This document discusses how many workplace wellness programs focus primarily on exercise but neglect nutrition, even though diet has a much greater impact on health outcomes. It argues that to truly improve employee health and reduce costs, wellness programs need to address both sides of the "battle of the bulge" by providing solutions that empower employees to make healthier food choices wherever and whenever they eat. New mobile technologies could help by providing personalized nutrition recommendations and discounts to make healthy options easier to identify and select at home, work and restaurants.

1. Many wellness programs are fighting only half the battle (of the bulge)
By Dale Rayman, FSA, MAAA, MHA
Companies are taking a hard look at their wellness programs, in an effort to ensure that time
and money spent on activity trackers, in-house yoga classes, stair-climbing clubs, fitness
membership subsidies and other perks are really paying off. Many companies find that after the
initial excitement over “Biggest Loser” competitions wears off, engagement declines and
outcomes don’t improve.
There may be a simple reason why: By focusing primarily on exercise, companies are only
fighting half the battle (of the bulge). Long-term, if workplaces want to impact their employees’
health status, and contain health insurance cost increases, they need to take on the other half
of that battle: food.
The stakes could not be higher for American workers’ health. In 1980, 15 percent of the U.S.
population was obese. Thirty years later, in 2010, 35 percent of Americans were obese – a 133
percent increase in a statistic one would hope would stay relatively constant (or even decrease)
over time. Over the same 30 years (1980 to 2010), the segment of the U.S. population that is
overweight has grown from 47 percent to 68 percent – a 45 percent increase. Even more
chilling is the fact that childhood obesity has nearly quadrupled over those three decades – to
almost 20 percent in 2010 from just over 5 percent in 1980. These childhood obesity figures
cannot be ignored by the business community because workplace health benefits cover whole
families.
Figure 1: Growth in adult and pediatric obesity over 35 years1
1 Source: The State of Obesity. stateofobesity.org
0%
5%
10%
15%
20%
25%
30%
35%
40%
1980 1985 1990 1995 2000 2005 2010 2015
U.S. Obesity Rates
PEDIATRIC ADULT

2. [For the editor:]
These are the values we used to create the graph:
Percent Obese
Year Pediatric (ages 12 to 19) Adult
1980 5% 14%
1985
1990 11% 21%
1995
2000 16% 24%
2005 17% 29%
2010 35%
2015 20.5% 38%
Experts expect skyrocketing obesity to be accompanied by an increase in diabetes and its
related comorbidities. Unless something changes, 52 percent of Americans will have diabetes or
pre-diabetes by 2020, according to UnitedHealth Group’s Center for Health Care Reform and
Modernization.
Where should we start?
It’s going to take a major effort to turn this ship around. From a Six Sigma point of view, the
best way to produce a systemthat reduces healthcare costs is to design it so fewer people need
services: in other words, improve the health of the population. Obviously, that’s no small task.
According to the CDC, over 80 percent of healthcare spending is driven by chronic illnesses,
which, by definition, are ongoing and generally incurable. Chronic illness accounts for an
amazing 91 percent of prescriptions filled.
But what drives chronic illness? Roughly 75 percent of chronic illness is attributable to lifestyle
behavior – the four most notable being diet, exercise, tobacco use and alcohol consumption.
Eighty percent of heart disease, stroke and Type 2 diabetes is attributable to three of those risk
factors – poor diet, inactivity and smoking. Of these three, it’s clear that workplace wellness
programs have focused least on food, and that’s a problem.
To improve wellness, we need to put our money where our mouth is: food
Wellness programs can’t afford to ignore the impact of food choices. Workers make more than
200 food decisions per day, including not only what to eat but also where to eat and with
whom. These decisions are made at work, at home, at restaurants and fast-food
establishments. They are made alone, with colleagues, with friends and with families.

3. A recent study in the Journal of the American Medical Association (JAMA) reinforces the idea
that nutrition is the single best way to improve health status. It shows that diet is the number
one factor impacting health status (Figure 2).2
Figure 2: Percentage of Disability-Adjusted Life-Years Related to the 17 Leading Risk Factors in the United States in 2010
The study was performed by the Burden of Disease Collaborators, a group of 488 experts. It
concludes that poor nutrition has roughly three times the impact on health status as low or no
fitness. This is not surprising when you consider three of the biggest health conditions that
signal our deteriorating health in America – obesity, diabetes and cardiovascular disease – are
directly correlated to eating.
Table 1: Impact of Chronic Disease on the U.S.Population
48% Percentof Americanswithatleastone chronicillness(source:Shin-YiWuand
AnthonyGreen,Projectionof ChronicIllnessPrevalence andCostInflation,RAND
Corporation,October2000)
2 “The State of US Health, 1990-2010:Burden of Diseases,Injuries,and Risk Factors.”US Burden of Disease
Collaborators.JAMA.2013;310(6):591-606.doi:10.1001/jama.2013.13805.

4. 86% Healthcare costsattributable topatientswithatleastone chronicillness(source:
cdc.gov/chronicdisease/overview/)
99% Medicare expensesattributable tochronicillness
70% U.S. deathsattributable tochronicillness (Source:The GrowingCrisisof Chronic
Disease inthe UnitedStates,PartnershiptoFightChronicDisease)
81% Hospital admissionsattributable tochronicdisease
91% Percentof prescriptionsfilledattributabletochronicdisease
76% Percentof all physicianvisitsattributabletochronicdisease
The Historical Ineffectiveness of Workplace Wellness Programs
Workplace wellness programs have a long history of over-promising and under-delivering when
it comes to health outcomes. Unfortunately, the majority of these programs have not had much
success in slowing the obesity trend or delivering on their promise of financial ROI. With respect
to direct medical cost, few programs are showing much more than a break-even return on
investment, and even that generally takes several years to achieve.3
One of the key issues is that most wellness programs invest more in fitness, stress reduction
and tobacco cessation than in improving nutrition (which, as we’ve seen, is the most significant
factor impacting health). That’s not hard to understand given the challenges in eating well in
our current culture. Even people who want to eat well face a multitude of challenges:
 The information is complex. For the average person, selecting the right balance of fiber,
carbs, fats, sugar, vitamins and sodium isn’t easy. A person might choose a low-fat diet;
however, “low fat” doesn’t mean we are watching the sugar, fiber, cholesterol, sodium
and so on (and many grocery items advertised as low fat have added sugars to help
improve the taste). Our hectic lifestyles make balancing our diets even more
challenging.
 When we choose to eat out, we are generally handcuffed by a lack of information. Other
than big chains which have to publish some nutritional information, restaurants aren’t
transparent about the nutrients in their meals. While the name of a dish might sound
healthy, we have little knowledge regarding the amount of sodium, cholesterol and
other harmful nutrients. Few people guess that the Cobb Salad with Avocado Lime
Ranch dressing at Chick-Fil-A has 300 more calories and three times as much fat as a
Chick-Fil-A Chicken sandwich (740 calories vs. 440 calories; 54 g fat vs. 18 g fat).
 We are surrounded by poor food choices. Fast food chains, junk food manufacturers,
and clever marketing campaigns clutter our environment. The food industry bombards
3 Return on investment in diseasemanagement: a review, Goetzel, Ozminkowski, Villagra,Duffy,Health Care
FinanceRev. 2005 Summer;26(4):1-19. http://www.ncbi.nlm.nih.gov/pubmed/17288065

5. the population with advertising of high-sugar, high-calorie foods and beverages—and
much more money is spent on promoting these than healthy foods. When was the last
time you saw a TV commercial for carrots?
 Portion sizes have increased. Based on one JAMA study, the average portion size for
many foods increased dramatically at restaurants and at home over a 20-year period.
These included a 34 percent increase in the average size of cheeseburgers, a 36 percent
increase in the average portion of French fries and a whopping 70 percent increase in
the average portion of salty snacks such as potato chips, pretzels and popcorn.4
When workplace wellness programs do take on the food part of the wellness equation, this
usually takes the form of diets that either involve counting calories or ordering special foods.
The first is time-consuming and the second is expensive and impractical considering our
modern on-the-go lifestyles.
Eating in America is social. We want to go where our friends, our families and our colleagues
go. Restricting not only what people can eat but also where they can eat will disengage the
majority of them. So companies have to find ways to reshape employees’ (and their families’)
food landscape at work, at home and when out to eat.
The key lies in meeting people where they are: Helping them navigate to healthier choices in
the cafeterias, cafes and restaurants where they choose to go. When they are at home, it
means helping them make healthy food choices whether they choose to cook or to order in.
Empowering Individuals to Eat Well
Clearly, the current ecosystem is not conducive to eating well. We are surrounded by poor food
choices and savvy marketing aimed at getting us to buy some of the most addictive food
products – those laden with added sugars and salt – all leading to confusion and decision
fatigue.
4 Nielsen SJ, Popkin BM. Patterns and trends in food portion sizes,1977–1998. JAMA. 2003;289:450–453.

6. Figure 3: Challenges to eating well surround employees
For workplace wellness programs to move the needle on nutrition, they must provide a solution
that makes it easy to eat healthy. Solutions need to allow workers to opt in to recipes that are
full of fiber, protein and healthy fats, while letting experts behind the scenes do all the work of
measuring calories, sugar and fat, linking to grocery stores, restaurants and cafes, and providing
coupons to help make buying healthy foods quicker and more affordable.
Comprehensive solutions should also take into account the complex social factors that surround
employees’ eating decisions. Employees need to know what the healthiest choices that
surround them are, whether they are at home, at work or on the go. And they need all of this
information personalized to match their dietary needs (whether vegetarian, vegan, pescatarian
or paleo), their health status (diabetic, hypertensive, etc.) and their allergies (peanuts, shellfish,
gluten, etc.). These new food solutions should recommend new healthy choices to employees
to expand their options for healthy eating. For instance: “If you liked sweet potatoes, you may
also enjoy…parsnips!”
A key feature of new food-based wellness programs is to leverage Big Data, such as huge
databases of information that provide up-to-date menus for a majority of the roughly 630,000
restaurants in the U.S. This nutritional content, which is not publicly available, except at a
handful of chain restaurants, will become power in the hands of employees who can now

7. confidently determine, at the click of an app, whether in fact the salad or the sandwich is a
better nutritional choice for them.
Behind the scenes, the expertise of nutritionists has been automated so that computers can
deliver information on hundreds of thousands of recipes and restaurant meals, in the form of
personalized healthy menus, along with instructions on where to buy ingredients and how to
get discounts. That’s how to reshape the food landscape and “crowd out” the unhealthy
choices that workers are constantly bombarded with – in essence, creating a safe, virtual
environment for making personalized healthy food choices.
Figure 4: A technology-enabled paradigm for healthy eating:
The final key is that these solutions have got to be native to mobile, marrying the latest in
digital technology with evidence-based personalized solutions wherever and whenever workers
need them.
Companies can stop fighting just half of the wellness battle. They can free their wellness
programs from the walls of headquarters with solutions that follow employees home, out to
dinner, to birthday parties and on vacation. Simple mobile solutions that navigate the complex
maze of nutrition information can act like Jiminy Cricket on the shoulder of employees, guiding
their food choices with the power of automated, customized, evidenced-based
recommendations. Empowered in this way, workers have the tools they need to put the brakes
on the obesity trend.

8. Dale Rayman is Vice President of Analytics and Chief Actuary of Zipongo, a San Francisco digital
nutrition company that makes it easy for consumers and employees to eat well. Dale resides in
Charlotte, North Carolina.
(704) 617-0599 (cell)
Dale.rayman@zipongo.com