Diabesity:Diabesity:How Diabetes and Obesity How Diabetes and Obesity

Are Changing Workers’ Comp Are Changing Workers’ Comp

SCWCEA 2009SCWCEA 2009

Brian J. Caveney, MD, JD, MPHBrian J. Caveney, MD, JD, MPH

Duke Occupational & Environmental MedicineDuke Occupational & Environmental Medicine

ObjectivesObjectives

epidemiology of obesity & diabetes epidemiology of obesity & diabetes

economic and legal impact on employerseconomic and legal impact on employers

risk of work injuryrisk of work injury

difficulties in causation analysisdifficulties in causation analysis

challenges in addressing obesity & challenges in addressing obesity & diabetes lifestyle factors & RTWdiabetes lifestyle factors & RTW

© www.cutweight.org

© Center for Consumer Freedom

© www.popular-pics.com

Obesity in Adults - 2007Obesity in Adults - 2007

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

© CDC, BRFSS, 2007© CDC, BRFSS, 2007

Obesity Prevalence in The U.S.Obesity Prevalence in The U.S.

46%

56%

65% 66%

75%

14%

23%31%

34%41%

15% 15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1976 - 1980 1988 - 1994 1999 - 2000 current 2015 Est.

overweight (BMI >25) obese (BMI > 30) HP 2010 Goal

Sources: Flegal et al. JAMA 2002; Wang et al, Epidemiologic Reviews 2007

0

1

2

3

4

5

6

7

1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06

Year

Per

cen

t w

ith

Dia

bet

es

0

2

4

6

8

10

12

14

16

18

20

Nu

mer

wit

h D

iab

etes

(M

illi

on

s)Percent with Diabetes

Number with Diabetes

Number and Percentage of U.S. Population with Diagnosed Diabetes

Source: CDC at http://www.cdc.gov/diabetes/statistics

Life ExpectancyLife Expectancy

““the steady rise in life expectancy during the the steady rise in life expectancy during the past two centuries may soon come to an end.”past two centuries may soon come to an end.”

► Olshansky et al., NEJM, 352(11): 1138-1145 (2005)Olshansky et al., NEJM, 352(11): 1138-1145 (2005)

Just 30 # overweightJust 30 # overweight 1 - 6 YLL1 - 6 YLL20 yo WM 100 #20 yo WM 100 # up to 13 YLL up to 13 YLL20 yo BM BMI > 4520 yo BM BMI > 45 11 - 20 YLL11 - 20 YLL

► Fontaine et alFontaine et al., JAMA., JAMA 289: 187-193 (2003) 289: 187-193 (2003)

►Morbidity: obesity = 20 years of aging!Morbidity: obesity = 20 years of aging!

Health Risks Associated with ObesityHealth Risks Associated with Obesity

Premature deathPremature deathType 2 diabetesType 2 diabetesHeart diseaseHeart diseaseHigh blood cholesterolHigh blood cholesterolStrokeStrokeHypertensionHypertensionGallbladder diseaseGallbladder diseaseOsteoarthritis Osteoarthritis (degeneration of cartilage (degeneration of cartilage and bone in joints)and bone in joints)Sleep apneaSleep apneaAsthmaAsthmaBreathing problemsBreathing problemsIncreased surgical riskIncreased surgical risk

Cancer (endometrial, colon, Cancer (endometrial, colon, kidney, gallbladder, and kidney, gallbladder, and post-menopausal breast post-menopausal breast cancer)cancer)Complications of pregnancyComplications of pregnancyMenstrual irregularitiesMenstrual irregularitiesHirsutism (presence of Hirsutism (presence of excess body and facial hair)excess body and facial hair)Stress incontinence (urine Stress incontinence (urine leakage caused by weak leakage caused by weak pelvic-floor muscles)pelvic-floor muscles)Psychological disorders Psychological disorders such as depressionsuch as depressionPsychological difficulties Psychological difficulties due to social stigmatizationdue to social stigmatization

Obesity is Associated with an Increased Risk of:

(Adapted from http://win.niddk.nih.gov/statistics/index.htm)

How Much Does Obesity Cost?How Much Does Obesity Cost?

Estimated $200 billion / year U.S. aloneEstimated $200 billion / year U.S. alone

Over Over 10%10% of all health care costs (20% by 2020) of all health care costs (20% by 2020)

Up to 60% of the cost of diabetesUp to 60% of the cost of diabetes

27% of health insurance increase (1987 – 200127% of health insurance increase (1987 – 2001))Average taxpayer = $175 (Med/Med)Average taxpayer = $175 (Med/Med)

CDC CDC << 400,000 deaths per year in U.S. 400,000 deaths per year in U.S.

Add. 350M gallons jet fuel last 10 yearsAdd. 350M gallons jet fuel last 10 years

Revert to 1998 - $254B to GDPRevert to 1998 - $254B to GDP

% increase in health costs% increase in health costs

Age

Smoking Obesity

%

Source: PLoS Med 5(2):242 (2008)

Other Costs in the WorkplaceOther Costs in the Workplace

2 - 3 X the sick days & other measures of 2 - 3 X the sick days & other measures of absenteeismabsenteeism

Up to 3 X likelihood of disabilityUp to 3 X likelihood of disability

Decreased productivity (presenteeism)Decreased productivity (presenteeism)

Increased group life & disability premiumsIncreased group life & disability premiums

Decreased morale & cooperationDecreased morale & cooperation

Major Workers’ Compensation implicationsMajor Workers’ Compensation implications

Source: Schmier et al, Scand J Work Env Health 2006

Missed Work Days by BMIMissed Work Days by BMI

Source: Am. J Health Prom. 20(1): 45-51 (2005)

Costs of DiabetesCosts of Diabetes

$174 – 200 Billion/year$174 – 200 Billion/year

1 of every 5 health care dollars spent on 1 of every 5 health care dollars spent on diabeticsdiabetics

2.3 X cost of non-diabetics 2.3 X cost of non-diabetics ($ 6649/yr($ 6649/yr))

1 million more Dxs per year1 million more Dxs per year

1/3 will develop in lifetime1/3 will develop in lifetime

Productivity loss of 6.6% (14 days/year)Productivity loss of 6.6% (14 days/year)Source: American Diabetes Association Stmt (2008)Source: American Diabetes Association Stmt (2008)

HealthFactors

Anxiety/Stress

Job

Factors!

Economy/Financial/Home/Life/Personal

Sleep, physical, mental

Other workplace impactsOther workplace impacts

Sleep apnea – recovery, CDLs shiftwork Sleep apnea – recovery, CDLs shiftwork

Arthritis – each 2# gain, 9-13% riskArthritis – each 2# gain, 9-13% risk

Diabetes – recovery time, wound healing, Diabetes – recovery time, wound healing, CDLs and shift workCDLs and shift work

Heat intolerance – WC casesHeat intolerance – WC cases

Response to neurotoxins/pesticidesResponse to neurotoxins/pesticides

Carpal tunnel syndrome - causationCarpal tunnel syndrome - causationfrom Schulte et al., AJPH 2007

Odds of Incurring an Acute Sprain or Strain

11.49

2.22

3.79

00.5

11.5

22.5

33.5

4

BMI < 25 BMI 25 - 30 BMI 30 - 40 BMI > 40

odds ratio

Source: Pollack et al. A J Epi 166(2) 2007

Hopkins Analysis of AlcoaHopkins Analysis of Alcoa

Ostbye, T. et al. Arch Intern Med 2007;167:766-773

Ostbye, T. et al. Arch Intern Med 2007;167:766-773

Mean Indemnity Claims Costs, Medical Claims Costs, and Number of Lost

Workdays per Claim by Body Mass Index (BMI) Category

11x

7x

13x

Normal BMI

Increased Cost by Length of Claim, Obese vs. Non-Obese Claimant

12.8

4.55.3

0123456

0 12 36 60months

clai

m c

ost

mu

ltip

le

Source: adapted from Laws C and Schmid F. Reserving in the Age of Obesity. © Copyright 2009 National Council on Compensation Insurance, Inc.

Sprague v. SAIFSprague v. SAIF

Sprague injures knee in 1976, again 1999Sprague injures knee in 1976, again 1999

Gained > 100 # in interim, devel. arthritisGained > 100 # in interim, devel. arthritis

Surgeons would not operate b/c wt.Surgeons would not operate b/c wt.

Had gastric bypass to reduce weight to Had gastric bypass to reduce weight to undergo knee surgeryundergo knee surgery

Couldn’t argue inj. caused obesity, but that Couldn’t argue inj. caused obesity, but that tx for obesity necessary to tx injurytx for obesity necessary to tx injury

Indiana, NC, etc…Indiana, NC, etc…

Oregon W.C. Board A133701

5 Models of the Interrelationships of Work, Obesity, and Disease

•Causation

•Exacerbation

•Apportionment

© Schulte et al., AJPH 2007

Diabetic complicationsDiabetic complications

Increased likelihood of many conditionsIncreased likelihood of many conditions

Harder treatment – medication tolerability, Harder treatment – medication tolerability, procedure risk, wound healingprocedure risk, wound healing

ADA Statement on EmploymentADA Statement on Employment ““Diabetes usually has no effect on an individual’s Diabetes usually has no effect on an individual’s

ability to do a particular job.”ability to do a particular job.” Capacity to judge safety difficultCapacity to judge safety difficult Hypo- vs. hyperglycemiaHypo- vs. hyperglycemia ““certain types of work schedules…can make it difficult certain types of work schedules…can make it difficult

…to manage diabetes effectively.”…to manage diabetes effectively.”

Prevalence of Mobility LimitationsPrevalence of Mobility Limitations

Source: CDC

Prevalence of mobility limitation by agePrevalence of mobility limitation by age

Source: CDC

Diabetic adult self-report: at least 1 Diabetic adult self-report: at least 1 day in last 30 (2004)day in last 30 (2004)

Source: CDC

Employer ResponseEmployer Response

IndividualIndividual Assume healthy and able to do jobAssume healthy and able to do job Robust ADA review processRobust ADA review process Get the right people for the jobGet the right people for the job

Job Level reviewJob Level review Know physical limits of each jobKnow physical limits of each job

Workplace Environment & BenefitsWorkplace Environment & Benefits

Carriers

Engineering/Operations

Facilities

HR/ Benefits

Legal

HealthPlan

Cafeteria

Management

Occ. Health

SAFETY

RISKMANAGE-

MENT

Duke Transition to FitnessDuke Transition to Fitness

WC claims with delayed recovery WC claims with delayed recovery

Transition “patient” to “wellness” Transition “patient” to “wellness”

⅓⅓ back, ¼ shoulder, others – most obeseback, ¼ shoulder, others – most obese

Free 3 months @ Duke Fitness Clubs with Free 3 months @ Duke Fitness Clubs with supervision, then on ownsupervision, then on own

94% satisfaction, over 88% (2007) said 94% satisfaction, over 88% (2007) said likely to make long-term lifestyle changelikely to make long-term lifestyle change

Return to Work PlanReturn to Work Plan

Perhaps extra scrutiny for RTWPerhaps extra scrutiny for RTW

Nurse case manager involvementNurse case manager involvement

Can’t do selective FFDs by DxCan’t do selective FFDs by Dx

Equipment safety and checksEquipment safety and checks

Visibility Visibility

Tools, maneuverabilityTools, maneuverability

Risks for reinjuryRisks for reinjury

The Importance of ErgonomicsThe Importance of Ergonomics

Lift Assist Team @ DukeLift Assist Team @ Duke

Nurses, aides have Nurses, aides have high back injury rateshigh back injury rates

Staff plus equipment Staff plus equipment added to high risk added to high risk areas @ Dukeareas @ Duke

WC claims 50%WC claims 50%

Restricted Days 36%Restricted Days 36%

© Arjo, Inc.

Days missed or restricted with 6 Days missed or restricted with 6 Nutritionist Visits per yearNutritionist Visits per year

source: Wolf et. al., JOEM, Volume 51(2): 139-145 (Feb. 2009)

Future Trends…Future Trends…

Behavioral EconomicsBehavioral Economics

Legal Tests of WellnessLegal Tests of Wellness

Benefits CoordinationBenefits Coordination

ErgonomicsErgonomics

Job AnalysisJob Analysis

Broader cultural goalsBroader cultural goals

Societal interventionSocietal intervention

Employer-based health care?Employer-based health care?

Questions?Questions?

Brian J. Caveney, MD, JD, MPHBrian J. Caveney, MD, JD, MPH

Duke University Medical CenterDuke University Medical Center

brian.caveney@duke.edubrian.caveney@duke.edu