Health and Economics of Lifestyle Medicine Strategies

Abstract

The cost of medical care in the United States is increasing at an unsustainable rate. The lifestyle medicine (LM) approach is essential to influence the root causes of the growing chronic disease burden. LM addresses health risk factors in primary, secondary, and tertiary prevention of developing disease rather than limiting resources and medical expenditures on acute care and reacting to illness, injury, and disease. Employers have much to gain financially from such an approach due to their status as the payer of health care costs for their employees, and as the recipient of productivity gains among their employees. This article discusses LM programs delivered at the worksite, including important findings from the University of Michigan Health Management Research Center. Examples of evidenced-based population LM interventions are summarized for physical activity, weight management, and nutrition programs that address chronic diseases such as cardiovascular disease, cancer, and diabetes mellitus. These approaches have the potential to reduce health care cost trends, increase employee performance/productivity, and improve patient health outcomes.

Much of the health care cost expenditures are for treating illness and little is for prevention and lifestyle medicine (LM).

Health and Economic Importance of Lifestyle Medicine

Health care spending was $3.6 trillion in 2018, representing 17.7% of the gross domestic product (GDP) or $11 172 for each person in the United States.¹ By 2027, health care spending will account for an estimated 19.4% of the GDP.² The GDP for health care spending in the United States is far greater than that of 10 of the world’s highest income countries.³ An important aspect of the Affordable Care Act was the ability for employers to offer incentives to employees participating in health and wellness initiatives to increase participation and improve health outcomes. However, by most measures, the US population is less healthy than that in other developed nations. Much of the health care cost expenditures are for treating illness and little is for prevention and lifestyle medicine (LM). Yet there is an abundance of evidence of LM’s effectiveness and the importance of behavioral health in the management of a variety of health risks and medical conditions.

LM at the Workplace

LM at the workplace has historically been provided to employees through wellness initiatives and other benefit programs offered by the employer. These programs have been well studied and are described in numerous reviews.^4-7 The early community and worksite wellness studies brought attention to the role of lifestyle in risk factors for disease and long-term survival of individuals in Framingham, MA,⁸ and Tecumseh, MI.⁹ These 2 studies supplied the basis of early wellness programming.

Wellness at the workplace grew out of the early 1970s, led by the 30 to 50 members of the Association of Fitness Directors In Business and Industry (George Pfeiffer, American Association of Fitness Directors in Business and Industry, personal correspondence). Their early focus on physical fitness and nutrition expanded, over the years, into a holistic approach to total wellness consisting of mind, body, spirit, and all the facets of life that influence one’s health, vitality, and quality-of-life. The mind-body-spirit connection combined with learnings from the Eastern philosophies, religions, medicine, and brain plasticity studies, as well as rapidly changing technologies, will continue to create future intervention initiatives for wellness and LM.

The first phase of worksite wellness research was conducted by the University of Michigan Health Management Research. It validated the Framingham data using the Tecumseh data,¹⁰ and led to defining the costs of high-risk versus low-risk individuals for each of 15 health risk factors such as smoking, blood pressure, and stress.¹¹ The next step was to justify categorizing individuals into risk groups with a low (0-2), medium (3-4), and high (5+) number of health risk factors by demonstrating that average health care costs were higher for groups with more health risks. This was subsequently confirmed by researchers and practitioners from around the world utilizing various risk factors and cut points.

The second phase of the workplace wellness studies was to show that change in costs followed a change in risks.¹² Consistent evidence showed that when participants adopted and continued healthier behaviors, their medical costs decreased, time-away-from work decreased, and they reported feeling better.¹³ One longitudinal study of employee wellness initiatives estimated a conservative return on investment (ROI) of approximately 1.5 over 5 to 6 years.¹⁴

The third phase of our workplace wellness studies was to predict who would be high-cost in the near future, knowing fully well the prediction of individual costs fluctuate after 3 or more years into the future. Using our longitudinal database, we developed a system to find the de-identified individuals most likely to develop diabetes.¹⁵ Each of the individuals in this study worked for the same company with the same health care benefits and had one or more dangerous conditions. We ranked the de-identified individuals according to their retrospective risks and health care costs, developed algorithms to estimate prospective health care costs over years 1 through 6, and then ranked the prospective data by costs and for the top 20% and lower 20% of the population. The Trend Management calculations were used to predict the associated health care costs over a 6-year period with a first year 87% success rate.¹⁶ The algorithms also identified the most critical risk factors contributing to the high costs allowing health coaches to focus on the most vulnerable risk factors.

Return on Investment

There are several published ROIs for comprehensive employer-based wellness programs. Such programs address several medical as well as mental health risk factors. Johnson & Johnson estimated the ROI for their wellness programs from $1.88 to $3.92 for each dollar invested from 2002 to 2008.¹⁷ Baicker et al reported that medical costs declined by about $3.27 for every dollar invested in wellness programs and absenteeism costs declined by about $2.73 invested in wellness programs.⁵ A wellness program at Dell Inc reported an ROI of 2.48.¹⁸ Several other studies have reported other outcomes for employers including reductions in absenteeism, decreased on the job productivity losses (“presenteeism”), and a range of ROIs.^19-21

This research identified 4 pivotal value propositions with widespread implications for LM within the workplace:

1. “Don’t get worse!”

2. “Take care of the healthy people!”²²

3. “Measure all possible outcomes!”

4. “Treat comprehensive wellness programs as a long-term (climate and culture) part of the strategy!”

Furthermore, LM must be careful to avoid underestimating the following factors:

1. The complications and complexity of health and poor health

2. The challenges in the environment of the home, workplace, and community

3. The challenges within individuals

4. The importance of shared values and shared results²³

Or overestimating the the following factors:

1. The interest levels of patients, employees, governments, or employers

2. The effectiveness of single-focused interventions

3. Our success in measuring and communicating results that matter

4. Our ability to explain the “why, what, and how” to stakeholders

A few examples of the importance of evidence-based LM are summarized below for cardiovascular disease, diabetes mellitus, and cancer.

Cardiovascular Disease (CVD)

The 2019 ACC/AHA Guidelines on the Primary Prevention of Cardiovascular Disease²⁴ recommends that adults aged 40 to 75 years be evaluated for CVD prevention before starting medications for hypertension or hyperlipidemia. Poor lifestyle choices surrounding diet, physical activity, alcohol intake, sleep, psychological stress, and smoking have clearly been associated with the development of CVD, with interventions that improve these lifestyle choices being associated with improved clinical outcomes.²⁵ There is good evidence of a dose-response relationship between physical activity levels and risk of heart disease, diabetes, and high blood pressure. Yet only 15% of adults participate in regular vigorous physical activity.²⁶

Diabetes Mellitus Programs

The prevalence of CVD is almost 2 times greater in adults with diabetes than in the general population.²⁷ For adults with type 2 diabetes mellitus, behavioral health interventions that address improving diet, tobacco cessation, and physical activity are essential to optimal control of the disease. The results of such lifestyle interventions have been associated with a lower CVD incidence and mortality in adults with diabetes.²⁸ Similarly, studies of patients with cardiometabolic conditions including diabetes and prediabetes have shown the effectiveness of interventions to increase physical activity using accelerometer- and pedometer-based interventions.²⁹

Cancer

Overweight, obesity, and tobacco use have been associated with increased risk of certain cancers. Smoking cessation and avoidance of passive smoke been associated with preventing and reducing the risk of cancers. Vernieri et al recently reviewed the status of diets and dietary supplements in the prevention and treatment of cancer.³⁰ Diets high in whole grains, fruits, and vegetables have been associated with a lower incidence of cancer. Studies of various dietary supplements to prevent cancer have not been associated with any benefits. In general, studies have confirmed the recommendations to prevent obesity, treat obesity, and encourage a healthy diet for all people. Such recommendations are made for cancer survivors to reduce the risk of secondary cancers and cancer recurrences. Lifestyle interventions that address tobacco cessation, diet, and obesity are clearly clinically important in addressing cancer.

Summary

Chronic disease is responsible for 90% of annual health care expenditures.³¹ LM serves to address the underlying causes of chronic disease, and encouraging healthy choices in the areas of sleep quality and quantity, nutrition, physical activity, misuse of alcohol and chemical substances, stress management, and preventive health services and screenings should be the top priority of the health care system. For lifestyle changes to become sustainable, they must be tailored to each individual, and to the environment (workplace, home, community) and culture. Worksite wellness programs and clinical approaches represent important aspects in addressing these challenges. LM interventions within the workplace can result in both a monetary ROI for companies and improved health for employees. Similarly, clinical interventions involving lifestyle behavior change in patients with CVD, diabetes mellitus, and cancer have led to equally important improvements in health. These represent promising approaches to help address the chronic disease epidemic and unstainable healthcare costs in the United States.