How Employers are Addressing Obesity

How Employers are Addressing Obesity

Old Way Versus New Way of Thinking

Past efforts by employers to support individuals who are overweight or have obesity have been only minimally effective. The old way of thinking may have prevented individuals from participating in programs or even changing their behavior. Employers need to embrace a new way of thinking.

Using a Stepped Approach

One size does not fit all in the treatment and management of obesity. A range of evidence-based interventions are needed for a holistic, whole-person approach and long-term success. A continuous process should include an annual evaluation of weight, and depending on BMI and the presence of comorbidities, inviting individuals to participate in one or more these stepped approaches. Below is an overview of each intervention and the potential weight loss that can be achieved:

The U.S. Preventative Services Task Force recommends that clinicians offer or refer adults with a Body Mass Index (BMI) of 30 or higher to intensive, multicomponent behavioral interventions.

  1. Lifestyle Modification: Lifestyle management and behavior change programs that encompass nutrition, physical activity and behavioral health components are the foundation of most employer weight management efforts. They are traditionally offered through employer-based wellness programs, point solution vendors, health plans and employee assistance programs (EAPs), and include activities such as coaching and educational programs, weight loss competitions, onsite fitness classes and walking clubs.
    • A weight loss of 3% - 5% can be achieved and have a positive impact on comorbidities, resulting in clinically meaningful reductions in triglycerides, blood glucose, hemoglobin A1C, and the risk of developing type 2 diabetes in the short-term. However, these programs may not be sufficient to maintain weight loss in the longer term. According to the CDC, those who lose weight gradually, one to two pounds per week, have a greater chance of success at keeping it off.

What is a point solution vendor?

Point solutions include specific vendor services that may fill a gap and address specific health issues in an employer’s health benefit offerings.

  1. Pharmacotherapy (Medications) + Lifestyle Modification: For those who have not succeeded with lifestyle modification programs or could benefit from additional assistance, adding anti-obesity medications (AOMs) can address some of the challenges that drive weight gain, help decrease appetite and increase adherence to lifestyle modifications.
  1. Surgical Intervention (Bariatric Procedures): Gastric band, gastric sleeve or gastric bypass involves making surgical changes to the digestive system to help individuals lose weight and is indicated for those who have multiple comorbidities and/or a BMI greater than 35. While these interventions have benefits, they are major surgical procedures that are associated with potentially serious risks and side effects. Long-term success requires permanent changes to diet and exercise.

Workplace Strategies

It’s vital that employers understand and address employee barriers to weight loss. Other priorities, such as caregiving, work stress or financial insecurity may limit individual engagement. Weight loss interventions will almost certainly attract more interest and engagement once those primary priorities have been addressed. Surveys, or better yet, focus groups can help to identify those priorities meriting employer attention. As employers, we need a toolbox with tactical approaches for obesity management that offers an integrated, comprehensive strategy to maximize the impact of available management options.
 - Bruce Sherman, MD Medical Advisor, National Alliance of Healthcare Purchaser Coalitions & Professor, Dept of Public Health Education, University of North Carolina, Greensboro

MBGH asked a group of employers what actions they are taking for those who are identified as overweight or have obesity. Responses included:

  • Offering coaching programs (mentioned most frequently) – including lifestyle modification programs from different point solution vendors or from those that provide chronic condition management programs.
  • Tying premium credits or other incentives to engage members in programs.
  • Tying incentives to results versus engagement.
  • Identifying ways to help members who are located across the U.S. (and in different socioeconomic status regions) to address access and affordability.

The workplace can contribute to the obesity problem, but it can also be part of the solution. There is a need for a paradigm shift away from common weight management programs which focus on self-directed weight loss attempts. Members can struggle and get frustrated with repeated cycles of diet and exercise resulting in a yo-yo effect of weight loss and regain. The stigma associated with obesity that is inherent in weight management programs must also be considered. For members who need the most support, stigma can be a primary reason for the lack of engagement.

Begin by looking at an employee with obesity as a whole person and provide an integrated and personalized strategy which can have greater success at attracting employee interest, as well as sustained engagement. Employees need both the knowledge to make healthy choices and the resources to act on that knowledge. This can be achieved through means as simple as workplace programs on nutrition, physical activity and weight management or an environment that supports activity such as onsite fitness centers and safe walking routes.

Improving Engagement in Employer-Sponsored Weight Management Programs

Employers can benefit from rethinking their current approach to weight management programs. This report offers some considerations that may improve program effectiveness, including:

  • Acknowledgement that current weight management programs have largely failed to achieve desired long-term objectives.
  • A need for attention to individual well-being concerns as “symptoms” that may take precedence relative to personal health concerns, including weight management.
  • Recognition that a holistic benefits strategy that supports workforce well-being may enhance individual interest and engagement in employer-provided weight management programs, and ultimately, may yield measurable business value.

Work-Related Accommodations

Individuals who are overweight or have obesity may benefit from employer assistance to ensure their working environment can accommodate them. Some individuals may also qualify for protections under the Americans with Disabilities Act (ADA) if their weight and associated symptoms (e.g., joint pain, mobility difficulties, shortness of breath, diabetes, etc.) “substantially limit a major life activity.” These underlying conditions may be a disability in its own right, regardless of the person’s weight. The ADA covers individuals who are “regarded as” disabled even if other criteria are not met. This article provides guidance, along with examples of accommodations and ways that employers can help.

Coordinating Vendor Solutions

Many employers today are focused on providing broad-based lifestyle management programs that address the health and wellness of the whole person to support their population with obesity, rather than specific obesity management initiatives. Others provide disease/care management programs that address comorbidities associated with obesity, yet often do not address obesity as part of the solution. When these offerings are made available through health plans or other vendors, they can have an unintended effect of decreasing focus on weight management as an organizational priority.

Alternatively, vendor offerings that target weight management can be made available to members who are overweight or have obesity – this approach can provide a more focused and impactful solution.

Regardless of what direction is taken, it is important to offer a coordinated approach to all vendor solutions to maximize effectiveness and success and to ensure vendors are accountable for outcomes. This is where performance- and outcomes-based contract clauses (see Section 3) can be essential to support long-term health improvement and potential reductions in future health care costs.

Evaluation Strategies

Most employers do not monitor or track the long-term success of obesity management interventions. Outcomes related to wellness programs, lifestyle and disease management programs, anti-obesity medication use, and other interventions are often evaluated individually instead of as part of a broader, more comprehensive effort to manage obesity across the population. This is compounded by the increasing number of point solution programs for conditions such as type 2 diabetes and musculoskeletal disorders, which are typically administered and evaluated in operational silos. A more comprehensive approach to evaluation of program impact will help to optimize use of available resources.

For employers, it is important to assess company policies, practices, and evaluation strategies related to support of members who are overweight or have obesity. The CDC suggests the following evaluation and management considerations to ensure alignment of organizational activities with weight management goals:

  • Review of participation and related outcomes from classes, lifestyle and/or disease management programs with weight management components offered internally and/or outsourced through vendors and health plans
  • Access to educational materials regarding prevention and management of obesity
  • Physical activity and nutrition-related policies
  • Environmental strategies including healthy food options in cafeteria and vending machines, and places for physical activity (exercise room, walking trails)
  • Incentives tied to obesity programs (see box on EEOC rules)
  • Partnerships with community resources for obesity-related programs (YMCA, local hospitals, health department)
  • Regular assessment of member attitudes and satisfaction with obesity management offerings

Equal Employment Opportunity Commission (EEOC) Rule Clarification on Incentives

On January 7, 2021, the Equal Employment Opportunity Commission (EEOC) issued updated proposed rules for employer-sponsored wellness programs that addressed incentives tied to wellness programs and outcomes. Within weeks, these proposed rules were withdrawn. For more information, review the articles provided in the resources section.

Approaches to evaluating an obesity management program can be separated into three broad categories.

  1. Early indicators are those measurable within the first 1-3 months of program implementation.
  2. Intermediate indicators are measurable between 6-12 months.
  3. Lagging indicators are evaluated in the 12 to 24-month timeframe.

The trending of early indicators is likely directional for intermediate indicators; favorable changes in early indicators are an early predictor of longer-term outcomes. The metrics for each of these three categories different insights into program effectiveness and are described in the table below.

When planning an obesity program, it is important to think through how the program will be evaluated and what relevant data will be available for analysis. The measures provided above represent a typical approach to program evaluation; however other measures or data points may also have importance depending on the program setting. For example, some employers may be interested in health equity and want to gain a better understanding of the race/ethnicity and income profile (or job category) of participants to ensure the program is of interest, accessible, and being appropriately used by all eligible individuals.