Opening Up on Obesity

Employers across the United States face high costs related to obesity among their workers, and many are taking steps to help their employees manage the condition in a way that goes well beyond simply advising them to exercise more and eat less.

In the International Foundation of Employee Benefits Plans’ 2022 survey of 361 corporations, multiemployer trust funds and public employers from the United States and Canada, respondents ranked obesity as one of the top workforce conditions for overall impact on healthcare costs. It ranked alongside serious conditions such as cancers, heart disease, mental health issues, arthritis and other musculoskeletal diseases, and diabetes.

Twenty-five percent of U.S. employers report obesity as one of their top-three costliest health conditions, says Julie Stich, International Foundation vice president for content. “Obesity among workers has adverse occupation-related consequences—work absence, impairment, limitation, and workplace injury—and increased healthcare and disability costs.”

According to “Obesity in the Workplace: Impact, Outcomes, and Recommendations,” a 2018 literature review of male and female workers in the Journal of Occupational and Environmental Medicine (JOEM), medical and drug costs are higher for those with a body mass index (BMI) higher than 25 and increase rather substantially for every BMI unit above 25. BMI represents an individual’s weight in pounds or kilograms divided by the square of their height in feet or meters.

Weight management, including fitness and nutrition programs, can be part of the solution, as can drug therapies that “reduce healthcare costs and improve worker well-being,” says Stich.

“More employers understand that obesity is a disease that can heighten the risk of other chronic conditions, such as high blood pressure, Type 2 diabetes, coronary heart disease and some cancers. Providing benefits that cover advanced therapies and weight management programs can help prevent more costly and life-threatening conditions rooted in obesity,” she says.

Defining Obesity

The World Health Organization (WHO) cites excessive weight and obesity as the “abnormal or excessive fat accumulation that presents a risk to health.” A BMI above 25 qualifies as “overweight,” while above 30 is “obese,” states the WHO, which adds, “The issue has grown to epidemic proportions.”

Nearly 38% of U.S. adults suffer from obesity, states the JOEM review. It finds obesity more common among women (40.4%) than men (35%), adding that “between 1960 and 2010 daily occupation-related energy expenditure decreased by more than 100 calories” among all workers as they shifted away from manual labor and toward desk jobs.

The U.S. Centers for Disease Control and Prevention (CDC) found the age-adjusted prevalence of obesity was 42.4% for U.S. adults in 2018. “There was no significant difference in the prevalence of obesity between men and women overall or by age group,” the federal health agency said in a 2020 report. The highest prevalence was seen in non-Hispanic black adults (49.6%), followed by Hispanic adults (44.8%) and non-Hispanic white adults (42.2%).

“The prevalence of obesity has been increasing for almost 100 years in the United States. Globally, there has been an increase in BMI since at least 1980 in developed countries,” says Wayne Burton, former global corporate medical director for American Express and one of the authors of the JOEM article.

“The cause of obesity is not straightforward. Many believe it is a problem of energy imbalance and the solution is to decrease caloric intake and increase physical activity. A combination of metabolic, genetic, environmental, behavioral, cultural and socioeconomic factors contributes to the risk for obesity,” he adds.

Jaynaide Powis, data and evidence manager for the nongovernmental World Obesity Federation, attributes the rise in obesity to global shifts in the availability, accessibility and marketing of unhealthy foods; marked changes in activity levels; poor mental health; sleep hygiene; and other factors—changes that urbanization and industrialization have accelerated. Other contributors include biology, genetic markers, access to healthcare and life events, according to World Obesity, which notes that simplifying the disease to any one cause can make it harder to treat.

World Obesity CEO Johanna Ralston adds, “There has been a great deal of misunderstanding and stigma associated with obesity and the misperception it’s a personal weakness that can be addressed by eating less and moving more.”

Katy Wong, chief pharmacy officer at Cigna Healthcare, says, “Many factors contribute to excess weight gain, including eating patterns, physical activity levels and sleep routines.”

Recognizing Obesity as a Disease

In 2013, the American Medical Association (AMA) recognized obesity as a chronic disease associated with more than 200 comorbidities. Common comorbidities reported by the CDC include high blood pressure, Type 2 diabetes, breathing problems such as asthma, joint problems such as osteoarthritis, and gallbladder disease.

“AMA recognition served to drive codification of the clinical need that existed. With that clinical recognition came billing codes (which are used to classify patient diagnosis, treatment and related medical supplies for health insurance reimbursement). It has been known for decades that obesity is a disease that requires a holistic approach to care management,” says Randy Vogenberg, principal at the Institute for Integrated Healthcare.

Holistic health considers the whole person and each individual’s interaction with the environment, according to the American Holistic Health Association. This approach includes traditional medical systems, mind/body/spirit interventions, manipulative and body-based approaches, biological therapies and energy therapies in combination with conventional medicine, according to the website of Western Connecticut State University’s Institute for Holistic Health Studies. 

Recognizing obesity as a disease helped to transform employer health policy and benefits, Vogenberg wrote in “Obesity – Rethinking Assumptions on Weight Management and Benefit Programs” in the May 2021 issue of HR Professionals Magazine, and it expanded the conversation beyond the familiar narrative of “insufficient willpower, lack of discipline and bad choices.”

“Recognition of obesity as a multifactorial disease opens up options to treat associated health conditions including cardiovascular disease,” says Ralston, who notes disease recognition improves clinical treatment and quality of care.

This formal recognition also “transformed employer health policies by increasing awareness of the financial impact of obesity” and encouraged employers take a “comprehensive approach” to obesity in the workplace, viewing it the way they do diabetes or heart disease, states “Obesity in the Workplace: What Employers Can Do Differently,” a 2020 report from the Center for Public Health at the Milken Institute.

COVID-19 and Obesity

The COVID-19 pandemic heightened awareness of obesity and its related health problems, according to Vogenberg’s HR Professionals article, which says those with obesity were at higher risk for contracting the virus, having complicated symptoms and dying. The CDC also found that those with excess weight suffered worse outcomes related to COVID-19. Obesity heightens the danger of suffering severe cases of COVID-19 and might “triple the risk of hospitalization” for those who contract the disease, the agency says.

“COVID-19 heightened awareness for gaps in the healthcare system, where many diseases were not being adequately managed,” says Vogenberg. “For employees or family members, the common problem is not so much [healthcare] plan coverage but the care delivery system. Fragmentation across healthcare delivery to members of employer plans has been a continuing issue.” COVID-19 also exacerbated well known social determinants related to obesity, he says.

Burton, the former medical director at American Express, adds that mental health issues and obesity increased during the pandemic, associated with unhealthy eating and more sedentary behaviors.

Financial Burden of Overweight, Obesity

World Obesity predicts the global economic impact of overweight and obesity will surpass $4 trillion annually by 2035. More than half the global population will be overweight and obese within 12 years if prevention, treatment and support do not improve, the organization states on its website.

“Obesity is now rising fastest in lower- and middle-income countries, many of which have large populations,” Powis says.

According to the JOEM review, obese workers increase costs, absenteeism and presentism. It found that, from 2011 to 2018, annual patient out-of-pocket spending rose to $632.53 from $371.32; medical costs to $7,924.53 from $3,863.34; sick days to 7.43 from 5.29; and short-term disability days to 4.77 from 1.94.

“Obesity-related conditions and comorbidities account for 20% of U.S. medical spending. In addition to increased health costs, employees lose valuable productivity,” says Wong, who describes cardio diabesity (the combined effects of obesity, Type 2 diabetes and cardiovascular disease) as “one of the most expensive condition categories to treat. The numbers are staggering,” she says. Cigna Healthcare estimates the cost of cardio diabesity at $719 billion annually in the United States.

Evidence-Based Wellness and Healthy Workplace

To address chronic weight management, employers must acknowledge the higher cost of care for obese employees, according to Vogenberg’s HR Professionals article. He believes a comprehensive strategy includes medical weight management, coverage of medical visits and clinical support. These solutions improve health risk and clinical outcomes and lower cost of care, creating a sustainable strategy, Vogenberg says.

“The issue has always been the long-term nature of the medical problem and need for employee/member engagement to be successful. Even companies that successfully addressed obesity have ebbed and flowed in their commitment to the problem. The same can be said about governmental programs. All these lapses shone brightly during the pandemic,” says Vogenberg.

Evidence-based programs that focus on prevention and treatment help health plan designers manage employees with obesity, according to the JOEM article, which notes that responsibility for managing obesity among the working population increasingly falls to employers.

“Evidence-based programs have long been in existence and typically look at a person holistically to manage obesity,” says Vogenberg, adding, “No one solution works for everyone or even all the time.”

Powis agrees. “Obesity will impact employees differently. We advocate that employers aim to improve overall health as opposed to focusing on weight and weight loss.”

Employers play a pivotal role in managing healthy behaviors, Wong says. They can make health and vitality a priority through a shared culture and established communication platforms—whether it’s wellness resources and programs or incentives to reduce absenteeism and increase productivity, she says.

The International Foundation of Employee Benefits Plans’ 2022 survey says 72% of respondents provide wellness initiatives to improve overall worker health and well-being, while 28% offer them to control or reduce health costs. Among respondents, 13% measure return on investment, while 10% monitor value of investment for initiatives such as employee engagement, recruitment and absenteeism.

Wellness programs require a long-term commitment from employers to be successful, says Leia Spoor, clinical director for employee benefits at Holmes Murphy. “If you are just doing this to save money, you’re in it for the wrong reason. The greatest impact on preventing and treating obesity will be on the people side of clinical care. Not everything can be proven to have an instant or immediate impact on cost,” says Spoor, who adds that success “depends on how you communicate the offerings. If you just provide [wellness] during annual enrollment, it will be dead in the water. If you have a full strategy including leadership messages, shared employee success stories, ongoing delivery to work and home, supportive environments, you’ll have the best opportunity to see success,” she says.

Erika Scrugham, vice president of benefits, at financial services company Synchrony, agrees. “We spotlight and give visibility to our plan coverage and resources throughout the year. We seek feedback from all employees on their specific needs and make adjustments to our programs on that basis,” she says, describing employee well-being as “a critical part of our culture.” Programs and benefits are designed in collaboration with employees, based on their feedback. Wellness initiatives provided to Synchrony employees through UnitedHealthcare include an annual $500 wellness reimbursement; well-being, career and financial coaching; and mental health services, including yearlong sabbaticals and a 12-sessions-per-year employee assistance program.

“I have personally taken advantage of our virtual personal training service over the past two months and seen positive results in weight loss and overall health,” says Jaron Martin, Synchrony associate vice president for operations. “Our own personal training manager put together a workout plan and made dietary suggestions that resulted in me losing 13 pounds in two months and bringing my blood pressure down to normal levels.”

World Obesity offers tips to foster a healthy work environment. Among them: create a culture of health; implement policies that tackle the stigma of obesity; pair prevention and treatment; listen to your employees; be wary of fad initiatives; communicate through multiple channels; and monitor progress, according to its “Creating Healthy Workplaces” white paper.

“Treatment of overweight and obesity needs to be tailored to the particular patient, whether it be lifestyle behavioral changes, medication and/or surgery,” says Burton. “Regardless, the treatment plan needs to be evidence-based, balancing risks and benefits of each approach developed by the healthcare provider.”

To provide holistic healthcare, employers should integrate benefit programs and connect medical, pharmacy and behavioral health, suggests Wong. When individuals struggle with obesity and weight loss, connected care with a cohesive service experience can make a big difference. “At Cigna, an integrated health plan allows us to see an individual’s full picture of health and specific health journey, which allows us to connect them to resources more quickly to drive meaningful engagement,” she says.

For those overweight or obese with physical jobs, employee safety should be integrated into overall employee health and wellness programs, says Ralston. It is important to emphasize the best means for safeguarding the health and safety of employees. “This should start with ensuring work environments are safe and accessible for people of all sizes,” she says.

“Actively listening and responding to employees on ways to better support them are key,” Scrugham says. “It’s also critical to ensure employees and their families are aware of the benefits and resources to care for their physical, mental, emotional and financial health.”