Binge drinking and childhood obesity will mean a changing climate for insurers in the years ahead, warns Professor Michael O'Donnell
As an industry, we are seeing a complete change in our understanding of the molecular biology of many illnesses. The march of progress means we are witnessing real advances in the treatment and prevention of heart disease and cancer.
The first drugs designed to be effective on specific tumours are coming on to the market. And with earlier and better treatment for heart disease, as well as much improved prevention, it is probable that in a few years' time, a heart attack will no longer be seen as a catastrophic event for most people.
However, there are some clouds on the horizon, including childhood obesity leading to adult obesity; binge drinking and how the problem of alcoholism can affect the workplace and metabolic syndrome - the phenomenon where obesity, diabetes, high blood pressure and high cholesterol combine.
The impact of these health problems, on employers and the wider insurance industry, will also be examined.
Drunken fights
We are all appalled by the scenes shown on television of gangs of drunken young people fighting and vomiting in city centres when the nightclubs throw them out.
Apart from the problems this behaviour creates for accident and emergency departments, there are long-term health issues. Between 1980 and 2000, there has been a 121% increase in the number of deaths from cirrhosis of the liver.
For employers there will be the financial burden of making adjustments to the workplace so people can remain in work, as well as the difficulties of filling vacancies as the proportion of the working age population with work capacity falls. With binge drinking, there are already difficulties faced by employers coping with absenteeism due to hangovers.
Furthermore, it is also estimated that up to 20% of workplace deaths are alcohol-related.
According to other studies, one in 12 employees has a drinking problem of some kind. The most recent British Household Survey showed that 26% of working men had consumed more than eight alcohol units (a unit is roughly half a pint, a small glass of wine or a single measure of spirits) in at least one day and that 14% of working women had consumed more than six units in a day.
Even lunchtime drinking or drinking before shifts can cause inefficiency, accidents and damage to customer relations.
But what can employers do about employees whose drinking adversely affects their work performance or their relationships with other employees?
Repeated but trivial absences from work on Mondays or Fridays or repeated episodes of time off for gastric problems or minor injuries are some of the key indicators.
However, even if a manager detects a possible link between absence and alcohol, they are often reluctant to confront it. Indeed, the manager should confine his or her remarks to the employee's actions, performance and conduct.
However, in the case of an employee who is suffering from an alcohol problem, doing nothing is short-sighted and potentially damaging to the workplace environment.
A US study on the cost effectiveness of treatment in industry showed remarkable gains for employees who had received treatment for their addiction or dependency. There was a 91% decrease in absenteeism, an 88% decrease in problems with supervisors, a 93% decrease in mistakes at work, a 97% decrease in workplace injuries and a 71% drop in injuries outside the workplace.
But prevention is always better than cure. The best approach for employers concerned about how to handle alcoholism in the workplace is to develop a written policy that sends a consistent message to all employees at every level. This policy should be emphasised and repeated at regular intervals, not just at the time of hiring.
There is a growing realisation, by employers and the insurance industry alike, that alcohol misuse and dependency problems in the workplace incur major costs.
However, early detection of employee alcohol abuse, followed by successful treatment by a professional therapist or doctor, can result in major gains in productivity and goodwill.
Low self-esteem
Current statistics suggest childhood obesity is at least four times more common than it was 30 years ago.
The Health Survey for England 2002 found one in six children aged between two and 15 was obese.
Childhood obesity is not simply a cosmetic problem. It can have an adverse impact on their developing sense of self and self-esteem.
As a result, obesity has been linked to low self-image, low self-confidence and even depression in some obese children.
Moreover, adolescent obesity is even more likely to persist into adulthood than childhood obesity. One study found that 69% of obese six- to nine-year-olds became obese adults compared with 83% of obese 10-14 year olds.
Most of the well-established risk factors for heart and circulatory diseases, including raised blood pressure, are present in overweight children. One recent US study found that nearly a third of overweight and obese adolescents had evidence of metabolic syndrome, which greatly increases the risk of diabetes, heart disease, stroke and some forms of cancer in adulthood.
The development of type II diabetes in children - a condition usually associated with middle-aged obese adults - is of particular concern, given the strong association between diabetes and cardiovascular disease, kidney failure, limb amputation and retinal damage leading to blindness. In some adolescent clinics, type II diabetes now represents up to half of new cases of diabetes.Despite the widespread belief that an increased consumption of junk food is to blame, there is evidence to suggest this is not the entire picture. Similarly, there is no good evidence that advertising has a substantial influence on children's food consumption. It seems that today's current epidemic of childhood obesity is primarily related to energy expenditure rather than energy intake.
Today, children expend about 600,000 fewer calories a day than children 50 years ago. Watching television and playing computer games contribute to a less active lifestyle and children are much less likely to walk to school. In a study of modern cities, over a third of children sampled spent less than five minutes walking each day.
The antidote to childhood obesity may be to find ways to increase children's activities in day-to-day life. One obvious way to do this would be to invest in safe walkways and cycle tracks so children could be physically active to and from school.
Another practical strategy would be to include a daily walk of 30 minutes in the school curriculum. In Toronto, children engaging in 60 minutes' activity a day during school time had better academic results than their relatively sedentary peers.
Active children are more likely to become active adults, avoiding health consequences associated with obesity.
Diabetes mellitus is characterised by raised blood sugar levels caused by either a lack of insulin in the blood or resistance to its mechanism of action in normally responsive tissues.
It is a common condition affecting 1-2% of the population. Around 90% of people with diabetes have type II diabetes, a disease that, until recently, was thought not to occur in children and young people, but began in adulthood and was associated with obesity.
However, type II diabetes is now beginning to be seen in children and young people due to the increase in childhood and adolescent obesity.
Compared with the non-diabetic population, there is a three- or four-fold increase in the risk of coronary heart disease and stroke and a 15-fold increase in the risk of losing lower limbs. Diabetes is also the commonest cause of blindness in the working population.
Cholesterol
Type II diabetes is often associated with obesity, raised cholesterol and high blood pressure. As such, "metabolic syndrome" (the phrase used to describe the collection of conditions associated with type II diabetes) may lead to an increase in coronary artery disease, strokes and peripheral blood vessel disease that cause so much of the increased mortality and morbidity in diabetes.
The good news is that the risk of these complications can be markedly reduced and perhaps prevented with appropriate intervention.
Studies have focused on improvements in the control of blood sugar, but there is also evidence that improvements in blood pressure control can be equally effective in reducing risk. Other studies have shown that lifestyle interventions, including changes in nutrition and increasing exercise, can also be effective. When it comes to lifestyle interventions, the major challenge is to convince people with diabetes they have a major role to play in ensuring they remain healthy.
Furthermore, how can people who are susceptible to diabetes - due to family history, low birth weight or obesity - be encouraged to lead a lifestyle that could prevent diabetes or significantly reduce the morbidity or mortality associated with it?
Patients must be encouraged to play active roles in the management of their disease and in the prevention of its complications, rather than being passive recipients of healthcare. The focus must be on solutions, not problems, and the general view is that something must be done to facilitate coherent and co-ordinated action across a wide number of areas. Behavioural change is the key to securing effective solutions to the public health challenge posed by obesity and its associated health problems.
Bio-psychosocial interventions are the key, not pharmaceutical intervention, which has its place but cannot be the long-term answer.
This approach necessitates an integrated strategy whereby health care professionals, employers, government and the individual patient work together.
Promoting healthier lifestyles, and preventing the onset of health problems related to obesity and excessive drinking, is perhaps the best way forward.
Employers may not have a responsibility to encourage staff to adopt healthy lifestyles - and workers have a responsibility to take their own health seriously - but employers can do much to promote healthy living by provision of healthy food and encouraging staff to take more exercise.
The evidence for the effectiveness of employer interventions is not yet solid.
However, such approaches demonstrate in a very concrete way that employers value their staff. Maybe it is not a question of whether employers should do something, but what would be the consequences of doing nothing?
Professor Michael O'Donnell is chief medical officer at UnumProvident.
COVER NOTES
- The rise in alcoholism, and its related health consequences, will become an increasing burden on society and will cause problems for employers and medical insurers.
- Drinking costs employers £6.4bn per year through absence, accidents and violence.
- Up to 17m working days a year are lost to alcohol-related sickness absence and up to 20 million days a year are lost through lower activity rates and increased mistakes due to alcohol consumption.
- The critical issue for insurers and society as a whole is that obese children are more likely to become obese adults. A recent study showed that 77% of obese children became obese adults.
- In the UK, the diabetic population is around 2.4 million and set to double in the next 10-15 years. Many of these new cases will be children.
- It is estimated that there are currently 150 million people with diabetes, and this is expected to double by 2025.
- The three healthcare issues - obesity, alcoholism and diabetes - are some of the most pressing concerns for the medical industry, the government and insurers.
