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A Mindshift on Obesity: Rethinking the Costly Epidemic

November 07, 2011

​Obesity is one of the biggest health challenges facing Australia. With almost 30% of the country's population now classified as obese, it is becoming a significant health and safety issue for businesses who want their employees operating at peak performance.

Obesity presents a significant cost to businesses in a range of ways. Obese staff are more likely to suffer from diabetes, hypertension, heart disease, cancer, and accidents. Companies are recognising this and they have boosted their efforts in employee and executive health; including medical check ups, cycling clubs and installing lockers and showers to encourage staff to exercise.

However, new research from the School of Psychiatry at the University of New South Wales (UNSW) highlights the need for companies to begin focusing on the mental and cognitive aspects of obesity to help staff to combat the disease.

The research found that in children, adolescents and adults, obesity can be linked to cognitive functions, particularly executive function, which controls tasks such as reasoning and planning. It sheds new insight into the cognitive impact of obesity, including how it could possibly prevent staff operating at peak performance through the impairment of executive function. But it also provides hope for companies looking to assist their staff in battling obesity.

The research indicates obesity may not be due to a lack of willpower and suggests that helping staff is more complicated than simple motivation and the provision of exercise equipment. It holds out hope for cost-effective corporate programs for treatment using cognitive remediation therapy to improve executive functioning. "Effective cognitive remediation therapy might help businesses help their employees control their weight," saysEvelyn Smith, co-author of the research paper recently published in the journal, Obesity Reviews.

Obesity has been called an epidemic. More than 25% of Australian men are obese and 24% of women. In the US, the fattest country in the world, some 32% of men and 35% of women are obese. Some estimates put obesity in Australia at close to or at 30%. "I think we are catching up," says Steve Hambleton, president of the Australian Medical Association (AMA).

Experts argue this could be the first generation that may not live as long as their parents due to obesity. Current treatments – including more radical procedures such as surgery – are not solving the problem that's exacerbated by poor diet, lack of exercise and consumption of tobacco and alcohol in a long-term, cost-effective manner, according to Hambleton.

Human genetics are based on the hunter-gatherer way of living, Hambleton notes. People are designed to have "survival" periods between meals: a human can exist without food for several weeks, and still have enough energy to be capable of gathering food. "We're physiologically designed to put aside a bit for rainy days," he says. "Of course, it never rains. There is ready access to enormous quantities of high-energy food. That's where our problem is – enormous access to the wrong sorts of foods, and it's cheap."
Ten years ago, obesity was thought to be confined to lower socioeconomic groups. But recent research shows that obesity straddles the social strata. "Now it's everyone," Smith says.

Weighing up Costs

Now at the forefront of workplace health and safety issues, the obesity surge is growing in importance for companies as the impact of the disease increases, observes Lynne Pezzullo, health economist at Access Economics. Hambleton describes the costs as "real" – and major – but difficult to quantify. He says obesity leads to increases in absenteeism, and increased risk of diabetes, higher risk of heart attack and stroke, premature departure from the workplace and a greater risk of accident. "If a chair is designed for 80kg then you have a 120kg person sitting on it, you're going to have a problem," he points out.
A 2010 study published in The Medical Journal of Australia found overweight and obese Australian adults cost the economy A$21 billion in direct health-care costs and other direct expenses, plus an additional A$35.6 billion in government subsidies. It found the direct cost of people being overweight and obese was significantly higher than previous estimates, and the bill will rise as more Australians tip the scales, creating individual and societal financial incentives for people to slim down.

In 2006 Access Economics released a report for Diabetes Australia on theeconomic costs of obesity. The updated report in 2008 found the financial cost of obesity was A$8.28 billion. The major cost was productivity costs at A$3.6 billion (44%), well above health system costs of A$2 billion (24%) and carer costs of A$1.9 billion (23%). The net cost of loss of wellbeing was a massive A$49.9 billion, taking the total cost of obesity to A$58.2 billion.

However, the exact impacts of obesity on business are hard to quantify, particularly given a lot of the costs are borne by obese people themselves, says Access Economics' Pezzullo. "There is a substantial productivity loss from various conditions. It's quite difficult to quantify as we haven't got a study that looks at that."
But the UNSW research paper, which reviewed 38 recent studies, has provided insight into how obesity could be affecting staff performance. Previous research had shown that obese adults and children are more likely to have lower cognitive performance, but was not entirely clear which aspects of cognition were affected.

Smith and her colleagues undertook a systematic review of research to try to find this out. "Deficiencies were found most consistently in the area of executive function," Smith says. Some of the major characteristics of executive dysfunction include: 

  • Difficulty with goal setting
  • Difficulty adapting to change
  • Low tolerance for failure
  • Not taking responsibility
  • Counting on Cognitive Reserve

Smith is reluctant to directly link executive dysfunction to poor workplace performance, in part due to not wanting to stigmatise obese people. "On average obese individuals have lower performance on executive function," Smith says. "But you can't say all of them will." And "cognitive reserve" must be factored in, she claims. For instance, an obese person may be a brilliant manager because his or her excellence is so elevated they still stand out relative to their peers. Therefore, it would be folly for an employer to reject a highly talented potential employee because of their weight.

But it's hard not to leap to the conclusion that obese people are not performing at their peak. Hambleton says companies, particularly larger companies, are taking action. One strategy is the annual executive medical. Beyond the test itself, there's value in telling people they will have a test, which may trigger the individual to act pre-emptively along with demonstrating that the company is interested in their wellbeing.
Employers are providing access to gyms, company cycle clubs, and installing showers and locker rooms so people can cycle to work. "There's a culture in the corporate world to be seen in the gym. If you go to a hotel gym at six in the morning all those people are sweating," Hambleton points out.

But current strategies to combat the obesity epidemic are not working. "They work short term, but not in the long term," Smith confirms.

Fad diets can lead to quick weight loss but it isn't sustained over longer periods of a year to five years. Anti-obesity pills are available, but they can increase the risk of heart attacks. Reality television shows that focus on weight loss may highlight the issue but invariably show people shedding kilos with the help of a personal trainer and cook. Hambleton notes these may not be cost-effective options for the rest of the population. Similarly, surgery is "right at the end of the line". While 60% of those who have a surgical intervention will lose 60% of their excess weight, "it's not really what you would want to spend money on if you could intervene earlier", Hambleton suggests.

How Weight Gain Goes Out of Control

The UNSW paper helps to explain why weight loss for obese people is so difficult and why existing treatments may not always be effective. It raises "the possibility that obesity is, at least in part, a neurological condition, not only a so-called 'lifestyle' disorder". A "vicious cycle" may also be present where obesity impairs executive function; and that impairment itself can exacerbate weight gain. "Weight gain might be out of [people's] control if they have low levels of executive function," Smith states. And this has significant implications for how businesses support staff. If weight gain is not entirely in the control of obese people, then simply providing gyms, health equipment and fitness programs may not be enough.

Businesses also may have to focus on the mental and cognitive aspects of treatment. Smith and her colleagues are already trialling cognitive remediation therapy, which is designed to improve neurocognitive abilities including attention, memory and executive function, on obese people. "By increasing the levels of cognitive function this may aid in helping individuals make suitable lifestyle decisions and stop the vicious cycle," says the paper, A Review of the Association Between Obesity and 
Cognitive Function across the Lifespan: Implications for Novel Approaches to Prevention and Treatment.

Cognitive remediation therapy has already been effective in treating conditions such as anorexia nervosa; helping sufferers gain weight and maintain it in the long term. As with obesity, anorexia sufferers have cognitive deficits that maintain the disorder. In the specific domain of feeding behaviour, obese individuals are too flexible, cannot plan a diet, and fail to associate health outcomes with food choices, which are all aspects of impaired executive function, the paper noted. "Although hypothetical, it is possible that cognitive remediation could treat obesity, by helping individuals maintain a healthy lifestyle long term," the researchers say.

Ten people have taken part in an executive function training trial at UNSW. They attended 50 minute sessions twice a week over four weeks. The trial will conclude at the end of 2012 after participants' one-year follow up. "The program simply aims to improve all aspects of executive function and generalise this to real life and eating," Smith says. The training focuses on shifting perspectives and includes training in attention-switching tasks. For example, people may be presented with the word "red" but in a blue colour. They have to mention blue and ignore what the word says. "It's hard," Smith says. "The brain has to shift that perspective." People claim their brain hurts at the end. MRI (magnetic resonance imaging) shows changes in the brain, Smith says.

New solutions are needed to address obesity, according to Hambleton, who adds that the UNSW research should trigger more research into cognitive performance and obesity. "We have to research it and take a closer interest." The paper also noted the "urgency to invest in novel obesity research and institute informed public health programmes". Smith believes training practitioners in cognitive remediation therapy so it can be delivered to the public is one solution. "However, surgery for the morbidly obese may be the only way," she concludes. Hambleton hopes the new research will bring on some fresh ideas. "It's fair to say we don't have solutions … Maybe there is something else we should be looking at."​
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