Spare Tire —
Employees at the tire maker who have high blood pressure or certain size waistlines may have to pay as much as $1,000 more for health-care coverage starting next year… the company will reward only those workers who meet healthy standards for blood pressure, glucose, cholesterol, triglycerides and waist size — under 35 inches for women and 40 inches for men.
According to that Wall Street Journal article, the tire maker claims they have to penalize fat employees because of “rising health-care costs and poor results from voluntary wellness programs.” But we already know what is driving healthcare costs and it is not, by and large, the fatties.
But, okay, for the sake of the skeptics out there who think fatties are driving the costs of healthcare, let’s run with that assumption to simplify the argument. Even if finding and “treating” all the fat people is the solution to out-of-control healthcare costs, let’s look at the two ways we have for finding those fatties.
First is Body Mass Index (BMI), which is what CVS is using. Everyone knows that BMI sucks because it doesn’t distinguish between fat and muscle. It’s just a ratio of height to weight, so it winds up including a lot of people who don’t have a lot of body fat into the net. Studies that actually measure the correlation between BMI and body fat percentage find this metric lacking:
Commonly used BMI cutoffs to diagnose obesity showed a pooled sensitivity to detect high adiposity of 0.50 (95% confidence interval (CI): 0.43-0.57) and a pooled specificity of 0.9… Commonly used BMI cutoff values to diagnose obesity have high specificity, but low sensitivity to identify adiposity, as they fail to identify half of the people with excess [body fat percentage].
The key here is specificity and sensitivity. A high specificity means that BMI is fairly good at finding people who have a low BMI and low body fat. But a low sensitivity means that only half the time does a person with a high BMI also have high body fat. As a result, even if CVS thinks making fat employees thin is an effective way to control healthcare costs, using BMI to find the culprits is highly flawed.
Which brings us to waist circumference (WC), which gets floated as a viable alternative to BMI whenever BMI is criticized. Except researchers have found WC is just as flawed as BMI when it comes to filtering out the fatties.
BMI, WC, and WSR [waist stature ratio] all performed very similarly as indirect measures of body fat, and they were more closely related to each other than with percentage body fat. Percentage fat tended to be slightly but significantly more correlated with WC than with BMI among men, but significantly more correlated with BMI than with WC among women; the differences were slight… As shown previously, and as would be expected from considerations of body composition, percentage fat does not increase linearly with body weight.
In other words, BMI, WC, and WSR produce similar correlations to body fat, and therefore WC is no more effective than BMI. The fact that CVS uses BMI and Michelin uses WC does not improve their chances of finding the deviant fatties and putting them on the path to thinness.
But the most damning testimony as to the futile nature of Michelin’s proposal comes from the man who originally proposed waist circumference as a risk factor for metabolic syndrome back in 1988. His name is Dr. Gerald Reaven, and they even named the cluster of symptoms associated with insulin resistance after him: Reaven’s Syndrome.
I wrote about Reaven’s 2005 change of heart, and how he believes that these risk factors have become a highly-flawed diagnostic checklist that is no longer useful in identifying those with insulin resistance, which is the underlying health problem that CVS and Michelin ultimately want to solve.
Reaven’s objection is simple and speaks straight to the heart of the problem with Michelin’s plan:
[A]lthough being overweight/obese increases the chances of an individual being significantly insulin resistant, by no means are all overweight/obese individuals insulin resistant, and, of greater clinical relevance, weight loss in overweight/obese individuals who are not insulin resistant does not lead to substantial clinical benefit. [emphasis mine]
Reaven also points out how BMI and WC are essentially identical:
At the simplest level, the values of the two variables were highly correlated in a recent analysis of data from ~20 000 participants in the National Health and Nutrition Survey (NHANES) from 1988–1994 and 1999–2000. More specifically, the r values were >0.9 in every subgroup analyzed and were essentially identical irrespective of differences in sex, age, or ethnicity.
You can read Reaven’s full objection in the journal Clinical Chemistry.
Michelin is stepping in and saying “All fat men and women need to lose weight or take a de facto pay cut of $1,000 per year,” except they’re dredging for fatties using a flawed metric and demanding a treatment that does not lead to “substantial clinical benefit” in those fat people who are not insulin resistant. Most importantly, though, is that even if they do get all their fat employees to go on diets, there is not one single weight loss method that shows the kind of long-term success rates that would pay off for Michelin in the long-term.
With zero evidence to back up their efforts, Michelin has launched one of the most intrusive and ineffectual employer wellness initiative ever developed, and this experiment in controlling healthcare costs is being conducted at the expense of their employees. Even worse, this is becoming the new normal for employers.
But even setting aside the flawed metrics and lack of solutions, this is out-and-out discrimination. They are singling out heavy employees for targeted health interventions, when similar health interventions aren’t forced upon their thin counterparts. I do not see any suggestion that Michelin will pressure health improvements from employees who smoke, drink, use drugs, practice unsafe sex, don’t get enough sleep or drive recklessly. And yet, all of these choices (if we’re assuming that being fat is a choice) contribute both to the poor health of employees and the cost of healthcare.
The reason Michelin will not go after other health choices is that if they did, Americans would overwhelming reject this as a gross invasion of privacy. Michelin and CVS are counting on the panic surrounding obesity to give them cover while they enact legal discrimination against fat employees
If Michelin is really, truly concerned about reigning in healthcare costs, then maybe they should do something about the gouging of our for-profit system by the device manufacturers and the pharmaceutical companies, rather than scapegoating fat people.
If you feel the same way, I encourage you to sign both the CVS Pharmacies and Michelin North America petitions, and to contact Michelin’s leadership team directly to let them know how you feel. If you need an idea of what to say, check out this letter I wrote to CVS management with a list of questions about their program. And as always, please spread the word about our petitions. THANK YOU!
Chief Human Resources Officer and Executive Vice President of Personnel
Executive Vice President
Managing General Partner of Michelin Group
Michael Ian Fanning
Vice President of Corporate Affairs
Director of External Communications
External Communications Coordinator
Director of Consumer Public Relations, Passenger Car & Light Truck
Public Relations Manager, BFGoodrich