Thursday, April 22, 2010

What's Wrong With Wellness? Weally?...

Wellness Programs in the near future? Cartoon from "In The Bleachers" by Steve Moore  

I work for a major corporation, the best in our industry by most measures.  Long, proud, heritage; that sort of place.  Despite that, we're a pretty ordinary large company, not that different from large American companies in very different fields.  Dear daughter-in-law works for a big pharma company and her corporate stories are more like mine than different.  Like most places, we're getting hammered by medical insurance costs, and again like most, we've signed onto one of those "Corporate Wellness" programs.  This is one of the latest fads to sweep the business community.  Like most fads, it has adherents, true believers, and skeptics.  Like most fads, again, it's overblown and accepted on faith. 

If you're not involved in one of these, beware.  The has set itself up to be even more invasively involved in your life through the health care takeover that recently passed.  You can expect to be forced into a plan like this soon, if you haven't already.  If you are deemed overweight, you may be put on a company-monitored diet, or sent to "fat camp" to loose weight.  If you are a smoker, you will probably be forced to take a smoking-cessation class.  You may think it's none of your employer's business if you smoke or eat bacon at home, but the thinks it's their business.  You may be financially penalized for not participating in a diet or stop-smoking class.  You may be denied care if you're a smoker or deemed to be overweight; that's routine in the UK, Canada and other countries with nationalized health care. 

Obviously, "wellness" - however imprecise that word might be - is a Good Thing.  The real question is if these plans actually improve health and cut costs.  The answer appears to be no.  There are just way too many conventional wisdoms that are wrong.  In a nutshell, all of the so-called indicators don't show so much that you are "well", they show that you're "young and healthy".  There is simply not enough hard evidence that taking a random group of adults, all of them products of an almost infinite set of life choices and genetics, and forcing behavioral changes on them will result in different health outcomes.  It's important to add that prevention, in general, drives up costs, it doesn't cut them.  This is pretty well known among those who study statistics. 

Take exercise.  Up until the mid 1970s, running and other forms of voluntary, adult exercising were pretty fringe behaviors.  Nowadays, admitting you don't exercise gets you looked at like some sort of Neanderthal.  This will be one of the first things they insist you do.  The reality, though, is that studies show only modest life extension, on the order of a few months, for a lifetime of exercising, easily less time than you spend exercising instead of something else you might prefer.  The other side of that is there is evidence of increased injuries and joint damage in sedentary adults who start exercising.  You could well argue that an arthritic knee or hip is better than a heart problem, but either chronic chest pain or a joint in need of replacement can make your life utterly miserable. 

If I may be a statistics geek, it could be that an adult who exercises regularly is part of a self-selected group that may well be different than the general population.  If these people have a lower rate of some illness, it might not have anything at all to do with the exercise; it could be another attribute of the people who self-select to be regular exercisers, or a large group of these attributes.  Taking the general population and having them start exercising may do nothing for them.  For example, in the early 70s someone did a statistical study that showed no marathon runner had ever had a heart attack.  Their conclusion was that running a marathon made you immune to heart attacks.  But when the running fad started, and people other than the self-selected marathoners of the 1950s and '60s started to do marathons, marathoners started having heart attacks.  Instead of the conclusion they reached, what they should have concluded was that the population of runners was different from the general population, and that some thing or combination of things in this group's lives prevented heart attacks. 

Now don't get me wrong: I have nothing against exercise if it's your choice and not something forced on you.  I started running in the late 1970s and at various times have been a runner, cyclist, and biathlete for over 30 years.  Like many 50-something runners, I had to have a knee cleaned out, and have been discouraged from running, so these days I cycle and lift weights.  I enjoy getting out and moving.  I just don't think that taking a bunch of sedentary people who have never done much exercise in their lives and making them active is going to do much in terms of making them healthier.  

You can hardly turn on the news without hearing that overweight people are less healthy than normal weight people so your Wellness program will probably measure you to make sure you're not overweight.  There are two problems: the first is defining "overweight"; the second is that most studies, and the strongest ones, point to an inverse relationship between weight and mortality (among mature adults), with obesity having a protective role - there's an excellent introduction here and virtually a homegrown encyclopedia here.  Those who grew up in the early to mid-20th century remember being compared to a set of height/weight tables originally developed by the Metropolitan Life Insurance Company.  These tables were eventually discredited for a variety of reasons.  The first was that there aren't really three well-defined frame sizes.  This is not to imply people don't come in different overall sizes, that's pretty obvious, it's just that there is no generally agreed upon standard for "small, medium, and large".  Another problem was that the basis of the charts was measurements of dead people at autopsy, who typically are not as healthy as living people (that was sarcasm, son).  The last 20-25 years have seen the rise of body mass index numbers, or BMI, used in place of those charts.  That's unfortunate.

What? What's wrong with BMI? It's exactly the same concept as the Met Life tables.   It's simply a height/weight table with one difference: there's no real mention of frame sizes so they give you a range you can be in, which many versions of the Met Life tables did, anyway.   There are only two pieces of information that go into BMI, weight and height (the definition is weight divided by height squared); it doesn't make it any more "scientific" if you measure in the metric system and square something.   All you're getting out is wt/ht.  If you pay attention to BMI stories, you know that almost any pro athlete or other fit, strong person, calculates to have dangerously high BMI.  When a cardiac patient can have a better BMI score than a combat-ready Navy SEAL, you need to throw away your scale.  If an underweight cardiac patient really does have a better long term health prognosis than an incredibly fit SEAL, we need to throw out pretty much everything else we think we know about "wellness". 

So if BMI doesn't matter, does that mean weight doesn't matter?  Weight is a pretty crude measurement - it says nothing about the quality of the health of the individual.  To be crude, if you have a prosthetic leg, it might weigh much or much less than your natural leg.  The weight does nothing to predict your long term survival.  Composition undoubtedly matters more than weight.  Does fat matter?  Possibly.  If anything matters, percent body fat probably matters.  The total amount of lean muscle mass probably matters.  That's the difference between the sickly cardiac patient and the SEAL, not their BMI.  It's not what they weigh, it's what they're made of. 

But doesn't this fundamentally say we can't even define what "overweight" is?  This is science; we can't resort to the "art" standard here: "I can't define it, but I know it when I see it".

If the intent is to give you a tool to determine your overall "wellness", BMI or weight are essentially useless.  An electronic body fat scale or other method of measuring percent body fat might be useful, but is there really good enough data to know how a certain value of %bf affects every possible race, nationality or combination?  In my world you would need extensive studies that map long term rates of disease  vs. % bf for all races, ethnicities and nationalities along with all of their diet compositions.  Not gonna happen in this lifetime.  

So let's skip over the weight issue and look deeper.  These are tools that you can't use at home - until that Star Trek tricorder is invented - but represent information you can get with a blood test under doctor's orders.  

The issues are not much less muddy here.  What are you going to measure?  Cholesterol gets measured pretty routinely, but would it make you feel better or worse to know that the reason we measure it is because we can?  Cholesterol was isolated early in the study of cardiovascular disease, and tests to measure it in patients were among the first.  There's a book in my list of recent and favorite reads called, "Good Calories, Bad Calories" by one of the best science writers living today (not my opinion; he has a stack of awards to back that).   He pretty much demolishes the idea that total cholesterol by itself is much of an indicator of anything.   Your ratios of  HDL ("good" cholesterol) to LDL ("bad") are more important indicators.   There are many others: HDL to Triglycerides, VLDL, other blood chemicals and tracers, that are more important than total serum cholesterol.  

Did you know that there is virtually no hard scientific data to back the wide recommendation for a 30% fat calorie diet - especially when opposed to, say, a 25 or 35% calorie from fat diet? Excellent summary here.  It is recommended because they really can't think of any reason to recommend anything different.  The 30% recommendation started before any research into effects of different percent calories was available.  Would it surprise you to know the dietary fat recommendations were political, not scientific?  Driven by democratic committee members, from George McGovern's presidential campaign?  In the intervening years, some of the alternative diets such as the ultra low, 10% fat diets have been studied and proven inappropriate for the general population.  There is woefully little science in any of the dietary recommendations that are common wisdom.  "Good Calories, Bad Calories" will also destroy any belief you might have that a healthy diet is a low fat/high carbohydrate diet.  It is probably the most important health-related book I've ever read. 

My favorite story in the wellness and health screening arena is that soon after I turned 40, I decided to get a physical and it included a cholesterol test.  It came back that my total cholesterol was moderately high, but my HDL was considered way too low.  They recommended that I do some exercise, perhaps walk around the block.  It struck me funny because I had ridden 100 miles on my bike over the weekend between getting tested and getting the results.  Clearly, the cause is not related to exercise.  Years later, my son (in his early 20s) was tested and had similar results.  The lipid profile we share is clearly genetic. 

I always think I'm not unique or special.  If I've experienced something like that, many others must have, also.  I believe that there must be thousands of other people who exercise, watch what they eat and do their best to "be well".  These people will be financially penalized for their genetics. 

So what's the big deal?  How can anybody be anti-wellness?  I'm not anti-wellness, I'm anti-intrusion into my life.  I'm adamantly anti-pseudo-scientific bullcrap, which is what most of the "wellness campaign" stuff is.  Adults should be responsible for themselves.  It is not the government's or your employer's responsibility to see if you do your daily exercises.  This is not Orwell's "1984", where you exercise in front of the cameras so they can verify you're doing it.  It's not even your insurance company's business if you exercise or pursue whatever roads to wellness you choose.  They are selling you a product.  If they told you that you could get a cheaper product if  you weighed less or smoked less, and you chose not to, they should just shut up, sell you the more expensive plan, and obey the contract you signed on to.  I suppose the biggest problem I have with these programs is that they treat you as if you're an idiot.  Like they are the first people you've ever come across in your life that have suggested exercise or weight control.   

Someone once told me the essential difference between liberals and conservatives is that conservatives believe in making their life choices while liberals believe in making your life choices:

If a conservative is a vegetarian, he doesn't eat meat.
If a liberal is a vegetarian, he wants all meat products banned for everyone.

If a conservative doesn't like guns, he doesn't buy one.
If a liberal doesn't like guns, he wants all guns outlawed.

In this situation it would be:

If a conservative thinks eating low fat and exercising is good, he starts eating less fat and exercising.
If a liberal thinks eating low fat and exercising is good, he demands that everyone be required to eat less fat and exercise more.

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