Promoting healthy weight: with obesity on the rise, EAPs can take advantage of their assessment, referral, and case management skills to help employers keep healthcare costs under control and encourage employees to maintain healthy lifestyles.

This is the first of two articles on promoting healthy lifestyles in the workplace. A follow-up article will describe an actual program and theoretical model devoted to promoting health), weight among workers.

Just as they reduced employers' costs associated with alcohol in the workplace, employee assistance programs have a clear opportunity to assist organizations in addressing obesity. While the ever-broadening focus of EA services has been criticized as one factor in the apparent decrease in EAPs' effectiveness in identifying alcohol problems among workers, it is incumbent upon employee assistance professionals to recognize the many challenges and issues tiering employers and their workforces and offer comprehensive and effective programs without compromising the integrity of what has made EAPs successful and valuable.

Obesity is one such challenge, and it is fast becoming a national epidemic. Nearly 65 percent of the U.S. adult population, or two out of three adults, is overweight or obese. (1) Obesity leads to at least 300,000 deaths annually (2) and places individuals at greater risk for diabetes, heart disease, hypertension, musculoskeletal conditions, stroke, some cancers, and depression. The effects of obesity and being overweight affect healthcare expenditures and productivity more than smoking and alcohol use. (3)

Overweight and obese employees can have a dramatic impact on a work organization's bottom line. The total cost of obesity to U.S. companies is estimated at $13 billion per year. (4) Obesity is associated with 30 million lost workdays, 239 million restricted activity days, 90 million bed days, and 63 million physician visits annually. (5)

The human and financial toll of obesity on workplaces is the basis on which EAPs should position themselves to address this issue. The EA field's focus on prevention, education, and referral to appropriate resources offers natural synergies to meet employers' need to minimize risks associated with obesity.

UNDERSTANDING OBESITY

To effectively address the health and business impacts of overweight and obese workers, it is important to understand what these conditions are as well as their causes and their physical, psychological, and social consequences.

Someone who is overweight has an excessive amount of body weight compared to set standards; someone who is obese has excessive amounts of body fat. Thirty-one percent of those who are overweight are obese. Both conditions occur when an individual consumes more calories than s/he burns. While some medical conditions, such as hypothyroidism, depression, and certain neurological problems, can interfere with the body's ability to maintain a healthy weight, (6) the causes of the imbalance between calories consumed and calories burned may include genetic, environmental, and/or psychological factors.

Genetics and family learning. Studies have revealed a genetic predisposition to obesity that is unrelated to lifestyle. Family norms also have a significant impact on learned eating behavior--parents who model poor eating habits and inactivity teach their children the same behavior. Family rules such as requiring that every item on a plate be eaten encourage overeating, particularly with portion sizes in America growing wildly out of proportion to individual nutritional needs.

Lifestyle factors. Lifestyle factors, including how much an individual eats and how much physical activity s/he performs, affect weight and health. Americans tend to eat high-fat, high-calorie meals and generally do not get enough physical activity. (7) The Centers for Disease Control and Prevention reports that 40 percent of U.S. adults do not engage in leisure-time physical activity and only 14 percent meet the standard of brisk walking for 30 minutes per day, five times per week. (8)

Stress. High-fat foods and diets high in non-complex carbohydrates inhibit the release of stress-fighting hormones. This supports the theory that chronic stress can lead to a constant urge to eat such foods. Food cravings are the body's attempt to alter brain chemistry in order to self-regulate hormonal imbalances created by stress. When stress is persistent, stress hormones maintain the stress response at a heightened level of alert, resulting in the formation of surplus fat ceils, elevation of blood pressure, and retention of salt.

Psychological factors. Individuals who habitually use food to deal with emotions lose the ability to regulate how they feel and their ability to maintain healthy ways of resolving problems. Overeating often leads to feelings of shame and guilt; to reduce the impact of these feelings, people often eat more, thus creating a never-ending cycle of psychological distress.

Social influences. Overweight and obese individuals are often viewed by society as lazy or incompetent. This makes overweight and obese individuals the target of discrimination and prejudice, continuing the cycle of stress, shame, guilt, depression, and overeating.

Cultural implications. Unlike abstaining from alcohol or tobacco, avoiding food is impossible, thus making changes in eating habits and lifestyle factors more difficult. Weight-related conditions and illnesses are on the rise, particularly among second-generation immigrants adopting the American lifestyle. It is particularly important for EA professionals to understand the cultural implications that can support or undermine a client's healthy weight goals. (For additional information on the cultural implications of health, see The Provider Guide to Quality & Culture at www.omhrc.gov/ cultural/cultural5.htm).

Age and gender. Weight gain can occur at any age, although weight gain is most common in middle age. Because men have more lean muscle mass, they tend to burn fat more easily and with less physical activity than women. In women, hormones influence body fat levels, energy levels, and the desire and craving for food. For women, weight gain is associated with periods of significant hormonal changes, including adolescence, pregnancy, the menstrual cycle, and menopause.

Income. Eating healthy foods is expensive. Less-healthy foods can be purchased more cheaply Luxuries like gym memberships, exercise equipment, and weights are not affordable for many Americans.

THE ROLE OF EAPS

With organizations continuing to struggle to control escalating healthcare costs, EAPs offer a range of services that can be customized to support employer initiatives that address the impact of obesity in the workplace. For example, many aspects of today's disease management programs are based on models very similar to EAP case management. Several of the more traditional EAP services benefit programs that adopt a disease management approach, including the following:

* Comprehensive diagnostic assessment with multiple screenings and preliminary identification of medical issues;

* Wellness education and prevention;

* Management consultation;

* Case management, including referral and follow-up; and

* Development of a multi-disciplinary network of referral sources. (9)

EA professionals can incorporate healthy lifestyle initiatives into their programs along a continuum, from a preventative and educational approach for the general employee population to long-term case management and follow-up programs for overweight and obese individuals. EAPs should consider providing comprehensive training to EAP staff and/or contracted affiliates on the impact of obesity from a financial and human perspective. This training should include skills development to learn how to assess issues associated with obesity and to provide motivational support and counseling to encourage individuals to become active in addressing this issue.

EAPs also should provide training to EAP staff on how to deal with the behavioral or psychological factors that contribute to weight gain and obesity.

Methods could include the development of a targeted behavioral modification plan focused on eating and activity behavior, the use of support groups and peer mentoring, and creating links to community healthy weight resources.

There are many concrete activities that organizations can adopt to promote a healthy workplace at little to no cost. The EAP should encourage employers to implement activities that (1) promote physical activity, (2) emphasize the importance of good nutrition, (3) support stress management skills for employees and managers/supervisors, and (4) communicate senior management support and commitment through incentives and employer-sponsored healthy lifestyle initiatives.

The EAP can also offer recommendations related to employee benefit design. For example, gastric bypass, the most common type of bariatric surgery, has helped many obese people lose weight and improve their lives, but it is also extremely risky and costly for companies when reimbursed through an employer's health plan. According to a 2003 survey by Mercer Human Resource Consulting, 48 percent of employers offer insurance coverage for bariatric surgery The costs to employers include not only the medical expenses associated with the surgery but also those associated with any complications or short- or long-term disability utilization.

To ensure that this surgery is not taken lightly and that less risky alternatives have been exhausted, the EAP can position itself with employers as a recognized expert, not necessarily in bariatric surgery, but rather in the identification of and connection to resources that can provide the behavioral health support necessary when contemplating major surgery. The EAP can also offer ongoing follow-up and support to ensure permanent and healthy lifestyle changes.

PREVENTION AND EDUCATION

As an employer considers implementing a healthy lifestyles initiative through its EAP, it is important to recognize that a successful program will only be achieved through a prevention and education effort that is sustained over time. It is critical that an employer remain firmly committed to supporting the health and well-being of its employees through a series of healthy lifestyle initiatives. This includes educating the workplace community on medical risk and offering solutions to improve the health and quality of employees' lives. Employees are more likely to take such initiatives seriously when they are supported by senior management and reflected in organizational policies and behavior.

Because the issues associated with being overweight and obese are complex, tackling this problem requires a multifaceted approach, including the use of behavioral health techniques. Employers will experience greater success when they focus on the behavioral issues associated with making a lifestyle change and deploy the EAP to be a resource to support and promote a healthy workplace. With their focus on prevention, education, assessment, referral, and follow-up, EAPs can effectively address one of our nation's fastest-growing public health concerns.

References

(1) National Center for Health Statistics. 2003. Chartbook on Trends in the Health of Americans. Atlanta, Ga.:Centers for Disease Control and Prevention.

(2) Actual Causes of Death in the United States. 1993. Journal of the American Medical Association.

(3) Sturm, R. 2002. The Effects of Obesity, Smoking, and Drinking on Medical Problems and Costs. Journal of Health Affairs, March/April (21): 245-253.

(4) Prevention Makes Common Cents: Estimated Economic Costs of Obesity to U.S. Businesses. 2003. U.S. Department of Health and Human Services. Washington, D.C.

(5) Wolf, A.M., and G.A. Colditz. 1998. Current Estimates of the Economic Costs of Obesity in the United States. Obesity Research (6): 97-106.

(6) National Institutes of Health. YEAR. Understanding Adult Obesity. Washington, D.C.: National Institutes of Health, Publication 01-3680

(7) Ibid.

(8) National Center for Health Statistics. 2001. Healthy People 2000. Hyattsville, Md.: Public Health Service.

(9) Paul, R., and L. Swanson. 1997. Disease Management and EAPs: Case Managing Chronic Conditions. EAP Digest. July/August.

Kathy Greco is director of quality and outcomes for the Health and Performance Solutions Department in ValueOptions' Employer Solutions Division. She is responsible for quality and outcomes initiatives supporting workplace-based services and products. She can be reached at [phone] or at [e-mail].

Rich Paul is vice president of Health and Performance Solutions in ValueOptions' Employer Solutions Division. He is responsible for operations, product development, and best practices supporting workplace-based services and products. He can be reached at [phone] or at [e-mail].

Brent Pawlecki is associate medical director at Pitney Bowes Inc. His responsibilities include managing the onsite medical clinics and wellness programs and serving as a consultant for the Disability Department and the workers' compensation, safety, and benefits design groups.