Vol. 49, No. 3
America's growing weight problem raises serious HR issues relating to health care costs, wellness, recruiting and employee relations.
The U.S. adult population is growing heavier at an unprecedented rate. The statistics stagger the mind, revealing a growing national crisis.
Employers are not unaffected by these events. Americans don’t leave their increasing waistlines at home in the morning; they bring them to work. And those extra pounds are having serious ramifications relating to health care costs, productivity, morale and potential employee discrimination.
As a result, HR professionals find themselves on the hot plate, facing the unenviable challenges of controlling costs, addressing the needs of a ballooning workforce, emphasizing healthy lifestyle options and sensitizing both the lean and the large to the advantages of overcoming harmful weight-based stereotypes.
A Health Crisis
Nearly two-thirds of all adults (64 percent) are either overweight or obese; nearly 14 percent (split evenly between men and women) are considered obese, up 61 percent since 1991, according to the National Center for Health Statistics, the Hyattsville, Md.-based statistical arm of the Centers for Disease Control.
The total costs to society from obesity’s scourge are estimated to be as high as $300 billion. The costs to employers, while smaller, are still enormous: Obesity costs U.S. companies an estimated $12.7 billion annually, reports the National Business Group on Health (NBGH), a consortium of major employers working to control health care costs. The higher an individual’s body mass index, or BMI, the higher the costs. (BMI is a ratio of height to weight. For more information, see “Measuring Obesity.”)
“Health costs go up within each BMI category,” says researcher Dee Edington, director of the Health Management Research Center at the University of Michigan. “Even a one BMI unit increase translates into dollars. Costs are pretty flat between 25 and 27.5 [within the overweight classification], but they really take off at 30 [the obese category].” (See “The Costs of Being Overweight.”)
On average, health care for obese workers costs 36 percent more than for normal weight workers, and medication costs 77 percent more, according to Roland Sturm, senior economist at RAND in Santa Monica, Calif., where he directs the Economic and Policy Research Program.
Direct costs of obesity include medical insurance, hospitalization, physician visits, outpatient testing/treatment, laboratory, radiology and pharmaceutical. Health insurance is responsible for $7.7 billion, followed by life insurance ($1.8 billion) and disability insurance ($800 million), according to the study “Estimated Economic Costs of Obesity to U.S. Business,” published in the American Journal of Health Promotion in 1998.
Indirect costs include decreased productivity and increased absenteeism. Obese employees are twice as likely to be absent 14 or more times per year. Paid sick leave associated with obesity costs employers an estimated $2.4 billion per year.
Even when they are on the job, a quarter of obese workers under-perform because of infirmities related to their weight, estimates Dr. Eve Olson, director of St. Francis Medical and Surgical Weight Loss Center, and author of “Obesity in the Workplace: A Case for Treatment,” (American Journal of Bariatric Medicine, 2003).
Overall, NBGH reports that obesity is associated with 39 million lost work days, 239 million restricted-activity days, 90 million bed days and 63 million physician visits.
More important, obesity significantly affects the health and quality of life of employees. The condition is a risk factor for a large number of chronic diseases, such as diabetes, heart disease, hypertension, musculoskeletal conditions, depression, stroke, poor female reproductive health, as well as endometrial, breast, prostate and colon cancers. It can contribute to the onset of these disorders and worsen them.
The Costs of Being Overweight
This table represents the percent distribution and mean medical and drug costs for 18,534 GM employees, broken down by body mass index (BMI) category.
||Total Cost (Mean)
||Drug (Mean) |
|Source: 2001 analysis by the Health Management Research Center, University of Michigan. |
Obesity also significantly affects life expectancy. Every year, between 280,000 and 325,000 people suffer premature deaths related to obesity.
With its relentless growth rate, soaring annual costs and deleterious effect on the length and quality of Americans’ lives, there is consensus that obesity is a full-fledged public health crisis. But experts disagree on what constitutes a workable solution.
“No HR manager will be surprised that obesity is unhealthy or costly,” observes Edington. “The issue is: What can you do about it that really works?”
A Flurry of Activity
To their credit, many companies are trying to find a solution to the obesity problem. “We find that between 40 percent and 50 percent of large employers are providing some kind of weight control assistance, either through Weight Watchers or a web site where people can track their calories,” says Camille Haltom, health care consultant for Hewitt Associates in Lincolnshire, Ill. “Many are looking at providing nutritional counseling.”
Data from the U.S. Department of Health and Human Services (HHS) show that even greater numbers of employers are involved in their employees’ battle of the bulge. HHS estimates that more than 80 percent of worksites with 50 or more employees—and almost all employers with more than 750 workers—offer health improvement programs, most with an obesity component.
Companies also are building incentives into health improvement programs. An incentive may be to offer reductions in co-payments when employees participate in health improvement or disease management programs. In such programs, low-risk people automatically get the reduced rate. High-risk people get the same benefit if they agree to participate in the program.
Savvy employers are finding cost-effective ways to offer these incentives, says Joe Marlow, senior vice president of Aon Consulting in Philadelphia. “They artificially increase the employee contribution so the net effect is break-even or even a savings,” he says.
Diet and Exercise
Studies show that such efforts can effectively reduce employees’ weight—and employers’ costs. The HHS 2003 report, Prevention Makes Common “Cents,” cites unnamed health promotion and disease prevention programs that “return a median of $3.14 for every dollar spent.” And the NBGH toolkit Best Practices and Strategies for Weight Management: A Toolkit for Large Employers lists companies and suppliers that seem to have winning formulas.
But experts who have tracked obesity solutions for extended periods attribute much of these short-term results to the “Hawthorne effect,” the theory that any intervention shows initially positive results that don’t last over time.
Edington has worked for two decades with a database that now totals 2 million employees; his findings show that weight loss efforts don’t pay off. “Weight loss money is money down the toilet,” he says. “Every diet program gets results, but none works beyond two years. There are individualized stories, but they can’t be generalized.”
Edington says employers have to realize that money spent trying to make obese people thinner is not a good investment—even when it works. Funds are more appropriately directed at helping thinner people stay within acceptable weight ranges, and keeping overweight and obese people from gaining even more.
Other experts agree that weight loss is not the most important focus for company-sponsored programs.
Encourage employees to improve their fitness—rather than concentrate on weight loss—says Glenn Gaesser, professor of exercise physiology at the University of Virginia and author of Big Fat Lies: The Truth about Your Weight and Your Health (Gurze, 2000). He argues that a person can be both fat and fit, and that it’s easier for a fat person to become fit than to become slim. The health problem is not obesity per se, but lifestyle, he says.
“Take people who are fat [BMIs over 30], cut out junk foods and put them on an exercise program—30 minutes of walking, five days a week,” says Gaesser. “I guarantee these people will improve their health and well-being in a matter of days, even if they don’t lose weight.”
When sedentary people are introduced to brisk walking, he says, “they will experience a risk reduction of 25 percent to 50 percent in major diseases, including diabetes and heart disease.”
Once you get to a moderate level of fitness, weight becomes irrelevant, says Gaesser. “Your risk of diabetes is no different than a thin person’s. It suggests that fitness is a more powerful predictor [than weight] of having a heart attack or diabetes.”
Tim Church, medical director of the Cooper Institute in Dallas, agrees that it’s more important for companies to focus on exercise. “It drives me nuts to see people spending money on diets—focusing on vanity rather than health. There really are two epidemics—obesity and exercise. An estimated one-third of Americans do no exercise at all; and another third don’t do enough. Start with the couch potatoes. Even if you can encourage them to do a little, it will have a major impact on their health—and your costs.”
The effects of exercise on workers’ life expectancy can be stunning: A long-term study of 25,000 men conducted by the Cooper Institute shows that the risk of premature death for men who were obese but fit was only a third of that for unfit obese men.
But some experts contend it’s inconsistent for someone to be fat and fit. “There’s no disputing the fact that the larger the BMI, the larger the risk,” says David Levitsky, professor of nutrition and psychology at Cornell University.
“Weight is the easiest way to identify someone at risk” of developing one of a number of serious health conditions, agrees Mary Kirkland, supervisor at KSC RehabWorks, The Bionetics Corp., a Langhorne, Pa., company that provides rehabilitative services to workers who sustain job-related injuries and that serves as a contractor to NASA at the Kennedy Space Center.
“You can have someone who looks overweight who appears healthy, but the more you are overweight, the more your risk factors increase. If you’re carrying an extra 50 pounds, regardless whether you’re fit, you will wear down,” says Kirkland, who also serves as president of the National Coalition for Promoting Physical Activity.
In the end, the debate over “fat and fit” is unresolved. But there is consensus that exercise and healthy food are essential, and that being both “fit and thin” is ideal. And that suggests that any program geared toward improving employee health should encourage participation among all workers—not just those who are overweight.
“Lean people who fail to exercise and eat right are getting a false sense of security when they look at their BMI,” Gaesser says. “Lifestyle and fitness are more powerful predictors of risk than weight.”
In fact, it may be more important for companies—from a cost-benefit analysis—to focus on prevention, helping thinner individuals develop healthy lifestyles and avoid becoming too heavy. One reason that prevention is so vital is that once workers experience a significant weight gain, it may be nearly impossible to undo the damage.
“The 20, 30 or 40 pounds people gain during their life is all fat, and it’s darn difficult to reverse,” says Gaesser. “People who want to lose the weight and keep it off have to live like monks and exercise one or two hours a day. Not too many people are willing to do that.”
Surgery as an Option—for Now
In addition to sponsoring healthy eating and fitness programs, companies also are starting to pay for employees to undergo bariatric procedures (stomach stapling or gastric bypass).
Proponents of bariatric surgery claim it’s the only proven way to cure obesity. Generally available only to people 100 pounds overweight or more, 63,000 operations were reported in 2002. The American Society for Bariatric Surgery estimates that when the figures are tallied for 2003, the number of surgeries will jump to 95,000, in part due to publicity surrounding the successful experiences of celebrities such as Luciano Pavarotti and Al Roker.
Although there are risks in any major surgery, the American Obesity Association contends that the mortality rate of .5 percent to 1 percent for bariatric surgery is acceptable. The group also claims that employers will save more than the costs of the procedure—which varies regionally from about $25,000 to $50,000—because the process reduces recipients’ risks for diseases like diabetes and hypertension.
Employers should pay only for procedures that are clinically proven, and, so far, only bariatric surgery meets the test, says Walt Linstrom, a partner in the Obesity Law and Advocacy Center, San Diego. “Invest in the surgery, not in popular diet, exercise and healthy living programs that don’t really work,” he says.
No thanks, say some employers, like Wal-Mart. The procedure is too costly, and there’s a lack of medical consensus about its safety, the company claims. Also, with annual turnover at 50 percent, the company fears too many people would sign on, get the costly operation, then leave for greener pastures. (Wal-Mart projects that 2,000 to 3,000 employees or family members would apply for the surgery.)
Cingular Wireless, which has 39,000 employees, discontinued paying for bariatric surgery after authorizing 400 procedures in the first half of 2003; costs for the operations ranged from $25,000 to $40,000. “We were well above the national norm on a procedure that is still considered high risk by many” says Lisa Hertel, executive director of Employee Health and Productivity in Atlanta.
“We don’t cover weight loss programs either,” she adds, “because the effectiveness is hard to measure over time. We are looking at ways to incent employees to take better care of themselves, but, like most employers, we’ve got limited funds to support a myriad of benefit areas. If employees want to take advantage of these programs, we support them, but they have to pay for them on their own. Our primary role is to encourage people to take better care of themselves and make good health care decisions through education.”
So far, Olson estimates that 25 percent of insurers and employers are offering coverage. More are following the rationale of Wal-Mart and Cingular. Olson also says that stomach stapling is becoming less common than gastric bypass because stomach stapling is effective only about half the time.
For now, employers are free to choose whether or not they will pay for such procedures. But change may be in the wind.
Powerful mainstream institutions like the U.S. Surgeon General, HHS, the American Obesity Association and certain health providers are working to have obesity designated a disease—not a lifestyle choice, which is how it currently is labeled. If that comes to pass, employers will be forced to cover obesity treatments just as they do treatments for heart disease.
The result could be higher co-payments for health insurance; some small or mid-size companies might even be forced to withdraw from providing health coverage altogether, experts predict.
The debate regarding obesity’s designation as a disease or a lifestyle choice has repercussions beyond health care costs. The way managers and co-workers perceive obesity can have profound effects on recruitment and hiring, discrimination and employee morale.
The fundamental question regarding manager and employee perceptions is this: Are obese people to blame for their condition? The answer appears to be “sometimes and to some extent.” (See “Predestination vs. Choice.”) But hiring managers and co-workers who assume that all overweight individuals lack self-discipline are likely making a mistake—one that can cause employers to miss out on talented workers.
And that is precisely what happens, research shows.
Rebecca Puhl, a researcher at Yale University, says employers often perceive obese people as lacking self-discipline, having low supervisory potential or being unfit for positions that require face-to-face contact. She adds that in experimental studies, overweight applicants are less likely to be hired than average-weight applicants.
For example, Esther Rothblum, a professor of psychology at the University of Vermont, found that when people were asked to rate resumes that were identical except for the weight of the candidate (which was listed on the resume), applicants who weighed 120 pounds did significantly better than ones who weighed 180.
Myrna Marofsky, president of ProGroup, a training and consulting company in Minneapolis, says if you believe obese people could do something about their appearance if they wanted, or that they’re lazy, sloppy, unmotivated and undisciplined (points not supported by research), it’s impossible to be objective. “Once these assumptions are made, your bias may cause you to overlook their talents and skills. You may be losing good people for no good reason.”
Even when obese people do land jobs, they tend to earn lower wages than their slimmer counterparts, studies show.
A national phone survey of 603 full- and part-time workers conducted for the Employment Law Alliance last October reveals that workers are cognizant of the undercurrent of discrimination in their midst. Nearly half of those polled (47 percent) believe obese workers suffer discrimination, 32 percent think these workers are given less respect and are taken less seriously, and 30 percent think overweight workers are less likely to be hired or promoted.
Size discrimination ranges from subtle to overt, but it’s a huge issue—comparable in scope to age discrimination in the United States, says attorney Linstrom. “It ranges from candidates who progress through telephone interviews and resume reviews only to be rejected at a face-to-face interview, to those who endure ‘get this fat bastard out of my office,’ ” or other offensive taunts, he says.
Training both managers and employees could help clear up misperceptions, but, overall, HR hasn’t paid much attention to size, allotting it a minor role in diversity training. “In most instances, HR is not aware of the problem. They’re trained to look for what’s in the affirmative action plan, and size is not mentioned,” Rothblum says. (Marofsky’s ProGroup, however, claims to be attracting wide interest in a stand-alone workshop that sensitizes workers and managers to biases that obese people encounter.)
Overweight individuals also may end up suffering unintended humiliations because employers simply don’t understand or recognize their needs.
For example, when Trudy Buford, organization citizen administrator for HealthPartners in Minneapolis, arrived early for a training session she was conducting, she was surprised to see four heavyset female employees already there. “They seemed embarrassed,” she recalls. “They told me they were there early to see if they could sit in the chairs. When I looked, I realized that a regular size person under 200 pounds could sit in them, but these women could not.”
For Buford, the encounter was an awakening. “I began to realize that size was an issue for many people,” she says. “We don’t know why people are overweight—it could be physical or mental. Either way, we have to be respectful.”
One reason employers may be unaware of such problems is that most victims of size-discrimination never complain. They’re embarrassed, blame themselves or don’t know size was used against them.
Tomecia Weaver, HR project manager for American Express Financial Advisers in Minneapolis, is an example. As an MBA/HR graduate student, Weaver was turned down for an internship with a large pharmaceutical firm. “When I didn’t get the job, I thought it was hard luck, then someone told me later what the real reason was. I was hurt, but I wasn’t surprised, and I didn’t blame the company. Overweight people are very accepting. They don’t stand up when it’s unfair; they suffer in silence.”
But the American Obesity Association is encouraging victims of weight discrimination to speak out. “BMI is not necessarily linked to job performance,” says Judith Stern, distinguished professor of nutritional and internal medicine at University of California, Davis, and the vice president of the American Obesity Association. “We want employers to feel it will cost them more [legally] not to hire and not to treat them fairly.”
So far, however, employers have the stronger legal hand.
The Americans with Disabilities Act (ADA) is the only federal law that protects obese individuals, and it’s triggered only when workers can prove that morbid obesity (BMI of 40 or more) prevents them from performing one or more essential life functions. Some states, like California, are more generous, eliminating the life function criteria.
States with the Highest Percentage
Of Obese Adults
In either instance, millions of overweight and obese workers with BMIs less than 40 are not protected.
Some local jurisdictions, such as the state of Michigan, the District of Columbia and certain cities—such as San Francisco; Santa Cruz, Calif.; and Madison, Wis.—specifically outlaw size or appearance discrimination, making it a protected class. But they are the exception. According to Dave Namura, manager of state affairs for the Society for Human Resource Management (SHRM), there’s no groundswell for more laws. “Obesity is not on the radar,” he says.
Michigan, the only state to offer legal protection based on size—and the state with the second-highest percentage of obese residents (see chart on page 50)—receives relatively few complaints of size discrimination. As of Dec. 21, the Michigan Civil Rights Commission received 59 contacts where the claimant alleged size discrimination, compared to 2,600 race-based and 1,600 sex-based contacts.
Except in jurisdictions with specific prohibitions, experts say HR may decide to minimize health care exposure by not hiring obese people. “It’s a strategy that some employers are taking on,” Linstrom says.
Others argue that failing to hire an otherwise qualified, healthy obese person based on future projections of illness and possible injury may be grounds for litigation. “If they’re being ‘regarded as’ or ‘perceived as’ disabled even though they’re really not, they have a mechanism under federal and state laws to challenge these decisions,” says Frank Alvarez, partner and national coordinator of U.S. Disability Management Practice for Jackson Lewis Schnitzler & Krupman, White Plains, N.Y.
But, Alvarez notes, proving the employer’s discriminatory motive is not easy. “How do you prove what’s in someone’s head?”
The best advice, experts suggest, is to look for the best-qualified candidates and administer job-related ability and medical tests that help weed out those who are unable to perform. For example, “Under the ADA you can conduct post-offer medical exams if you do it for all applicants,” Alvarez says. “You have to show that the medical conditions you rely on actually prevent the individual from performing the job.”
Once screening is complete, choose the best candidate. If the person turns out to be obese, assume the higher risk as a cost of doing business, say experts. Still, when a hiring decision comes down to two comparable candidates, one of whom is obese, apparently there is no legal constraint to counter what some employers may consider a compelling economic argument for choosing the non-obese candidate.
Meanwhile, LuAnn Heinen, director of the NBGH’s Institute on the Costs and Health Effects of Obesity in Minneapolis, urges HR to leverage its influence with suppliers to ensure that vending machines and cafeterias offer healthy alternatives and that health providers include strong health management programs.
“It’s in our self-interest to take action wherever we can demonstrate positive ROI,” she says. “We’re not asking you to spend a lot of money; do a lot of little things and keep what works. And, put your money where you get the biggest bang. The goal is to reverse the trend. Just to flatten the trend line would be a victory.”
But for Edwin Foulke, 2003 chair of SHRM’s former Workplace Health and Safety Committee, little victories are no longer enough. “The obesity epidemic is a smoldering time bomb on HR’s doorway,” he says. “The problem has been identified, but so far, real solutions haven’t been discovered. Unless they are—and soon—the economic fallout will be devastating. The health care and workers’ comp systems may collapse, many employers will be driven out of business … or all of the above.”
Robert J. Grossman, a contributing editor of HR Magazine, is a lawyer and a professor of management studies at Marist College in Poughkeepsie, N.Y.