Mayo’s Incentive and Obesity Study: Overplayed, Undisclosed, or Undermined?

The Mayo Clinic announced yesterday a study showing that “financial incentives help weight loss study participants drop pounds, stick with program.” The study will be presented tomorrow at the American College of Cardiology conference in San Francisco. The findings are already attracting more than their fair share of media attention, but [spoiler alert!] there may be more to this story than meets the eye.

Mayo’s news release describes the study design: “All [100] participants were given a goal of losing 4 pounds per month up to a predetermined goal weight. Participants were weighed monthly for one year… Participants in the incentive groups who met their goals received $20 per month, while those who failed to meet their targets paid $20 each month into a bonus pool. Participants in both incentive groups who completed the study were eligible to win the pool by lottery.”

Study subjects were Mayo Clinic employees. 62% of the incentivized participants completed the program, compared to only 26% of the unincentivized participants.  Participants receiving incentives lost an average of 9.08 pounds, compared with 2.34 pounds for those not receiving incentives.

This is a small study, but it sure paints a rosy picture of incentives. It will be interesting to learn the details from tomorrow’s presentation.

Will the presentation acknowledge that, while it seems inevitable that overweight people are more likely to stick with a program and achieve weight loss goals if they’re paid to do so, previous research has demonstrated the potential undermining effect of lifestyle incentives. As a result of the undermining effect, incentivized weight loss participants may be more likely to regain weight after the cash stops rolling in.

And we can only hope that, when the Mayo study is publicized more broadly, its pitchmen appropriately disclose that the study’s lead author is the scientific advisor and reportedly a stock holder of GymPact, the mobile app that promises to “incentivize your exercise.”

Karoshi: Death by Overwork in Japan

Karoshi -- Japanese "salary men" work late into the night before clocking out

As American managers puzzle over how to help employees “thrive” at work, Japan struggles at the other end of the spectrum — how to keep employees from working themselves to death. Karoshi, literally translated as “death from overwork,” is an officially recognized cause-of-death in Japan. In the United States, one of the few countries where employees work more paid hours than Japanese employees, we commonly think of karoshi as someone else’s problem. But is it?

Karoshi is a well known phenomenon in Japan, where victims commonly work 14-hour days, seven-day weeks and die at an early age. Some karoshi victims have been known to work 80 straight days and more than 100 hours of overtime for months at a time. This brutal regimen is rooted in a culture that reveres hard work and self-sacrifice, as well as a 1980′s economic boom that drove demands for productivity, followed by a grueling economic recession that led to deep-seated job insecurity ever since. A 2004 International Labour Organization survey revealed that more than six million Japanese were working an average of more than 60 hours per week.

The first documented case of karoshi occurred in 1969, reportedly when a 29-year-old married man working in the shipping department of Japan’s largest newspaper died suddenly of stroke while at work. The Workers Compensation Bureau of Japan’s Ministry of Labor eventually deemed shift work and overwork as the causes of the death. Five years later, the man’s family received compensation.

In subsequent years, karoshi became an increasingly known phenomenon in Japan, predominantly among white collar workers known as “salary men.” The direct medical causes of karoshi were usually heart attack and stroke. A variation of the phenomenon is karo jisatsu, suicide due to overwork. (Suicide is believed to be underreported due to its stigma in Japanese culture, but in 2009 Japan’s national police agency estimated that 10,000 suicides, of the total 30,000 occurrences in Japan that year, were related to work.)

Tetsunojo Uehata, the medical authority who coined the term, defined karoshi as a “condition in which psychologically unsound work processes are allowed to continue in a way that disrupts the worker’s normal life rhythms, leading to a buildup of fatigue in the body and accompanied by a worsening of preexistent high blood pressure and a hardening of the arteries, finally resulting in a fatal breakdown.” More specifically, karoshi is linked to crushing workloads, relentless hours, absence of work/life balance, and silent suffering with no outlet to express dissatisfaction and no influence over work conditions.

In 1994, the government’s Institute of Economics estimated the number of karoshi deaths at around 1,000 or 5 percent of all deaths from cerebrovascular and cardiovascular disease in the 25 to 59 age group.

Some researchers have drawn a connection between the Japanese prevalence of karoshi and the nation’s commitment to lean production, the efficiency-above-all else approach to manufacturing that ultimately helped spawn the Lean Six Sigma approach that has taken American industry, especially healthcare, by storm.

One of the most notorious cases of karoshi occurred in 2002, when Kenichi Uchino, a 30-year-old manager of quality control at Toyota, collapsed dead at 4am — at work — having perservered more than 80 hours of overtime each month for the previous six months. Toyota and the Japanese government refused to compensate Uchino’s family, arguing that much of the overtime was voluntary and unpaid. Japanese courts didn’t buy it, and the family was compensated by both the government and Toyota. (Compensation for karoshi has been reported to frequently be the equivalent of $20,000 per year and up to $1 million dollars in punitive damages). The case led to systematic reform — new government regulations limiting overtime and promoting work-life balance, and corporate reforms, as well.

According to an insightful article by British journalist Emma Holmqvist

In response to mounting pressure, many Japanese companies are now making an effort to establish a better work-life balance… Toyota has upped its game, and has attempted to limit overtime to 360 hours a year, which amounts to about 30 hours monthly. Meanwhile, some companies run recorded announcements to urge their staff to go home or take a break at certain times, while firms such as Nissan have introduced telecommuting to ease the burden of employees with children. Taking the overtime issue more seriously still, a string of large corporations have begun operating with days strictly prohibiting overtime, requiring staff to leave the office promptly at 5:30pm.

But the extent to which these changes have influenced rates of karoshi is unclear. Widespread reports suggest that Japanese workers continue to work exorbitant overtime hours — off the books (“cloaked overtime” or furoshiki). And cases of overwork leading to non-disabling illness and to neglected health are not tracked. Indeed, the nature of the culture is that even true cases of karoshi, for which victims’ families can be compensated, are not likely to be reported. Some have speculated that the reigning issue has shifted — from prevalent work-related stroke and heart attack to a greater prevalence of work-related suicide.

Does karoshi exist in the United States, one of the few industrialized nations where employees work more reported hours than Japanese employees (though it’s believed that the Japanese tip the scales with cloaked overtime)? Some writers have drawn comparisons, such as Matthew Reiss writing on American Karoshi in the New Internationalist, and a Bostinno.com post called Karoshi: How Chronic Long Hours May Kill, And How Startup Life May Point to the Future.

American culture differs from Japan’s. In the United States, individualism reigns supreme. And the U.S. tradition of organized labor and workplace regulation reflects a different attitude toward the employee/employer relationship. Perhaps the difference in Japanese and American approaches to karoshi can best be illustrated with this observation: Whereas Japan has been criticized for sweeping karoshi under the rug, the U.S. has given karoshi little attention beyond one company’s development and the subsequent popularization of the video game “Karoshi: Suicide Salaryman.”

When it comes to employment and health, are Americans having strokes and heart attacks — or committing suicide — after suffering in silence under crushing workloads?  Or is something else at work? We’ll get to that in an upcoming post.

Pedometer Programs: 10,000-Steps-Per-Day or Individualized Goals?

I don’t advise pedometer program participants to strive for 10,000 steps per day.Pedometer 10,000 Steps
Having each individual aspire to an identical goal flies in the face of everything I’ve learned — or is it assumed?– about behavioral change. But participants have heard the 10,000-step mantra, and sometimes adopt it as a goal. Ultimately, many report getting discouraged when they clip on their pedometers and realize they only walk a baseline of 2,000 or 3,000 steps per day, at which point a 10,000-step goal can be a real motivation crusher.

Where did this 10,000-step goal come from? What are the alternatives? And what’s been shown to work? Pedometer programs are reasonably effective, but solving these mysteries may lead to Continue reading

“Shocking” Obesity Myths, Presumptions, Facts, and Financial Disclosures

Today’s issue of the New England Journal of Medicine features an article called Myths, Presumptions, and Facts about Obesity. The article has caused a stir in the media, prompting headlines like, “Shocking Dieting and Obesity Myths of 2013 Exposed by NEJM,” ”7 Big Fat Lies about Weight Loss,” and “7 Obesity Myths Shattered.”

Myths about Obesity

Some of the myths — beliefs commonly and fervently held (and perpetuated by both journalists and scientists), despite evidence to the contrary — include things like: Continue reading

Thinking Again About Today’s Report On Preventive Health and Costs

This morning, Reuters published an article titled “Think preventive medicine will save money? Think again.” The news story, already published in numerous outlets and currently flashing across the social web, revolves around a report released today by the Trust for America’s Health, a non-profit, reportedly non-partisan think-tank. According to the Trust, the report, A Healthier America 2013: Strategies to Move from Sick Care to Health Care in Four Years, ”provides high-impact recommendations to prioritize prevention and improve the health of Americans.”

Specifically, the Trust report states, “prevention is the most effective, common-sense way to improve health and reduce health care costs in the United States.”

If the Trust is making news with its preventive approach to reducing health care costs, why is the focus of the ensuing media buzz to “think again” about whether the construct works? Continue reading

Counting on Pedometers for Workplace Wellness

The first pedometer illustrations by Leonardo da Vinci.

The first pedometer illustrations were done in the 15th century by Leonardo da Vinci.

With all the chatter these days about whiz-bang innovations in employee wellness — mobile apps, body sensors, social media, and such — overshadowed is the lowly pedometer program. But why? I’d venture to guess that most employers running robust wellness programs, and even smaller employers just getting started, are offering some sort of pedometer-based program.

What are we to make of these programs, in which employees — usually in teams —  wear a pedometer for several weeks and record the total number of steps they take each day? Are they little more than the minor league of more hi-tech solutions? Continue reading

If Wellness Doesn’t Reduce Health Costs, Why Do It?

[The following is adapted from a comment I wrote in an online dialog with Al Lewis, author of Why Nobody Believes the Numbers: Distinguishing Fact from Fiction in Population Health Management. The original comment appeared in the Yahoo Wellness Managers Group -- the granddaddy of online communities for employee wellness managers.]

The most optimistic thing I can say about employee wellness return-on-investment (ROI) is that it may be possible. But, as I illustrated in my previous post, it’s certainly not common or likely. The question is: Does this matter? Continue reading