Lifestyle diseases and employee health
Sarah Silcox reports on a recent seminar that explored the impact of three major public health challenges on the workforce of tomorrow.
Are employers sitting on a public health time bomb, as increasing numbers of us drink and eat ourselves into ill health and disease? This was one of the questions asked by a recent seminar, "The impact of today's lifestyle on tomorrow's workforce", marking the first anniversary of the Centre for Psychosocial and Disability Research at Cardiff University.
The seminar, attended by employers, the medical profession, policymakers and insurers, focused on the implications of recent trends in obesity, diabetes and alcohol consumption for employers and the economy. It followed the first seminar held by the newly established centre last year, which concentrated on vocational rehabilitation and biopsychosocial aspects of sickness absence.
This year's event explored the underlying causes of epidemics in binge drinking and obesity, and what employers can do to influence the lifestyle behaviours of employees in order to modify what would otherwise be the significant impact of these behaviours on individual wellbeing and organisational productivity. It sought to explain why employers should be concerned about the growing public health problems of obesity, alcohol and type II diabetes (T2D), and to identify what needs to be done to minimise the effects of these modern conditions, which increasingly threaten the health of both western and developing workforces.
Childhood obesity and long-term risk
Childhood obesity, and its extension into adulthood, was explored by Dr David Ashton, group medical director of BMI Healthcare. We see it all around us, he said, in junk food consumption and the lack of physical exercise taken by many children. The problem is now so acute that many parents see their children's risky eating and exercise behaviours as normal and do not perceive their weight as a problem. "Even some paediatricians do not understand the issue," Ashton adds. The number of obese children between the ages of two and 15 has risen threefold since the mid-1980s, so that 16% of this group - 1 million children - are now obese. In the European Union, 400,000 children become obese every year.
Ashton presented an interesting analysis of the causes of this childhood obesity epidemic, rejecting the commonly received wisdom that TV advertising of energy-dense snacks is to blame. He rejects the findings of a major review published last year by the Food Standards Agency, suggesting that the Hastings review used only patchy evidence, obtained from a literature review, to reach its conclusion that the TV advertised diet was less healthy than the recommended one. Only two of the studies trawled by the review showed that advertising had a positive impact on calorific intake, which Ashton describes as "pretty unimpressive". In addition, where the research does show an impact, it is very small - the influence of parental behaviour on children's eating habits was 15 times that of TV advertising.
"There is no reason to think that a ban on TV advertising would lead to less obesity", he adds, citing the examples of Quebec and Sweden, where similar bans have produced no obvious effect: "For every complex problem, there is a simple solution, but it's always wrong." The current emphasis in public policy on food advertising is a "distraction", he suggests, but recognises that shifting the blame onto food companies makes good media copy, and is politically attractive as it distracts attention from other policy failings.
Food advertising is not to blame for childhood obesity, but lack of physical exercise is, Ashton argues. Despite the availability of the 1,400-calorie Big Mac plus fries, which some children eat as a "snack" on a Saturday morning shopping trip, energy intake has actually fallen in the UK since the war. Ashton claims, therefore, that the problem does not lie on the "energy in" side of the metabolic equation, but on the "energy out" side, and points to the fact that an average child now expends 600 calories less a day than 50 years ago, and that 70% of children travel to school by car, compared with only 37% in 1964.
What are the consequences of obesity for the economy and society? Ashton suggests that one tack would be to adopt the US model and simply re-engineer everything to accommodate our growing girths - shopping trolleys are getting bigger and some airlines now make larger passengers buy two seats. But obesity has profound health effects, including diabetes, gout and cardiac problems. The most important measure used by Ashton in his children's clinic is waist size, which reveals much about deep-lying fat. This fat leads to an increased resistance to insulin and other risk factors, including a lowering of "good" cholesterol, all of which combine to form the metabolic syndrome, bringing with it an increased risk of a range of circulatory and cardiac diseases.
Between 70% and 80% of obese children become obese adults, so this syndrome tracks into adult life, meaning your risk of developing all the associated health problems is higher if you have been obese as a child. Obesity also leads to psychological morbidity, including low self-esteem, poor self-image and depression. Alarmingly, half of new cases of T2D, which is usually a disease of later middle age, are now diagnosed in children. The potential economic costs of overweight and obese people are £7.4 billion, "destabilising healthcare budgets", Ashton remarks.
Obesity solutions
Individuals and their parents need to acknowledge the problem of childhood obesity - fathers are "very bad" at accepting their child is overweight, according to Ashton. Corporations and governments need to do the same, and to stop talking in euphemisms, but "face up to the problem and attack it, not disguise it". Symptomatic of the trend, he adds, was the recent decision of clothing retailer Gap to launch a new outsize range of children's clothes called "Husky" in the US, rather than offend parents by using more direct language.
Government and policymakers must stop looking for simple solutions - a disease with many causes needs multi-factorial interventions. "We need to be bold" and tackle obesity at a population level, in addition to helping individuals. The government needs to foster a no-blame approach, and to curb its obsession with sport as the solution to most people's physical activity deficit. Special funding is needed for what Ashton calls "activities for daily living" initiatives. Guided self-help, not nannying, is needed - he suggests that some people are already moving away from healthy eating in response to "constantly being told what they should eat". Nutrition for life and smart food choices should be on the national curriculum, and schools should promote physical activity in addition to sport, for example, by developing safe routes to schools - Ashton controversially suggested that the £2.4 billion planned spend on the London Olympics should be used to fulfil this aim and produce real improvements in public health.
Diabetes and the metabolic syndrome
T2D, the onset of which is often insidious,
rises with age, and up to 50% of older middle-age people in some ethnic groups
in the
Tomlinson painted a graphic picture of the scale of the problem, noting that the number of cases worldwide will double over the next 25 years, from 140 million in 2000 to 280 million by 2025. The rate of increase is also predicted to accelerate from 3.6 million new cases a year to 5 million by the end of the period. In the UK, for every known instance, there is an undiagnosed case of T2D. The causes of the condition are complex, but include obesity, a decline in physical activity and urbanisation (T2D appears to be an issue, particularly for those moving from rural to urban areas, especially when this is associated with migration, with 50% of older Asian men in the UK suffering from the condition).
Professor Stephen Tomlinson explored metabolic syndrome in more detail, describing it as a "deadly quartet" of obesity, hypertension, diabetes and dislipidaemia. The debate on the causes of the rise in T2D is often reduced to one of genetic versus environmental factors, but Tomlinson believes both play their part. For example, family history is important, accounting for between 20% and 40% of cases, but there is also evidence that low birth weight pre-programmes people for the development of metabolic syndrome, and there are also links with obesity in later life and some early-life influences.
The economic and health costs of the T2D epidemic are huge - the condition accounted for 6% of the NHS budget in 2000, and the economic costs are estimated at '2.6 billion - a figure primarily made up of GP and primary care resources, as well as the fact that those with T2D often have other health problems that need treating. Solutions are complex, but it is possible to reduce the risk of developing the condition by changing diet. Screening is also possible, but care needs to be taken in communicating the results, as frightening people is likely to be counterproductive, Tomlinson argues. There is a need to educate and engage people susceptible to T2D, and those who have already been diagnosed. The condition has major policy implications and big personal, economic and global costs, he concludes.
Binge drinking and health
Alcohol, Dr Guy Ratcliffe acknowledged in his presentation to the Cardiff seminar, has been around for a long time and is part of society. Dr Ratcliffe is medical director of the Medical Council of Alcohol (MCA), a body founded by doctors as a forum for the better understanding of alcoholism, its prevention and treatment. However, he feels its impact on health has taken a back seat compared with smoking and recreational drug use. The government published an alcohol strategy last year, which is designed to tackle binge drinking and its harmful consequences for health and crime.
Most of us drink sensibly and within guidelines, Ratcliffe said, adding that the language of sensible drinking and "units" now adorns much advertising of alcoholic products. But alcohol is a mood-altering drug, leading some drinkers to feel less inhibited, argumentative and even "punchy", so that 70% of attendees in hospital accident and emergency units on weekend nights are under the influence. The concept of a unit of alcohol should be an easy one to understand, but is not. For example, a unit in the US is bigger than one in the UK, and a unit in Australia is larger still; "and all this assumes that people want to know how many they've drunk in the first place", Ratcliffe adds. He talked about metabolism and rates of absorption and how these differ between men and women.
The health impact of alcohol is significant and, although we are not yet able to predict which groups will develop alcoholic liver disease, it is fair to say that the risk increases for men drinking six to seven units in a night, or five for women, on a regular basis over 10 to 15 years. This kind of behaviour can culminate in cirrhosis and liver failure in the worst cases and is occurring in ever-rising numbers, which has led to a trebling of the mortality rate from this condition in recent years. Cases of alcoholic liver disease are now seen in ever-younger people, and doctors are now witnessing well-developed cirrhosis in people in their early 20s.
Ratcliffe described the symptoms of dependence - including the crucial one of increasing tolerance, meaning more is needed to achieve the desired effect - as "very unhelpful". There is co-morbidity with psychiatric problems, so that 5% of those with alcohol difficulties are dependent on other drugs. There is also an association between alcohol dependency and eating disorders, and suicides in young people. Of course, evidence suggests that alcohol, and red wine in particular, can have beneficial effects on the cardiovascular system, but only at the lowest levels of intake and in people over the age of 40. Treatment for alcohol problems requires the individual to recognise that they need help, followed by supervised detoxification and abstinence. Few therapeutic drugs are available, apart from those used in the initial detoxification, drugs to block alcohol metabolism and some anti-craving drugs.
Ratcliffe noted that workplace alcohol policies have been developed by many larger employers, often as part of occupational health (OH) procedures, adding that his own organisation, the MCA, has developed guidelines for use by smaller workplaces with no OH support. Safety-critical organisations usually have clear protocols that employees are required to follow, but there is less prescription for non-safety-critical industries. Employees need to accept responsibility for their own consumption but, Ratcliffe concluded, should be able to expect an empathetic response from managers, OH and health and safety professionals at work if they have problems.
Can you make employees healthy?
Michael O'Donnell, chief medical officer of UnumProvident, sponsors of the centre, answered his own question "can you make your employees healthy?", by saying he does not know, but "we should try because it's worth it".
Many organisations claim that employees are their most valuable asset, but how many employees believe that this is the case? If employees remain to be convinced, is this because employers fail to look after people properly? O'Donnell quoted a recent survey from Employee Benefits magazine that found many employers operate support schemes such as employee assistance programmes and health promotion, but do not see these as part of an overall strategy to manage sickness absence and employee health. Employers need to demonstrate that they value employees, to stop them feeling unmotivated, going off sick, becoming less productive, committing acts of sabotage or leaving the workforce prematurely.
Employers should take sickness absence seriously, because it means they are paying people not to work and, in cases of long-term absence, losing valuable "man hours". Absence also impacts on customer service and quality and affects the morale of those left at work. The huge cost of paying incapacity benefits to 2.7 million claimants has an effect on us all. Sickness absence can also be symptomatic of other workplace problems that need fixing - as an example, O'Donnell suggested that the high rates of sickness absence among ward nurses revealed in recent research is likely to be connected with working environment and organisational culture.
Good health promotion programmes should be holistic, and need to consider all aspects of wellness and wellbeing, O'Donnell outlined. They should be designed to make work better, as well as focusing on individual lifestyles and, he adds, employers could do worse than to use the HSE stressors as a basis: "You can't argue with these." However, he does feel that the relative importance of each of the stressors used in the HSE's management standards approach to stress is more debatable. Health promotion programmes should include individual health-risk appraisals, looking at smoking behaviour and weight for example, and need to incorporate a follow-up consultation. Health education, healthy eating food options in staff restaurants with variable subsidies (for example, making it cheaper to eat a salad), and involving employees are important elements of health promotion. O'Donnell's own prescription for making work better includes introducing flexible working to enable parents to juggle responsibilities, talking to employees about what they think works and making changes accordingly, and treating staff with respect, which means banishing bullying and harassment. What about the costs of all this? "Doing nothing will cost you more than doing something," O'Donnell warns.
Summing up, the centre's director, professor Mansel Aylward, returned to the psychosocial aspects in the seminar's programme - principally the role that behavioural factors play in getting us all to acknowledge and tackle public health issues like obesity and alcoholism. For example, getting parents to accept their child has a weight problem, or self-acknowledgement in the case of a worker with alcohol problems, are both vital for improvements in public health.
There is also a psychosocial issue inherent in communicating the risks of these public health challenges to people, Aylward believes. There is a need to engage with people about what they think and provide them with relevant information, rather than treat them as passive subjects - we used to have a public health "observatory", now we talk about public health "intelligence", he remarked. These health messages need to be simple - one excellent example is the modern message on the management of back pain developed by Professor Gordon Waddell and colleagues, which has done much to change GP and patient understanding and behaviours.
