Diabetes and Cardiovascular Disease

Article Summaries on Work Site Health Promotion, Economic Analysis of Work Site Health Interventions, Disease Management, and Diabetes Diagnosis and Screening

Health Promotion and Productivity

Aldana, Steven G. (2001). Financial Impact of Health Promotion Programs: A Comprehensive Review of the Literature. American Journal of Health Promotion, 15(5), 296-320.

  • This literature review investigates the ability of health promotion programs to reduce medical expenses and absenteeism by examining their impact on employee-related expenses. The nature of the findings and quality of the literature were examined to ask 2 questions: a) Do individuals or populations with high health  risks have worse financial outcomes than individuals with low health risks? b) Do health promotion programs improve financial outcomes?
  • 72 studies from peer-reviewed journals were examined to compare the financial status between people with high-risk behaviors (e.g. smoking, drinking) and those with low-risk behaviors. The studies were then analyzed to see if health promotion programs helped to improve financial status.
  • Conclusions:  Good correlational data exist between high stress levels, obesity, and multiple risk factors and higher illness related absenteeism rates and health care costs.  The correlation between other factors such as: seat belt use, high cholesterol, diet, hypertension, alcohol abuse and illness related absenteeism and health care costs is either not conclusive or unknown. Most studies demonstrate that health promotion programs can have a measurable impact in curbing medical expenses and are also considered an effective method for helping employers reduce levels of absenteeism and fitness programs are associated with reduced health care costs.


Goetzel, R.Z., Ozminkowski, R.J., Bruno, J.A., Rutter, K.R., Isaac, F., Wang, S. (2002). The Long-Term Impact of Johnson & Johnson's Health & Wellness Program on Employee Health Risks. Journal of Occupational and Environmental Medicine, 44(5), 417-424.

  • This study reports the effectiveness of a newly configured Johnson & Johnson's Health & Wellness Program in reducing the health risks of company employees.
  • A total of 4586 employees participated in two consecutive health screenings, held at least a year apart from each other, where assessments were given for 13 major health risk factors. Johnson & Johnson offered a $500 medical benefit plan credit as an incentive to employees for participating in the study.
  • Assessments indicate that the program was successful in reducing many of the risk factors examined. In addition, due to the financial incentive, approximately 90% of domestic U.S. employees taking part in the study. These results demonstrate that a corporate culture that encourages health promotion can have a positive impact on health and medical costs.


Ozminkowski, R.J., Ling, D., Goetzel, R.Z., Bruno, J.A., Rutter, K.R., Isaac, F., Wang, S. (2002). Long-Term Impact of Johnson & Johnson's Health & Wellness Program on Health Care Utilization and Expenditures. Journal of Occupational and Environmental Medicine, 44(1), 21-29.

  • This study estimates the long-term impact of the Johnson & Johnson Health & Wellness Program on health care expense and demand for medical services.
  • Using claims data, employees were followed for up to five years before and four years after the Wellness Program was initiated.
  • Results indicated a large reduction in medical expenses during the four years after the program was started (approximately $224.66 per employee per year). These benefits, which mostly occurred in years three and four, point to the success of corporate health programs at bringing long-term substantial economic benefits.


Ozminkowski, R.J., Goetzel, R.Z., Smith, M.W., Cantor, R.I., Shaughnessy, A., Harrison, M. (2000). The Impact of Citibank, NA, Health Management Program on Changes in Employee Health Risks Over Time. Journal of Occupational and Environmental Medicine, 42(5), 502-511.

  • This study estimated the impact of the Citibank Health Management Program on changes in health risks among Citibank employees.
  • The health profiles of 9,234 employees were used to track changes in health risks over time. After an initial assessment, those with the greatest risk for poor health outcomes were invited to participate in an intensive intervention program, while lower-risk employees were given basic medical support.
  • Citibank's savings on medical expenses ranged from $4.56 to $4.73 for every dollar invested in the Health Management Program. The results indicate the effectiveness of devoting a large proportion of health intervention resources to small high-risk populations within a corporation.


Riedel, J.E., Lynch, W., Baase, C., Hymel P., Peterson, K.W. (2001). The Effect of Disease Prevention and Health Promotion on Workplace Productivity: A Literature Review. American Journal of Health Promotion, 15(3), 167-191.

  • This literature review focuses on the relationship between health status and worker performance since reducing health care costs.
  • A total of 146 publications spanning a range of health issues were examined to provide different perspectives on the effects of employee health on productivity. The review focused on publications printed during calendar years 1993-1998.
  • Findings from the review provide strong evidence to the link between health status and productivity in addition to the effectiveness of disease prevention and health promotion interventions. Examples of these interventions, along with their relative cost and performance impact, are given as a guide for employers interested in starting a health promotion program.


Stave, M.S., Muchmore, L., Gardner, H. (2003). Quantifiable Impact of the Contract for Health and Wellness: Health Behaviors, Health Care Costs, Disability, and Workers' Compensation. Journal of Occupational and Environmental Medicine, 45(2), 109-117.

  • This study offers an analysis of the health and wellness intervention program offered at GlaxoSmithKline.
  • The health behaviors and medical benefits use of 6049 employees were examined for a period of four years.
  • Results indicate that average annual savings from the program equal $613 per participant, with reductions in disability costs accounting for the majority of the savings. 


Disease Management

Sidorov, J., Shull, R., Tomcavage, J., Girolami, S, Lawton, N., Harris, R. (2002). Does Diabetes Disease Management Save Money and Improve Outcomes? Diabetes Care, (25)4, 684-689.

  • This study examines the impact of disease management programs on medical costs for patients with diabetes.
  • Health care costs from diabetics enrolled in a health maintenance organization (HMO)-sponsored disease management program were compared with those who were not in disease management. The study was conducted on patients enrolled in a federally qualified, not-for-profit group model HMO.
  • Based on this HMO population, an opt-in disease management program appeared to be associated with lower health care use, significant savings, and higher health care quality.


Economics Cost Analysis

Cost-Analysis of Diabetes and Other Chronic Illnesses

Ramsey, S., Summers, K.H., Leong, S.A., Birnbaum, H.G., Kemner, J.E., Greenberg, P. (2002). Productivity and Medical Costs of Diabetes in a Large Employer Population. Diabetes Care, 25(1), 23-29.

  • This study examines the economic burden of diabetes from an employer's perspective through a rigorous review of medical, pharmacy, and disability claims.
  • Claims data from a national Fortune 100 manufacturer were used to compare the medical and work productivity cost of beneficiaries with and without diabetes.
  • Results show that diabetes imposes a significant economic burden on employers, with $4,410 being the annual cost associated with the disease. Selecting health plans that provide enriched benefits to diabetes patients may help employers deal with this economic burden.


Productivity and Economics

Ng, Y.C., Jacobs P., Johnson, J.A. (2001). Productivity Losses Associated with Diabetes in the U.S. Diabetes Care, 24(2), 257-261.

  • This study provides an estimate of the cost of productivity losses in the U.S. due to diabetes.
  • Data were taken from the 1989 National Health Interview Survey and analyzed in regard to labor force participation, hours of work lost, and the economic value of lost work attributable to the complications and duration of diabetes.
  • The magnitude of lost-productivity costs ranged from $3,700 to $8,700 per year, with the presence of complicating factors (i.e. high blood pressure, heart disease) being the most important predictive factor. Avoidance or delay of those complications will have a strong impact on health-related costs.


Economic Analysis

The Diabetes Prevention Program Research Group (2003). Costs Associated with the Primary Prevention of Type 2 Diabetes Mellitus in the Diabetes Prevention Program. Diabetes Care, 26(1), 36-47.

  • This study describes the cost of the Diabetes Prevention Program (DPP) intervention to prevent or delay type 2 diabetes through medication and lifestyle modifications.
  • DDP enrolled 3,234 participants with impaired glucose tolerance (a precursor to diabetes) and tracked the cost of medication and intensive lifestyle interventions over a three year period.
  • Results showed that, despite modest incremental costs, both medication and lifestyle interventions can effectively delay or prevent progression from impaired glucose tolerance to type 2 diabetes.


The CDC Diabetes Cost-effectiveness Group (2002). Cost-effectiveness of Intensive Glycemic Control, Intensified Hypertension Control, and Serum Cholesterol Level Reduction for Type 2 Diabetes. JAMA, 287(19), 2542-2551.

  • This study compares the cost-effectiveness of several treatment interventions on complications of type 2 diabetes.
  • Using a model to illustrate how diabetes would progress over a lifetime, common interventions such as controlling blood sugar, blood pressure, and cholesterol were examined as to whether or not their benefits justified the financial burden.
  • Of the three types of interventions, controlling blood pressure proved to be the most effective in terms of reducing costs from complications. However, though blood sugar and cholesterol monitoring are slightly more expensive interventions, both are still needed to improve overall quality of life and to control health complications that can occur with type 2 diabetics.


American Diabetes Association (2003). Economic Costs of Diabetes in the U.S. in 2002. Diabetes Care, 26(3), 917-932.

  • This study estimates the medical expense and lost productivity costs attributable to diabetes and compares medical expenditures between individuals with and without diabetes.
  • Medical expense was estimated using data from a 2002 national health care survey. Lost productivity analysis was based on estimates of lost workdays, restricted activity days, existence of permanent disability, and deaths attributable to diabetes.
  • The total estimated cost of medical expenses and lost productivity attributable to diabetes is $132 billion. Health care spending in 2002 for people with diabetes was more than double what spending would be without diabetes.


Anderson, D.R., Whitmer, R.W., Goetzel, R.Z., Ozminkowski, R.J., Wasserman, J, Serxner, S. (2000). The Relationship Between Modifiable Health Risks and Group-level Health Care Expenditures. American Journal of Health Promotion, 15(1), 45-52.

  • Building on earlier research done with individual employees, this study provides a group perspective of the cost impact of modifiable health risks (e.g. smoking, stress).
  • Data on health and lifestyle behaviors were gathered on over 46,000 employees from six large corporations. Statistical models were used to make associations between behavior risks and health costs over a six-year study period.
  • Results show that up to 25% of total medical costs are associated with modifiable health behaviors. If these behaviors could be controlled through interventions such as workplace health promotion programs, the potential savings on health care costs would be substantial.


Goetzel, R.Z., Anderson, D.R., Whitmer, R.W., Ozminkowski, R.J., Dunn, R.L., Wasserman, J. (1998). The Relationship Between Modifiable Health Risks and Health Care Expenditures: An Analysis of the Multi-Employer HERO Health Risk and Cost Database. Journal of Occupational and Environmental Medicine, 40(10), 843-854.

  • This study examines a broad range of health risk behaviors (such as smoking and poor nutrition) on the medical care costs of working individuals.
  • Statistical models were used to follow over 46,000 employees for up to 3 years after an initial health risk appraisal. The large sample of employees, drawn from the Health Enhancement Research Organization (HERO) database, provided more than 113,000 person-years of experience from which data and conclusions could be drawn.
  • Results show that these health risk factors, most notably depression and stress, are associated with significant increases in health costs for each individual employee.


Roux, L., Donaldson, C. (2004). Economics and Obesity: Costing the Problem or Evaluating Solutions. Obesity Research, 12(2), 173-179.

  • This article examines the changing role of economics in obesity care, making the case that experts should focus on measuring the cost-effectiveness of preventative interventions rather than calculating the financial burden of the disease.


Wang, L.Y., Yang, Q, Lowry, R., Wechsler, H (2003). Economic Analysis of a School-Based Obesity Prevention Program. Obesity Research, 11(11), 1313-1324.

  • This study conducts the first economic evaluation of an obesity-reduction program by assessing the cost-effectiveness and cost-benefit of a school-based intervention designed to reduce obesity in middle-school age children.
  • Five middle schools in Massachusetts participated in a trial program where nutrition and healthy lifestyle lessons were infused into academic and physical education classes. After two years, results from the trial were compared to a control group of five schools where no intervention had taken place.
  • Results indicate that the prevalence of obesity among girls participating in the program intervention was reduced significantly compared to those in the control schools. Economic analysis, which reveals that society could expect to save $7313 per year due to the program, speaks to the cost-effectiveness of obesity-reduction programs in general.


Wang, F., McDonald, T., Champagne, L.J., Edington, D.W. (2004). Relationship of Body Mass Index and Physical Activity to Health Care Costs Among Employees. Journal of Occupational and Environmental Medicine, 46(5), 428-436.

  • This study examined the relationship between physical activity and health care costs among normal weight, overweight, and obese employees.
  • A total of 23,490 corporate employees were classified into the three weight groups and asked to fill out a health risk appraisal questionnaire. Calculation of the health care costs was based on results from the questionnaire and on individual medical claims data.
  • Results show that high health care costs are mainly associated with obese sedentary employees. With almost 25% of the sample group being classified as obese, the estimated maximum potential savings amounted to $790,326 per year if all obese sedentary employees could become physically active.


Disease Management and Diagnosis and screening

Carter, A.W., Borchardt, N., Cooney, M., Greene, D. (2000). Dual Test Diabetes Screening Project: Screening for Poor Glycemic Control in a Large Workplace Population. Diabetes Technology and Therapeutics, 2(4), 529-536.

  • This study examines the practicality and effectiveness of a new diabetes screening method for use in a large employee population.
  • A total of 100 male and 177 female employees participated in the test, which comprised of taking a finger prick of blood and analyzing it for sugar abnormalities with two different monitors.
  • Approximately 15% more individuals with abnormal blood sugar levels were detected with the new screening method as compared to the traditional blood glucose test. The new method, which takes 4.3 minutes to administer and costs less than $20 per person, provides a cost-effective way to screen for diabetes in a large workplace. 


Diabetes Prevention and Management and Worksites

Trief, P.M., Aquilino, C., Paradies, K., Weinstock, R.S. (1999). Impact of the Work Environment on Glycemic Control and Adaptation to Diabetes. Diabetes Care, 22(4), 569-574.

  • This study sought to determine whether or not the work environments of diabetic adults have a direct effect on their metabolic control or their ability to adapt to the disease.
  • A total of 129 insulin-dependent adults who worked outside the home were given a special test to determine the average blood sugar level over the previous 3 months. The participants were then interviewed and given surveys to assess their thoughts concerning diabetes in the workplace.
  • Results show that, though there no direct link between work environment and metabolic control, the workplace can have a significant impact on how an individual copes with diabetes. Broadening the scope of diabetes education programs to include supervisors and coworkers may improve a person's ability to adapt to the disease.


Assessment Tools and Questionnaires

Kessler, R.C., Barber, C., Beck, A., Berglund, P., Cleary, P.D., McKenas, D., Pronk, N., Simon, G., Stang, P., Ustun, T.B., Wang, P. (2003). The World Health Organization Health and Work Performance Questionnaire (HPQ). Journal of Occupational and Environmental Medicine, 45(2), 156-173.

  • This report describes the World Health Organization's Health and Work Performance Questionnaire—a self-report instrument designed to estimate the workplace costs of health problems in terms of job performance, absences, and injuries.


Koopman, C., Pelletier, K.R., Murray, J.F., Sharda, C.E., Berger, M.L., Turpin, R.S., Hackleman, P., Gibson, P., Holmes, D.M., Bendel, T. (2002). Stanford Presenteeism Scale: Health Status and Employee Productivity. Journal of Occupational and Environmental Medicine, 44(1), 14-20.

  • This report describes the Stanford Presenteeism Scale—an instrument used to assess the extent to which lower productivity and decreased work quality affects employees when they are physically present at their jobs.


Loeppke, R., Hymel, P.A., Lofland, J.H., Pizzi, L.T.,Konicki, D.L., Anstadt, G.W., Baase, C., Fortuna, J., Scharf, T. (2003). Health-Related Workplace Productivity Measurement: General and Migraine-Specific Recommendations from the ACOEM Expert Panel. Journal of Occupational and Environmental Medicine, 45(4), 349-359.

  • This report presents a thorough review of six major assessment tools designed to measure productivity losses in employees with migraine headaches. Because of the high prevalence, severity of symptoms, and disability associated with migraine headaches, report findings can also be used to assess the workforce impact of diseases such as diabetes.


The U.S. Department of Health and Human Services' National Diabetes Education Program is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention with the support of more than 200 partner organizations.