JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 64, NO. 17, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.08.016
EDITORIAL COMMENT
Healthy Lifestyles and Personal Responsibility* Paul A. Heidenreich, MD
T
he significant and growing cost of health care
taken, these 8 million patients will create a substan-
in the United States has centered attention
tial health and financial burden for the United States.
on avoidable medical expenditures. Hospi-
However, if we can identify the important com-
tals have been a major focus for reducing preventable
ponents of a healthy lifestyle, we can create in-
care, with Medicare imposing financial penalties if a
centives for patients to live a healthy life, reduce the
hospital’s 30-day all-cause readmission rate for heart
incidence of disease, and lower healthcare costs. In
failure and other select conditions is below the U.S.
this issue of the Journal, Agha et al. (6) identify
average (1). However, all sectors of the healthcare
important “lifestyle” predictors of the development
system are now targets for reducing waste, with pro-
of heart failure for women. They used data from a
viders asked to “choose wisely” (2) and patients
cohort of more than 84,000 post-menopausal women
financially rewarded by health plans for living a
from the Women’s Health Initiative who were free
“healthy life” (3). Although shared accountability for
of heart failure and provided information on their
health between the individual and the rest of the
lifestyle and subsequent outcomes. A healthy life-
healthcare system is worthwhile, we must know to
SEE PAGE 1777
what extent any patient’s “lifestyle” is modifiable before we hold him or her financially responsible.
style score was created using 1 point each for not
A primary purpose for focusing on lifestyle is the
smoking, having a healthy diet, remaining physically
avoidance of chronic disease. According to recent
active, and maintaining a healthy body mass index
estimates, 58 million individuals in the United States
(BMI). The investigators found a strong relationship
are working with significant chronic illnesses, and the
between the healthy lifestyle score (0 to 4) and
cost of treating chronic disease accounts for up to 75%
the incidence of heart failure, which developed in
of national healthcare expenditures (3,4). Indirect
1,826 women over a mean follow-up of 11 years. The
costs attributable to time lost from work are also
results are all the more impressive in that they
substantial, 4 times higher for those with chronic
confirm
disease than for healthy employees (4).
Finland (7) and in U.S. males (8). The authors note
previous
findings
from
populations
in
Heart failure in particular deserves attention given
that randomized trials promoting lifestyle inter-
that the cost of heart failure care is expected to more
ventions have been successful at decreasing cardio-
than double during the next 20 years because of the
vascular disease risk (9). Thus, we should be able to
aging of the U.S. population (5). By 2030, it is ex-
target these lifestyles to improve health and reduce
pected that 1 in 33 people in the United States will
cost of heart failure.
have heart failure (5). Unless preventive measures are
Holding patients and employees accountable for the health impact of their behaviors is growing in popularity. One of the largest U.S. employers, the grocery
*Editorials published in the Journal of the American College of Cardiology
store chain Safeway, has stated that it believes 70% of
reflect the views of the authors and do not necessarily represent the
healthcare costs are attributable to unhealthy behav-
views of JACC or the American College of Cardiology. From the Veterans Administration Palo Alto Healthcare System, Palo Alto, California, and the Stanford University School of Medicine, Stan-
iors (10). They estimated that an obese employee in 2011 would cost an additional $1,400 in healthcare
ford, California. Dr. Heidenreich has reported that he has no relationships
dollars annually compared with a nonobese employee.
relevant to the contents of this paper to disclose.
In addition, Safeway estimated that the unhealthy
Heidenreich
JACC VOL. 64, NO. 17, 2014 OCTOBER 28, 2014:1786–8
“behaviors”
high
preventable condition, and only 11% strongly agreed
cholesterol, and lack of exercise each cost an extra
that obesity had a genetic component. Approximately
$500 to $650 per employee per year (10). Michelin
half of the employers agreed or strongly agreed that
recently switched from providing credits for all em-
smokers should pay a higher premium; however, 25%
ployees participating in a plan for improving health to
also agreed or strongly agreed that obese employees
a stricter strategy that only provides rewards (up to
should pay a higher fraction of their healthcare costs
$1,000 off healthcare costs) if the employee meets
than nonobese employees.
healthy
of
Personal Responsibility
uncontrolled
standards
for
blood
hypertension,
pressure,
glucose,
One of the goals of the Affordable Care Act was to
cholesterol, triglycerides, and waist size (11). It set the
prevent health plans from linking insurance pre-
waist circumference threshold at less than 35 inches
miums to health status (18); however, in its goal to
for women and 40 inches for men. If someone does not
improve wellness, the Affordable Care Act allows
meet the standard, they can receive a smaller credit if
employers a substantial amount of flexibility in
they sign up for a health-coaching program (11).
their programs that can financially penalize those
These financial incentives would be reasonable if
with poor biometric measures. It remains to be seen
everyone had a similar opportunity and ability to
whether
reach the goal. But how much of obesity is a lifestyle
improving wellness without penalizing patients who
choice, and is holding everyone to the same stan-
have limited ability to improve because of genetic or
dard appropriate? The large increase in obesity in
other nonmodifiable factors.
these
programs
will
be
successful
in
Western countries in the past several decades has
We in the medical community need to do more to
been interpreted by some to indicate obesity is
combat the all too common view that poor health
largely due to a change in patient choices regarding
outcomes (high BMI, hypertension, hyperglycemia,
diet and physical activity. However, substantial
and hyperlipidemia) are simply due to poor health
hereditability for weight (80%) and BMI (70%) has
choices. Someday, we may know enough to person-
been found in twin studies (12). Even among chil-
alize incentives that account for genetic, socioeco-
dren born since the recent obesity “epidemic,” the
nomic, and other barriers an individual faces in
hereditability of childhood BMI is 60% (13). Genetic
attaining the recommended healthy lifestyle. For
differences also have been observed for taste of
now, we should limit employee and patient rewards
food (14), ability to exercise (15), and preference for
to healthy choices (diet, exercise, lack of smoking)
smoking (16).
and not equate these with healthy outcomes.
The findings of substantial genetic effects on BMI are in stark contrast to employers’ views on obesity
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
(17). Among 505 public and private employers sur-
Paul Heidenreich, Veterans Affairs Palo Alto Health Care
veyed in 2007, 93% believed obesity was the “result
System, 111C Cardiology, 3801 Miranda Avenue, Palo
of poor lifestyle choices,” 87% viewed obesity as a
Alto, California 94306. E-mail: [email protected].
REFERENCES 1. Gu Q, Koenig L, Faerberg J, Steinberg CR, Vaz C, Wheatley MP. The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving
Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Radiology and Intervention, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Stroke Council.
9. Knowler WC, et al., for the Research Group. type 2 diabetes
vulnerable populations. Health Serv Res 2014; 49:818–37.
Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail 2013; 6:606–19.
metformin. N Engl J Med 2002;346:393–403.
2. Beller GA. Tests that may be overused or misused in cardiology: the Choosing Wisely campaign. J Nucl Cardiol 2012;19:401–3. 3. Mujtaba BG, Cavico FJ. Corporate wellness programs: implementation challenges in the modern American workplace. Int J Health Policy Manag 2013;1:193–9.
6. Agha G, Loucks EB, Tinker LF, et al. Healthy lifestyle and decreasing risk of heart failure in women: the Women’s Health Initiative Observational Study. J Am Coll Cardiol 2014;64:1777–85.
Barrett-Connor E, Fowler SE, Diabetes Prevention Program Reduction in the incidence of with lifestyle intervention or
10. Renda L. Focusing on What Matters Most: Healthy Behavior and Accountability. The Institute for HealthCare Consumerism website. Available at: http://www.theihcc.com/en/communities/employ ee_communication_education/focusing-on-whatmatters-most-%E2%80%93-healthy-behavior-a_ gqk6ur59.html. Accessed September 15, 2014.
7. Wang Y, Tuomilehto J, Jousilahti P, et al. Lifestyle factors in relation to heart failure among Finnish men and women. Circ Heart Fail 2011;4:
11. Kwoh L. Shape up or pay up: firms put in new health penalties. Wall Street Journal, eastern
Monica, CA: RAND Corporation, 2012. Document No. OP-373-DOL.
607–12.
5. Heidenreich PA, Albert NM, Allen LA, et al., on behalf of the American Heart Association Advocacy Coordinating Committee, Council on
between modifiable lifestyle factors and lifetime risk of heart failure. JAMA 2009;302: 394–400.
12. Walley AJ, Asher JE, Froguel P. The genetic contribution to non-syndromic human obesity. Nat Rev Genet 2009;10:431–42.
4. Mattke S, Schnyer C, Van Busum KR. A Review of the U.S. Workplace Wellness Market. Santa
8. Djoussé L, Driver JA, Gaziano JM. Relation
edition. April 6, 2013:A.1.
13. Wardle J, Carnell S, Haworth CM, Plomin R. Evidence for a strong genetic influence on
1787
1788
Heidenreich
JACC VOL. 64, NO. 17, 2014 OCTOBER 28, 2014:1786–8
Personal Responsibility
childhood adiposity despite the force of the obesogenic environment. Am J Clin Nutr 2008;87: 398–404. 14. Mennella JA, Pepino MY, Reed DR. Genetic and environmental determinants of bitter perception and sweet preferences. Pediatrics 2005;115:
Genetic influences in sport and physical performance. Sports Med 2011;41:845–59. 16. Loukola A, Hällfors J, Korhonen T, Kaprio J. Genetics and smoking. Curr Addict Rep 2014;1: 75–82.
e216–22.
17. Gabel JR, Whitmore H, Pickreign J, et al. Obesity and the workplace: current programs
15. Puthucheary Z, Skipworth JR, Rawal J, Loosemore M, Van Someren K, Montgomery HE.
and attitudes among employers and employees. Health Aff (Millwood) 2009;28:46–56.
18. Madison K, Schmidt H, Volpp KG. Smoking, obesity, health insurance, and health incentives in the Affordable Care Act. JAMA 2013;310: 143–4.
KEY WORDS cardiovascular diseases, primary prevention, risk factors
VOL. 64, NO. 17, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.08.016
EDITORIAL COMMENT
Healthy Lifestyles and Personal Responsibility* Paul A. Heidenreich, MD
T
he significant and growing cost of health care
taken, these 8 million patients will create a substan-
in the United States has centered attention
tial health and financial burden for the United States.
on avoidable medical expenditures. Hospi-
However, if we can identify the important com-
tals have been a major focus for reducing preventable
ponents of a healthy lifestyle, we can create in-
care, with Medicare imposing financial penalties if a
centives for patients to live a healthy life, reduce the
hospital’s 30-day all-cause readmission rate for heart
incidence of disease, and lower healthcare costs. In
failure and other select conditions is below the U.S.
this issue of the Journal, Agha et al. (6) identify
average (1). However, all sectors of the healthcare
important “lifestyle” predictors of the development
system are now targets for reducing waste, with pro-
of heart failure for women. They used data from a
viders asked to “choose wisely” (2) and patients
cohort of more than 84,000 post-menopausal women
financially rewarded by health plans for living a
from the Women’s Health Initiative who were free
“healthy life” (3). Although shared accountability for
of heart failure and provided information on their
health between the individual and the rest of the
lifestyle and subsequent outcomes. A healthy life-
healthcare system is worthwhile, we must know to
SEE PAGE 1777
what extent any patient’s “lifestyle” is modifiable before we hold him or her financially responsible.
style score was created using 1 point each for not
A primary purpose for focusing on lifestyle is the
smoking, having a healthy diet, remaining physically
avoidance of chronic disease. According to recent
active, and maintaining a healthy body mass index
estimates, 58 million individuals in the United States
(BMI). The investigators found a strong relationship
are working with significant chronic illnesses, and the
between the healthy lifestyle score (0 to 4) and
cost of treating chronic disease accounts for up to 75%
the incidence of heart failure, which developed in
of national healthcare expenditures (3,4). Indirect
1,826 women over a mean follow-up of 11 years. The
costs attributable to time lost from work are also
results are all the more impressive in that they
substantial, 4 times higher for those with chronic
confirm
disease than for healthy employees (4).
Finland (7) and in U.S. males (8). The authors note
previous
findings
from
populations
in
Heart failure in particular deserves attention given
that randomized trials promoting lifestyle inter-
that the cost of heart failure care is expected to more
ventions have been successful at decreasing cardio-
than double during the next 20 years because of the
vascular disease risk (9). Thus, we should be able to
aging of the U.S. population (5). By 2030, it is ex-
target these lifestyles to improve health and reduce
pected that 1 in 33 people in the United States will
cost of heart failure.
have heart failure (5). Unless preventive measures are
Holding patients and employees accountable for the health impact of their behaviors is growing in popularity. One of the largest U.S. employers, the grocery
*Editorials published in the Journal of the American College of Cardiology
store chain Safeway, has stated that it believes 70% of
reflect the views of the authors and do not necessarily represent the
healthcare costs are attributable to unhealthy behav-
views of JACC or the American College of Cardiology. From the Veterans Administration Palo Alto Healthcare System, Palo Alto, California, and the Stanford University School of Medicine, Stan-
iors (10). They estimated that an obese employee in 2011 would cost an additional $1,400 in healthcare
ford, California. Dr. Heidenreich has reported that he has no relationships
dollars annually compared with a nonobese employee.
relevant to the contents of this paper to disclose.
In addition, Safeway estimated that the unhealthy
Heidenreich
JACC VOL. 64, NO. 17, 2014 OCTOBER 28, 2014:1786–8
“behaviors”
high
preventable condition, and only 11% strongly agreed
cholesterol, and lack of exercise each cost an extra
that obesity had a genetic component. Approximately
$500 to $650 per employee per year (10). Michelin
half of the employers agreed or strongly agreed that
recently switched from providing credits for all em-
smokers should pay a higher premium; however, 25%
ployees participating in a plan for improving health to
also agreed or strongly agreed that obese employees
a stricter strategy that only provides rewards (up to
should pay a higher fraction of their healthcare costs
$1,000 off healthcare costs) if the employee meets
than nonobese employees.
healthy
of
Personal Responsibility
uncontrolled
standards
for
blood
hypertension,
pressure,
glucose,
One of the goals of the Affordable Care Act was to
cholesterol, triglycerides, and waist size (11). It set the
prevent health plans from linking insurance pre-
waist circumference threshold at less than 35 inches
miums to health status (18); however, in its goal to
for women and 40 inches for men. If someone does not
improve wellness, the Affordable Care Act allows
meet the standard, they can receive a smaller credit if
employers a substantial amount of flexibility in
they sign up for a health-coaching program (11).
their programs that can financially penalize those
These financial incentives would be reasonable if
with poor biometric measures. It remains to be seen
everyone had a similar opportunity and ability to
whether
reach the goal. But how much of obesity is a lifestyle
improving wellness without penalizing patients who
choice, and is holding everyone to the same stan-
have limited ability to improve because of genetic or
dard appropriate? The large increase in obesity in
other nonmodifiable factors.
these
programs
will
be
successful
in
Western countries in the past several decades has
We in the medical community need to do more to
been interpreted by some to indicate obesity is
combat the all too common view that poor health
largely due to a change in patient choices regarding
outcomes (high BMI, hypertension, hyperglycemia,
diet and physical activity. However, substantial
and hyperlipidemia) are simply due to poor health
hereditability for weight (80%) and BMI (70%) has
choices. Someday, we may know enough to person-
been found in twin studies (12). Even among chil-
alize incentives that account for genetic, socioeco-
dren born since the recent obesity “epidemic,” the
nomic, and other barriers an individual faces in
hereditability of childhood BMI is 60% (13). Genetic
attaining the recommended healthy lifestyle. For
differences also have been observed for taste of
now, we should limit employee and patient rewards
food (14), ability to exercise (15), and preference for
to healthy choices (diet, exercise, lack of smoking)
smoking (16).
and not equate these with healthy outcomes.
The findings of substantial genetic effects on BMI are in stark contrast to employers’ views on obesity
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
(17). Among 505 public and private employers sur-
Paul Heidenreich, Veterans Affairs Palo Alto Health Care
veyed in 2007, 93% believed obesity was the “result
System, 111C Cardiology, 3801 Miranda Avenue, Palo
of poor lifestyle choices,” 87% viewed obesity as a
Alto, California 94306. E-mail: [email protected].
REFERENCES 1. Gu Q, Koenig L, Faerberg J, Steinberg CR, Vaz C, Wheatley MP. The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving
Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Radiology and Intervention, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Stroke Council.
9. Knowler WC, et al., for the Research Group. type 2 diabetes
vulnerable populations. Health Serv Res 2014; 49:818–37.
Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail 2013; 6:606–19.
metformin. N Engl J Med 2002;346:393–403.
2. Beller GA. Tests that may be overused or misused in cardiology: the Choosing Wisely campaign. J Nucl Cardiol 2012;19:401–3. 3. Mujtaba BG, Cavico FJ. Corporate wellness programs: implementation challenges in the modern American workplace. Int J Health Policy Manag 2013;1:193–9.
6. Agha G, Loucks EB, Tinker LF, et al. Healthy lifestyle and decreasing risk of heart failure in women: the Women’s Health Initiative Observational Study. J Am Coll Cardiol 2014;64:1777–85.
Barrett-Connor E, Fowler SE, Diabetes Prevention Program Reduction in the incidence of with lifestyle intervention or
10. Renda L. Focusing on What Matters Most: Healthy Behavior and Accountability. The Institute for HealthCare Consumerism website. Available at: http://www.theihcc.com/en/communities/employ ee_communication_education/focusing-on-whatmatters-most-%E2%80%93-healthy-behavior-a_ gqk6ur59.html. Accessed September 15, 2014.
7. Wang Y, Tuomilehto J, Jousilahti P, et al. Lifestyle factors in relation to heart failure among Finnish men and women. Circ Heart Fail 2011;4:
11. Kwoh L. Shape up or pay up: firms put in new health penalties. Wall Street Journal, eastern
Monica, CA: RAND Corporation, 2012. Document No. OP-373-DOL.
607–12.
5. Heidenreich PA, Albert NM, Allen LA, et al., on behalf of the American Heart Association Advocacy Coordinating Committee, Council on
between modifiable lifestyle factors and lifetime risk of heart failure. JAMA 2009;302: 394–400.
12. Walley AJ, Asher JE, Froguel P. The genetic contribution to non-syndromic human obesity. Nat Rev Genet 2009;10:431–42.
4. Mattke S, Schnyer C, Van Busum KR. A Review of the U.S. Workplace Wellness Market. Santa
8. Djoussé L, Driver JA, Gaziano JM. Relation
edition. April 6, 2013:A.1.
13. Wardle J, Carnell S, Haworth CM, Plomin R. Evidence for a strong genetic influence on
1787
1788
Heidenreich
JACC VOL. 64, NO. 17, 2014 OCTOBER 28, 2014:1786–8
Personal Responsibility
childhood adiposity despite the force of the obesogenic environment. Am J Clin Nutr 2008;87: 398–404. 14. Mennella JA, Pepino MY, Reed DR. Genetic and environmental determinants of bitter perception and sweet preferences. Pediatrics 2005;115:
Genetic influences in sport and physical performance. Sports Med 2011;41:845–59. 16. Loukola A, Hällfors J, Korhonen T, Kaprio J. Genetics and smoking. Curr Addict Rep 2014;1: 75–82.
e216–22.
17. Gabel JR, Whitmore H, Pickreign J, et al. Obesity and the workplace: current programs
15. Puthucheary Z, Skipworth JR, Rawal J, Loosemore M, Van Someren K, Montgomery HE.
and attitudes among employers and employees. Health Aff (Millwood) 2009;28:46–56.
18. Madison K, Schmidt H, Volpp KG. Smoking, obesity, health insurance, and health incentives in the Affordable Care Act. JAMA 2013;310: 143–4.
KEY WORDS cardiovascular diseases, primary prevention, risk factors
