This document discusses improving community well-being through individual and environmental factors. It provides examples of research showing relationships between well-being, health outcomes, costs and productivity. The author advocates applying principles from "Blue Zones" to create employer communities with high well-being, engagement and economic/social progress through natural movement, purpose, social connection, healthy eating and more. Specific steps are outlined to assess opportunities and implement strategies over 12-24 months through leadership, policies, communications and participation.

1. Activating Your Community for Well-Being Ben Leedle, Chief Executive Officer, Healthways Inc.

2. The Problem… and a Solution Source: Centers for Diseases Control and Prevention, University of California at San Francisco, Institute for the Future. Reprinted from Advances, Robert Wood Johnson Quarterly Newsletter, 2000; 1:1 Influencers of Health Access to Care Environment Genetics Health Behaviors Health Behaviors U.S. Healthcare Expenditures 88% Other Access to Care (treatment) 4% 8% 10% 20% 20% 50% 22

5. Individuals ● Experts ● Environments ● Relationships Improve Well-Being

7. Well-Being at the National Level Source: Gallup-Healthways Well-Being Index Community Survey 2009, n=353,849 2009 2008 Fourth Quintile Third Quintile Second Quintile Top Quintile Ranking: Bottom Quintile

8. Well-Being at the Regional Level 199 200 173 174 Des Moines Cedar Rapids Mason City Davenport Pierre Sioux Falls Rapid City Fourth Quintile Third Quintile Second Quintile Top Quintile Ranking: Bottom Quintile 295 241 South Dakota Iowa 2008 Congressional District Ranking by Well-Being Index (out of 436 Districts) Source: Gallup-Healthways Well-Being Index Community Survey 2008, n=352,549

9. Well-Being at the Regional Level 40 50 133 66 Des Moines Cedar Rapids Mason City Davenport Pierre Sioux Falls Rapid City Fourth Quintile Third Quintile Second Quintile Top Quintile Ranking: Bottom Quintile 156 194 2009 Congressional District Ranking by Well-Being Index (out of 436 Districts) South Dakota Iowa Improvement by one quintile from 2008 to 2009 Source: Gallup-Healthways Well-Being Index Community Survey 2009, n=353,849

10. Cedar Rapids, Iowa, June 15 2008

11. The Transformational Recovery (I) Impact of 2008 Floods on Cedar Rapids and Surrounding Regions Cedar Rapids FEMA Public Asssistance and Hazard Mitigation Payments and DOT Payments Per Capita (2008) Overlaid on Congressional District Quintiles by Well-Being Index (2009) Very High High Moderate Low 6 4 12 77 77% 7% 9% 8% 74% 5% 9% 11% 93% 1% 4% 2% County Impact Number of Counties Household Losses Public Sector Losses Business Losses Loss Intensity Ratio 2.0 + 1.0 – 2.0 0.5 – 1.0 < 0.5 Source: FEMA Individuals and Households Program, Small Business Administration’s Disaster Loan Program, Uninsured Losses Declared by Iowa State income tax filers (2008), FEMA Public Assistance Program, FEMA Hazard Mitigation Program, U.S. Department of Transportation Repairs to transportation infrastructure per capita, Small Business Administration’s Disaster Loan program per capita, agriculture crop peril payments per square mile; Evaluating Direct and Indirect Economic Outcomes of the 2008 Iowa Weather-Related Disasters, Swanson et al., Iowa State University Staff Report, August 2010; Gallup-Healthways Well-Being Index Community Survey 2009, n=353,849 Weather Related Loss Estimates Housing and business structures Infrastructure Educational facilities Cultural and historic landmarks Agriculture and the environment Total estimated losses $1.33B 0.66 0.30 0.28 0.93 $3.50B

12. The Transformational Recovery (II) Well-Being at the Local Level 2008 2009 Metropolitan Statistical Area (MSA) Ranking by Well-Being Index and Composite Sub-Indices (out of 187 MSAs) Fourth Quintile Third Quintile Second Quintile Top Quintile Bottom Quintile Cedar Rapids Source: Gallup-Healthways Well-Being Index Community Survey 2009, n=353,849 Overall Rank 150 12 Life Evaluation 121 42 Emotional Health 170 1 Physical Health 64 5 Healthy Behavior 182 46 Work Environment 144 144 Basic Access 39 4 63.2 I learned or did something interesting yesterday 2009 66.5 I did not experience sadness yesterday 2009 Examples of Emotional Health Geographic Disparities Relative to National Composite Score for MSAs 66.5 80.2 Examples of Healthy Behavior Geographic Disparities Relative to National Composite Score for MSAs I ate healthy all day yesterday % who don’t smoke 2009 2009

13. The Transformational Recovery (II) Well-Being at the Local Level 2008 2009 etropolitan Statistical Area (MSA) Ranking by Well-Being Index and Composite Sub-Indices (out of 187 MSAs) Fourth Quintile Third Quintile Second Quintile Top Quintile Bottom Quintile Cedar Rapids Source: Gallup-Healthways Well-Being Index Community Survey 2009, n=353,849 Overall Rank 150 12 Life Evaluation 121 42 Emotional Health 170 1 Physical Health 64 5 Healthy Behavior 182 46 Work Environment 144 144 Basic Access 39 4 57.4 My supervisor treats me like he/she is my partner 2009 Examples of Work Environemnt Geographic Disparities Relative to National Composite Score for MSAs

14. The Transformational Recovery (III) Families Retained, Some Employment Losses but Well Managed Shares of Statewide Population Gains K-12 Public School Enrollment (Baselined to October 2005) 102% 101% 98% 96% 100% 2005 2006 2007 2008 2009 2007 2008 2009 +3% +2% +1% 0% -1% -2% -3% -4% Employment Changes 2007-2009 High Impact Counties Nonfarm Job Changes: Cedar Rapids vs. New Orleans Source: Evaluating Direct and Indirect Economic Outcomes of the 2008 Iowa Weather-Related Disasters, Swanson et al., Iowa State University Staff Report, August 2010

16. Chronic Disease Productivity Impact: ~3x Health Care Cost Impact Chronic Disease Economic Impact in the U.S. 2003 (Annual Costs) Total Cost $1.3 Trillion Source: Milken Institute 2007 Treatment Expenditures 21% Lost Productivity Cost 79% $0.3 Trillion $1.0 Trillion

17. Science Linkages Confirming the Value Examples of Recent Publications on Risk Reduction 10 — 25% Risk Reduction $0.4T — $1.1T 10 Year Impact 10 — 50% Risk Reduction $0.6T — $1.4 T 10 Year Impact

18. Emerging Science (I) Well-Being Relationship to Medical Events 0-50 (n=109) >50-60 (n=151) >80-90 (n=683) >70-80 (n=582) >60-70 (n=347) >90-100 (n=363) Admission ER Visit Percent Well-Being Score (Composite) Low High Impact of Well-Being on Event Frequency -83% -49% Source: Wellmark Data, Healthways Center for Health Research Analysis (n=2,235) 0 5 10 15 20

19. Well-Being Relationship to Medical Costs 0-50 (n=109) >50-60 (n=151) >80-90 (n=683) >70-80 (n=582) >60-70 (n=347) >90-100 (n=363) Annual Costs ($) Well-Being Score (Composite) Low High Impact of Well-Being on Claims and Rx Costs Claims Rx Total Source: Wellmark Data, Healthways Center for Health Research Analysis (n=2,235) 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000

20. Emerging Science (II) Well-Being Relationship to Performance Productivity Loss by Emotional Health 10 9 8 7 6 5 4 3 2 1 0 Low High 0 5 10 15 20 25 30 35 40 Productivity Loss (%) Emotional Health Source: Effects on Well-Being of Healthways Effective LifeStyle Programs Phase II, Evers, KE, Prochaska, JO, Castle, P. & Prochaska, JM. 2010 (under review), n=4100

21. Well-Being Relationship to Performance Continued Productivity Loss by Physical Health 0 5 10 15 20 25 30 35 40 Productivity Loss (%) 10 9 8 7 6 5 4 3 2 1 0 Physical Health Low High Source: Effects on Well-Being of Healthways Effective LifeStyle Programs Phase II, Evers, KE, Prochaska, JO, Castle, P. & Prochaska, JM. 2010 (under review), n=4100

23. They Were Asked . . . “What are Your Goals?” fitness nutrition job/career relationships big dreams emotional mental health life events hobby/skill development financial physical health time management weight loss school spiritual stress personal time environment goal for others quitting learning People reported a surprisingly complex tapestry of connected topics Source: Healthways MeYou Health, Essential Research March 2010

27. Putting Science into Practice (II) Modeling Behavior-Condition Relationships A complex relationship between behavior – condition drives development and severity of health conditions To understand what will happen to a population, a Monte Carlo Simulation Model is employed Once a population is profiled, repeated random interactions weighted to epidemiologic probabilities are used to “age” a population five years Effects of behavior change initiatives can be assessed by adding in probabilities that a program will have an effect along with the probability of recidivism

30. Blue Zones Principles – Applying to an Employer Community Move Naturally Right Outlook - Purpose Now - Downshift Eat Wisely - 80% Rule - Plant Slant - Wine@5 Belong - Right Tribe - Community - Loved Ones First THE POWER 9

33. How Do You Make it Real in 12 — 24 Months? Improve Well-Being EXECUTION Improved Business Performance RESULTS Adopt Well-Being Principles, Power 9 CULTURE Leadership Policy Communi-cations Participation (Social Network) AUDIT & BLUEPRINT Environment

34. Recommended Approach Certification Implement Track Progress Outcomes Well-Being Productivity Business Performance Well-Being Assessment Vitality Coach and Compass Vitality Simulation Model Environmental Assessment Assessments Communications Leadership Environment and Policy Participation Blueprint

36. What “You Can Do Right Now” Seven Steps to Improved Company Well-Being Assemble Back of the Envelope Data # Employees Gender % Male Female Age % 65+ 55-64 45-54 35-44 18-34 Employees’ Current State of Health Average Well Poor Employees Lifestyle Behaviors Average High Risk Low Risk Average Medical Costs Per Employee (estimate all-in for current year including Rx, Copays etc.) $ X 0.3 = Employee share Costs of Absenteeism Costs of Presenteeism $ Company cost $ Total costs PEPY Multiply total medical costs by 0.3 $ $ Multiply absenteeism costs by 7.7 X 7.7 = Assess your readiness to change 1 2 Pick 3 behaviors to target beyond current programs Physical Activity Diet Non-smoking Desirable alcohol use Standard of care compliance Stress management Sufficient sleep Health screenings 4 Write down the opportunity as sized by the simulation 5 $ $ Healthcare savings by 2015 $ Productivity savings by 2015 Total savings by 2015 Let off some steam with a game of Community Clash 6 http://www.meyouhealth.com/clash/ Improved performance through improved employee well-being is or will be a top five CEO agenda item for next fiscal year I personally plan to devote at least 15% of my time to this opportunity I am dissatisfied with my current set of initiatives and plans around health Improving the vitality of the communities in which my employees, customers and business partners work is aligned with my stated company goals , as well as being just the right thing to do I recognize the community levers we can pull in the 30 mile home radius around each of my locations http://wellness.weforum.org/ Simulate the cost of doing nothing 3 I can personally mobilize visible and committed leadership to this effort Investigate becoming a certified Healthways Blue Zone 7 http://healthwaysbluezones.com and share the results with a friend Source: Healthways Blue Zone Toolkit 2010; all rights reserved

37. Activating Your Community for Well-Being Ben Leedle, Chief Executive Officer, Healthways Inc.