Obesity and the AMA, Part Two

A likely unanticipated consequence of the AMA’s decision to label obesity a disease, even though their own scientific council said not to, is that this might serve as the macguffin leading to furtherance of a protected class of people.  This has serious implications not only for employment discrimination, but also for wellness programs, which often hinge vastly overblown claims of being able to help the obese who they almost universally label as “high risk” people.

Well, what if people who are obese, who are no doubt tired of being condescended to, first by wellness companies, and now by the AMA, decide that they are going to seek medical approval to opt out of wellness programs?  A study recently published in the journal Translational Behavioral Medicine reports on a highly coercive, electronically monitored walking program for obese people: 17% opted not to participate and another 5% actually got their physician’s approval to opt out.  The physician approval to opt out is key to any resistance strategy.

Under the final wellness rules issued by the federal government earlier this year, physician certification that it is medically unadvisable for an employee to participate in a wellness program creates a burden for the employer and wellness vendor.  They must provide reasonable alternatives that do not disadvantage the employee in terms of either time or cost and that address the physician’s concerns.

Further, if the employee’s physician disagrees with offered alternative, the employer and wellness vendor must provide a second alternative.  The coup de grace is that “adverse benefit determinations based on whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program are considered to involve medical judgment and therefore are eligible for Federal external review.”

Targeting people based on body mass index (BMI) is an intellectually, morally, scientifically, and mathematically bankrupt approach.  The AMA’s decision will actually help obese people and advocates for their dignified treatment in the workplace and society start to understand that they can refuse to opt in to these insulting programs and, simultaneously, be protected from penalties.  Clearly, this is the opposite of what unsuspecting employers expect when vendors (and their own brokers) sell them these programs: more useless doctor visits, less leverage with penalties…and more employee disgruntlement.  Not just the obese will be disgruntled, but also those who have to pay the penalties because their BMI is too high to get the reward but not high enough to get a doctor’s note.

We believe that one of the most important ways for bringing the current spate of conventional workplace wellness programs to a grinding halt is for obese people to refuse to participate in them and to seek their physician’s guidance on every alternative offered to them.  After all, the most important voice in organized medicine says that they have a disease and participating in a wellness charade run, more likely than not by people with no clinical or public health expertise, is not only a danger to their health but potentially a source of embarrassment and ridicule that they cannot and should not be coerced to endure.

Employers, on the other hand, ought to engage in a different dialogue with their wellness vendors.  Ask your vendor if it calculates BMI.  If it does, ask the vendor to explain why, given the paucity of evidence that knowing BMI is in any way a proxy for health status.  Then, if you really want to help the people in your workplace who are obese, do these things for and with your people instead of to them: inventory your workplace’s entire relationship to food, everything from the treat bowls at employees’ workstations, to what’s in your vending machines, to what you serve at company-sponsored events.

Create company-wide food service guidelines even if all you have are vending machines onsite.  Bring in a registered dietitian to give workshops on healthy eating.  Work with local food retailers to develop focused couponing and discounting programs that encourage your workers to make better choices when they shop.  Bring in wellness vendors, such as Stickk (a Gold Standard company), that can help people have fun while trying to improve their health, instead feeling like they’re being dragged to the health woodshed.

But, above all else, tell your people (obese or not) that your wellness goal is not to insult them, diminish them, or make them feel sick when they aren’t.  Wellness, by any reasonable definition, should give people tools that empower them.  How much they are willing to do is ultimately up to them.

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.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.

11 replies »

  1. HI Shirie,
    So heart-warming to hear a physician talk like that. Are you familiar with Health at Every Size and the Association for Size Diversity and Health? (ASDAH) if not and if you would like to know more – feel free to contact me at robisonj@msu.edu – thanks – Jon

  2. Yup. Fat people pretty much know they’re fat. Calling it a “disease” is a cop-out, insulting, and unhelpful. All those “wellness” centers and diet companies could get a big boost, but it improves nothing for anyone.

  3. Actually Deron,
    The reality is exactly the opposite of what you believe. There is a significant and rapidly growing body of evidence that demonstrates that stigma not only does not spur people to lose weight or be healthier – but as I said does exactly the opposite – I suggest you update your review of the literature – for instance read Puhl’s work from Yale on stigma – or any of the recent research on what happens to kids when they are singled out for their weight – references available on request – of course, the idea that fat people need to be reminded they are fat by their doctor’s is ridiculous because 1) they are already pretty sure they are and 2) their doctor has nothing to offer them that won’t more than 95% of the time result in weight cycling which decreases both physiological and psychological health – and, by the way, the estimates on what “obese” people cost are based on so many estimates upon estimates as to make them relatively unintelligible – if you are really concerned about the cost of health care in this country I would suggest going after the greed (hospitals, pharmaceuticals, insurance co., etc) and over-diagnosis and over-treatment that are the the major causes – suggest reading Dr. Otis Brawley – How we do harm – and any
    of Dr. Nortin Hadler’s books. –

  4. I think the idea of an FAQ document for physicians on how to handle the machinations of their patients’ workplace wellness programs is a brilliant idea and one worth pursuing.

  5. We need to be cautious about saying the overweight or obese people (or using any other superficial descriptive label) are the essential cost drivers. What about the 25% of people who are normal weight but metabolically unhealthy (as measured by cardiometabolic markers)? Or, we could just say that all poor people are the cost drivers, because well, they’re poor and more likely to be in ill-health. Oh, wait, they’re also less likely to get care and their share of the care pie is far smaller than most people realize.

    In my experience, competent primary care providers are not reluctant to talk to their patients. The problem is that their dialogue is one of (too) many taking place. Even with all we know about the difficulty of ensuring that medicine in the community is practiced in an evidence-based manner, it is beyond ludicrous to think that employers, supported by feckless, medically ignorant wellness vendors, should enter this space at all.

  6. Obesity is a very sensitive topic, so much so that many health care providers are afraid to talk to their patients about it. As cold as this may sound, social stigma is becoming less of a motivating factor to maintain a healthy weight as a higher percentage of the population becomes obese. Our culture has become one in which we’re are so afraid to offend others, that we are not willing to hold them accountable for the role they play in driving up cost for everyone.

  7. John,
    There is actually another layer at issue here which may be a bit different from some other wellness programs. Since there is no documented efficacy for weight loss programs at the worksite (or anywhere else for that matter) – and since there is growing evidence that these programs can engender significant iatrogenic consequences – no one regardless of BMI should be engaging in them and no health professional including physicians should be recommending them to their patients. We have decades of research supporting these conclusions. If we are serious about evidence based and science based there is simply no way to justify doing this to people regardless of how much we don’t like fat or think it is unhealthy. From a business standpoint when organizations ask me if they should consider weight watchers or some other weight loss intervention I ask them what might happen if they went to their CEO about some intervention they would like the company to invest time and money in that was guaranteed to fail 95% of the time.This is, according to decades of research what they are doing if they implement weight loss programs.What the physician should say in their note is that the individual should not take part because: 1) there is less than a 5% chance that they will be successful, 2) there is a 95% chance that they will gain the weight back – which will make any related health benefits worsen and 3) their health can be improved without weight loss by involving them in programs that help them to come to peace with their bodies and their food and programs that address their well being in a non-coercive, holistic way. Anything else is scientifically and ethically indefensible. Jon

  8. I’m kinda interested in the question around the rules on physician approval. Can you tell us a little more about how this works? Is this basically a note from your doctor kind of thing? And how is the typical doctor supposed to evaluate this kind of thing with any kind of objectivity- clearly your point – what kind of scenario do you see playing out? I think you’re basically going to get the doc’s philosophical reaction to wellness programs as a whole – which is either going to be nuanced (my reaction varies) or non-nuanced. I’m for wellness. I’m against it kind of thing. Come to think of it, I’d like to see you do something like a FAQ for docs looking at the whole wellness issue.