Alabama 'Obesity Penalty' Stirs Debate

WebMD has a good story on Alabama's plan to do BMI (body mass index) screenings on state employees and require those classified as obese to pay an additional $25 per month on their health insurance-- a so-called "fat tax."

Count Dr Jeffrey Levi, executive director of the Trust for America's Health, as an opponent of the state's plan. "Just addressing this through the health care system is insufficient. What are we doing about the workplace environment? What's served in state cafeterias and hospitals? We need to do the voluntary things first for people to be able to make healthy choices before forcing punitive measures."

How punitive is the new measure? "Even with a $25 monthly bill, Alabama state workers boast a plum health care plan," notes the article. "Single state employees pay no insurance fees, [Deborah] Unger [clinical director for the Alabama State Employees Insurance Board] says, while family plans -- which can include a spouse and several children -- only cost $180 per month. Spouses and children of state workers will not be subject to the wellness screenings."

The implicit assumption behind the new program is that obesity correlates with poor health, which in turn correlates with higher health care costs. But, asks WebMD, "does thin and trim always equal fit and healthy?" Not necessarily. Citing a recently-published study on cardiometabolic risk factors and weight (which I noted in a previous post), WebMD concludes: "Lifestyle and activity levels certainly vary between individuals, but the link between weight and health doesn't appear to be absolute. And unlike many conditions which remain discrete, obesity is on full display."

So, the debate over Alabama's "fat tax" encapsulates two larger issues that invariably get raised in any discussion of ways to improve people's health (and thereby bring down costs of the healthcare system): first, whether a recommended intervention approach is adequately grounded in findings of empirical research; and second, what kinds of incentives are most effective at getting people to change their behaviors. These are two issues that I hope to be looking at in more detail over the next few months.

fat can be fit?

Yesterday's Washington Post carried an article about a recently-published analysis of data captured by the 1994-2000 National Health and Nutrition Examination Surveys (NHANES) which concluded, basically, that a) a lot of fat people are fit and b) a lot of thin people aren't. (Yes, I know, that's a crude way of saying "Among US adults, there is a high prevalence of clustering of cardiometabolic abnormalities among normal-weight individuals and a high prevalence of overweight and obese individuals who are metabolically healthy.)

This comes shortly after studies by researchers from Michigan State University and Hope College "with findings tending to refute commonly held stereotypes about the personality traits of overweight employees" (those stereotypes being that overweight job applicants and employees are "less conscientiousness, less agreeable, less emotionally stable, and less extraverted than their "normal-weight" counterparts").

Are we starting to see a reassessment of the conventional wisdom of the last five to ten years regarding obesity (i.e., it's a major public health menace and must be fought with vigor on several fronts)? Or are these just some random research artifacts?

Habits- Alexander Technique

This past weekend, I attended a free introductory lecture on the Alexander Technique (A.T.) given by a delightful young couple who have been certified to teach the technique. I won't go into detail as to what drew me to the lecture-- other than to say that a) I've had life-long issues with poor posture and body mechanics, and at my current stage in life (late 50's) they're getting harder and harder to ignore, and b) unlike other "alternative therapies" such as yoga, reiki, etc, the A.T. tends to take a more cerebral approach, which I personally find more appealing. Towards the end of the lecture (which also included a hands-on demonstration of A.T. training), I had a little mini-insight.

That insight had to do with habits: Habits are the things we do unconsciously. They can be good or bad. You don't change habits so much as you un-learn old (or bad) habits and replace them with new (or good) ones. To un-learn ("break") habits, you first have to become aware of them. This requires consciously stepping outside of yourself and being able to see yourself from that perspective. You then have understand why you do what it is you're doing, and then based on that information consciously stop doing it. But that's not enough: You have to introduce the new habit. And there, you reverse the process: You begin with a series of conscious actions and you repeat them until they become unconscious.

(Yeah, I know-- this is nothing more than the Lewin model of change, applied on the personal level. But I finally "got" it!)

I mentioned this to the teacher, and he smiled and then pulled a framed quote from the wall, and then began to read the quote. It was from a 1918 book by F. M. Alexander, the originator of the Alexander Technique (Man's Supreme Inheritance: Conscious Guidance and Control in relation to Human Evolution in Civilization; see Google Books for more-- and note, btw, that the introduction was written by John Dewey):

Thus it will be seen that the difference between the new habit and the old is that the old was our master and ruled us, whilst the new is our servant ready to carry out our lightest wish without question, though always working quietly and unobtrusively on our behalf in accordance with the most recent orders given.

Nicely put.

Seven Habits of Healthy People

When I saw this press release announcing the launch of The 7 Habits of Healthy People, a new employee wellness program that's the result of a partnership between Inspire Health and Franklin Covey, I thought "of course-- you could see this coming." I have to confess being ignorant about Inspire Health (at least until now), but Franklin Covey-- well, there's a marquee brand in the world of mainstream, business-oriented self-improvement resources. Given that, along with Dr Covey's Seventh Habit (Sharpen the Saw)-- with its emphasis on balanced self-renewal, including staying in good health-- and along with the heightened emphasis in recent years on employee wellness programs, it makes sense to see a 7 Habits of Healthy People program being offered.

So what are those seven habits? Well, the partners are being coy here. The press release directs you to a page on Inspire's website. Once you get there, you can click through to a video advertised as "Hear from Dr. Stephen Covey how living The 7 Habits can change your life." But the video is quite short (a minute or two at the most) and-- how can I say this without sounding snarky?-- full of generalized bromides about habits, character, and destiny-- but with no hint as to what the 7 Habits of Healthy People might be. You're also invited on Inspire's web page to "print our sales sheet," which I did-- and it, too, was very general and gave no clue as to what the 7 Habits of Healthy People might be.

OK, I guess they want to discourage frivolous browsers, the type of people who go into the bookstore and leaf through the books, noting whatever it is they want to note, and walk out not having made a purchase (or then go to the library to check it out). Fair enough.

But now I've got my curiosity piqued. What are those key habits and behaviors that, if I adopt them, will make me healthy? So I did a quick search to find references to "seven habits" and "healthy people" and, looking at only the first couple (after throwing out the ones that referred to press releases for this particular venture-- and there were a lot of those, btw), I came up with some interesting findings.

There was this article entitled "The 7 Habits of Highly Healthy People" posted in February 2007. The author, Adrian Adams, writes about these seven habits:

1. get regular exercise
2. drink water
3. eat right
4. take supplements
5. get a good amount of sleep each night
6. practice good hygiene (ncluding good oral hygiene)
7. have a good attitude

Another article, with a publication date of May 2007 references a "new" (actually, if you follow their link, you'll find it dates back to 2000, if not earlier) study by the UCLA School of Public Health which found a correlation between lower mortality (and lower rates of disability) and these seven health habits:

1. Don't smoke.
2. Drink moderately or don't drink at all.
3. Get a good night's sleep of seven or eight hours.
4. Exercise 30 minutes at a time, several times a week.
5. Eat moderately to maintain weight in relation to height.
6. Eat regularly, whether that's two meals a day, three or five.
7. Eat breakfast every day.

A June 2007 post with the title "7 Habits of Healthy People" offers the following "Seven Habits for Living Longer":

1. Water
2. Oxygen
3. Food
4. Spinal Balance
5. Exercise
6. Positive Thoughts
7. Rest

And then there's this July 2007 article on "The 7 Habits of Thin (Healthy) People." (Hmmm... "Thin" = "Healthy" .... I guess the author doesn't agree with this crowd.) What are they?

1. Carbs: know good from bad
2. Fat: ditto
3. Nutrition counts
4. Portions
5. Water
6. Exercise
7. Hormone balance

Finally, there's an actual book (imagine that! people still write books, not just blog posts) with the title 7 Habits of Highly Healthy People. Published in June of 2007, it's attained an Amazon sales rank of 704,980 (not exactly generating many royalties for its author, Curry Pikkaert, but given his bio and the book description-- the author pastors a Reformed Church in western Michigan and his book has a distinctly Christian emphasis-- it's safe to guess that he was motivated to write the book by something other than money). Unfortunately, you can't browse inside the book (nice feature that Amazon offers, btw) so here, too, you're left guessing as to what those 7 Habits might be.

But wait: There's a clue. "If there are 7 basic deadly sins," we read in the Product Description, "are there not also 7 basic life-producing virtues?" And further on, we read: "Since the object of our focus is what most frequently influences us, it is important to focus on the development of the habits that produce the 7 virtues." Aha! So the 7 Habits of Healthy People are probably linked to the 7 Contrary Virtues, i.e. those virtues that you cultivate in order to avoid falling prey to the 7 Deadly Sins (that is, you would cultivate humility to keep from falling into pride, kindness to keep from envy, abstinence to keep from gluttony, chastity to keep from lust, patience to keep from anger, liberality to keep from greed, and diligence to keep from sloth). In other words (my version here):

1. don't let things go to your head
2. be nice
3. go on periodic fasts
4. take cold showers
5. when someone pushes your buttons, count to ten before responding
6. share your stuff
7. have plenty of constructive hobbies

OK, readers, now it's your turn. What do you see as the seven habits of healthy people? (And btw, if you happen to have insight into what Franklin Covey & Inspire's list looks like, please let me know.)