PENALTIES RELATED TO BMI AND WEIGHT LOSS
UPDATED: September 2013
Increasing numbers of employers are implementing financial incentives for employees to lose weight. The Obesity Society (TOS) recommends that employers who wish to use incentives to motivate employee health-behavior change focus on employee health behaviors and participation in health promotion programs. We recommend against requiring employees to meet a certain body mass index (BMI) or weight as an outcome of participation in an employer-sponsored wellness program.
BACKGROUND AND STATEMENT OF THE PROBLEM
Many companies are facing increasing health insurance premiums because of potential health risks among employees with obesity. As a result of these rising health care costs, some employers have begun to implement financial incentives to employees who can keep their body weight in a healthy range (1). Other companies are imposing financial penalties such as charging overweight employees more in health care costs. As an example, Alabama has passed regulations in its state employee health plan, which impose a surcharge on employees who have a BMI ≥ 30 kg/m2. North Carolina’s state employee health plan will soon deny access to the more generous coverage options if the employee’s BMI exceeds certain limits (2,3). Other states are contemplating similar measures (4). Currently, 27% of employers are using financial incentives and 12% are using penalties to induce employees to participate in weight management programs (5).
Implementing financial incentives and penalties related to employee BMI raises a number of concerns:
First, applying financial penalties for obesity penalizes a condition rather than a health behavior that can be directly modified. BMI, and other biometric markers of health such as blood pressure and cholesterol, are influenced strongly by genetics and external environmental factors and can be more difficult for some individuals to control than for others (6). Penalizing individuals with a BMI ≥ 30 kg/m2 ignores the complex genetic and environmental contributors of body weight that are beyond personal control. Although it cannot be disputed that taking personal responsibility for health is necessary for the successful management of most chronic health conditions (e.g., hypertension, diabetes), it is not expected that personal responsibility alone is sufficient for the management of these other conditions.
Second, imposing financial penalties based on body weight alone incorrectly assumes that all individuals should have a BMI < 30 kg/m2 in order to be healthy. There are many individuals with a BMI in the ‘normal’ weight range who have chronic health conditions such as hypertension, hyperlipidemia, diabetes, or who are physically inactive, or who engage in other risky behaviors. Conversely, there are people who are overweight or obese who are in good health, have healthy nutrition and activity habits, and whose blood pressure and cholesterol are in the healthy range (7-9).
Third, substantial scientific evidence indicates that it is unreasonable for employers to expect their employees to lose large amounts of weight and maintain significant weight loss over time, even with intensive treatment options (10,11). This means that many people who have a BMI ≥ 30 kg/m2 will be unable to maintain significant weight loss despite legitimate efforts to do so. Among individuals who have a BMI ≥ 35 kg/m2, even if they were able to initially reduce their body weight to a BMI under 30, biological factors make weight loss maintenance at that level unlikely (12-14). However, there is considerable scientific research showing that small, achievable weight losses of 5-10% can produce important improvements in health, even when BMI ≥ 30 kg/m2 (13,14). This evidence underscores the importance of focusing on health behaviors rather than absolute BMI levels.
Fourth, in many, if not most, instances, insurance plans do not cover evidence-based treatment for obesity, such as group behavioral treatment or pharmacotherapy. Imposing added charges for employees with obesity in these plans is even worse than simply penalizing them for a pre-existing condition; it is penalizing them for a pre-existing condition whose treatment the plan doesn’t even cover.
Fifth, given substantial racial and ethnic disparities in the prevalence of obesity, insurance surcharges on employees with obesity will disproportionately target minorities, and incentives based solely on absolute BMI cut-offs will disproportionately be out of the reach of many minorities.
Finally, employers mandating differential treatment of individuals based on BMI serve to institutionalize the already pervasive stigmatization of obese people. Employees with obesity currently face numerous inequities in the workplace, including barriers to hiring, lower wages, less potential for promotion, unfair job termination, and stigmatization from co-workers and employers (15). Imposing additional penalties will reinforce stigma and discrimination against obese individuals.
As the leading scientific and professional organization on obesity, TOS recommends the following:
Employer incentive programs should be structured to reward employees for engaging in healthy behaviors, such as taking steps toimprove awareness of personal health indices, making measurable changes in health behaviors such as nutrition or exercise, orparticipating in an evidence-based weight management program.
Employers should avoid using BMI as a basis for financial penalties or incentives. Employers should not make determinations about employee health based on body size without consideration of additional health indices.
For employers who choose to incentivize participation in weight management programs, their insurance plans should reflect this by covering responsible weight loss programs that use evidence-based interventions.
Employers should avoid singling out overweight and employees with obesity, and instead position their health initiatives as a goal to achieve overall wellness for all employees, regardless of their body weight.
Employers who offer incentive programs should ensure that they create a supportive workplace environment that provides opportunities for employees to be healthy and practice long-term healthy behaviors (e.g., healthy cafeteria and vending options, gym discounts, attractive stairwells, etc).
The Obesity Society is the leading scientific society dedicated to the study of obesity. The Obesity Society is committed to encouraging research on the causes, treatment, and prevention of obesity as well as to keeping the scientific community and public informed of new advances in the field. For more information, please visit www.obesity.org.
1. Gabel JR, Whitmore H, Pickreign J, et al., Obesity and the Workplace: Current Programs and Attitudes Among Employers and Employees, Health Affairs. 2009; 28: 46-56.
2. Alabama to place ‘fat tax’ on obese state employees. Available at: http://latimesblogs.latimes.com/booster_shots/2008/08/alabama-places.html. Accessed February 13th, 2011.
3. State of North Carolina Session Law 2009-16, Senate Bill 287. Available at: http://www.ncga.state.nc.us/Sessions/2009/Bills/Senate/PDF/S287v8.pdf. Accessed Feb. 17, 2011
4. Put surcharge on obese state workers to lighten the load on S.C. taxpayers. Available at:
http://www.postandcourier.com/news/2010/sep/17/put-surcharge-on-obese-state-workersto-lighten/. Accessed February 27, 2011.
5. Towers Watson. 16th Annual Towers Watson/National Business Group on Health
Employer Survey on Purchasing Value in Health Care. Accessed June 26, 2013, at: http://dhss.alaska.gov/ahcc/Documents/meetings/201210/Towers%20Watson%20Shaping%20HC%20Strategy%20Report.pdf
6. Perusse L, Bouchard C. Gene-diet interactions in obesity. American Journal of Clinical Nutrition 2000; 72: 1285S-90S.
7. Karels AD, St-Pietter DH, Conus F, Rabasa-Lhoret R, Poelhman ET. Metabolic and body composition factors in subgroups of obesity: What do we know? J Clin Endocrinol Metab 2004;89:2569-2575.
8. Ruderman N, Chisholm D, Pi-Sunyer X, Schneider S. The metabolically obese, normal weight individual revisited. Diabetes1998; 47: 699-713.
9. Tsai AG, Wadden TA. Systematic review: An evaluation of major commercial weight loss programs in the United States. Annals of Internal Medicine 2005; 142: 56-66.
10. Franz MJ, VanWormer JJ, Crain AL, Boucher JL, Histon T, Caplan W, et al. Weight-loss outcomes: A systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. Journal of the American Dietetic Association 2007; 107: 1755-67.
11. Svetkey LP, Stevens VJ, Brantley PJ, Appel LJ, Hollis JF, Loria CM, et al. Comparison of strategies for sustaining weight loss.JAMA 2008; 299: 1139-1148.
12. Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations toweight loss. N Engl J Med. 2011;365(17):1597-604.
13. Wing RR, Phelan S. Long-term weight loss maintenance. American Journal of Clinical Nutrition 2005; 82: 222S-5S.
14. Wadden TA, Butryn ML, Byrne KJ. Efficacy of lifestyle modification for long-term weight control. Obesity Research 2004; 12: 151S-162S.11.
15. Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity 2009; 17: 941-964.