Healthy Lifestyles and Personal Responsibility∗

Healthy Lifestyles and Personal Responsibility∗


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VOL. 64, NO. 17, 2014


ISSN 0735-1097/$36.00



Healthy Lifestyles and Personal Responsibility* Paul A. Heidenreich, MD


he significant and growing cost of health care

taken, these 8 million patients will create a substan-

in the United States has centered attention

tial health and financial burden for the United States.

on avoidable medical expenditures. Hospi-

However, if we can identify the important com-

tals have been a major focus for reducing preventable

ponents of a healthy lifestyle, we can create in-

care, with Medicare imposing financial penalties if a

centives for patients to live a healthy life, reduce the

hospital’s 30-day all-cause readmission rate for heart

incidence of disease, and lower healthcare costs. In

failure and other select conditions is below the U.S.

this issue of the Journal, Agha et al. (6) identify

average (1). However, all sectors of the healthcare

important “lifestyle” predictors of the development

system are now targets for reducing waste, with pro-

of heart failure for women. They used data from a

viders asked to “choose wisely” (2) and patients

cohort of more than 84,000 post-menopausal women

financially rewarded by health plans for living a

from the Women’s Health Initiative who were free

“healthy life” (3). Although shared accountability for

of heart failure and provided information on their

health between the individual and the rest of the

lifestyle and subsequent outcomes. A healthy life-

healthcare system is worthwhile, we must know to


what extent any patient’s “lifestyle” is modifiable before we hold him or her financially responsible.

style score was created using 1 point each for not

A primary purpose for focusing on lifestyle is the

smoking, having a healthy diet, remaining physically

avoidance of chronic disease. According to recent

active, and maintaining a healthy body mass index

estimates, 58 million individuals in the United States

(BMI). The investigators found a strong relationship

are working with significant chronic illnesses, and the

between the healthy lifestyle score (0 to 4) and

cost of treating chronic disease accounts for up to 75%

the incidence of heart failure, which developed in

of national healthcare expenditures (3,4). Indirect

1,826 women over a mean follow-up of 11 years. The

costs attributable to time lost from work are also

results are all the more impressive in that they

substantial, 4 times higher for those with chronic


disease than for healthy employees (4).

Finland (7) and in U.S. males (8). The authors note






Heart failure in particular deserves attention given

that randomized trials promoting lifestyle inter-

that the cost of heart failure care is expected to more

ventions have been successful at decreasing cardio-

than double during the next 20 years because of the

vascular disease risk (9). Thus, we should be able to

aging of the U.S. population (5). By 2030, it is ex-

target these lifestyles to improve health and reduce

pected that 1 in 33 people in the United States will

cost of heart failure.

have heart failure (5). Unless preventive measures are

Holding patients and employees accountable for the health impact of their behaviors is growing in popularity. One of the largest U.S. employers, the grocery

*Editorials published in the Journal of the American College of Cardiology

store chain Safeway, has stated that it believes 70% of

reflect the views of the authors and do not necessarily represent the

healthcare costs are attributable to unhealthy behav-

views of JACC or the American College of Cardiology. From the Veterans Administration Palo Alto Healthcare System, Palo Alto, California, and the Stanford University School of Medicine, Stan-

iors (10). They estimated that an obese employee in 2011 would cost an additional $1,400 in healthcare

ford, California. Dr. Heidenreich has reported that he has no relationships

dollars annually compared with a nonobese employee.

relevant to the contents of this paper to disclose.

In addition, Safeway estimated that the unhealthy


JACC VOL. 64, NO. 17, 2014 OCTOBER 28, 2014:1786–8



preventable condition, and only 11% strongly agreed

cholesterol, and lack of exercise each cost an extra

that obesity had a genetic component. Approximately

$500 to $650 per employee per year (10). Michelin

half of the employers agreed or strongly agreed that

recently switched from providing credits for all em-

smokers should pay a higher premium; however, 25%

ployees participating in a plan for improving health to

also agreed or strongly agreed that obese employees

a stricter strategy that only provides rewards (up to

should pay a higher fraction of their healthcare costs

$1,000 off healthcare costs) if the employee meets

than nonobese employees.



Personal Responsibility








One of the goals of the Affordable Care Act was to

cholesterol, triglycerides, and waist size (11). It set the

prevent health plans from linking insurance pre-

waist circumference threshold at less than 35 inches

miums to health status (18); however, in its goal to

for women and 40 inches for men. If someone does not

improve wellness, the Affordable Care Act allows

meet the standard, they can receive a smaller credit if

employers a substantial amount of flexibility in

they sign up for a health-coaching program (11).

their programs that can financially penalize those

These financial incentives would be reasonable if

with poor biometric measures. It remains to be seen

everyone had a similar opportunity and ability to


reach the goal. But how much of obesity is a lifestyle

improving wellness without penalizing patients who

choice, and is holding everyone to the same stan-

have limited ability to improve because of genetic or

dard appropriate? The large increase in obesity in

other nonmodifiable factors.







Western countries in the past several decades has

We in the medical community need to do more to

been interpreted by some to indicate obesity is

combat the all too common view that poor health

largely due to a change in patient choices regarding

outcomes (high BMI, hypertension, hyperglycemia,

diet and physical activity. However, substantial

and hyperlipidemia) are simply due to poor health

hereditability for weight (80%) and BMI (70%) has

choices. Someday, we may know enough to person-

been found in twin studies (12). Even among chil-

alize incentives that account for genetic, socioeco-

dren born since the recent obesity “epidemic,” the

nomic, and other barriers an individual faces in

hereditability of childhood BMI is 60% (13). Genetic

attaining the recommended healthy lifestyle. For

differences also have been observed for taste of

now, we should limit employee and patient rewards

food (14), ability to exercise (15), and preference for

to healthy choices (diet, exercise, lack of smoking)

smoking (16).

and not equate these with healthy outcomes.

The findings of substantial genetic effects on BMI are in stark contrast to employers’ views on obesity


(17). Among 505 public and private employers sur-

Paul Heidenreich, Veterans Affairs Palo Alto Health Care

veyed in 2007, 93% believed obesity was the “result

System, 111C Cardiology, 3801 Miranda Avenue, Palo

of poor lifestyle choices,” 87% viewed obesity as a

Alto, California 94306. E-mail: [email protected]

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Personal Responsibility

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KEY WORDS cardiovascular diseases, primary prevention, risk factors