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Interview with Bill McBride about Fitness Delivery

Bill McBride is the co-founder and CEO of Active Sports Clubs. He is an industry veteran in the field of health and wellness, and has served as the Chairman of the Board of Directors for IHRSA, a Board Member on ACE’s Industry Advisory Panel, and currently serves as a Medical Wellness Advisor for the Medical Wellness Association. Bill also sits on the advisory board of several other companies including Fit3D, Club Solutions, Club Industry and previously has worked with Zuberance and MiGym. Bill has been a mentor of mine for several years. You can learn more about Bill at his personal website BMC3.com.


1) Given your vast experience in the wellness industry what are three universal truths in “getting it right” that apply to all fitness delivery (not just health clubs) that have surprised you in the sense that they are not industry standards?
  1. There is a lot of fitness delivery that is “contracted” on the assumption it is all homogeneous – a commodity. I need a clean “house”, so I hire a housekeeping company.  I need fitness, so I hire fitness people.  Fitness is very personal and people that are qualified and engaging are critical; but for a company, the brand delivery and standards that the brand represents are also critical.  Getting the right people on the bus, training, and “enrolling” fitness delivery professionals seems to be a constant challenge in all aspects of fitness delivery (regardless of distribution channel).  I am not surprised by this fact, but I am surprised by the slow progression in solving this problem on a broader scale.
  2. The true power of group fitness is often discussed and most people “get it”, but it hasn’t been truly leveraged as of yet. Think for example of “Debbie’s Class” – Debbie is a member.  Why not have a class just for Debbie and her friends?  Why not personalize group fitness further?  This could be done with school mom groups, civic groups (Girl Scouts), and neighborhood friends that walk together, etc.  Personalizing group fitness is rarely approached in this way. Approximately 44 percent of club members exercise with a friend. There is an opportunity there. 
  3. I’m surprised by how many health clubs look the same in regards to layout and offering. The lack of true differentiation and uniqueness in the space seems intriguing.  This is what Curves figured out earlier on.  We need different configurations and approaches to bring in new members. 

2) Why do you think the health club industry has not been more involved in the evolution of health technology? Only recently are you seeing health clubs really integrated with digital health devices, when the industry (as the experts in the area of wellness) could have had more of a hand in shaping these products?

Human nature seems to favor a scarcity mentality, instead of an abundance mentality.  I think club operators were (or in many cases are) afraid of outside “competition” that could cost them members.  Even my friends at MYZONE, whom I’m a big fan of, were reluctant to open their system for participants to download their data at home until recently.  I asked them over 4 years ago to open their system because I wanted our members to download and see their data in real time.  Their position back then was ‘no’, we want users to go to the club to download their data, this forces a club visit for our clients’ clubs/gyms. In their defense, they viewed their product as a club retention tool, not an activity increasing tool. While on the surface that may make some sense, just as scarcity mentality always seems to make sense in the short-term.  But long-term, an abundance mentality always wins out.  MYZONE came around and gave me some credit in their shift in thinking, but the world has already realized it’s a transparent, information-based reality now. Clubs have to realize this and embrace broader thinking as active lifestyles will always need professional human support.

3) You and I are both fans of Michael Porter. I just read Zero to One where Thiel builds off Porter’s ideas and suggests that the current entrepreneurial dogma of iterating off competitive ideas is a race to the bottom. In the book Thiel highlights using examples how perfect competition can destroy an industry. I believe a case could be made that is happening in the health clubs industry, especially anyone that goes up against the main chain operators. Where are people getting is right in the industry? Put another way, what are the common attributes of the players that are able to rise above the low cost health club model?

This is the million-dollar question.  The high-end that can’t be replicated with ease (cost of entry too high) will always serve a consumer need: Exclusive, lifestyle, family and prestige based. These companies create an emotional bond, evoke status and its members are brand connected and in many cases for generations (think Four Seasons, fine dining, etc.).  The low cost play will also have a steady stream (think fast food or Motel 6). It’s the accidental middle that are in the most trouble.  Middle price point players with a strong value proposition (reasonable but not low price) and a very controlled expense structure can do nicely if engineered properly.  Now for the current twist, we have the boutique offerings – not a high cost of entry, but a very high perceived service level.  In this modality, I think boutique hotel (Kimpton or Joie de Vivre).  These are high service offerings and very nice, but relatively small and some “nostalgically older”.  The concepts that are too trendy seem to be short-lived.  So anticipated trends versus modalities that stay around is another avenue of consideration worth thought. For example karate, yoga, Pilates and cycling have proven not to be trends. And how low can the low price point go? I heard recently of a $5 a month club.  At some point soon, I expect to see a “free” club model with all revenues and profits come from ancillary programming like retail, clothing lines and ads within the club. Free with premium offerings, or a play like Pact where you actually get paid to workout.  I agree with you that a large segment of the industry doesn’t appear to be working towards adaptation. 

4) Guessing that you do not think this question is an all or none proposition, how do you think the rapid expansion of workplace wellness programs, and the emergence of open access residential wellness solutions, will evolve how (and who) is providing fitness delivery today?

There are many corporate wellness companies in the space already.  The older ones are simply staffing agencies.  Nothing wrong with that, but there is an opportunity for the health club management providers to play a much bigger role than they do today.  Free fitness access is here in a lot of places and it will continue to grow.  Parks, trails, in hotels, on company campuses and residential complexes – access to activity and fitness is going to continue to rise.  Wellness is a nebulous term.  What does that mean?  Lifestyle engagement and promotion of activity through fitness, movement, sport and recreation will grow and prosper.  The industry (health club or health club/fitness center management) must realize the genie is getting out of the bottle..  Think abundant solutions and total well-being, not just fitness and not just what can accomplished in a single space.

5) I know you enjoy the guesses of futurists and are an inherent forward-thinker. Regarding fitness delivery, you wrote a great article for Club Insider (Are We Asking The Right Question?) where you answered the question, “what will be the same in ten years?” Your argument for taking this approach was it is a more compelling question than “what will be different in ten years?” This is probably true; however, it does leave me the opportunity open to ask it, “What will be different in how we will deliver fitness in ten years?”

I believe the industry will be forced to morph from sales and marketing with great facilities (as the current historic primary focus) and more towards programming, coaching, wellness/medical services in very engaging environments.  We will see different looking clubs (I hope) with much more holistic services and creative designs.  I envision it to Lifestyle Centers …not just rooms with equipment, as those rooms and outdoor spaces with equipment will be commonplace by then.  And not just studios to move around like we have today… It will be more about the “feeling” and “community”.  This is where technology and wellness/medical integration will be game changing.  I see more with wearables and digital health that support total well-being, disease management and prevention.  Technology that can help people form and maintain habits, make activity/exercise more “fun” or “tolerable” and support individuals utilizing wellness professionals to improve their quality of life.  A lot of people in our industry focus on results.  Results are a by-product of a great offering.  The focus should be on delivery and habits.  I do believe that great structural design, warm & friendly social activity and innovative programming will always be around …just as we will still have hotels for rooms away from home, and great restaurants for good meals on the go …but there will be disruption like hotels saw with the shared economy (Airbnb) and restaurants saw with social shopping (Groupon). There are big things on the horizon and I am excited for the future.

 

Interview with Dr. Robert Rucker about Nutrition and Academics

Dr. Robert Rucker is a Distinguished Professor Emeritus in the Department of Nutrition and the School of Medicine at the University of California at Davis. A list of his accomplishments include tenure as the President of American Society for Nutrition, an American Association for the Advancement of Science Fellow, as well as an American Society for Nutrition Fellow. Dr. Rucker has over 35 years of experience researching nutrition and biochemistry. He is also my father and is the ghostwriter for almost all of the pyrroloquinoline quinone (PQQ) content found on this website.


1) One of the debated topics in nutrition is whether weight management is really just a matter of calories in/calories out; or alternatively, significantly influenced by the types of calories that are consumed. Based on your rich understanding of nutrition and biochemistry, where have you landed on this debate?

This question is not as easy to address, as some would make it.  Energy regulation – the factors associated growth, work, and maintenance of body temperature – is complex and multifaceted.  Clearly when energy intake is less than needed, body tissue becomes a metabolic energy source; however, weight gain or loss as inferred from periodically weighing oneself on a scale is not a function of a simple algorithm, particularly in the short-term.  As it relates to weight gain or loss of body tissue, each of the major components contain differing amounts of energy.  For example, a pound of stored fat is ~ equivalent to 3600 kCal per pound.  Muscle tissue is the equivalent of 700-800 kCal per pound.  Independent of its water content, a well-nourished adult has about 400-500 grams or 1600- 2000 kcal of stored carbohydrates, mostly as liver and muscle glycogen.  When or how much of a given tissue is utilized as energy sources varies depending on the timing of meals, exercise, and a need to maintain body temperature. Utilizing tissue energy also causes varying amount of water release. Thus, 2-3 days of severe dieting (e.g., generating a 3000-4000 kCal deficit) could translate into a one-pound loss or a 5-7 pound loss, as measured on a bathroom scales, depending on factors in addition to only estimating calories-in minus calories-out.

Regarding diet composition, there are a number of scenarios wherein the composition of food also plays a role in net weight gain and loss.  An obvious one is a diet high in simple sugars, particularly fructose or high fructose corn serum (HFCS).  Our knowledge of the control energy homeostasis has increased dramatically over the last decade resulting in an appreciation that food or energy intake is orchestrated by complex signals originating from adipose tissue, the pancreas, and the gastrointestinal tract, plus others.  Differences in food composition can affect these signals, which in turn can influence food intake and body heat regulatory circuits.   With respect to fructose or HFCS, both are weak stimulators of insulin and the adipose-derived hormones that control food intake, in contrast to glucose, a much stronger stimulator.  Moreover, although fructose is eventually converted to glucose, the process is not rapid and fructose, as such, is not “stored”.  And, fructose is a better “driver” of triglyceride synthesis than glucose.  Add to this that body heat regulation is very precise.  Compounds, such as fructose, that are rapidly absorbed and are not easily sequestered or rapidly metabolized can compromise body heat regulation.  Thus, calories from fructose or HFCS are less likely to allow one’s metabolic system to regulate itself at least in the short term. 

What can happen? The liver slows oxidative metabolism when there are energy excesses, particularly if an abnormal elevation in the body core temperature can result.  What the liver may perceive as an excess of potentially hazardous fructose-derived calories are converted to triglyceride and next sequestered away in adipose as a protective strategy.  In this regard, some of the energy derived from fructose is rendered ‘out of the picture’ and may even result in some weight gain, because of its conversion and “storage” as fat.  

Again, these kinds of questions are not easily addressed.  An example that I sometimes use in lectures is that over the course of a year, most in the class will consume anywhere from ~ ½ to one million calories (at a daily expenditure of  ~1500 to 2500 kCal per day, which translates into consuming a ~ton of food per year).  Given that an annual normal weight gain or loss is usually no more than a pound or two, it says a lot about the exquisite precision of food intake regulation, as well as body mass and heat regulation.  Throw in dozens of genetic factors and other variables and it is easy to ascertain that there are good reasons for controversy and our inabilities to address (easily) weight management when it deemed important.

2) Given all that you have researched, what are the three most impressive compounds you have come across (other than PQQ)? You can choose either based on their historic significance and/or the fact you have been impressed by their demonstrated physiological benefit.

In the late 1700s – Antoine Lavoisier, the so-called “Father of Nutrition and Chemistry” described that metabolism and oxygen were inexorably linked.   He also demonstrated oxygen was related to animal heat production.  Accordingly, oxygen would be one of the molecules.  In the latter part of my career, concepts related to cell signaling and secondary signaling molecules begin to be major influences.  As a consequence, Nitric oxide (NO) and 3′-5′-cyclic adenosine monophosphate are two others that I would add.  NO is an important cellular signaling molecule involved in many physiological and pathological processes; cyclic-AMP works in part by triggering the activation of certain proteins involved in cell signaling.  Knowledge regarding their underlying mechanisms of action facilitated my way of thinking about the mechanisms of action of certain dietary biofactors, such as pyrroloquinoline quinone (PQQ).

3) As the world increasingly points to poor nutrition for the rise in healthcare costs, little has been done to improve the nutritional education in top-tier medical schools. You were a nutrition professor at a top-tier medical school. Why do you think this is?

A part of the answer is that there is no medical board certification for nutrition.  There are 24 boards that certify physician specialists.  Many hospitals demand that physicians must be board certified to practice or bill for a specialty.  Accordingly, when there are nutritional issues, they are usually handled by a paramedical (i.e. a dietitian or a nurse) or occasionally a pharmacist with nutrition as a sub-specialty.

With that said, many medical schools do give nutrition training some kind of “lip-service”, although it is often less than it used to be. Most medical schools have moved to more integrated curricula and problem-based learning. At Davis there used to be a strong course in nutrition, but as the Davis medical school curriculum became more and more integrated, the visibility of nutrition was truncated.  Regrettably, as long as nutrition remains as a non-board certified area, I don’t sense that there will be a move to make nutrition more visible, even though there is seldom an argument regarding its importance.

4) On the topic of research, some of the fondest conversations I’ve had with you are discussions regarding the thoughts of intellectuals who take either side of Thomas Kuhn’s work. We have discussed articles like The Truth Wears Off and books like Laboratory Life. Do you think there is “real world” truth to be found, or do you think as seekers of the “truth” we are tasked with inventing it?

As a starting point, I agree with Kuhn’s premise that scientific advances are characterized by dynamic shifts in thinking, i.e. what he defines as paradigms,  ” universally recognized scientific achievements that, for a time, provide model problems and solutions for a community of practitioners”.  In my life time, the major paradigm shifts that have most influence my thinking as a biologist have been: 1) the Watson and Crick model of DNA and its importance, 2) concepts related to cell signaling, 3) concepts important to epigenetics (changes in metabolic regulation caused by gene expression rather than an alteration of the genetic code itself), 4) polymorphisms  (metabolic changes caused by point mutations in a gene or genes), and descriptions based on metabolic allometric scaling (ways of describing how the characteristics of living creatures change with size).  If I were to note more fundamental principles – Darwinian evolution, the principles of thermodynamics applied to biology, and the concept of nutritional essentiality in the context of given nutrients or metabolic processes would be at the top of the list.  Each of these paradigms can be described historically in the context of Kuhn’s stages of scientific development, which ends with the establishment of concepts that truly influence changes in how we think about a problem.

Regarding ‘Are there real world truths to be found?’ I certainly hope so. However, to find such truths, I would argue that one has to engage in clear rational thinking directed at seeking out evidence for the truth; a process along the lines of what Richard Dawkins implies, when he emphasizes the importance of asking the right question.  In contrast, inventors of “truth” in my experience tend to be more concerned with faith, authority, or profit (in a broad context).

Although far less philosophical, the Jonah Lehrer article in the New Yorker, The Truth Wears Off, also provides some very important perspectives that – as you note – have been the topic of several of our discussions.  With respect to nutrition, this has been an interesting period, particularly as it relates to the assessment of validity and reliability of certain nutrition-related assertions and their presumed relationship to important health issues.  In some instances, our lack of rational thinking has caused some “true believers” to promise too much.  For a premise to become health policy, the data and observations behind it must be reliable and reproducible.  Unfortunately, we too often let belief and personal perceptions over ride the facts of a given question or premise. 

With regard to why there is so much controversy as it relates to nutrition, some reasons that are developed in the Lehrer article, such as those offered by John Ioannidis (e.g., Why most published research findings are false. 2005; PLoS Med 2: e124) are provocative.  However, they are mostly statistically in nature.  Now that we have larger and presumably better databases and better tools to examine them, plus the ability to ask better questions, it should not be surprising that some amount of previously published research may not be easily or consistently replicated.

I tend not to throw barbs, if the studies in question are complex in nature and initially were carried out for a good purpose.  As an example – In studies of osteopenic bone diseases, such as osteoporosis, the highest rates for hip fracture, as an outcome measure, are often observed in those of Scandinavian decent, who are located predominately in the North Central parts of the US. The lowest rates for hip fracture are observed in those of African decent, who are located predominately in the South.  Consequently, it is not unreasonable to surmise that observations related to hip fractures made 3-4 decades ago in studies performed in Minnesota or North Dakota may not match the results of similar studies, if repeated using a contemporary and highly diverse Californian or Floridian based subject pool, some of whom may be a blend of an identifiable Scandinavian and African-derived gene pool. Further, studies for purposes of comparisons are often difficult to match with respect to the age, sex, and/or activity levels of subjects.  It is now more difficult to control environmental and epigenetic factors than in the past, because of our ability and freedom to travel or consume more diverse diets.  With more genetically diverse subject populations and more complexity in lifestyle, there is greater likelihood that there may be regression to some kind of statistical mean, i.e. less significance noted in a study than may have been noted previously. 

Other issues are barriers that we have rightly put into place for the protection and more ethical treatment of subjects. For example, many of the early paper regarding basic human nutritional requirements were reasonably correct in their conclusions.  However, the studies were often performed using institutionalized individuals (prisoners or mental patients) who could be studied for long periods or subjected to metabolic risks using protocols that simply cannot be used today. 

The ways that we report and characterize research can also present problems. Current research often uses past research as a potential starting point or platform, i.e. Kuhn’s second level of discovery before an actual paradigm emerges.  However, most research (past and present) is/was not published unless its outcome demonstrates some type of statistically significant positive effect.  It is the common practice of most journals not to publish null or negative observations.  Again, it is not unreasonable that some current replications of past work may differ, particularly when there is a better sampling of subjects and use of improved analytical methods. 

More troubling to me is the mismanagement of data by those who should know better.  The reason why some health-oriented work cannot be reproduced is because it is the product of data dredging designed mostly to identify relationships with some arbitrary level of statistical significance. If the “data dredge” is merely a search for statistical significance, it is too easy to make wrong inferences.  There is little wrong in using an arbitrary statistical endpoint to better define a hypothesis or question, but to report such findings as facts without some type of independent conformation or validation is disingenuous at best.  More egregious, of course, is reporting only selected data in order to show some kind of statistically positive effect.  There is also dishonest reporting.  When I was more involved in journal editing and management, it was troubling to discovery that work using the same pool of subjects had been published in different formats in other journals.   The issue was not so much self-plagiarism or lack of consolidation; rather, it was the implication that the observation submitted to a given journal was from different sets of independent observations. The number of independent research papers on a given substance is sometimes used as a measure that the product is safe or efficacious. One may have a different opinion of efficacy or safety with the knowledge that the reported data was from a single set of subjects, rather than multiple independent sets of subjects and each reported in separate papers.

Regrettably, the commercial nutritional supplement business is perhaps the worst offender.  Very little research is done independently and most often is driven by marketing goals.  As we now know, it is possible to buy the results that you might want from some of the commercial research outlets for publication in one of the dozens of online journals, many of which serve as “vanity presses”.  The other areas that compromise good nutritional practice are the constraints placed on the policing of the supplement industry, because of the Dietary Supplement Health and Education Act and the impact of having it as a part of our National Institutes of Health, a National Center for Complementary and Alternative Medicine.  The Center’s goal is to support research and provide information about complementary health products and practice, but what it defines as evidence-based medicine often isn’t, and credibility is given to alternative concepts, where little is deserved.

5) Piggybacking off that, as I embark on my own journey aspiring to be an expert in the field of workplace wellness, based on your vast experience, what advice can you pass down to me as I continue the search for “truth” with a drive to contribute to the greater good?

Success, particularly the effective movement of ideas, is all about “networking”.   Bruno Latour and Steve Woolgar clearly make this point in their book, LABORATORY LIFE: The Construction of Scientific Facts. I was lucky enough to be mentored by individuals who can trace their academic history back to those who discovered or defined the functions of given vitamins or nutritionally essential minerals.  What was transferred to me, as a part of that network, was a way thinking; also the importance of maintaining a high integrity. It is also essential to have a thought out, as well as thoughtful, work plan; and, as Latour and Woolgar note, one’s credibility rests on whether you are perceived as reliable.  The challenge is to maintain integrity in workplaces (e.g., the commercial aspects of nutrition and wellness) that often talk about integrity and validly, but seldom want to test for it, and that are driven in large degree by the marketing of what are sometimes shallow promises.

 

Workplace Wellness | Moving Beyond Employee Health towards Employee Well-Being

“A happy worker is a productive worker” might sound like an overly simplistic maxim, but that does not make it invalid. Various business theoreticians, coaches, educators, “experts” and authors have explored the concept of employee wellness, realized its complexity and potential, and linked it to corporate sustainability and long-term success. Since the scope of workplace wellness (and general well-being) is so vast, employers are often left puzzled when deciding where to start and which areas to tackle.

Saw a habit, reap a character

In his seminal work, The 7 Habits of Highly Effective People, Stephen Covey discussed not only personal achievement, but character building as well. The influential Dr. Covey argued passionately that one needs to preserve and enhance oneself first, and that personal renewal takes time and dedication. It is also essential to the implementation of the other proposed habits (Covey, 1989). In other words, looking after your physical, social/emotional, mental and spiritual well-being (Covey’s four “self-renewal” areas) is his crucial 7th habit in the architected algorithm of business and personal success.

The concept of self-renewal goes well beyond simply “not being ill”. It is about finding the equilibrium that will enable one to live well, handle challenges (resilience), and produce great results (productivity).

Employees’ basic needs

Tony Schwartz, the chief executive of The Energy Project, a consulting firm, echoes some of Dr. Covey’s beliefs, too. His work involves propagating systemic investment in employees, beyond just paying them a salary, and meeting the complex needs of the workforce that will in turn perform better. Mr. Schwartz elaborates on Covey’s work by identifying four basic needs that should be met if a company wants its workers to be more satisfied and more productive:

  • Renewal (physical needs)
  • Value (emotional needs)
  • Focus (mental needs)
  • Purpose (spiritual needs)

In short, if workers are supported to reenergize (e.g. take regular breaks), feel valued and appreciated, are able to focus on the task at hand, and believe there is a higher purpose to what they are doing (something bigger than them), they will perform significantly better, as demonstrated in a study conducted by The Energy Project for the Harvard Business Review (Schwartz & Porath, 2014).

Moving towards a definition of wellness

A more holistic approach towards workplace wellness might be catching on, but a uniform definition of wellness has yet to emerge, which can make certain initiatives and programs seem trivial. For example, while some might consider giving employees intermittent breaks to be a way of promoting balance and personal renewal, critics might argue the value and significance of such in-direct strategies for business success.

Twenty years ago, Anspaugh, Hunter and Molsley (1995) captured the wellness’ multi-dimensional character and the implications for contemporary wellness programs when they coined the following definition of wellness:

A composite of physical, emotional, spiritual, intellectual, occupational, and social health; health promotion is the means to achieve wellness. Difficulty functioning in any of these areas has a negative impact on the others. For this reason, a comprehensive worksite health promotion program needs to address each of these issues (p. 206).

The notion that wellness expands beyond the absence of illness and disease is far from a new idea. Even earlier, in 1976, Dr. Bill Hettler talked of a six dimensional wellness model; the physical component being just one of six parts of his wellness wheel (National Wellness Institute). Nonetheless, some dimensions of Hettler’s model often stay ignored, and the more bio-medical view still takes the lead, sometimes obstructing progressive approaches to health, wellness and overall success by giving priority to the reductionist corporeal view.

What stands in the way of launching ‘holistic wellness’ strategies?

Often, habits and deeply ingrained patterns of (corporate) behavior stand in the way of meeting employee needs such as those described and researched by Covey, Schwartz and their colleagues. Despite a growing evidence base that supports employee satisfaction as a component of well-being, in many companies, old paradigms persist (Schwartz & Porath, 2014). However, employers seem to be increasingly recognizing the complex needs of their workers. In fact, it could simply be that the complexity of these needs makes the task of satisfying them more daunting.

Addressing the physical aspects of well-being appears to be somewhat the easiest jumping-off point, and many wellness programs focus on these (alone) perhaps because they are easy to quantify. A broader shift in corporate mind-set that would consider other (less tangible) needs is less common.  

Are we sometimes limiting ourselves to the physical dimensions of health when designing and promoting wellness programs? Is that the reason that workers’ performance and participation doesn’t improve as much as we in the industry would hope? In order to embrace everything wellness stands for, more energy needs to be dedicated to exploring different areas of general employee satisfaction. Ideas such as promoting healthy work relationships, providing a sense of belonging and value, listening, and encouraging life balance are important -especially to millennials (Harter, Schmidt, & Keyes, 2002, Towers Watson 2012 Global Workforce Study). In many ways, meeting employees’ needs – physical and non-corporeal – is what workplace wellness represents, and when executed well, it is bound to result in both a happier workplace and improved productivity.

When Do Workplace Wellness Incentives Cease to be Voluntary?

This is a recent NPR clip about the current state of workplace wellness. It’s a pretty good summary of the current state of affairs so I wanted to post it. The transcript of the audio is below. 

Most medium to large employers offer some sort of wellness program for their workers. That can range from health screenings, to weight loss, and smoking cessation programs. Many employees like these options, and employers like that they can help hold down health insurance cost. But, there are legal questions about how far employers can go to encourage participation. NPR’s Yuki Noguchi has the story.  

Yuki Noguchi: Scott’s Miracle Grow makes products for the care and health of lawns. The Marysville, Ohio company says it wants to nurture its 8,000 employees the same way.

Jim King: It’s very much of a family culture here.

Yuki Noguchi: Jim King is a spokesman for the Scott’s company, which offers discounted prescriptions, annual health screenings, and some free medical care. In states where it’s legal, it refuses to hire people who smoke.

Jim King: We’ve been screening for tobacco use for about a decade. We no longer employ tobacco users.

Yuki Noguchi: That provision landed the company in court several years ago. A new hire failed a urine test for nicotine, lost his job offer, and sued the company arguing it was meddling in private affairs in order to drive down costs. He lost on appeal in 2012. About 80% of Scott’s employees submit to health screenings, and those who make unhealthy choices pay more for health insurance. King says Scott’s wellness policy attracted outside scrutiny, but employees embrace it.

Jim King: Once people understood what the program actually was, they recognized that it wasn’t anything like Big Brother at all. In fact, what we were doing was providing them tools.

Yuki Noguchi: Participation in the wellness program at Scott’s is not mandatory. In fact, under the law, such programs must be voluntary. But, regulators are now trying to define what voluntary means. Some hospitals require their workers get flu shots, which is controversial among those who can’t or don’t want to get vaccines. Beyond that, there are questions about money. For example, is a big financial penalty for non-participation too coercive? What about incentives for completing health screenings? Nico Pronk is Chief Science Officer at HealthPartners, a hospital system. He researches the effectiveness of wellness programs and says their design matters. He says incentives can work, but you have to be careful not to overdo it.

Nico Pronk: Once the incentives amounts go over a certain threshold, it may become a little bit more coercive.

Yuki Noguchi: Last year, the Equal Employment Opportunity Commission sued several companies, alleging their policies were too heavy handed. They argued those companies required health screenings or made non-participants bear the full cost of health insurance. Christopher Krysinksi is Associate Legal Counsel at the EEOC. He notes that, in a separate proceeding, the Commission is considering regulations to define what companies are allowed to do to encourage participation in wellness programs.

Christopher Krysinski: Limited incentives are permissible as long as the maximum incentive for participating doesn’t exceed 30% of the total cost of coverage.

Yuki Noguchi: Krysinski says employers must make sure that programs comply with many laws, including health and genetic information privacy, the Affordable Care Act, and the Americans with Disabilities Act. Employers can’t use a worker’s health against them.

Christopher Krysinski: There are opportunities for discrimination. This information that’s collected as part of a wellness program can’t crossover to anyone who deals with making employment decisions.

Yuki Noguchi: Business groups say they are striking a balance between encouraging participation and protecting the choice of their workers. Brian Marcotte is President and CEO of National Business Group on Health, a policy group representing large employers. He says most health care costs are lifestyle related and employers want to reduce costs. But, that’s not the only calculation companies are making.

Brian Marcotte:    At the end of the day, employers want healthy, productive, engaged, resilient employees in the most competitive workforce possible. And investments in health and well-being are part of that equation.

Yuki Noguchi: Nancy Hammer is Government Affair’s Counsel for the Society for Human Resource Management. She says employers want to draw in, not compel workers.

Nancy Hammer:   Health care and wellness is an employee benefit. So, you got to do something that is attractive to your employees.

Yuki Noguchi: No one benefits, she says, if no one uses the programs. Yuki Noguchi, NPR News, Washington.