Saturday, April 9, 2016

Wait... I'm Not the Only One Questioning Wellness Programs?

I think I wrote my first anti-wellness program piece back in 2010, "What's Wong With Wellness? Weawy?"  (do an Elmer Fudd or Baba Wahwah speech impediment; it makes sense - weawy).  Perhaps the most important paragraph was fairly early in the piece, and I stand by it today, almost six years later to the day:
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 
If you read Karl Denninger at Market Ticker, you know he regularly talks (well, alright, almost preaches) that low carb diets are the answer to most of our current health problems and that the conventional wisdom is flat out wrong.  Example 1. Example 2Example 3 (all within 2 days).  Newsflash: Karl's right.  The fact that lots of doctors are coming around to this is more evidence.  I could fill a post with links, but that's not the point. Furthermore, there's simply not good quality science to match our obsession with making everyone in the country look like concentration camp survivors.  How many times do they need to find that higher BMI patients have better outlook and survival than thinner counterparts before they stop calling it paradoxical?  (also)  I recently lost a close friend to complications of liver cancer.  He had lost 80 pounds due to the complications - he wasn't large to start with - and I think he would have had a better chance if he hadn't lost that 80 pounds and was more robust.  It wasn't the cancer that got him. 

According to Jonathon Adler writing in the Volokh Conspiracy, the premises of these corporate wellness programs are being questioned at all levels.  A conference is coming (on tax day) to get some collaboration going on between more folks.
On April 15, the Law-Medicine Center at the Case Western Reserve University School of Law is hosting a full-day conference “Corporate Wellness Programs: Are They Hazardous to Well-Being?”  Speakers include Dr. Soeren Mattke of the Rand Corporation, Dr. Michael Roizen, chief wellness officer of the Cleveland Clinic Foundation, Prof. Dennis Scanlon of Penn State, Prof. Sam Bagenstos of Michigan, Christopher Kucynski of the EEOC, Prof. Jessica Roberts of the University of Houston, Prof. Harald Schmidt of Penn and Elizabeth Click of CWRU.
Adler, in turn, quotes from NY Times piece by Austin Frakt and Aaron E. Carroll in September 2014.
Wellness programs are popular among employers. An analysis by the RAND Corporation found that half of all organizations with 50 or more employees have them. The new survey by the Kaiser Family Foundation found that 36 percent of firms with more than 200 workers, and 18 percent of firms over all, use financial incentives tied to health objectives like weight loss and smoking cessation. Even more large firms — 51 percent of those with 200 workers or more — offer incentives for employees to complete health risk assessments, intended to identify health issues. . . .

The Kaiser survey found that 71 percent of all firms think such programs are “very” or “somewhat” effective, compared with only 47 percent for greater employee cost sharing or 33 percent for tighter networks. . . .

What research exists on wellness programs does not support this optimism. This is, in part, because most studies of wellness programs are of poor quality, using weak methods that suggest that wellness programs are associated with lower savings, but don’t prove causation. Or they consider only short-term effects that aren’t likely to be sustained. Many such studies are written by the wellness industry itself. More rigorous studies tend to find that wellness programs don’t save money and, with few exceptions, do not appreciably improve health. This is often because additional health screenings built into the programs encourage overuse of unnecessary care, pushing spending higher without improving health.
Again, the company I just retired from had a wellness program for years.  It started out gradually: they want you to see a doctor and get tested for various risk factors.  Two years later, goals were set for those risk factors.  The year after that, you got penalized for not meeting their goals.  In the early days, you got a price cut in your insurance costs if you got tested and by the time I left you paid extra if you didn't meet the goals.  Around the annual screenings was a virtually continuous three-ring circus of activities to get employees to participate in group diets, or running clubs (never acknowledging that your cardio may be killing you) or other nonsense.   Treating employees differently by charging them more or less for insurance because of blood test scores or other physical aspects is breaking the Americans with Disabilities Act.  I have no doubt that if companies get actual data that shows they're not getting their sufficient return on their wellness investments, those programs will go away.  Companies are always efficient about maximizing profits, right?  I'm less optimistic that any wellness nonsense encoded into Obamacare will ever go away.   


  1. Honestly it would be a totally different issue if the 'experts' were right. But there is virtually zero evidence that any of the fad diets make a difference. Is it low fat or low carb? All the experts point in different directions on this. Then there are the vegetarians and vegans who are convinced it is neither but that low or no meat is the answer. IMHO there is simply no magic food or harmful food sold in our super markets. There are fads and biases and even a handful of strange beliefs out there but no proof. Eat a variety of foods, don't discriminate against a food or class of food and eat everything with moderation. But even then there is really no evidence that eating immoderately is harmful either.

    1. Eat a variety of foods, don't discriminate against a food or class of food and eat everything with moderation. There's less evidence that statement is true than you think, but that's not the point of this piece.

      The point of this piece is that wellness programs are intrusive, offensive and ineffective. "Wellness" is a great idea, but there's horribly little hard science that says these programs are good for people or will save the companies money. To begin with all of these diet or lifestyle studies are subject to one enormous, unavoidable problem: they're not controlled, double blind studies. It's far too expensive to put thousands of people in a metabolic ward under lab conditions. Without a hard scientific justification, the wellness programs become human experimentation without the subjects' willing approval. As do the national dietary guidelines, like the Food Pyramid or My Plate. That's unethical in any lab in the country, if not in the world.

      The best summary is "one size never fits all". In the diet realm, you're quite right that there is no magic food, but there are foods that are better or worse for specific people. A study from Stanford (? I think - the A to Z study) recently demonstrated that the lowfat diets work for people with high insulin sensitivity, but for the insulin resistant people they showed low carb diets worked much better. The insulin sensitive can eat low carb or a low fat or anything they want and lose weight, while insulin resistant people need to stick to low carb. The hidden gotcha is that the standard low fat diet seems to cause insulin resistance in people that are genetically predisposed, just based on the population statistics of the last 30 years.

      As I said in the piece, I could list references all day, but that's not the point.

  2. If you have a health problem diet (a specific diet) may well benefit you. A good example is diabetes. If you are diabetic a diet can improve your day to day health and extend your life. No question, no argument. If you do not have a health problem affected by diet than none of this is true and all food is simply 'food'.

    To your point that some foods are better or worse (for specific people). true for specific people and untrue for the other 85% of the population. And that is my point. I apologize if I strayed too far from your main point but you did bring up diet and that is my pet subject. There is so much misinformation out their, people who will tell you that they can prevent cancer or make you live 10 years longer, low carb, low fat, no meat, yadda, yadda, yadda. But it is all hokum. There is now "good food, bad food. There is most certainly foods that have more of the necessary nutrients we need but if in the end we are getting our nutrients from our food what difference then does it make that you eat white rice instead of brown rice? The American diet gets a lot of criticism but it generally does give us our MDRs unless you choose to follow one of the many fad diets. I still feel the best advice is eat everything, eat what you like and eat with moderation. AND if you have a health problem that requires a special diet follow your doctors advice. Notice I didn't say follow some author's advice or some friend's advice.

    1. It's inevitable that we be colored by our experiences and viewpoints in life. I see the 60+% of insulin resistant, pre-diabetics and diabetics in this country who would benefit from carb restriction and think that's important. My brother is fully diabetic (type 2), my mom also was, and I've successfully intervened to prevent it. So far, I'm stable as an insulin resistant pre-diabetic and want to keep it that way, if not reverse it. The way I see it, the numbers are almost the opposite of what you say: instead of 80% can eat whatever they want, it seems to me it's closer to 20%. I freely admit I may be wrong and that the picture may not be complete.

      The most important point is that it's not an employer's position to regulate our lives, especially with the current state of knowledge, yet that's exactly what the wellness programs do.

  3. Diabetes is a genetic illness. It is often mischaracterized as 'caused' by eating improperly but that isn't true. The rates of diabetes hasn't changed. People of Northern European descent have a 6-8% diabetes rate. People of African or native South American descent have 2-4 times that rate. American Indians also have very high rates of diabetes while the aborigines of Australia tend towards 100%. You don't get it from eating sugar or carbs you get it from your parents and grandparents.

    Prediabetes is kind of an awkward thing. It is freely diagnosed in people who do not have diabetes will never have diabetes but the doctor simply wants to scare them into losing weight or eating better. What is meant by prediabetes is certain blood tests show high than normal levels (or simply in the high range of normal levels) of markers that can also be associated with diabetes. BUT that does NOT mean they have diabetes or will ever have diabetes. It is (often/typically) 'doctor-speak' for 'you are fat and need to lose weight how can I scare you into doing what is right'.

    These tests assume certain things which are not controlled. For example probably everyone who runs marathons will test "pre-diabetic" (whatever that means) because they are eating so much and carb loading. When I ran in marathons I would easily eat 3000-4000 calories for breakfast the day of the race and all of it carbs. However it is probable that EVERYONE who dies of starvation will have excellent results in those infamous 'pre-diabetes' tests. Their blood sugar will be awesome and if they were to have lived would have been deemed healthy.

    So what do these tests really mean? Most certainly get tested for diabetes (the fasting blood sugar test is the best one). Certainly if you are very overweight you should lose weight. (not just over BMI 25 but 30-60 lobs over normal weight for your height and body type). And you should get regular excercise. Will any of this actually make you live longer or avoid getting sick? NO! It will make you feel better about yourself and perhaps make you enjoy life more but for the most part it doesn't make a lot of difference in health.

    Diet advice should be to eat a diverse diet and make sure you are getting the MDRs. Avoid fad diets like the plague. And enjoy eating things you like in moderation.

  4. Recently had a quad-bypass. The nutritionists are still filling people with the "guit eating salt and fat" bull hockey. But my cardiologist told me, "Ignore whatever they tell you. Cut the carbs, eat healthy (non-processed) food and don't worry about all that other stuff."

    And yes, wellness programs are a joke. The carrot here is additional money for our Health Savings Plan.

    The wellness programs remind me of the useless Safety Programs. I get 3 or 4 safety emails a day. And everyone just deletes them. Safety is a leadership issue. If your supervisor cares, and knows what he's doing, your job will be 100% safer. Watching a million Power Point presentations is useless and just becomes static in the background...

    1. Well, congrats on making it through the quad bypass. And it sounds like your cardiologist is on top of things.

      There have been a couple of massive statistical data mining studies on the roughly half century of pushing low fat diets and the results have not been friendly to the low fat dogma. They've said that the link to saturated fat is rather weak and telling people to cut fat and meat consumption isn't effective at preventing the first or recurrent heart attacks. I recall reading that in a British Medical Journal article back in '97!

  5. Note well that they NEVER recommend changes to the most preventable health risk. After all, those are Preferred Species.