Ergonomic Strategies for the Rising Rate of Obesity in America’s Workforce Engineering, Psychosocial and Post Claim Analysis to Reduce Risk

June 2011

Aon Risk Solutions | Global Risk Consulting © 2011 – Aon Corporation

Brief Description: This white paper has been prepared to review the rising trend of obesity in the U.S. and the impact that this may have specifically to the ergonomic strategies within organizations. After a discussion on the background and impact of obesity, this paper will analyze and develop strategies for addressing pre- and post- claim ergonomic solutions for the overweight and obese population.

Co Authors: Vicki Missar, Associate Director; Gail Gilmore, Senior Consultant; Jodi Glunz, Senior Consultant

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 1

Aon Ergonomics Ergonomics, as defined by the Board of Certification for Professional Ergonomists (BCPE), "is a body of knowledge about human abilities, human limitations and human characteristics that are relevant to design. Ergonomic design is the application of this body of knowledge to the design of tools, machines, systems, tasks, jobs, and environments for safe, comfortable and effective human use" (BCPE, 1993). The goal of ergonomics is to decrease risk of injury/illness, enhance worker productivity, and improve the quality of work life. Aon’s approach is to combine the body of knowledge with metrics-driven goals and objectives to yield significant returns on our client’s investment. This white paper has been prepared to review the rising trend of obesity in the U.S. and the impact that this may have specifically to the ergonomics strategies within organizations. After a discussion on the background and impact of obesity, this paper will analyze and develop strategies for addressing pre- and post- claim ergonomics solutions for the overweight and obese population.

Background According to the Center for Disease Control and Prevention (CDC), over the past 20 years, the United States has seen a dramatic increase in obesity among its population. The colored state map (below) shows the prevalence rate of obesity in 1985

1. As shown, in the 24 years prior, five percent or less of the U.S. population was considered obese. Now compare that map with the second map (BRFSS 2009) where 33 states had a prevalence rate of obesity equal to or greater than 25% in 2009. As a result of these staggering statistics, there has been a significant effort on the part of U.S. government, health agencies and other entities to drive education and reduction of this leading health risk. Further, this problem is not endemic to the U.S. The International Obesity Taskforce estimates that approximately one billion adults are overweight, causing the World Health Organization (WHO) to create a global strategy on Diet, Physical Activity and Health. 2

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 2

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 3

Obesity is creating a toll on the health care system as well. Obesity, in the simplest terms, is an abnormal accumulation of fat. A common measure of weight is referred to as BMI. BMI is a ratio of weight to height squared and provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems.16 The medical impact on an obese individual with a body mass index of 30 or higher or an overweight individual (BMI of 25 or higher) is equally disconcerting given that an abnormal accumulation of fat taxes the body. Complications and health problems include: coronary heart disease, Type 2 diabetes, cancers (endometrial, breast, and colon), hypertension (high blood pressure), dyslipidemia (e.g., high total cholesterol or high levels of triglycerides), stroke, liver and gallbladder diseases, and osteoarthritis, to name just a few. According to Finkelstein et al. (2009) 3, one percent of the GDP, or $147 billion dollars per year, is spent treating obesity-related ailments and obesity was responsible for 27% of the rise in inflation-adjusted health spending between 1987 and 2001. In addition, these researchers found that across all payers (Medicare, Medicade, Private Pay, etc.), per capita spending for the obese individual is $1,429 higher per year, or roughly 42% more compared to that for someone of normal weight. Overweight (OW) and obese (OB) individuals are not only affecting the health and well-being of the U.S. population in general, but they are also significantly impacting the U.S. workforce. According to Workforce Management 4, an online magazine published by Crane Communications Inc., the obesity epidemic costs U.S. private employers an estimated $45 billion per year in medical expenditures and worker absenteeism.

The Workforce Management report also found that obesity was associated with a 36% increase in health-care spending, which is higher than what is associated with spending on smoking. Further, Duke University conducted a study published in the Archives of Internal Medicine in 2007 5 which found that obese individuals experienced more than twice the number of claims than their “recommended-weight” employees (11.65 claims per 100 Full Time Employees (FTE) compared to 5.80 claims per FTE). In addition, the study found medical claim costs, lost workdays and indemnity claims costs were higher among obese claimants, and the claims most strongly affected included ergonomic-related stressors resulting in pain or inflammation and strain or sprain-related injuries. As noted in the Duke University study, once a claim is filed, the cost of medical care and indemnity can be nearly seven times that for a recommended weight employee. This is due, in part, to the fact that OW/OB individuals are often plagued by underlying pre-existing conditions that make it difficult to effectively treat the work-related injury.

With the rising trends in OW/OB employees impacting the workforce, what can an employer do to reduce the impact of these costs? Since ergonomic-related stressors have been shown to be a significant loss driver for this population, this white paper will focus on ergonomics risk reduction strategies as it relates to the OW/OB workforce. Research has found that obesity is often accompanied by excess fat storage in tissues (other than fat tissue), including liver and skeletal muscle, which may stimulate inflammation that causes or aggravates a large number of diseases. 17 As ergonomists, we can expect to see a greater number of musculoskeletal injuries given this potential outcome of OW/OB individuals. So, what can we do?

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 4

Preventative Ergonomics and OW/OB Workers

The OW/OB worker will require a whole range of different ergonomics considerations compared to a recommended weight individual. Think about this... a 5’ 5” individual of normal body weight on the upper end of the scale weighs 149 lbs. An overweight individual of the same height is carrying 31 pounds more while performing the same job. Now consider that the obese individual is carrying 93 pounds more than the normal weight individual and the impact of obesity is obvious and significant. As shown below, there is a significant difference in abdominal depth for a normal individual compared to an obese individual, which adds a whole new dimension to criteria for reaching.

While BMI is a widely used measure in the OW/OB category, waist circumference is another means of measuring OW/OB, particularly from an ergonomics perspective. A waistline of more than 40 inches for men, or 35 inches for women has been linked to heart disease, respiratory illnesses and other illnesses 6. Results have shown that regardless of BMI score, those with larger waist sizes are at greater risk of weight-related health issues. (Numbers pertaining to waist circumference and the subject’s height and weight were used to come to an understanding about waist sizes). Rather unsurprisingly, studies reveal that people with a larger waistline face a bigger risk of disease or malady as compared to those that have a more trim body frame. Waist measurement, even in children, can accurately forecast who is likely to develop metabolic syndrome, a condition defined not only by waist size, but also by the presence of two or more additional health problems, i.e., high blood pressure, high cholesterol, high triglycerides, or insulin resistance. Metabolic syndrome significantly increases the risk of heart disease and leads to an early onset of Type 2 diabetes 7.

Those with a higher BMI also incur higher medical costs, as in the published numbers. Patients with 41-inch waists pay about $2,600 more per year in annual medical expenses than those with 32-inch waists, according to a 2002 study in the journal Obesity Research 8. Larger waistlines can lead to more frequent lower back pain, greater breathing difficulties, and persistent cough, compared with people with less abdominal fat.

As stated previously, the anthropometrics of the OW/OB employee are different in terms of waist circumference, which can impact inherent factors of the workstation design. A larger waist circumference can create additional distances and require an extended reach at the work station, as shown below. For

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 5

example, an individual male with a waist circumference of 40 inches will have different workstation requirements than a male with a 34 inch circumference. Ergonomics practitioners applying design guidelines need to assess and adjust anthropometric guidelines for the OW/OB population since the standard “average” population anthropometry may not address this rising trend.

Figure 1: Abdominal depth of normal weight person compared to OW/OB individual in relation to reaching distances.

The additional protrusion of the waist increases a torque on the spine, adding greater weight-bearing requirements to the lower back, as well as the reaching challenges for the OW/OB individual. Consider a worker with a backpack containing 31 or 93 additional pounds. Now imagine this worker performing the same job as a normal weight individual. This additional weight may create general physical issues including poor mobility, increased joint pain, and challenges when bending, stooping, lifting, reaching, balancing, pushing/pulling, and others. As shown in the biomechanical model analysis (below) using the 3 Dimensional Static Strength Prediction Program from the University of Michigan, the impact of OW/OB is clear. The strain of the additional weight makes lifting a 20 lb. box an issue for the knees, thereby creating a potential injury risk. Thus, the “lift with your legs” model taught in many ergonomics training programs may not be optimal if the individual is OW/OB given the other inherent strength capability issues that can result in the lower extremities, e.g., the knees. Thus, although research has found that lifting with your legs and back as a unit provides additional strength and stability when lifting a load, an obese individual may be at greater risk of knee injury by nature of their anthropometry. Furthermore, straddling the load may be necessary, and the OW/OB worker may not have this ability. The employer should consider migrating to a policy of no floor-level storage and ensure objects are placed at thigh level to waist level to avoid low level material handling scenarios.

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 6

Figure 2: 3DSSP model showing an average female and an OW/OB female performing the same lift. Note the knees are at an unacceptable strength capability level indicating a risk of injury in this joint for and OW/OB individual.

As shown above, the OW/OB individual or workforce brings unique ergonomics complexities into the equation. Just as global ergonomics programs have to consider population differences in various countries (e.g., height differentials), programs should also consider the following when dealing with an OW/OB population or individual:

1) Understand the workforce dynamics and plan for population variations

2) Apply necessary adjustments in the anthropometric standards when designing for a OW/OB

individual or workforce or workstation

3) Improve layouts and workflow for enhanced efficiencies

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 7

4) Maximize or implement 5S program to address organization and order in an effort to reduce

wasted motion and unnecessary steps

5) Use time/motion studies or spaghetti diagrams to further refine human efficiency opportunities

6) Evaluate material weight and placement for eliminating manual material handling exposures

including overhead reaching and floor level lifting

7) Establish policies and procedures for ergonomics standards and design guidelines for consistent

implementation throughout the organization

8) Determine accommodations necessary for OW/OB populations including chairs, supply locations,

walking distances to accomplish tasks, seated versus standing tasks, anti-fatigue equipment,

vibration dampening opportunities and others.

9) Structured job rotation programs that include job enlargement, skill expansion and variation in

time spent of various activities. For OW/OB population where engineering controls may be

limited, a formal job rotation program that moves employees through other jobs will help maintain

a flexible workforce while allowing employees to alternate through different physical exertions.

10) Partner with the non-occupation program to include ergonomics tools and techniques for

employees while at home. This can include tips on computer use, gardening and other activities

where ergonomics can be addressed.

By addressing the physical elements of workplace design in relation to the OW/OB individual or workforce, the ergonomics program helps further the reduction and elimination of workplace ergonomics risk factors. This will go a long way to maintaining a healthy, injury-free workforce. Aon has a team of highly qualified, board-certified professional ergonomists capable of fine tuning a company’s ergonomics program to address OW/OB populations.

Psychosocial Impacts of OW/OB Benjamin Franklin is credited with coining the proverb “an ounce of prevention is worth a pound of cure” and this is true for management of work-related mental stress disorders. The National Council on Compensation Insurance (NCCI) found that OW/OB workers have reduced work performance and that this performance deteriorates as the number of medical conditions increases. Furthermore, studies have shown that obesity is linked to millions of lost work days as well as millions of work days with restricted activity. Stress also contributes to the development of OW/OB individuals.

When OW/OB employees are exposed to stressors besides current health conditions, their bodies’ hormones and nervous system prepare for a “fight or flight response.” This leads to elevated heart rate

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 8

and diversion of blood to muscles that impact both the cardiovascular and immune systems. Employers need to understand that stressors in either work or non-work environments can potentially impact an individual’s performance in other life roles. Regardless of the risk factors, early recognition and intervention are crucial to minimizing the degree of associated disability. Psychological stressors are diverse and often difficult to isolate. Additionally, an individual’s psychological response to potential stressors will also depend on the individual’s personality traits and coping skills, and support systems available within his/her environment.

Obesity is not regarded as a psychiatric disorder, and therefore is not listed in the DSM-IVR as a psychiatric illness. The risk of obesity is higher in patients with psychiatric disorders than in individuals without psychiatric disorders. There are three types of workers compensation claims that can result: 1) Mental-physical – mental stress that causes physical injury; 2) Mental-mental – emotional disability without physical injury; and 3) Physical-mental – an emotional reaction to a physical injury. OB/OW employees are more prone to physical injury given their mental component. Many studies have shown that when employers are going through a layoff, employee tension levels peak and employees binge on unhealthy food, eat at their desks, and refrain from physical activity during lunch breaks fearing repercussions. Also, after a stressful day at work, some employees watch TV and “pig out”. Studies have shown that watching TV for long periods of time is associated with being overweight.

The takeaway for vigilant employers:

Promote good coping skills for stressful time

Develop wellness programs for employees

Provide weight management programs

Provide an Employee Assistance Program (EAP)

Change management and work stress coping strategies (i.e. Surviving layoffs and reorganizations)

Work-life balance and job satisfaction

Employee fitness programs

Employers who understand the psychosocial aspects and necessity of the above programs will find themselves not only saving money, but also providing a better and healthier workplace for their employees.

Post-Claim Ergonomics: Validating the Claim Aon’s Musculoskeletal Claim Validation (MCV) approach helps employers validate claims submitted by their employees. Medical costs associated with workers compensation claims are steadily increasing. A study by the National Council on Compensation Insurance (NCCI) 9 showed that medical costs accounted for 45% of the total claim costs in 1986. In 2006, NCCI found that medical costs accounted for 59% of the total claim costs, representing a 31% increase. In 2009, the NCCI study showed that medical costs

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 9

continued to outpace the Medical Consumer Price Index. Aon’s own research on cases referred to our MCV services showed the following:

1. OW/OB accounted for 56.52% more MCV claims than non OW/OB claims.

2. OW/OB denied MCV claims still cost 58.94% more in total incurred costs that non-OW/OB denied

MCV claims.

3. OW/OB accepted MCV claims cost 177.11% more in total incurred costs than non-OW/OB

accepted MCV claims.

A recent study in the Journal of Occupational and Environmental Medicine 10 reported that 50% of OW/OB individuals reported one to three leading heart/circulatory-related illnesses and more than 30% reported two or more illnesses. In addition, a study in the Archives of Internal Medicine 11 showed that medical and indemnity costs were more than double for obese workers than for normal weight individuals. Thus, determining whether the claim is valid will help ensure the following: 1) the risk factors were or were not present to cause a work-related musculoskeletal disorder; 2) the employee’s issues are covered under the appropriate program (workers compensation or major medical). In 35 states, Aon has assisted clients in validating a questionable work-related musculoskeletal injury and providing the adjuster with a tool to adjudicate the case.

Thus, this impact of OW/OB on the workers compensation system is pronounced, and when an employer questions the work-relatedness of a musculoskeletal claim, Aon has a proven tool to assist employers in this determination.

Conclusions The U.S. – and global – workforce has been dramatically affected by the OW/OB epidemic. Higher absenteeism and higher medical and workers compensation costs aside, there are human factor approaches that can assist in mitigating risk factors. While robust wellness and structured EAP programs are effective, our paper presents ergonomics interventions and recommended strategies for the OW/OB population. Utilizing Board Certified Ergonomists to develop a pre- and post- loss strategy is one tool to assist organizations is preventing musculoskeletal injuries for OW/OB employees. Designing for the normal population may not apply as this epidemic continues, and the one-size-fits-all workstation implementation programs may not be appropriate, or at best, must be adjusted to the OW/OB employee trends within the organization.

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 10

References 1. http://www.cdc.gov/obesity/data/trends.html 2. http://www.who.int/topics/obesity/en/ 3. http://obesity.procon.org/sourcefiles/FinkelsteinAnnualMedicalSpending.pdf 4. http://www.workforce.com/section/00/article/25/46/91.html 5. http://archinte.ama-assn.org/cgi/reprint/167/8/766 6. http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm 7. http://care.diabetesjournals.org/content/29/2/404.full.pdf 8. http://www.nature.com/oby/journal/v14/n4/full/oby200683a.html 9. http://www.propertycasualty360.com/2010/10/15/ncci-releases-2009-wc-claims-study# 10. http://journals.lww.com/joem/Abstract/2010/10000/The_Costs_of_Obesity_in_the_Workplace.4.aspx 11. http://www.lexisnexis.com/community/workerscompensationlaw/blogs/workerscompensationlawblog/a

rchive/2010/03/27/the-impact-of-obesity-on-the-resolution-of-workers-compensation-claims.aspx 12. http://www.ncbi.nlm.nih.gov/pubmed/20858984 13. http://psychcentral.com/lib/2007/coping-with-job-stress/ 14. http://www.ccohs.ca/oshanswers/psychosocial/stress.html 15. http://www.cdc.gov/healthyweight/assessing/bmi/ 16. http://www.sharecare.com/question/how-does-obesity-affect-body

Contact Information

Vicki Missar Associate Director AGRC +1.469.867.6196 vicki.missar@aon.com Jodi Glunz Senior Consultant AGRC +1.414.336.6686 jodi.glunz@aon.com Gail Gilmore Senior Consultant AGRC +1.818.523.3249 gail.gilmore@aon.com

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 11

Aon Risk Solutions | Global Risk Consulting | Casualty Risk Control Proprietary & Confidential 12

About Aon

Aon Corporation (NYSE: AON) is the leading global provider of risk management services, insurance and reinsurance brokerage, and human capital consulting. Through its more than 59,000 colleagues worldwide, Aon delivers distinctive client value via innovative and effective risk management and workforce productivity solutions. Aon's industry-leading global resources and technical expertise are delivered locally through more than 500 offices in more than 120 countries. Named the world's best broker by Euromoney Magazine's 2008, 2009 and 2010 Insurance Survey, Aon also ranked highest on Business Insurance's listing of the world's largest insurance brokers based on commercial retail, wholesale, reinsurance and personal lines brokerage revenues in 2008 and 2009. Visit www.aon.com for more information.

Disclaimer Aon Global Risk Consulting (AGRC), the global risk consulting division of Aon Risk Solutions, delivers Ergonomic and related services.

Copyright 2011 Aon Inc. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any way or by any means, including photocopying or recording, without the written permission of the copyright holder, application for which should be addressed to the copyright holder.