Andrew Sykes and Colin Bullen explain why less is more for employers or insurers when designing wellness programmes
Why do so many wellness programmes fail? Certainly looking at the US experience, despite 30 years of effort at improving population health and thousands of wellness companies offering all sorts of solutions, the health of the average US citizen is still poor compared to what it could be. The same is true for many countries around the world.
We all know we should be offering better programmes, motivating employees, addressing areas of wellness like smoking cessation, stress management, healthy eating, financial fitness, work-life balance and others.
More is required but with a small and reducing budget. No wonder we are failing. But what if that assumption is wrong? What if we are better served by less, not more?
The average employer has a very limited budget for wellness programmes (despite the irony that over 70% of sick care costs are driven by health habits). We would all like to see that budget increase, but what could we do to make the absolute best of what we have? We believe the answer might be to do only one thing, and do it very, very well. That one thing is exercise. But why?
There are many things that don't add much value in wellness programmes. Yet we spend money on them year after year, somehow hoping that this year they will have an impact they have never had before - if we're even evaluating the impact. Health risk assessments, biometric screenings, biggest loser competitions, and smoking cessation programmes are just a few examples of money spent for little, if any, return beyond the cost of the programme. It is not that quitting smoking does not produce results - it is that the cessation programmes do not have very high success rates. The same goes for programmes focused on other habits.
We know that almost everyone should be exercising, including those (with appropriate direction from their physicians) who are suffering from chronic diseases or who are in recovery from most medical procedures. We know this, and yet at least 40% of people don't do any exercise at all. Perhaps as many again exercise insufficiently to meet the basic guidelines. Although a few people will change their habits in response to, for instance, knowing their numbers, sadly the vast majority of people will seek drug therapy to address high cholesterol, high blood pressure and other risk factors under the guidance and support of their personal physician. Worse still, once on drug therapy, people are often less motivated to change their health habits, believing that the drugs will now take care of the problem.
Not all health habits are equal
Why focus on exercise rather than the whole range of wellness initiatives? Surely the obesity and diabetes epidemics are more pressing, expensive problems to address? Well no, they're not, and here is the evidence.
? Exercise prevents - or treats - more conditions than any single medication, therapy, procedure or medical intervention. We know that at least 45 diseases are less likely to arise, or be less severe and costly, for those who are fit versus unfit. Exercise treats or prevents depression, chronic pain in multiple sclerosis, headaches, impotence, heart disease, high blood pressure, diabetes and many other diseases, often (though not always) more effectively than the leading drug in each therapeutic class.
Exercise works very quickly. According to the Physicians Committee for Responsible Medicine in Washington DC, over 90% of patients on oral diabetic medications and 75% of patients on insulin were able to get off their medications after 26 days on a proposed diet and exercise regime.
Hang on, did that say exercise and diet? Yes. However, people who exercise:
? Have greater willpower to resist the temptation of unhealthy food. Exercise improves heart rate variability (a good thing), reduces cravings, boosts willpower and increases persistence with new tasks - persistence being an important element of eating a healthy diet
? Have increased energy, the core source of motivation to put other healthy habits into action
? Sleep better, which helps with appetite control for up to three days following a good night's sleep
We're not saying a good diet is not important, just less important. Remember, most companies have a limited budget and are trying to maximise their return. The least fit 20% of people have five times the prevalence of diabetes compared with the fittest 20%, but the apparent range based on nutrition habits alone seems to be narrower. Since we can't afford to do everything, we should focus on those things that will have the greatest impact.
The impact on other health habits from exercising is not limited to diet. Starting or increasing exercise is one of the most effective ways to quit smoking. Exercise is the 'gateway habit' to other good habits. The fittest 20% of people include only 5% of smokers, while the least fit 20% include over 30%.
Exercise drives positive performance
In the US, the lens through which we often compare wellness initiatives is the likely impact on medical claims costs. Through that lens, exercise outperforms disease management and drug therapy for risk factors such as hypertension, cholesterol and many other treatment-based modalities. However, when we look at the impact on positive performance, exercise really outperforms. For example:
? Students that are the most fit get up to 20% better grades than the least fit in English, Maths
and other subjects. They have better discipline and attendance records. Interestingly, there appears to be
no difference in academic performance based on body mass index
? Fitter 10-year-old children tend to have a bigger hippocampus and perform better on a test of memory than their less-fit peers
? Forty minutes of walking, three times per week, improves episodic memory and executive control functions by 20%
? A year of exercise can give a 70-year-old the brain connectivity of a 30-year-old, improving memory, planning, dealing with ambiguity and multitasking
? In one study, complex decision-making improved by 70% in response to exercise
? Mental errors fell by 27% for fit workers on concentration and memory tasks
? Nasa is quoted as saying that stamina improves by 100% (in the last two hours of each day) for those who exercise that morning.
When was the last time your business achieved that kind of improvement in the same day? Some of the performance impacts of exercise are almost immediate, even for those who have not exercised for years.
To be fair, as with all data in wellness, we are hypothesising causal relationships from data on correlation and no one has ever conducted a true double-blind experiment to tease out cause. There could be a hidden third variable. However, we believe that a sober look at the data makes the hypothesis that exercise is overwhelmingly the single most important health habit look very likely to be true. Yet a problem persists that prevents a greater focus on exercise to the exclusion of other health habits.
We are in love with breadth, not depth. Wellness vendors and buyers want programmes with 'something for everyone' and that address all possible aspects of health, health management and wellness. But the price of this is not doing very well the one thing that makes the world of difference - getting people to exercise effectively almost every day.
The problems caused by growth in behaviour-related non-communicable diseases are global, not just
specific to the US. The lessons we've learned here are just as relevant in any industrialised economy as they are for Americans. As the quantified-self movement evolves (people using 'trackers' to measure their exercise and health habits), we predict that the data to prove that exercise really is the 'killer app' for keeping us alive, healthy and productive will emerge even
more strongly.
Until that time, we hope this convinces you that employers around the world should focus on this foundational habit with their limited budgets.
References
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Health, United States, 2012. www.cdc.gov/nchs/hus.htm
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Dwyer-Lindgren, L, Freedman, G, Engell, RE, Fleming, TD, Lim, SS, Murray, JL & Mokdad, AH (2013) Prevalence of physical activity and obesity in US counties, 2001-2011 Population Health Metrics 11(7)
Count by Health at Work Wellness Actuaries based on variety of research articles. See also: en.wikipedia.org/wiki/Neurobiological_effects_of_physical_exercise
Cardiorespiratory Fitness and Metabolic Risk, Scott M Grundy, Carolyn E Barlow, Stephen W Farrell,Gloria L Vega, and William L Haskell. Cooper center longitudinal study
www.fitnessblender.com/v/article-detail/Stop-Smoking-Exercise-Plan-How-Exercise-Can-Help/be/
California Physical fitness test, 2004 results, calf dept of ed April 2005.
Also www.cooperinstitute.org/pub/news.cfm?id=71
news.illinois.edu/news/10/0915_brain_development_and_fitness_art_kramer.html
www.newsweek.com/can-you-build-better-brain-66769
Hung, T-M, Tsai, C-L, Chen, F-T, Wang, C-C, & Chang, Y-K (2013). The immediate and sustained effects of acute exercise on planning aspect of executive function. Psychology of Sport and Exercise, 14, 728-736.
Winter, B, Breitenstein, C, Mooren, F C, Voelker, K, Fobker, M, Lechtermann, A, Knecht, S (2007). High impact running improves learning. Neurobiology of Learning and Memory, 87, 597-609.
Hung, T-M, Tsai, C-L, Chen, F-T, Wang, C-C, & Chang, Y-K (2013). The immediate and sustained effects of acute exercise on planning aspect of executive function. Psychology of Sport and Exercise, 14, 728-736.
Colcombe, S, & Kramer, A F (2003). Fitness effects on the cognitive function of older adults. Psychological Science, 14(2), 125-130.