loss of concentration, mental acuity and work productivity · nutritional shortages, notably calcium and iron · long-term exacerbation of high blood pressure · and long-term weight gain! It is doubtful that many employers read the medical literature, however, to get the complete picture on these NBGH recommendations, including the lack of proven long-term effectiveness, the poor evidence for actual health benefits, and the overwhelming evidence for potential risks to their employees. Nor are they probably aware that the mandated employee screening, weight loss and “wellness” programs they are initiating as a result of the NBGH guidelines may prove to be a liability for their companies. But consumers have an interest in the research. And employees might rightly ask if an employer or government can force them to comply with policies that have no sound evidence of being effective or beneficial, but do have evidence they could jeopardize their health.
Modest weight loss maintained for a year is hardly commanding evidence of long-term effectiveness for intense interventions. In fact, the dismal failure of any type of intervention in achieving long-term success was highlighted in the acclaimed, comprehensive review of more than 500 studies on dieting and weight loss by David Garner, Ph.D., and Susan Wooley, Ph.D.. They concluded: “It is difficult to find any scientific justification for the continued use of dietary treatments of obesity.”
· The USPSTF concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults.
In fact, according to the USPSTF, evidence for dietary counseling was “limited by reliance on self-reported diet outcomes, limited use of measures corroborating reported changes, limited followup data beyond 6 to 12 months, and enrollment of study participants not representative of the primary care patients.”
Effectiveness
The Guide admits that the USPSTF concluded that the evidence was insufficient to recommend routine screening for overweight in children and adolescents as a means to prevent adverse health outcomes. But they disregard the lack of evidence and include interventions for children, with the justification that screening is included in certain health organization guidelines.
Benefits
In other words, there is no evidence that weight loss interventions reduce “morbidity” — actual clinical illness or disease — or premature deaths, but since certain measurements and lab numbers change there must be some health benefits!
Notice they felt necessary to reiterate how limited any supporting data was for any actual benefits of weight loss. But what is important to note is that they confuse “risk factors” with actual disease and indications of health status. They define “risks” by using indirect measures — blood sugar levels, blood pressure or cholesterol levels — they believe to be associated with real disease and hope readers (employers) will think those mean the same as the actual disease and measures of health. But the evidence has repeatedly shown that they are not.
Safety and Risks
They didn’t try very hard to find the studies, and it is unlikely that many employer benefit managers will take the time to do so, either. If so, they would discover volumes of evidence showing harms from weight loss interventions, just as the NIH had reviewed. And the dangers identified at the NIH conference were not the result of enormous weight losses or extreme diets, but as little as 10 pounds and even moderate calorie restrictions. As the experts at the NIH reported, studies that appear to show benefits of weight loss are seriously flawed. Study after study — Framingham Heart Study, CARDIA study, the CDC NHANES I, MRFIT, Harvard Alumni Study, Dutch Elderly, Alameda County, Baltimore Aging, Honolulu Heart, Lipid Research, British Heart — has shown that weight gain with age, or stable weights, for both men and women offers the lowest death rates; while dieting, weight loss or fluctuating weights (yo-yoing), significantly increases the risk of actual death, cardiovascular diseases, type 2 diabetes and cancers.
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