My Last Lecture

Michael P. O’Donnell, MBA, MPH, PhD, Editor in Chief
American Journal of Health Promotion

In celebration of my final comments as editor in chief of the American Journal of Health Promotion, I offer reflections

This issue, Volume 30, Number 8, of the American Journal of Health Promotion, published in November 2016, is the last one for which I will serve as editor in chief. My first, Volume 1, Number 1, was published in June 1986, 176 issues, 30 years and 5 months ago.
Given that this is my last issue; I am going to invoke a privilege that is sometimes bestowed upon esteemed professors in academia; the honor of presenting a ‘‘Last Lecture.’’ Last lectures allow the professor the opportunity to share wisdom that has accumulated over a decades-long brilliant career, and insights that can serve as foundation building blocks for students constructing their careers and against which colleagues can compare their own contributions to knowledge and society. Sometimes last lectures do meet those lofty standards. Other times, they confirm that it is indeed time for the professor to retire. The message is greeted with vociferous and sincere heart felt applause and celebration in either case. My goal with this editorial is to fall somewhere in the middle on the performance and importance spectrum, and my hope is that it will be greeted with vociferous and sincere heart felt applause and celebration, not for me, but for all that our field has accomplished in the past 30 years. Rather than trying to weave a coherent single message, I would like to reflect on several somewhat unrelated points, some tactical, some aspirational, and some existential, in a rambling fashion.

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Lessons for Wellness Programs from the Taxation of Risky Health Behaviors: Additional Material

by Dr. John Cawley, PhD
Professor, Department of Policy Analysis and Management, and Department of Economics, Cornell University

This blog post provides additional information that supplements the essay “Lessons for Wellness Programs from the Taxation of Risky Health Behaviors,” published in the American Journal of Health Promotion this month. (July/August Issue, 2016 DOI: 10.1177/0890117116658726)

That essay focused on lessons regarding smoking cessation and weight loss because those are the two health outcomes that are most frequently the outcome of workplace wellness programs. This blog post provides additional information regarding alcohol and drug abuse. Although these are less often the objective of workplace wellness programs, understanding how they respond to taxation and other economic disincentives is useful more generally for understanding how habitual or addictive behaviors respond to incentives.

Responsiveness of Alcohol Abuse to Alcohol Taxes
Evidence suggests that consumers are responsive to prices and taxes on alcohol. Over 100 studies have been published that estimate the impact of higher alcohol prices on the demand for alcohol; the mean of the estimated price elasticities is -0.51, implying that a 10% increase in the price of alcohol would decrease the demand for alcohol by 5.1%.(26) However, a more recent study that uses more accurate data on alcohol prices from supermarket scanner data of purchases concludes that the true elasticity of demand is lower: roughly -0.3.27

A large literature examines the impact of alcohol taxes on the adverse outcomes that result from alcohol abuse. The last increase in the Federal tax on alcohol was in 1991, and it raised prices by roughly 6%. That tax hike is estimated to have reduced injury deaths by 4.5% and also lowered violent crime, aggravated assault, and robbery.(28) More generally, alcohol taxes (beer taxes are most commonly studied) have been found to reduce a wide variety of social harms, such as child abuse committed by women (but not men), homicides of children, teen abortions, gonorrhea and syphilis, work days lost due to industrial injuries, and suicides by men but not women.(3)

This indirect evidence is consistent with taxes reducing binge drinking or other forms of alcohol abuse.

Responsiveness of Illegal Drug Use to Disincentives
The limited evidence that exists suggests that even use of addictive drugs responds to incentives. Although several states have recently legalized medicinal or even recreational use of marijuana, most addictive drugs remain illegal in the majority of the U.S. As a result, there is no evidence on how consumers would respond to changes in taxes on such drugs. However, there is relevant evidence from studies that examine the responsiveness of drug use to: 1) changes in drug prices; and 2) incentives for quitting drugs.

There are relatively few studies of the responsiveness of drug use to prices, given the scarcity of data on illegal markets. The limited available evidence suggests that the price elasticity of drug use is -0.3 for marijuana, -1.0 for cocaine, and -0.89 for heroin.(3)

Additional evidence comes from the field of drug treatment known as contingency management, which offers incentives for drug addicts to abstain from drug use, and uses drug tests to verify compliance. A meta-analysis concluded that such incentives raised the probability of drug abstinence by 30%, with larger effects for rewards that were more valuable.(29)

All of the References from Dr. John Cawley’s Article on “Taxation for Risky Behaviors” are provided below.

1 Kaiser Family Foundation and Health Research and Educational Trust. 2015. Employer Health benefits: 2015 annual survey.

2 Cawley, John. 2014. “The Affordable Care Act Permits Greater Financial Rewards for Weight Loss: A Good Idea in Principle, But Many Practical Concerns Remain.” Journal of Policy Analysis and Management, 33(3): 810-820.

3 Cawley, John, and Christopher J. Ruhm. 2012. “The Economics of Risky Health Behaviors.” Chapter 3 in: Thomas G. McGuire, Mark V. Pauly, and Pedro Pita Barros (editors), Handbook of Health Economics, Volume 2. (Elsevier: New York), pp. 95-199.

4 Cawley, John. 2015. “An Economy of Scales: A Selective Review of Obesity’s Economic Causes, Consequences, and Solutions.” Journal of Health Economics, 43: 244-268.

5 Callison, Kevin & Robert Kaestner, 2014. “Do Higher Tobacco Taxes Reduce Adult Smoking? New Evidence of the Effect Of Recent Cigarette Tax Increases On Adult Smoking,” Economic Inquiry, 52(1): 155-172.

6 DeCicca, Philip and Logan McLeod. 2008. “Cigarette taxes and older adult smoking: Evidence from recent large tax increases”, Journal of Health Economics, 27(4): 918-929.

7 Sloan, F. A. & Trogdon, J. G. 2004. The impact of the master settlement agreement on cigarette consumption. Journal of Policy Analysis and Management, 23(4), 843-855.

8 Levy, D. E. & Meara, E. 2006. The effect of the 1998 Master Settlement Agreement on prenatal smoking. Journal of Health Economics, 25, 276-294.

9 Gallet, C. & List, J. A. 2003. Cigarette demand: A meta-analysis of elasticities. Health Economics, 12, 821-835.

10 Cahill K, Hartmann-Boyce J, Perera R. 2015. Incentives for smoking cessation. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD004307. DOI: 10.1002/14651858.CD004307.pub5.

11 Fletcher, J. M., Frisvold, D., & Tefft, N. 2010. Can soft drink taxes reduce population weight? Contemporary Economic Policy, 28(1), 23-35.

12 Fletcher, J.M., Frisvold, D.E., Tefft, N., 2011. Are soft drink taxes an effective mechanism for reducing obesity? Journal of Policy Analysis and Management 30 (3), 655–662.

13 Chaloupka, F.J., Powell, L.M., Chriqui, J.F., 2011. Sugar-sweetened beverages and obesity: the potential impact of public policies. Journal of Policy Analysis and Management 30 (3), 645–655.

14 Cawley, John, Andrew Hanks, David Just, and Brian Wansink. “Incentivizing Nutritious Diets: A Field Experiment of Relative Price Changes and How They are Framed.” NBER Working Paper #21929, 2015.

15 U.S. Department of Agriculture. 2013. Healthy Incentives Pilot (HIP) Interim Report, by Susan Bartlett et al. Project Officer: Danielle Berman, Alexandria, VA: July 2013.

16 List, John A., Anya Samek, and Terri Zhu. 2015. “Incentives to Eat Healthy: Evidence from a Grocery Store Field Experiment.” CESR-Schaeffer Working Paper No. 2015-025.

17 Patel, Mitesh S., David A. Asch, Andrea B. Troxel, Michele Fletcher, Rosemary Osman-Koss, Jennifer Brady, Lisa Wesby, Victoria Hilbert, Jingsan Zhu, Wenli Wang, and Kevin G. Volpp. 2016. “Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013–15 Study.” Health Affairs, 35(1): 71-79.

18 Cawley, J., Price, J.A., 2013. A case study of a workplace wellness program that offers financial incentives for weight loss. Journal of Health Economics 32, 794–803.

19 Finkelstein, E.A., Linnan, L.A., Tate, D.F., Birken, B.E., 2007. A pilot study testing the effect of different levels of financial incentives on weight loss among over-weight employees. Journal of Occupational and Environmental Medicine 49,981–989.

20 Volpp, K.G., John, L.K., Troxel, A.B., Norton, L., Fassbender, J., Loewenstein, G., 2008. Financial incentive based approaches for weight loss: a randomized trial. Journal of the American Medical Association 300, 2631–2637.

21 Chetty, R., Looney, A., & Kroft, K. 2009. Salience and taxation: Theory and evidence. American Economic Review, 99(4), 1145-1177.

22 Blumenthal, K. J., Saulsgiver, K. A., Norton, L., Troxel, A. B., Anarella, J. P., Gesten, F. C., Chernew, M. E., & Volpp, K. G. 2013. Medicaid incentive programs to encourage healthy behavior show mixed results to date and should be studied and improved. Health Affairs, 32, 497–507.

23 Cawley, John, Davide Dragone, and Stephanie von Hinke Kessler Scholder. 2016. “The Demand for Cigarettes as Derived from the Demand for Weight Control.” Health Economics, 25(1): 8-23.

24 Mann, R.A., 1972. The behavior-therapeutic use of contingency contracting to control and adult behavior problem: weight control. Journal of Applied Behavior Analysis 5 (2), 99–109.

25 Equal Employment Opportunity Commission. 2016. “Regulations Under the Americans With Disabilities Act.” Federal Register, May 17.

26 Wagenaar, A. C., Salois, M. J., & Komro, K. A. (2009). Effects of beverage alcohol price and tax levels on drinking: A meta-analysis of 1003 estimates from 112 studies. Addiction, 104, 179-190.

27 Ruhm, Christopher J. & Jones, Alison Snow & McGeary, Kerry Anne & Kerr, William C. & Terza, Joseph V. & Greenfield, Thomas K. & Pandian, Ravi S., 2012. “What U.S. data should be used to measure the price elasticity of demand for alcohol?,” Journal of Health Economics, Elsevier, vol. 31(6), pages 851-862.

28 Cook, Philip J., and Christine Piette Durrance. 2013. “The virtuous tax: Lifesaving and crime-prevention effects of the 1991 federal alcohol-tax increase.” Journal of Health Economics, 32: 261-267.

29 Lussier, J. P., Heil, S. H., Mongeon, J. A., et al. (2006). A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction, 101, 192-203.

Innovations in the Use of Incentives and the EEOC

By Paul E. Terry, PhD, President of HERO
Editor, The Art of Health Promotion

The July/August 2016 issue of The Art of Health Promotion features expert commentaries relating to the final rules issued by the Equal Opportunity Employment Commission (EEOC) last month. As most employers hoped, the rules better align the EEOC rules with the Affordable Care Act (ACA) wellness provisions. They also offer more clarifications about the boundaries that human rights proponents consider critical to fairness in employee relations and attempt to address the balance between voluntariness and accountability.

“The rules essentially say voluntariness means ‘‘either/or’’ when health contingent designs that take vital measures are used. Either show progress toward, or achieve a clinical standard, or show some effort.”

Join Us for our Webinar: Innovations in Incentives and the EEOC Final Rules

Tuesday, August 2 | 1:00 pm (eastern)



Michael P. O’Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion
Karen Horgan, MBA
Co-Founder and President, VAL Health
Jim Pshock
Founder, President and CEO, Bravo

Will the new EEOC rules keep employers sponsoring wellness programs out of court with the EEOC? Time will tell. A great place to start would be to banish the use of the word required in incentives programs. Autonomy rates up there with mastery as a prerequisite to behavior change, a tenet too overlooked in the use of incentives. I don’t think the EEOC could be any clearer that there is no such thing as ‘‘outcomes-based’’ incentives. Nor could they be more cautionary about the risks of requiring employees to do anything to attain an incentive. Too many incentives schemes I’ve reviewed connote that employees will be penalized if they don’t hit a ‘‘required’’ target. It shows either an indifference or an ignorance about both the ACA and the EEOC’s guidance in the use of incentives. The rules essentially say voluntariness means ‘‘either/or’’ when health contingent designs that take vital measures are used. Either show progress toward or achieve a clinical standard, or show some effort.

Like research on how incentives work in education policy, we are in the nascent stages of discovering how new methods for monitoring, feedback, and rewards can improve health. Harvard researchers, for example, have experimented with millions of dollars in incentives attempting to improve behaviors like reading for thousands of students and report both promise and pitfalls. On these pages, I have interviewed Edward Deci, the father of intrinsic motivation as well as Robert Eisenberger, the father of perceived organizational support. Putting their amazing bodies of work side by side proves the point that incentives can, but don’t always, sap intrinsic motivation. Nor can incentives ever be expected to substitute for the effects organizational leaders can have on employee agency and self-determination. Research shows that when they go the extra mile they get more healthy engagement in return.

Can Diabetes Prevention Improve Health and Save Medicare Money, Does Medicare Care Know, and Why Is This Important?

by Michael P. O’Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion 

The success of the YMCA Medicare Diabetes Prevention Program in reducing weight and Medicare spending has simulated the Chief Actuary of CMS to authorize nationwide reimbursement of the
program. This could stimulate rapid expansion of community-based programs to prevent diabetes and shows the potential to reduce Medicare spending through health promotion.

On March 14, 2016, Paul Spitalnic, chief actuary for the Centers for Medicare and Medicaid Services (CMS), issued a memo certifying that the Medicare Diabetes Prevention Program (Program) provided by the Young Men’s Christian Association (YMCA) of the United States to Medicare recipients met the standards of improving health and reducing Medicare spending (1) necessary for Medicare to agree to cover the cost of the Program for eligible Medicare recipients nationwide.

This is the first health promotion approach certified by Medicare through this process and has the potential to stimulate rapid growth of community-based health promotion efforts.

The program, its evaluation, the certification process, and their significance are reviewed below.

Y-USA Diabetes Prevention Program
In 2011, the YMCA of the United States received a Health Care Innovation Award grant for US$11,885,134 from the CMS to expand its Diabetes Prevention Program to prediabetic Medicare recipients. Program goals were to enroll at least 10,000 people, reduce weight 5%, reduce risks of diabetes, hypertension, and hypercholesterolemia for at least half of the enrollees, and save at least US$1.8 million in Medicare costs by June 2015. (2)
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The Global Health Promotion Issue

By Paul E. Terry, PhD
Editor, The Art of Health Promotion

Join us for a live webinar – Tuesday, May 24 | 1:00 pm eastern
The Global Issue hosted by Paul Terry and featuring two authors from the May issue of the Art of Health Promotion – Tsitsi B. Masvawure, D.Phil, MSc and Wolf Kirsten, MSc
Learn More

In this “The Global Issue” of The Art of Health Promotion, policies, programs and cases are featured from Singapore, Brazil, Australia and the United Kingdom. Readers will learn that the global rationale for prevention and health promotion shares much in common with the United States but the wellness movements in these countries also depart from our cultural norms in significant ways. Where the influence of culture on individual health practices is a growing focus of U.S. based wellness, you will see in these reports from abroad there are “contextually and culturally relevant” policies, programs with “multifarious components” and “workplace ecosystems” all indicating a longstanding appreciation for the vital interaction between people, policies and places. There would be unintended consequences were a workplace wellness advocate to attempt to export an American style wellness approach into these environments. In case you missed it, that last sentence was a grand understatement. My colleague and friend, Dr. Ricardo De Marchi, offers important insights into the “Brazilian Health Promotion Moment” in his blog post below.

I was joined in my closing commentary in this May/June issue by Dr. Tsitsi Mavawure, another longtime friend and colleague. Tsitsi is a black female Zimbabwean born and raised in Bulawayo. In Paul’s view she can be unduly deferential on some matters and, paradoxically, unreasonably stubborn on other matters. What Tsitsi sees as being respectful, Paul witnesses as submitting to victimhood. Paul is a white male American born and raised in Minnesota. In Tsitsi’s view he can be impatient, insensitive and domineering. What Paul sees as self- confident, Tsitsi witnesses as arrogant. Did we mention we’re dear friends?

We are proud to be co-founders, with Shepstone Musiyarira, of a non-profit organization we named “Shape Zimbabwe.” Shape was dedicated to HIV/AIDS prevention and for several years we grew grant funding support to mobilize college students throughout Zimbabwe to develop and lead “talk shows” and music based education programs grounded in peer counseling principles. Reflecting on our work together during a tumultuous time in Tsitsi’s country, the aspects of Zimbabwean culture that Paul and Tsitsi both find disturbing relates to the objectification of women and the entitlement mentality of tribal leaders. Similarly, there are aspects of American culture we mutually disapprove of such as our obesogenic environment. Though we mutually celebrate and deeply appreciate most aspects of our native cultures, it still seems that when we are in conflict our disagreements can be traced to a naiveté about the inexorable influence of our cultures. Though Tsitsi thinks Paul should be more acquiescent, he’s simply not wired for it. Though Paul wishes Tsitsi could discount the anachronistic influence of her elders, she’s often not disposed to such. Our arguments are fundamentally the unintended consequence of presuming one or the other of us is culturally unencumbered. See our closing commentary to learn more about how we’ve come to reconcile our cultural differences.

Showing the Brazilian Health Promotion Moment for Global Corporations

By Ricardo De Marchi, MD

The political and economic situation in Brazil demands a new calibration between employer health strategy and design innovation by health care and health promotion providers alike. Right now, human resource departments must pay better attention to improving population health, which can be amplified by the establishment of stronger evidence showing that there is positive return on investment. A case must be made indicating why health promotion represents an attractive proposition for employers. This commentary suggests ways for optimizing guidance for decision making about how health promotion can be advanced as a best practice for businesses.

The search for consistent and effective health promotion services can be troublesome for employers because differentiating between various purchasing plans from the available, but limited, providers is never an easy task. Nevertheless, Brazil is gradually opening our doors to better opportunities as we embrace the concept of health promotion and we are enjoying increasing acceptance concerning the importance of prevention by investors, doctors, health plans, human resources and financial people.

Increasingly, Brazilian employers are implementing health promotion programs based on accepted health guidelines. Companies are fully reengineering many of their clinical and benefit programs because they must put the brake on investments and adapt themselves to the necessary austerity. Restructuring and reorganizing health care is mandatory for both sides: vendors and employers. Technology has an important role in this picture. Good offers must be comprehensive, fast to implement, easy to drive, and affordable. Despite the shortage of these offers, they are still being implemented.

Despite the economic pressures experienced in our country, Unilever is a prime example from a growing group of companies offering intelligent and innovative attention to the improvement of employee well-being. And how is ‘well-being’ defined? Unilever recognizes that healthy employees contribute to a culture of high performance and productivity. One key objective is to impact the lives of Unilever employees by not only improving their health, but also enhancing their livelihoods. This is essentially our definition of well-being.

Doctor Elaine Molina, the current health manager at Unilever, says that there is strong support from headquarters for making health a main pillar of something they call the “Sustainable Living Plan.” This plan is intended to benefit all employees, particularly those who live in some of our poorest regions. Molina mentions that prevention is a difficult concept for some cultures to understand and that this tendency to discredit the well-being concept is a barrier that must be overcome. In fact, such resistance seems to be a main challenge in her day-to-day work. On the positive side, Unilever believes that the ROI of health promotion is 3:1, something they continue to demonstrate annually. Currently, the company is focusing their priorities in mental health. Again, they view technology as a critical component in the design of interventions and are testing delivery systems based on mobile apps.

Health Care Delivery Issues in Brazil
Because many employers are assuming more responsibility for the costs of health such as impaired productivity, we are witnessing an increasing demand for health promotion services. There is a changing attitude among company leaders and they appear to be targeting three groups in particular:

1. Health Consumerism: This is a growing trend in Brazil with people ever more aware of self-care and interested in how to manage more aspects of their personal health. Though many more are discussing the need for better self-management, it remains difficult to find reliable resources.

2. Physicians: Investors are looking at the quality of health assistance and the quality of the practices of physicians. Some employers are developing networks of preferred physicians and nominate them for the quality of their service and satisfaction metrics collected via client evaluations. In the future it is likely employers will consider all appointments and prescriptions and review the education policies and personal health management practices of hospitals. They will also review the credentials of the physician groups, technology connecting physicians, health providers, users and company, and finally, inquire about the process of “how to make the right use of the health benefits.” These criteria are regularly mentioned in corporate health meetings.

3. Health Systems Management: Though health executives in Brazil share the goals of their U.S. counterparts related to higher quality with lower costs, such complexity will require a better integration among providers and employers, and more than that, the integration must also exist among the providers themselves. To achieve this goal, a strong management system must be in place. The problem is that good tools are costly, take a long time to implement, and always depend on the quality of the existing recorded data. The basic reforms in health care delivery cost and quality will provide the infrastructure needed before the health system can pivot to the equally important work of disease prevention and health promotion.

Increasing the Focus on Health
Though much still needs to be done to reform Brazil’s medical delivery system, it remains that more and more prominent organizations see the links between health system reforms and the imperatives in our industries to improve productivity. Many community and health system leaders intend to make health and productivity more valued and manifest it among their constituents. One such leader is SESI. SESI is the Brazilian acronym for the social service industry and this organization is a long standing, big player in the country’s health sector that is busy moving toward the goal of increasing health awareness among the workforce. They are doing so through conferences, regional events, electronic materials, global alliances, dissemination of evidence, creation of an observatory, and training programs. The movement that SESI leads started in the Brazilian state of Santa Catarina where the local SESI is collaborating with allied worldwide industry professionals to advance employer sponsored health and well-being.

Due to the deep impact on health by the economic and political struggles in Brazil, there must be a rapid response. The more we know, the more we see the need to change the current health system which demands cooperation across all sectors. Over the next five years, such cooperative initiatives should address comprehensive risk management, the influence of the culture on diverse groups, prevailing health issues such as mental health, the creation of more affordable health plans, incisive health promotion programs, improved incentives, communication and management, and better understanding of the possible benefits for all participants. Providers with experience, knowledge and credibility that are able to deliver services for the whole population are better positioned to face these demands. Many are redesigning their approaches and a population based focus is now more accepted than before.

Acknowledgement: Our thanks to Emma Wheeler for extensive editing support in the development of this “Global Health” issue.

Which is More Dangerous International Terrorism or Secondhand Smoke?

by Michael P. O’Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion 

I asked myself the question about the relative danger of international terrorism or secondhand smoke on December 18, 2015, just 16 days after a terrorist attack killed 14 people and seriously injured 22 at the Inland Regional Center in San Bernardino, California. I am a little nervous about posing this question publicly because I do not want to minimize the extend of the tragedy, the pain suffered by the families and friends of those who were killed, the emotional trauma inflicted on the coworkers who lived through the trauma, or the fear experienced by the entire city of San Bernardino. I ask this question because on the same day, an estimated 115 people died of secondhand smoke in the United States, including an estimated 3 infants.1 This is in addition to the approximately 1200 people who died that day from direct smoking,2 but the comparison to deaths from secondhand smoke is more appropriate because the deaths from terrorism and the deaths from secondhand smoke both occurred from physical assaults on those who are now dead. The terrorist assault was with a bullet. The secondhand smoking assaults were with a compound of toxins so powerful that the extract from just 1 cigarette puff has been shown to cause damage at the genetic level.3

The national TV news networks continued to be consumed by the San Bernardino attack for weeks after the shootings. A Google search I conducted on December 18 produced 75 600 000 Web sites featuring the San Bernardino attacks. Proposals from right-wing politicians to address the problem have ranged from prohibiting all Muslims from entering the United States4 to “carpet-bombing” the cities ISIS occupies in Arab nations “until the sand glows.”5 I searched and searched the Internet for comparable outrage at the 115 killed by secondhand smoke on December 18 but could not find a single story. Yet in the 16 days since the shooting, an estimated 1840 people have died of secondhand smoke.

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SAGE Publications is Now the Publisher of American Journal of Health Promotion

By Michael P. O’Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion

I am excited to announce that SAGE Publications has acquired the American Journal of Health Promotion. SAGE is now responsible for all aspects of publishing the Journal, starting with this issue, the March 2016 issue.
This is a significant transition, given the independent ownership of American Journal of Health Promotion since its founding in 1986 and for me, given my service as editor in chief during those 3 decades.

I am excited by this transition for 2 reasons.

First, I am excited because this transition ensures that American Journal of Health Promotion will have a home, a solid foundation, on which to continue to grow and evolve for decades to come, long after I have been put out to pasture.

Second, I am excited because SAGE is the new publisher. Six different publishers approached me about acquiring American Journal of Health Promotion. I chose SAGE because of who they were, who they are, and who I believe they will become. SAGE was founded in 1965, by Sara Miller (now Sara McCune), when she was only 24 years old and continues to be led by Sara in her role as executive chair of the SAGE group of companies. SAGE was an early driver in publishing social science research methods and is now the world’s largest publisher in that area. In fact, SAGE is credited with helping to build the field of evaluation, which is, of course, the focus of most of the articles published in the American Journal of Health Promotion. In the subsequent 50 years, SAGE has grown to employ more than 1500 employees globally and now publishes more than 900 journals in addition to more than 800 books, reference materials, and databases each year. SAGE is the fifth largest publisher of clinical medicine in the world and also publishes some of the leading journals in business, humanities, natural sciences, and technology. SAGE has also innovated across media platforms, offering products and services in print, digital, and video formats.

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The Food Issue

By Paul Terry, PhD
Editor, The Art of Health Promotion
CEO and President, Health Enhancement Research Organization

The articles offered in this month’s journal issue explained how our relationships with food have been disrupted and how we can restore a healthy communion with eating through better informed choices. Dr. Kevin Walker writes about how our disengagement with food production and the cavalier individual choices we now make about food purchases has disassociated us from the collective consequences of our new eating habits.

Dr. David Katz argues that we need to coalesce more deliberately around the many points of agreement experts have about what constitutes a healthy diet if we are to counter the confusion that comes with the daily delivery of blog abetted nutritional nonsense. We reference Katz’ “True Health Initiative” and his colleague Susan Benigas expands on this work in the following Blog Post interview:
An Interview with Susan Benigas, The American College of Lifestyle Medicine
Susan, you’re passionate about the work of The American College of Lifestyle Medicine. Where does the “True Health Initiative” fit in the strategic scheme of things for your organization?

Susan Benigas: The American College of Lifestyle Medicine (ACLM) is the nation’s professional medical association for physicians, allied health professionals, healthcare executives and others who are dedicated to a lifestyle medicine-first approach to true ‘health’ care. But even more so, ACLM is a convening of healthcare professionals who share a passion for the urgent need to transform health and healthcare, understanding that simply prescribing more pills and procedures is not in the best interest of patients, nor will it create sustainable human health or a sustainable healthcare system.

As president of ACLM, David has expanded the focus of the College emphasizing “lifestyle in medicine,” as well as “lifestyle as medicine.” The former has been the primary focus of ACLM since its inception: lifestyle used as a therapeutic intervention to prevent, and, more importantly, to treat and, often, reverse the lifestyle-related chronic conditions that are all too prevalent both in the U.S. and in many other nations around the world. The latter speaks to our culture: the need to create cultures and communities that bring clarity to and support healthful lifestyle choices that clinicians ‘prescribe’ and we as citizens self-prescribe as we take far more personal responsibility for our health.

ACLM has been a springboard for the launch of the True Health Initiative—with David’s vision being to ignite a global movement focusing on “lifestyle as medicine.” The True Health Initiative Council of Directors, assembled via David’s personal invitations, serves as the unified, authoritative global voice to espouse the foundational principles of healthy living.

Thinking long term, what is your vision for the True Health Initiative, especially with respect to impacts you may be able to quantify?

We’re in the midst of a seismic shift in healthcare, as we move from a fee-for-service to a value and outcome-based healthcare delivery system. How is value delivered? How are improved outcomes delivered? The answer: Through lifestyle medicine! Lifestyle medicine is about identifying and eradicating the cause of disease. When we consider that 80% or more of all dollars spent on healthcare in this country pay or the treatment of conditions rooted in poor lifestyle choices, it goes without saying that educating, equipping and empowering people to protect their health and fight disease through the power of their lifestyle choices is essential. This is the focus of the American College of Lifestyle Medicine: lifestyle in medicine. Our vision is a nation and world in which every healthcare executive and medical practitioner commits to a lifestyle medicine-first approach to care. We like to say that Lifestyle medicine is the medicine with only positive side effects.

Coupled with this is the vision for a nation and world of ‘Blue Zones’—communities built and designed, at every level, to support healthful lifestyle choices. From pedestrian-friendly design to restaurants of all kinds that offer a plethora of selections that support an optimal dietary lifestyle.
The ultimate vision for the True Health Initiative is that it will be looked to as the ‘Consumer Reports’ of health information, whereby misinformation, misinterpreted research, and the deluge of conflicting and confusing health-related reporting can be clarified once and for all by the True Health Initiative Council of Directors—the global, unified, authoritative voice espousing the foundational principles of healthy living and healthy eating.

How can our Journal readers get involved, show their support and advance “True Health?”

On the True Health Initiative home page (, all who have a shared passion for creating a culture of health are invited to register to become part of the campaign. As the initiative builds and grows, it will provide tools and resources that can be used by members to help promote the foundational principles of healthy living and healthy eating in their own communities.

On the home page of the American College of Lifestyle Medicine (, we encourage all who are interested in joining with us to transform health and healthcare to sign-up to receive the ACLM newsletter and to consider joining. ACLM offers an outstanding array of member benefits for our physician, doctoral, healthcare executive, clinician and non-clinician members. Plans are already underway for Lifestyle Medicine 2016, set for October 23-26 in Naples, FL. David will be a featured keynote reporting on the progress and impact of the True Health Initiative, as we marry lifestyle in medicine with lifestyle as medicine. As David likes to say, “Feet, forks, fingers, sleep, stress and love” are key—each representing a foundational pillar of health and a transformed and sustainable ‘health’ care system.

An Interview with Kevin Walker, Ph.D., Professor, Michigan State University, The College of Veterinary Medicine, Department of Large Animal Clinical Sciences.
Most of what we read about food is compartmentalized such as the effect of dieting, emerging food-related diseases, or calories versus nutrition. You’re looking at food in a much broader context, why?
Kevin Walker, Ph.D. I’ve always been drawn towards the connections of seemingly distinct topics. For example, when I came to Michigan State University I was asked to participate in meetings linking food manufacturing, employment opportunities, and desired lifestyles. That led to further collaboration with various multinational food companies and diverse faculty from different colleges across campus. My interest was linking together different expertise on contemporary food-related challenges.

Dr. Kevin Walker

I’ve identified fifteen decision points that determine how the modern food system operates. As mentioned in the article, they comprise the intersections of six important elements: consumers, food uncertainty, resources, governance, science, and food providers. Any one decision affects others, so it’s hard to prioritize which ones are most important.

But as examples, decisions regarding “public safety nets” (the intersection of food uncertainty and governance) dramatically affect access to food as population grows and faces increasing structural income disparity. Behind “science a la carte” (the intersection of consumers and science) are decisions that say science and technology that make food less expensive are acceptable, but so also are ignoring threats to the environment that threaten comfortable lifestyles. “Resource stewardship” (the intersection of resources and food providers) entails decisions of whether or not to deplete finite petroleum reserves by shipping food overseas for processing and back, because the labor costs make it more profitable.
If I can jump ahead to food-related health decision points that I’m working on as a result of unintended consequences they are: “fraudulent or adulterated foods,” “fight over transparency,” “dilution of science,” “deficient health safeguards,” “rampant energy misuse,” “calories over nutrition,” and “culture against genetics.”
Some of what you’re saying strikes me as failure of government to act. Is it not the responsibility of government to do more?

Ideally, yes. But traditional government with its laws and regulations is just one way individuals pursue collective interests. Another way is through culture with its norms and behaviors. Common courtesies, not littering, helping others in distress are acceptable norms and behaviors we practice that help define our culture. If we think about, acceptable norms and behaviors such as cooking practices, hygiene, use of utensils are ways to ensure better health and food safety.
Perhaps the person who best illustrated how norms and behaviors apply to governance such as sharing resources like water was Elinor Ostrom. In 2009, she received the Nobel prize in economics for her work that documented examples around the world. Prior to her death, the World Bank commissioned her to prepare a white paper on global warming. Part of the reason for the lack of action, she pointed out, was that global warming was framed at such a high level, individuals didn’t believe their actions were part of the bigger problem.

It’s the same with food. Because of the modern food system, the role of consumers and food-related health appears isolated from the production of food. In fact, some address nutrition policy as separate from agriculture policy. I would contend they’re linked as both are steered by the same modern food system.

I recently read an article of young professionals wanting to eat more healthy food while insisting it be convenient and not take time away from their busy schedules. It sounds like a good idea, but whether they recognize it or not, behind their decisions centered on better health are acceptable norms and behaviors that say time is more important than food waste that happens as a result. Food waste translates into resource depletion and environmental loss. When the societal norms and behaviors shift around food-related health and food production, then traditional government will follow behind.

What would you say is the biggest food-related challenge we face?
Not asking questions. At one time, people were responsible for producing the food they consumed. They were personally vested in how food tied to health that sustained life. The advantage of the modern food system is it made calories consumed almost free. All we had to do was show up, choose what foods we wanted, possibly prepare something, and eat.

When food requires so little, we don’t ask whether it’s reasonable to believe that access to food requires having money? When questions like this are never asked, we start to think that money offsets any need to consider biological and geophysical forces that make food possible.

There are other questions worth asking as well such as what can food teach me as it relates to health? Or what am I willing to learn from food? These are very different questions then asking what can food do for me?

What can we do at the individual level?

I suggest starting with increased awareness about how we connect to food. By stepping back, observing, and listening one realizes just how much our culture and identity is wrapped around abundance and convenience without commitment. Sure, we still laugh when children say milk comes from the refrigerator, but then we live as if food originates from supermarkets and restaurants. Historically, food always required more time and effort than what modern society has been willing to invest.
Next is conscious awareness of how food-related decisions we make align with the way we want to live. Besides the decisions I mentioned earlier, there are a host of others we can’t ignore that relate to unintended consequences. As examples, for food-related health, our decisions determine how much society tolerates adulterated or fraudulent foods like fish and imported honey. For food safety, science can inform but we decide what’s safe. And for the environment, our decisions ultimately determine how much we value nature which obviously has ramifications for personal health.

At a minimum, we can stop wasting food, thereby preserving resources and the environment. We can practice breaking the mindset that our only role as consumers is at the tail end of the food system. Or that the main tool to better food-related health options is through choices we make at supermarkets and restaurants. Instead of looking at food as a means of entertainment or recreation, we can look at it as a path to build community and teach connection to one another and other living species. We can challenge politicians who say the almost ~$1 trillion farm bill is in consumers best interests by asking how it improves consumers health?
Finally, can you give some simple examples of how increased awareness has changed how you live?

The more I learn, the less complicated decisions become. It’s easier to see the connection to health and resist the formula behind many processed foods (the decision point I call “culture against genetics”). I’m also more aware of where food originates and make personal decisions accordingly. I’m more mindful of the compromises being made between business profit and personal health that plays out everyday in product labels, advertising, and manufacturing standards.
When I eat, food is more than what I put into my mouth. Instead of reaching for more dressing to boost kale or spinach palatability, I’m more grateful for the marvelous events that brought together energy and fiber my body needs and that I’m about to consume. I’m less needful of foods designed to stimulate sensory pleasures like taste; I’m more appreciative of simpler foods that promote health.

Closing Commentary
Could a Broader Social and Educational Diagnosis Inform Fairer Food Policies?
By Anna Terry, M.N., R.N., P.H.N. and Paul E. Terry, Ph.D.

This Blog Post adds additional detail to the closing commentary from this month’s Art of Health Promotion section: “The Food Issue” and offers references used throughout the full commentary.

The articles offered in this journal issue explained how our relationships with food have been disrupted and how we can restore a healthy communion with eating through better informed choices. In the full closing commentary, we built on these themes by examining how nutrition science and food policies are linked to issues of individual justice, economic fairness and environmental preservation.

We proposed that changing consumer attitudes and awareness about both local and global food chain realities is needed if we are to overcome the natural resistance to food policy changes that are focused primarily on individual health and are commonly felt as merely about limiting freedoms and choices. Successful tobacco policy reform took decades. Unless we increase consumer awareness about the health consequences of our current food distribution system as well as the economic, individual and social justice issues fostered by our current food supply, it may take even longer to affect policies that change food demand and make healthy eating the easy choice, particularly in economically disadvantaged communities.

The Difference between Food Policy and Tobacco Policy
Those who have even a modicum of schooling in nutrition understand the health benefits of policies that limit intake of sugar, salt and fat. Nevertheless, thousands of health care organizations worldwide, with a mission to protect health, continue to make sickening levels (literally) of sugar, salt and fat the easy choices for patients and their employees every day. This restraint about limiting choices, where tobacco free buildings and grounds are now common place, bespeaks the fundamental difference between food and tobacco policy making. There is no health benefit to tobacco but we need food. Hence, unlike the long road that led to policy reforms in tobacco, changing food policy may start with the case for protecting health, but the case for limiting access to bad for your foods will also benefit from a deeper appreciation of how our choices about foods can also be bad for other people, their communities and our planet.

How would worksite and/or school based food policy changes be decided, communicated and sustained using such a holistic paradigm? We would begin by assessing how our food consumption patterns are affecting individual and population health across the global food system.

Food Workers Deciding between Paying for Food or Rent
A nurse learns if someone is hypothermic a related factor may have been exposure to cold. In the case of an impaired food distribution system, a primary related factor is the prevalence of poor working conditions. A “flexible labor” force has become endemic to agriculture and when a worker does not have guaranteed hours they often cannot afford food if they are still working to pay for rent. In the case of tomato production in Mexico, for example, vulnerable populations are recruited for flexible labor to maximize profits during harvest. Their story, as told by Deborah Barndt in Women Working the NAFTA Food Chain, explains how “hundreds of poor Indigenous workers, brought in by trucks and housed in conditions of squalor in makeshift camps, do much of the picking during the three-to-five month harvest season.” (1999, p. 71). Ironically, cheap labor and the related low prices for foods results in small changes in market supply or demand resulting in outsized impacts on the poor. After one recent change in commodity demand, the World Bank estimated 44 million people fell below the poverty line due to rising food prices (Knaup et al, 2011).

An even more ironic example of good intentions producing bad outcomes come from The Green Revolution and the introduction of ‘western’ style farming techniques to developing countries. In her book “Staying Alive,” Vandana Shiva explains how these techniques displaced women from food production, degraded the soil and undermined peasant knowledge of seed and water management. She critiques hybrid seeds in particular stating, “These technologies … were aimed neither at protecting the soil and maintaining its fertility, nor at making food available to all as a basic human right” (Shiva, 1989,p. 104). Her critique of hybrid seeds is not solely about added production costs but the injustice of the patents that accompany the seeds and rules that protect their sale in market. In ‘Protect and Plunder’ Shiva explains how companies “can collect rent for every seed sown” thus displacing subsistence farmers and consequently changing local food availability, local livelihoods and economic stability. (Shiva, 42). Shiva is not alone in her criticism of the Green Revolution, in their book Food Rebellions!, authors Holt-Gimenez and Patel note, “An unspoken objective of the Green Revolution was to avoid implementing agrarian reform. In this sense, the Green Revolution was less a campaign to feed the urban poor than a strategy to prevent the rural poor from seizing land to feed themselves” (2009, p. 669).

While seemingly contradictory, food aid is also related to the impaired food distribution system. Post World War II, food aid helped to feed the poor while simultaneously undermining the resurgence of local food markets. This practice continued throughout the world. Over abundance of food grown in the North was “used as a battering ram to open up markets in the global South for the benefit of…agro-industries-to the detriment of farmers in the South who could not compete” (Holt-Gimenez and Patel, 530). This practice is seen today through programs like USAID that rely on US agriculture to feed the global South.
Using Pragmatic Solidarity

We believe that the timing is right for workplaces and schools, employing the “pragmatic solidarity” described in this Journal’s full commentary, to be a leading force in alleviating the burdens of food waste and food insecurity. What’s more, including this broader objective in food policy making not only makes healthy eating choices the easy choice, but also the socially responsible choice.

Barndt, Deborah, ed. (1999) Women Working the NAFTA Food Chain: Women, Food and Globalization. Toronto: Sumach Press.

Brown, Sandy & Getz, Christy. “Farmworker Food Insecurity and the Production of Hunger in California,” in Alkon and Agyeman, Cultivating Food Justice: Race, Class, and Sustainability.
Dangl, “Brazil: Lula and the Landless” in Dancing with Dynamite: Social Movements and States in Latin America, pp. 119-137
Farmer, Paul. (2010) “Making human rights substantial” in Saussy, ed, Partner to the Poor: A Paul Farmer Reader.
Guthman, Julie. (2011) Weighing In: Obesity, Food Justice, and the Limits of Capitalism. Berkeley: University of California Press.
Holmes, Seth, and Philippe Bourgois. (2013) Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States. Berkeley: University of California Press.
Holt-Gimenez, Eric, and Raj Patel. (2009) Food Rebellions!: Forging Food Sovereignty to Solve the Global Food Crisis. Cape Town; Oakland, CA; Boston, MA: Pambazuka Press.
(2) Holt-Gimenez, Eric and Patel, Raj. (2009) Food Rebellions!: Crisis and the Hunger for Justice (Kindle Locations 511-513). Food First Books. Kindle Edition. Oxford: Pambazuka Press.
Holt-Gimenez, “Food Security, Food Justice, or Food Sovereignty?” in Alkon and Agyeman, Cultivating Food Justice: Race, Class, and Sustainability.
Knaup, Hornad. Schiessl, Michaela and Seith, Anne. (2011) “Speculating with lives: how global investors make money out of hunger,” Parts 1-4, Der Spiegel.
Lee, Katie. (2014). The Farm Bill and International Food Aid: What You Need to Know. The Huffington Post. Posted 2/6/2014. Retrieved from:
National Public Radio. (2015) ‘Just Eat It,’ Filmmakers Feast For 6 Months On Discarded Food. Retrieved from:
Rutten, Lila and Yaroch, Amy and Patrick, Heather and Story, Mary. (2012) Obesity Prevention and National Food Security: A Food Systems Approach. Review Article. ISRN Public Health. Volume 2012. Article ID 539764. Retrieved from:
Shiva, Vandana. (1989) Staying Alive: Women, Ecology and Development. London: Zed Books.

USAID.GOV (2011). “Our Neighbors, Ourselves: Guatemala’s Chronic Malnutrition Crosses Borders. Nov/Dec 2011. Retrieved from:
World Food Programme. (2015) Hunger Statistics. Retrieved from:

How Do You Spell Audacious? D-A-V-I-D space K-A-T-Z and the True Health Initiative

By Michael P. O’Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion
Director, Health Management Research Center; Clinical Professor, School of Kinesiology, University of Michigan

David Katz is kind of an amazing guy, a Renaissance man: prolific author, gifted speaker, association leader, innovative physician, nutrition activist, scientist, inventor, entrepreneur, teacher, poet, athlete, father of talented kids, telegenic broadcaster, and visionary. Audacious visionary.

David just launched one of the most audacious public service ventures I have ever encountered, the True Health Initiative. Its Web site describes the vision of the True Health Initiative as ‘‘a world where all people live long and healthy lives, free of preventable chronic disease.’’ (1) When David says ‘‘world,’’ he means the whole world. It is important to point out that David is keeping a low profile in the public face of the True Health Initiative, but he is the spark that ignited its emergence and the driving force pushing it forward.

The slogan of the True Health Initiative is ‘‘a global consensus on lifestyle as medicine.’’ The consensus is backed up by the work of the more than 250 health experts David has engaged from nearly 30 nations to serve as council members.

Read full article

The Wellbeing Issue

By Paul Terry, PhD
Editor, The Art of Health Promotion
CEO and President, Health Enhancement Research Organization

In the January /February 2016 issue of The Art of Health Promotion, we examine the movement from wellness to well-being. The national adoption of the well-being concept has been rapid though the term has been elusive per a consensus definition. Still, what I love about the movement is that it reflects an era of expansiveness, maturation and innovative thinking in health promotion. To explore the state of the well-being movement I feature a report from Oklahoma State University (OSU), who trademarked the moniker “America’s Healthiest Campus®.” Though Dr. Suzy Harrington, the author of the OSU story, refers to theirs as a wellness movement, I invited her to share their strategic approach because it impresses me as a fulsome example of what most are now characterizing as well-being. Perhaps wellness and well-being will mingle as overlapping terms for years to come. Nevertheless, OSU’s strategy not only revitalizes all the dimensions of the wellness wheels from the 1970’s, but it is wrapped within an incisive organizational development framework. 

Whether the well-being term proves to be trendy or truly trending in the field of worksite-based health promotion, it remains that efforts to define, intervene on and lead in “well-being” are not new. What’s more, the term has been a staple of political economics and social policy long before its current run at replacing wellness. To wit, you will get double the results from a web search on the terms “well-being and social policy” compared to “well-being and health promotion.” In my commentary in this month’s issue of The Art of Health Promotion, I featured those health experts and organizations that I consider the prime movers of the well-being movement in health promotion. But, at the outset, I would invite readers to consider a truly broader proposition: that we will not do the well-being term justice if it is simply wellness warmed over. If we borrow from the rich well-being traditions of community development and social theory and fortify these with ingredients from positive psychology, brain science and wellness, only then might the well-being term become transformative in the field of health promotion.

Workplaces remain a researcher’s green field for developing robust, scientifically valid, well-being approaches. Proving the well-being case will not come from studies on programs as much as requiring tailoring approaches according to the unique well-being needs and goals of each organization. The article from Harrington in this issue explains the strategy model she developed in collaboration with OSU stakeholders campus-wide that accounted for the dynamic interactions between individual and organizational well-being. But it will not be until we implement the sophisticated measurement approaches recommended in an incisive article contributed by Dr. Siyan Baxter, also featured in this month’s issue, that we could aspire to achieve consensus on what constitutes an effective approach to positively influencing well-being.

Given the immature state of the art for advancing well-being in the workplace, there are innumerable opportunities for leadership and innovation. Indeed, the problem is not what needs improving, because everything from assessment to interventions to evaluation is green space. Health promotion professionals are devising definitions of well-being, but given the scarcity of population-based evidence that can influence well-being, we could be risking our credibility. It’s hubris to infer that health promotion has a corner on a concept that economists and social reformers have studied long before us. We can march boldly ahead, however, with an assumption that each organization we work with is capable of framing and pursuing those dimensions of well-being that are most congruent with their culture, values and organizational objectives. For just such an exemplary approach, read on.

The OSU Well-Being Strategy Model
By Suzy Harrington, DNP, RN, MCHES

(Full details are available in the Harrington article in the January/February issue of The Art of Health Promotion.)

Oklahoma’s State of the State’s Health grades each Oklahoma county’s health indicators like a report card in a color map approach, comparing our state to the national average. Because Oklahoma consistently ranks in the lower 10 percent of the nation’s overall health, it is not surprising that the maps are in the lower grade colors. Interestingly enough, in several areas, including obesity, Payne County, home of OSU’s primary campus, is leading the way with the highest grade. It could arguably be said it is because they have been “Striving to be America’s Healthiest Campus” for years. However, it only ranks a “C,” so there is great work still to do. OSU’s goal is for all of our nine OSU and A&M affiliate campuses to lead the way in every state indicator. Remembering that OSU has a county extension service office in every single county who excels in community wellness, we have the opportunity to get straight A’s in every county across the state. We have room to improve so we’ve built these components.

OSU Wellness Strategy Model
The OSU/A&M Wellness Strategy Model is a rotational model. The three outer levels reflect the vision, which interdependently rotate around the central mission to LIVE America’s Healthiest Campus®.

Let’s explore the different levels of the model: For Full Details on this model, see this month’s issue of The Art of Health Promotion. 

(why) LIVE America’s Healthiest Campus®
Central to the model, the bull’s eye, is the mission. We ARE America’s Healthiest Campus®. Our goal is to be it and to live it, living at our best to be the most productive, most engaged, most successful, most happy we can be.

(who) Enrich the lives of our students, employees and communities
Our vision is to enrich the lives of our students, our employees and the communities in which we live, learn, work and play to be the best they can be. OSU has five campuses, four A&M affiliate campuses and 77 county extension service offices.

Happy, engaged, content employees support our mission of successful graduates while increasing creativity, production and job satisfaction. Worksite wellness outcomes typically focus on return on investment (ROI), or dollars saved in injuries. Insurance and pharmacy claims are a hot topic. The more important OSU question is the value on investment, or the softer measures of more active engagement, strong work-life balance, more pleasure, more joy — essentially a higher quality of life. Retention is a measure of wellness for happy employees and students will remain loyal and stay. OSU is committed to achieving healthy work environments.

(what) Harmonize the physical, emotional, spiritual, social and professional dimensions of wellness
As previously mentioned, OSU wellness is the harmony of our physical, emotional, spiritual and professional dimensions of wellness. Each of the five dimensions is comprised of several elements within. I will briefly describe each dimension and address one of the elements within.


  • Active Living
  • Nutrition
  • Hydration
  • Tobacco-free
  • Adequate rest
  • Injury free
  • Preventive and clinical care

The Physical dimension is what individuals most commonly think of when they think of wellness. At OSU, we stress that it is all about moderation, availability and choices (except for tobacco in which there is no safe level).






Mental health and well-being

  • Confidence/self-affirmation
  • Self-compassion
  • Resilience
  • Stress management

Emotional harmony is vital and could arguably be said to drive the other dimensions, for confidence, resilience and self-compassion empower individuals (students and employees)to “say no” to illicit drug use, excess alcohol, violence, unnecessary spending, etc., in other dimensions.

When asked “how are you” most used to answer “fine.” Now, more typically, the answer is “busy” or even “crazy busy,” like it is a badge of honor. Who wants to be crazy?? The more resilient and confident we are around change and whatever life throws at us, the more energy we have for life.







  • Alcohol smart
  • Leisure/art
  • Drug free
  • Violence free
  • Sexual health
  • Relationships

We are social animals and thrive in a “tribe” of shared values. Social harmony is about positive peer pressure and role modeling. Social isolation leads to increased eating, drinking, sleeping, depression and other health risks, while decreasing energy, creativity and self-determination. Making time for leisure is something that is often overlooked. Simply put, we need time to “breathe.” Think about the breathing – it is the process of inspiration and expiration. We need leisure time to inspire us.






  • Faith
  • Values
  • Joy
  • Gratitude
  • Mindfulness
  • Sense of purpose/hope/optimism

Spirituality is much more than religion and is also often overlooked. It is our faith and sense of purpose, hope and optimism, our joy and gratitude, our values and living for each moment that sustains us. Happy, confident people have a sense of hope and purpose. They eat less and are more content. They are better team players, better at relationships, more active and fun, more motivated, creative and productive and quicker problem solvers since they see problems as a challenge and not a roadblock. Because of this, they are often more prosperous as well.







  • Lifelong learning
  • Leadership development
  • Financial wisdom
  • Creativity
  • Career development

Lifelong learning is the university mission for both students and employees, as are career and leadership development. To demonstrate the harmony with the other dimensions of wellness, think about students during finals. Professional wellness is their focus, as might be spiritual (purpose), while physical wellness (eating and sleeping ) and emotional wellness (stress) may not be a priority. Yet they all harmonize together as all are necessary and will shift and re-harmonize as soon as finals are over.

(how) Synergize the personal, interpersonal, organizational and environmental levels of change
As we move to the outer ring, the model demonstrates the multifocal ways we change behavior. It is about the synergy of personal, interpersonal, organizational and built environment, sharing resources and cross pollinating. You may notice it is the socioecological model without policy. Policy is found in the Organization section. This requires a top down, bottom up approach, addressing health at all levels.







  • Readiness
  • Determination
  • Responsibility
  • Health literacy
  • Efficacy
  • Knowledge
  • Skills
  • Attitude
  • Discovery

This section is about getting individuals educated, empowered and engaged.

This level is traditionally where we find health promotion and disease management – products, services, events and goods targeting individual behaviors of education, empowerment and engagement. Wellness is about personal responsibility, but it is so much more, as the rest of the model demonstrates. Everyone learns and responds differently, with different levels of readiness and determination, with different knowledge, skills and attitudes. Ultimately, our goal is to be the best we can be. 








  • Connectivity and outreach
  • Peer support
  • Communication
  • Cultural competencies
  • Trust
  • Sense of community
  • Relationships

Camaraderie, peer support and role modeling are vital. This is where the social movement of a culture of safety and wellness really happens. It is organized by the organizational section, but this is where the “rubber meets the road.” To harness this, we implemented an AHC Innovator initiative this year. AHC Innovators are a vital component of a new OSU collaborative wellness network. They are enthusiastic and committed employee change agents or wellness champions.







  • Easy healthy options
  • Sustainability
  • Safety
  • Built environments
  • Risk management
  • Trigger management
  • Social determinants
  • Occupational and environmental health/safety

It is important for the right choice to not only be the easy choice, but also the fun choice. This is a priority for the environmental implementation. A couple of examples that OSU offers are new tobacco-free signage, safe marked walking paths both outdoors and within the student union, “Choose Orange” healthy food labels and the new “Where’s Pete Discovery Walking Trail.” It is about nudging people to discover, use and enjoy healthy choices. And it isn’t just about activity, it is about all the dimensions of health.






  • Culture of wellness
  • Leadership support
  • Policies and processes
  • Collaboration
  • Services, programs, resources
  • Best practices
  • Academic research
  • Outcomes focus
  • Marketing and communication
  • Fun
  • Aligned incentives

The organizational section is where the culture of wellness infrastructure can be found. This is the greatest opportunity. It requires an integrated, collaborative, evidence-based approach, leveraging partnerships at all levels. Much of my work as Chief Wellness Officer is done here.

Culture of Wellness Organizational Structure
The Wellness Strategy Model sets the wellness constructs, but to systemize it, several organizational components needed to be place.

1)     Wellness Councils

2)     Wellness Innovator System

3)     Outcomes and Impact Tracking

Wellness Councils
Each institution is asked to maintain a multidisciplinary wellness council to develop and sustain local initiatives and collaborate within the system-wide culture of wellness, including recruiting and sustaining departmental innovators. Suggested membership includes stakeholders who represent a cross section of the employee and student population such as:

  • Wellness Services
  • Human Resources
  • Counseling Services
  • Health Service
  • Dining Services
  • Facilities and Grounds
  • Parking and Transportation
  • Communications
  • Marketing
  • Academics
  • Athletics
  • Students
  • Alumni Association
  • Residential Life
  • Environmental Safety
  • Community Outreach and/or Cooperative Extension
  • All AHC innovators are encouraged to attend







Each institution wellness council has two representatives at the OSU/A&M Wellness Council to include the chairperson and a “super” innovator. In addition, an OSU/A&M Student Wellness Council was recently developed to also provide input to the OSU/A&M Wellness Council.













Wellness Innovator System
OSU had strong top down leadership support but didn’t have a formal grassroots network, so one was developed.

AHC Innovators:
AHC Innovators are employees and students who enhance living America’s Healthiest Campus® (AHC). In addition to communicating, engaging and collaborating within their departments or student organizations, they are encouraged to generate initiatives and creatively implement wellness strategies. Through a communication network, innovators are provided the tools, resources and support necessary to facilitate healthy lifestyle choices for their peers. They are also responsible for completing the annual Certified Healthy recognition application for their department or student group.


AHC “Super” Innovator:
Each institution designates at least one AHC Super Innovator who serve as the wellness liaison in communicating, engaging and collaborating with the AHC Innovators and potential AHC Innovators within their institution. This individual is committed to advancing the OSU/A&M culture of wellness.

In collaboration with management and employees, Super Innovators are responsible for the following:

  • Collaborate operationally with other institutional Super Innovators
  • Annually identify monthly messaging points and challenges in collaboration with  the Chief Wellness Office, Human Resources and wellness services
  • Promote the culture of wellness components within their institution
  • Align with America’s Healthiest Campus® initiatives
  • Support the development and implementation of employee and student wellness policies and councils
  • Support ongoing assessment/monitoring of the effectiveness of wellness programs, services and resources

This position is a contributing member of each institution’s Wellness Council and the OSU/A&M Wellness Council.

Conclusion and Next Steps – Outcomes and Impact Tracking
Next steps include identifying, measuring and tracking measurable health and well-being outcomes and impact objectives. At minimum, return on investment (ROI), value on investment (VOI) and quality of life indicators that support increased engagement and retention must be examined. 



Allocative efficiency: A type of economic efficiency that “assigns relative values to health and non-health related goals to determine which goals are worth achieving, given the alternative uses of the resources, and thereby determining which programs are worthwhile” Allocative efficiency is informed through conducting a CBA
CBA: Cost benefit analysis, a form of economic evaluation where both the measurement of valuation for costs and benefits/effects/consequences are shown in monetary units
CEA: Cost-effectiveness analysis, a form of economic evaluation where the measurement of valuation for benefits/effects/consequences is natural units. When ‘healthy years’ or ‘health utility’ is the measure of interest the analysis can be referred to as a cost-utility analysis (CUA)
Health economic evaluation: Informs the decision maker(s) on how best to allocate their resources, with the aim to measure and optimize health benefits for a population. Defined as “the comparative analysis of alternative courses of action in terms of both their costs and consequences”41
Health utility: Preference-based measure of health status (for example SF-6D), known as a multi-attribute utility instrument (MAUI)
HRQOL: Health-related quality of life; a multi-item measurement of the domains of health. Instruments can be generic, disease or population specific
Production efficiency: Informed through a CEA or CUA, it gives a price for achieving a particular goal. Within health economics, outcomes are restricted to health benefits. It offers technical advantage when evaluating uncertainty and does not require outcomes to be monetized, rather pertains to the decision rule that an intervention is worthwhile if its cost-effectiveness ratio is less than the maximum willingness to pay (the threshold value).
ROI: Return on investment. An outcome from cost-benefit analysis that is expressed as a ratio formula, represented as (cost-benefit)/cost
Threshold value: The amount of money needed to produce an effective outcome that is deemed reasonable. This could reflect budget constraints, best alternative use of funding or other decision maker considerations such as their specific goals and guidelines. Decisions to fund a WHP program may relate to the relative importance of outcomes, conditional on the threshold value to further invest



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