Improving Engagement in Employer-Sponsored Weight Management Programs

Bruce W. Sherman, MD, and Carol Addy, MD, MMSc

As an important focus for healthcare cost management, employers have been expanding their efforts to address unhealthy lifestyle behaviors as a substantial contributor. Although outcomes-based wellness incentives have been widely embraced as a means to foster individual engagement in healthier lifestyle activities, the value of this practice remains questionable for most employers, particularly when it comes to weight management. With employee engagement cited as the greatest challenge by 58% of employers,1 and nearly half of companies having weight management program participation rates of less than 10%,2 the principal question remains: What can be done to facilitate greater employee engagement in employer-provided weight management initiatives?

One reason for poor employee engagement may be that employers are excessively focused on healthcare cost containment, to the detriment of individual well-being. To this end, benefit design strategies have increasingly embraced high deductible plans as a means to address near-term employer financial pressures,1,3 obliging individuals to accept greater responsibility for healthcare consumerism. We postulate that one unanticipated consequence of this action is to shift healthcare purchasing—not health—to become a greater individual concern. The result is that individuals are now experiencing greater stress related to personal financial concerns,4 often in association with healthcare costs. In fact, medical debt is the most common reason for personal bankruptcy filings.5

In 1945, the World Health Organization disseminated a broad-based definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”6 In this context, any stressors experienced by individuals may be considered as “symptoms” of suboptimal health. Accordingly, employer focus on physical health concerns that may be asymptomatic—despite work, relationship, and financial stressors—warrant consideration as a focus for intervention. Admittedly, although these nonphysical health concerns may generate few, if any, healthcare costs, work performance may still suffer.7 Additionally, despite growing recognition of the business value of a healthy workforce, the current “siloed” approach to medical cost containment, through directed focus on physical health issues, minimizes the significance of other elements of well-being and their contribution to a more broad-based approach to health. As such, discounting or overlooking individuals’ symptoms due to stressors experienced in other well-being domains may have an important consequence.

Individuals tend to give their attention to life stressors, which are likely to represent a greater priority relative to the adoption of healthy lifestyle behaviors. Although individuals with obesity may be cognizant of few, if any, weight-related symptoms or associated health risk factors, they may instead be preoccupied by other life concerns. As a result, focusing on meaningful weight management may well be a low personal priority, causing individuals to be unwilling to engage in beneficial lifestyle-based initiatives. Moreover, these individuals may also perceive little support from their employer for their other, more personally impactful concerns, and feel resentful for the employer’s focus on lifestyle behaviors.8,9 Unfortunately—and almost paradoxically—the failure of employers to appreciate and provide support for workforce well-being issues, coupled with limited employee life skills, may result in even greater challenges for long-term weight management for many individuals, particularly those who are inclined to default to unhealthy eating and sedentary behaviors as coping mechanisms.

Many employers espouse integrated approaches to weight management, including lifestyle behavior change programs, prescription medications, and bariatric surgery, which may prove to be successful in achieving short-term weight loss; however, the greatest value can only be realized through approaches that achieve long-term weight management. Meaningful engagement is critical to achieving and maintaining healthy weight in the workforce over the long haul; for that reason, we propose that focusing on more effective and broad-based attention to individual well-being as a whole, rather than only on weight management, as one element of physical health, is a more fundamental component to achieving long-term success. Summarized below, recent research literature provides a conceptual basis in support of our hypothesis.

Concurrent and effective management of patients’ social issues has been shown to improve clinical outcomes,10 ostensibly by addressing barriers to compliance, as well as building trusting relationships.11,12 Participation and outcomes in existing weight management programs have not been particularly impactful, given that the current clinical focus on personal health in general—and weight management, in particular—typically fails to incorporate personal priorities and stressors that may assume greater individual priority. In support, a 2014 National Business Group on Health/The Futures Company/Aon consumer survey revealed that financial stress was the most prevalent concern, followed by work-related issues, relationship issues, and then family health issues. Personal health concerns ranked ninth on the priority list.4

Further, employers may be substantially (and unknowingly) contributing to these stressors. According to a recent Gallup survey, only 12% of employee respondents feel that employers support their well-being, with the vast majority of employees seeing their job as a detriment to overall well-being.13 Compounding the issue, is that in contrast to the growing focus on healthcare consumerism and employer-provided resources, most employers have failed to effectively promote access to resources to address individual well-being concerns unrelated to physical health. The current emphasis on healthcare costs—to the detriment of other well-being concerns—may result in a less than desirable overall impact. Individuals who are thriving in physical health only, versus thriving in all domains of well-being, have more health-related lost work time, a greater likelihood of a work-related injury, and are more likely to leave their employer for another position.13 Employer attention to multiple workforce well-being domains can have important and measurable business consequences.

These findings suggest that workforce well-being is a consideration that few employers appear to systematically and comprehensively support. Effective attention to personal “symptoms,” whether physical, emotional, financial, or work-related, may clear the path for individuals to address other, lower-priority personal concerns, including weight management. In addition to adopting a thoughtful approach to weight management offerings, employers may want to begin by identifying and addressing the primary issues generating employee stress. For example, if work stress is a major concern, it is also likely having consequences on physical health, as well as work productivity.

In recent years, employers have embraced primarily reactive tactics to address identified health issues. For most, incentives have been an administratively straightforward option, with employers embracing increasingly greater dollar amounts to achieve desired outcomes.14 However, the longer-term impact of financial incentives for behavior-based programs, such as smoking cessation and weight management, has been limited.15,16 This may in part be due to the need for sustained participant commitment to these programs, along with competing individual priorities that may detract from meaningful and sustained lifestyle change.

Learnings from evolving behavior change incentives research may have relevance for employer weight management programs. For example, Halperin et al evaluated different incentive approaches to employee smoking cessation, showing that loss aversion and pre-commitment attracted substantially fewer individuals than a rewards-based approach, but long-term smoking cessation numbers were no different between the study groups.17 Patel et al evaluated the impact of immediate, delayed, and lottery-based incentives on weight loss outcomes, with results revealing no significant differences in weight loss among the different study groups, including the control arm.18 Insights from these and other studies applied to weight management ultimately may improve both participation rates and outcomes. Until such time that additional guidance is available, employers are likely to be better served by proactively taking into consideration the bigger picture of employee well-being, with the acknowledgement that physical health is only one consideration. Promotion of employee well-being is a responsibility that must be acknowledged and shared by both the employer and the individual in order to reap longer term benefits.

Employee well-being must be driven by a supportive and sustainable culture that is actively endorsed by the most senior leaders within an organization. Establishing this culture provides a sense of leadership competence, credibility, and commitment to employees, and serves as the “road map” for dissemination of fully aligned policies, procedures, and communications. As an example, providing educational materials, tools, and programs to employees as part of a transparent and well-conceived strategy with an overarching objective of achieving employee well-being, is far more likely to drive engagement as opposed to tossing a health promotion activity “over the fence”—a tactical approach that may appear to employees, at best, as an afterthought, and at worst, a conflicting or misaligned initiative. Such a tactical approach likely limits participation, due to employees feeling that their employer is telling them what to do, or that their employer is primarily motivated by cost savings. In contrast, alignment of individual and organizational priorities reinforces a sense of shared accountability and a common goal—the well-being of the workforce as a facilitator of enhanced business performance.

In a similar vein, for health plans and other healthcare delivery system stakeholders, incorporation of individual well-being considerations into patient interactions may have substantial implications. Low engagement rates in chronic condition management programs may at least, in part, be associated with what has traditionally been a primarily clinical focus on the closure of gaps in care and patient compliance with provided treatment. Although not a panacea, patient–clinician connectedness is associated with improved treatment compliance11 and greater medication adherence.19 Admittedly, while individual well-being may not be at the nexus of these findings, it undoubtedly plays an appreciable role.

As with patient–provider interactions in the clinical space, employers may want to consider reframing their weight management efforts in the context of a broader and longer-term well-being strategy. For example, biometric data may highlight the opportunity for effective weight management initiatives at the population level. Cross-tabulation data may provide additional insight into population-level factors associated with high BMI and inform employer opportunities to address identified concerns. Further, aggregate health risk assessment or other employee survey data may reveal opportunities for organization-level changes regarding workplace policies, practices, or other sources of stress that may serve as barriers to employee engagement in health-related offerings, including weight management programs. Instead of amalgamating a series of “quick fix” tactics into an ineffective “solution,” employers may be wise to establish a broader framework that highlights an overarching and long-term commitment to workforce well-being and that seeks to identify and address the barriers to achieving this objective.

There is a substantial gap in the current employer approach to weight management that overlooks nonclinical “symptoms” related to well-being issues, many of which are not physical health concerns. A growing research literature base offers support for incorporating well-being considerations as a means to improve the effectiveness of individual engagement in existing health management efforts, including weight management. Accordingly, employers, plan sponsors, or other entities with weight management programs may want to ensure that resources are available to effectively address personal well-being priorities more broadly rather than limiting focus to physical health concerns. By so doing, they may clear the path for greater individual engagement in available weight management offerings, and realize greater value from their investments in these programs.

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