What’s Science Got to Do With It?

What’s Science Got to Do With It?

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Penn State University is now embroiled in a national controversy over the ham-handed launch of its coercive and intrusive wellness program, which can cost recalcitrant employees as much as $1,200 per year for not joining.  That ignominy of being the most distasteful and coercive program, however, belongs to Blue Care Network of Michigan, which recently published results from their “voluntary” walking program designed exclusively for their obese enrollees.  The invitation to join was extended to enrollees with a body mass index (BMI, which is an unscientific, mathematically bereft proxy for health – see Keith Devlin’s excellent article ) of 30 or greater.  The program was “voluntary” as long as you were okay with paying $2,000 in added insurance premiums if you did not volunteer.

Avoiding the $2,000 price tag came with its own cost in dignity and privacy.  Enrollees agreed to either: 1) wear an electronic pedometer and connect it to their computer daily to document completion of at least 5,000 steps or, 2) join Weight Watchers or some other approved “weight cycling” program.  This princely sum is not irrelevant to most families.  In fact, it is almost exactly equal to per capita spending on food eaten at home in the US and about four percent of median US household income in 2011.  So, in a household occupied by a single adult, this will almost buy your groceries for a year, meaning that is hard to refuse, and the less money you make the more likely that resistance will prove futile.

The BCN strategy legitimizes telling people who look a certain way that they should submit to online, electronic monitoring or pay more for their insurance than people who don’t look that way.  Why would an obese person submit to this when it is entirely possible that he or she is fitter and more metabolically healthy than an normal weight unfit person who would never be condescended to this way?

More disturbing is the prospect that this is only the leading edge of life-invading monitoring by the wellness industry.  It is easy to envision sleep monitoring because you have bags under your eyes.  Or, what about wrist-worn breathalyzers to make sure you don’t go over the one or two drink limit, or sneak cigarettes after lying on your health risk appraisal that you don’t smoke?  How much electronic surveillance would you be willing to undergo on the pure guesswork that it might save someone (i.e., your employer or your health plan) money?


Almost a third of the people who “volunteered” for the BCN walk-a-thon were angry and felt coerced into joining the program. (Actually, this was about a third of the only 12% of participants who bothered to answer the satisfaction survey.)  Their outrage is understandable considering that the criterion for participation was their appearance (because we know that thin people all get the recommended amounts of daily physical activity, right?), as opposed to objective measures, such as cardiorespiratory fitness, cardiometabolic markers, or how many steps they already walked in a day .  Even more amazingly, because these risk managing master minds collected absolutely zero pre-program data, there is no way to know whether the intervention increased anyone’s fitness, improved their cardiometabolic markers, or saved any money.

Finally, there is this nugget: , 47% of participants surveyed initially said they disliked being strong armed into the program.  At the end, more than 30% still felt that way. It’s possible that people who lost weight changed their minds, although it will be interesting to see how they feel when they gain the weight back, which according to the last 25 years of published research most of them certainly will.  Maybe then, BCN can give everyone two monitoring devices and entice them with $4,000.  In any case here is the compassionate response about this from the authors (at page 8 of 13).

“…nearly a third of them did not like the program…. Nevertheless, given mounting costs associated with sedentary behavior, approaches to financially incentivize healthy behaviors are likely to expand and gain political support…”

So, in this “seminal work” we are left with this: people didn’t like it, we have no idea of its impact on any meaningful health measure or financial outcome, but despite nearly total ignorance of value, we should do it anyway. Why?   Because both the government and large corporations have staked a claim to beating back the “obesity epidemic” using the cudgel of differential insurance premiums to drive health behaviors.  This stems from the falsehoods trotted out by the C-suite at Safeway during debate over the Affordable Care Act, which gave politicians the cover to claim that this was a good idea for everyone.

The BCN program shows that we have sunk to a new low in the US.  It is the most coercive, penalty-laden weight loss program that either of us has ever seen which, at the end of the day, measured almost nothing except a highly leveraged participation rate.  There is not a single word in the entire paper about the importance of organizational culture change as a foundation for helping individuals change behaviors.  This exclusion perpetuates the idea that wellness is something you do to people, instead of something you do with and for them.

Jon Robison, Ph.D., MS, has been teaching at Michigan State University for almost 20 years. He presents at health-related conferences throughout North America and is the co-author of The Spirit and Science of Holistic Health: More than Broccoli, Jogging and Bottled Water, More than Yoga, Herbs and Meditation.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

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53 Comments on "What’s Science Got to Do With It?"


Guest
Ggood Health
Nov 17, 2014

Save cost for good wellness is a good idea for everyone.

Guest
Jan 24, 2014

Thanks Monica – you said – “How can so much of our public heath policy be based on junk science? It seems obvious this isn’t about health at all, but discrimination pure and simple.”

I am so sorry you have to put up with this crap! and your evaluation is right on the money! (pun intended)

Guest
Monica Misky
Jan 24, 2014

Thank you so much for writing this. I am one of those angry BCN members you mentioned in the article. I am “volunteering” for the program because if I don’t comply, the premiums/copays/deductibles/co-insurance goes up for my entire family. And it’s quite a difference. I am fit, healthy, and very active…and happen to have a BMI over 30. I participate in group bicycling, adventure racing, and yoga, just to name a few. My husband is in the same (fat) boat. I can’t understand the purpose of this penalty, other than to make it so demoralizing and time consuming that people opt out and pay a higher rate. But I won’t steal the organic produce out of my kid’s mouths just because of pride. How can so much of our public heath policy be based on junk science? It seems obvious this isn’t about health at all, but discrimination pure and simple.

Guest
Paul Ernsberger
Aug 26, 2013

There is a long history of insurance surcharges against stigmatized groups like obese people. These surcharges definitely add to profits. An early example is the surcharge on obese people buying life insurance starting in 1904. It was alleged that obese policyholders died more often, but there was little evidence of this at that time. As the surcharges increased, fewer and fewer obese people bought life insurance until people with life insurance coverage ended up being far leaner than the general population. The same will happen with health insurance and is already happening –the surcharges are driving more obese people into the ranks of the uninsured.

Guest
Aug 26, 2013

Paul, thank you for your comment. I had no idea that the insurance industry’s push against the obese went back as far as 1904.

Guest
Aug 23, 2013

Haley,
It was not the purpose of this entry to address the ACA in its entirety but only to comment on the ridiculous Blue Cross program which is based on the recommendations evolving out of the Safeway Amendment. These recommendations promote the use of differential insurance premiums used as carrots and sticks (mostly sticks) to coerce employees into taking HRA’s, and biometric screens and participating in so-called wellness programs like the one we discussed here. I am happy to discuss this aspect of the ACA all you want. If you are looking for some political statement about the larger bill you are not going to get that from me. This issue and this post are not about right or left or conservative or liberal. They are about science. Let me know if you want to talk further about the science (or lack of it) that is behind these issues. I am happy to do that as well as to suggest what we might do instead. If you are after some bigger issue you will have to go elsewhere for your debate. Hope this helps – glad to continue the conversation if you are interested. – Jon

Guest
Aug 23, 2013

You are right Linda – Michigan is the only state that actually has a law against discrimination according to size – Of course, I would guess that lawyers had a look at this first and the financial risk of taking on the Blues would be extremely high – Jon

Guest
Haley
Aug 23, 2013

ok- one more time Jon- if you believe the incentives need to be changed, what about the ACA should be changed?

specifically, otherwise, you are as without solutions as is often claimed about the right.

Guest

I’m surprised that an obese employee has not sued for illegal discrimination.

In any case, the design shows an ignorance not only of science but also of human behavior. When will people realize that science will always win?

Guest
Aug 22, 2013

Thanks for the comments Shawn, Reverend, Science is fun, Joanne, and David – Taking some hope from the ongoing Penn State uprising – maybe it is time to turn this nonsense around! – forcing people to be healthy is a true oxymoron! – Jon

Guest

I agree with the authors wholeheartedly. My parents were brutal in their hatred of me, putting me on a starvation diet from the age of 5 — setting me up for disordered eating and low self-esteem. I shudder to think what they would have done to me if the school had sent them a letter to encourage them to be harsher with me so that I would be thinner.

Guest
Shawn Connors
Aug 22, 2013

In the mid 19th Century William Harvey of England lectured that disease came from swamp vapors and planetary movements. And he was highly respected. Today the social construct (almost everybody thinks) is that obesity is the cause of most things unhealthy. And people and institutions that really believe that today will look as ridiculous as Harvey does in retrospect. It turns out germs were the culprit escaping the notice of Harvey and his ilk. It’s too bad health insurance has anything to do with employment. But since it does, the best we can do is make the work enjoyable, appreciate the people that add value to the core competency of the organization, and use common sense – like treating everyone with dignity and respect. And let’s end this madness of spending time and resources picking on the fat kids.

Guest
Aug 26, 2013

As a former fat kid, I am all in favor of not picking on them. I can speak to just how infuriating and insulting that is.

We should not, however, forget that obesity is not a benign state. Even though cohort studies show that obese adults are often metabolically healthy at a given point in time, obesity clearly causes metabolic alterations (such as inducing a pro-inflammatory state and altering glucose metabolism) that create disease over the long term.

Addressing the problem forthrightly and creatively, while still allowing people to keep their sense of dignity and independence, is critical. Clearly, the BCN weren’t thinking that way.

Guest
Shawn Connors
Aug 27, 2013

Vik – we probably agree on more than we’d disagree on regarding the obesity issue. Some of our colleagues in workplace wellness need to remember that people don’t seek employment so that they can lose weight, and improve their lifestyles. But if they enjoy their work, feel appreciated, and make strong social connections at work, that is probably going to do more for them than any weight loss or wellness program. I’ve been in more than one workplace hell bent on a getting a wellness program or biggest loser’s competition going while, at the same time their culture was hostile and stressful. For now I’d be thrilled if more workplaces treated employees with respect and supported them, and if the wellness experts would simply stop doing more harm than good.

Guest
Aug 27, 2013

Shawn, you are so right on multiple counts. At the end of the day, quality of life (at work or outside of it) is what makes us look forward to the next day and the next and the next. If the QOL is poor (as it is for far too many Americans, obese or not), the next day appears only as a burden, not a gift. Employers need to make that workplace feel like a gift and give people abundant opportunities to do for themselves (as much as they want). I suspect you and I would agree that happy, forward-looking employees will make better choices more often than not. Thanks so much for the exchange!

Guest
Science is fun
Aug 22, 2013

I wonder if the 17% difference in people who no longer felt strong armed at the end also correlated to a number of people who had been coerced into more extreme interventions, such as weight loss surgery.

If the standard calorie-deficit approach (more movement and/or less energy consumed) is only 5% effective, I suspect BCN shamed many people into WLS.

*full disclosure: speaking only anecdotally, I do know one person this happened too. I’ve wondered for awhile now how much was coercion because this person was historically very anti-weight loss industry.

Guest
Aug 22, 2013

Blue Cross seems right in line with the governmental and corporate mainstream as lately demonstrated in the NSA leaks. The powerful believe they have the right to keep us under surveillance and control our behavior. They claim this is for our own good (“health” or “safety”), but to believe that claim, we would have to trust that a) they actually care about us and b) they know what is good for us. Both of these beliefs seem extremely improbable.

Keep up the fight guys!

Guest
Science is fun
Aug 22, 2013

This is exactly what I was thinking. How convenient that we are surveilling EVERY aspect of human lives! It’s interesting that we are focusing on fat people first, but fat people are so demonized by society that most people won’t stand up for them. It’s for a fat person’s own good that they be less fat. Once it’s commonly accepted that fat people must be surveiled, when it’s time to get the thin folks on board (to keep them from becoming fat, of course), it’ll be fairly easy. Or so they hope.

Dear authors: Excellent article btw!

Guest
Joanne Ikeda
Aug 22, 2013

Great article! Makes one wonder what the Blue Cross administrators were thinking when they decided to do this. Of course it won’t work but the dunces at Blue Cross can say they are doing something (causing harm rather than good) about the OBESITY EPIDEMIC.

Guest
Aug 26, 2013

Joanne,

I also think that we should stop calling it the Obesity Epidemic. The word epidemic applies to ailments or conditions that are either spreading aggressively throughout a population or is ubiquitous (obesity clearly is neither, as 2/3 of the population is NOT obese and the rates are stabilizing). When we use the word epidemic, what we’re doing mostly is ratcheting up the rhetoric in ways that suit the interests of the obesity industry, which includes weight cycling companies, wellness vendors, researchers, and others who actually need the problem to persist because that’s how they make money.

Guest
Aug 22, 2013

Sandy – though I hesitate to compare this stuff to the Nazis – being Jewish as I am – the rest of what you had to say about these programs is unfortunately close to the reality – thanks – Jon

Guest
Sandy
Aug 22, 2013

Those popularized “cardiometric measures” you mention are just as unscientific, mathematically berefit proxies for health as BMI.
They are primarily associated with aging, as well as genetics, socio-economic stresses, etc. This is just the latest and
currently politically correct way to discriminate against those who our culture views as undesirable and less valuable to society….
the aging, sick, fat, disabled, unborn, innocent and frail.
The notion that any healthcare professional or credible patient advocacy group would advocate any behavioral or dietary
mandates to save healthcare costs or prevent diseases of aging is a very slippery, discriminatoryand harmful slope. Not to
mention scientifically unsupportable.These “wellness” programs are riffe with pseudoscience. Their real purpose is to make
vast amounts of profit for the insurance companies (follow the money with testing labs, diets, pharmaceuticals and exercise
programs), not in any real ability to prevent chronic diseases of aging. Their even larger purpose is government control over
citizens. The parallels to the old Nazi healthy and fit bodies campaigns are so close, they’ve become indistinguishable.