Weight Maven

Did you see this news item? Whole Foods is planning to give incentives — in their case, store discounts — to workers who meet certain health measures.

I am of very mixed mind on this issue. On the face of it, encouraging healthy behaviors seems like a great idea. Yet the deeper you look at it, the more that you see that there are questions about these kinds of incentives — especially when they are tied to the workplace. Unfortunately, the rising cost of health care (and our Congress’ inability to do anything about it) means that we’re very likely to see more of these programs.

Paul Campos, author of The Obesity Myth, is not a fan.

Campos on Whole Foods

Campos makes the point that lower BMIs aren’t necessarily good proxies for health:

In terms of BMI, the Whole Foods discounts correlate with increasing mortality risk. The most sophisticated study on this subject, published in 2005 in JAMA by Katherine Flegal et. al., … found 86,000 excess deaths per year in the United States associated with “normal” weight when compared to the mortality risk among people with BMIs in the 25-29.9 range.

You’re reading that right: Whole Foods’ employee discounts based on weight are inversely related to mortality risk. So you have a policy that’s not merely discriminatory on its face, but completely irrational on its own terms.

Now, there are issues with the mortality risk and low BMI. Some argue that the risk from low BMI is due to smoking and diseases like type 1 diabetes and cancer, and thus, being slightly overweight doesn’t provide the protection that some studies appear to show. (Campos claims that the research he cites (PDF) does control for smoking and pre-existing conditions.)

Whether or not some extra weight is protective, it is certainly the case that the Whole Foods program penalizes one group (the overweight), while apparently rewarding non-overweight people with behaviors that presumably increase mortality risk and health care costs (eating disordered individuals, people who abuse drugs or alcohol) and those 30 million or so who can be categorized as normal weight obese.

Campos also points out that it’s a questionable policy to make the people who supposedly need healthy food pay more. And he sees the irony as well:

All this is a classic example how the habitus of upper class people in America ends up getting projected onto the broader culture, under the rubric of “a healthy lifestyle.” It’s also an example of how healthism and junk science are powerful weapons in the fight to avoid that most dreaded thing, a fair and efficient health care system for all Americans. Few myths in that fight are more pernicious than the idea that if you get sick it’s your fault, because you didn’t make healthy choices, such as searing that Ahi tuna you bought at Whole Foods after lightly coating it in $30 a bottle olive oil.

Other programs, similar questions

Safeway was recently touted for their incentive plan, though it turns out that the success of the program was not quite what it seemed:

Rewarding or penalizing people based on wellness tests may save money over the long run, but Safeway hasn’t proved it. … a review of Safeway documents and interviews with company officials show that the company did not keep health-care costs flat for four years. Those costs did drop in 2006 — by 12.5 percent. That was when the company overhauled its benefits, according to Safeway Senior Vice President Ken Shachmut.

The decline did not have anything to do with tying employees’ premiums to test results. That element of Safeway’s benefits plan was not implemented until 2009, Shachmut said.

And Sandy at Junkfood Science makes a good case that what appears to be a wellness incentive may well be good old fashioned discrimination:

Ideal health risk indices — from BMI, blood pressure, blood sugars to cholesterol — are mostly euphemisms for thin and young. Those who believe that their own good health is because they eat “right,” exercise and have perfect numbers are often young and upper-income and not old enough to experience age-related changes. Their genetic good fortune is not evidence of good behavior, either. Evidence-based research to date has shown these health indices are primarily measures of aging, genetics and social stresses, and not significantly malleable with “healthful” diets and lifestyles. With aging, the “ideal” numbers of healthy 20-year olds cannot be achieved for most workers without taking controversial and risky prescription drugs or temporarily lowered by undergoing mostly ineffective weight loss measures.

This is very problematic IMO (especially with the recent SCOTUS decision on corporate political donations). It’s a cynical view to be sure, but there is a curious relationship between the food, health care, diet and pharmaceutical industries. I’m not sure they all want to see everyone get the “personal responsibility” religion!

Carrot? Or stick?

As if we could anyways. A recent NEJM article points out some of the problems with this. Achieving good health measures is not the same as avoiding speeding tickets:

If people could lose weight, stop smoking, or reduce cholesterol simply by deciding to do so, the analogy might be appropriate. But in that case, few would have had weight, smoking, or cholesterol problems in the first place. Moreover, there is a social gradient. A law school graduate from a wealthy family who has a gym on the top floor of his condominium block is more likely to succeed in losing weight if he tries than is a teenage mother who grew up and continues to live and work odd jobs in a poor neighborhood with limited access to healthy food and exercise opportunities. And he is more likely to try.

So are health incentives carrots? Or sticks?