Health Promotion That Saves People and the Planet and an Interview With Dr Sara Singer

Abstract

Recently the Business Roundtable released a “Statement on the Purpose of a Corporation” which pronounced that alongside increasing shareholder value, businesses need to play a role in environmental and consumer protection. These stated “commitments” signed by 181 CEOs of leading companies include “supporting the communities in which we work,” “investing in our employees,” and “embracing sustainable practices.” Skeptics will take a wait and see attitude about these business leaders’ words and await more deeds, but others view this as an affirmation of an employer leadership philosophy that many have been championing for decades. For example, the book Building a Culture of Health: A New Imperative for Business examined the interface of social and business trends and argues that 4 pillars are needed if business is to accrue the advantages of leading with a culture of health. These pillars are community, consumer, employee, and environmental health. This editorial summarizes current initiatives and studies relating to these pillars and the Business Roundtable’s commitments and includes an interview with Dr Sara Singer. Singer is an organizational development expert, business scholar, and coinvestigator of a national study that examines business engagement in the 4 pillars and sets a baseline for how involved businesses are in addressing social and health issues.

Keywords

sustainability consumerism dietary recommendations person-centered health promotion environmental health

What’s not to love about a good food fight? Well, when one side says evidence proves the other side is throwing rotten food, but the other side claims the same evidence proves it isn’t rotten, such technical banality can take the fun out of it. So it was with the media hype about the “red meat papers” that played out after the Annals of Internal Medicine pusblished dietary recommendations that “adults continue current unprocessed red meat consumption” and “continue current processed meat consumption.”¹ The 18 study authors called themselves the “nutritional recommendations consortium” (NutriRECS), and in spite of unequivocal rejection of the NutriRECS findings by the American College of Physicians, the Harvard T.H. Chan School of Public Health, the American Heart Association, the American Cancer Society, The True Health Initiative and many renowned nutrition scientists like Marion Nestle and Walter Willet, The New York Times nevertheless featured the study as “a remarkable turnabout” now that the health benefits of reducing meat consumption are “not backed by good scientific evidence.”²

If the food fight was just about the quality of observational studies, it would be messy enough. But it was a seemingly incidental decision by the study authors, at least one that I didn’t find experts commenting upon, that turned this scientific tussle into a stimulating debate. That is, NutriRECS decided to base their recommendations on “summaries for health effects, values, and preferences as well as cost, acceptability, and feasibility of a recommendation to decrease meat consumption.” Go figure. Recommendations based on health affects AND acceptability? Let’s discuss. First, to dispense with the obvious, there are perturbing parallels between our love of red meat and other personal preferences relating to killers like tobacco or high-capacity firearms. People loved their cigarettes and it didn’t stop us health promoters from vilifying them. The cigarettes that is, not the people. Or so I hope. Nevertheless, it remains that factoring individual preferences into health promotion recommendations invites a fascinating, albeit, dizzying dimension into health communications and health education practice.

When it comes to adherence to healthy eating guidelines, I have speculated in past articles that concerns about the environment may well surpass protecting our personal health as the personal value and preference that compel consumers to eat less meat.^3,4 Although the NutriRECS authors based their guidelines, in part, on assumptions that it’s not feasible for people to give up their burgers, I think they missed the point by not factoring in values relating to global sustainability. To wit, what I found more impressive than the mobilization of hundreds of scientists against NutriRECS was the reaction of countless consumers. By the closing of the reader comments section for the Times article, there were 1534 comments. The most “recommended,” reflecting the values of hundreds of others who commented similarly, came from Suzanne who wrote: “Whether or not it is good for our bodies is becoming beside the point. Raising cows for beef—producing animals, actually—is destroying the Amazon and other forests. Eating red meat is very bad for the planet and that should be reason enough to stop.” Suzanne should have been NutriRECS 19th author as she surely would have dissented when “the panel focused exclusively on health outcomes associated with meat and did not consider animal welfare and environmental issues.”

The Business Roundtable Rethinks the Purpose of a Corporation

Imbedded in the tirades against the NutriRECS article were accusations that the study’s lead author had conflicts of interests given ties to the food industry. It is not incidental that the food fight and subsequent consumer reactions about environmental sustainability occurred around the same time that the Business Roundtable released a statement about their commitment to environmental and consumer protection. Signed by 181 CEOs of America’s leading corporations, including food companies like Coke and Land O’ Lakes, the “Statement on the Purpose of a Corporation” includes “supporting the communities in which we work,” “investing in our employees,” and “embracing sustainable practices.”⁵ The statement was billed as a “commitment.” When compared to the time-honored notion that corporations exist primarily, if not solely to increase shareholder value, embracing such social causes seems rebellious, even Jack Welsh-esque. But these social commitments also seem decidedly strategic at a time when a majority of millennials are suspect of, if not outright, hostile toward capitalism. Leading democratic candidates for president have policy platforms firmly ensconced in valuing consumers and workers and in advancing equitable access to health care and conscientious environmental protections. Could consumers be emerging as the new invisible hand-guiding corporate pronouncements about their purpose?

“What the customer thinks he is buying, what he considers ‘value,’ is decisive—it determines what a business is, what it produces and whether it will prosper.”

Peter Drucker

The food fight raises similar questions about the primacy of scientists as stakeholders for evidence-based health guidelines alongside the values of the consumers for whom the guidelines ostensibly exist. Reflecting on the popular “patient-centered care” trend in medicine, a term that bases “shared decision-making” on “patient preferences, needs, and values,”⁶ I’d venture that surgeons still prevail when it comes to how to wield their knives. Similarly, Richard Shinder, a financial services’ executive, opined in the Wall Street Journal that the private sector confuses their role relative to the public sector when they add social objectives to their missions. When considering a corporate purpose that includes sustainability or employee health, Shinder writes: “While all are worthy objectives, they are either derivative of the objective to maximize shareholder value or a distraction from it. Either way, things aren’t likely to end well for any business that opts to please stakeholders over shareholders.”⁷ That’s why things didn’t turn out well for NutriRECS. By factoring in consumer preferences, they managed to alienate the Annals of Internal Medicine’s real stakeholders, the who’s who of the scientific community.

Are Employers Ready for all 4 Pillars of a Culture of Health?

Skeptics will take a wait and see attitude about the Business Roundtable’s commitment to this new purpose for business but count me among those who will be cheering this as an affirmation of an employer leadership philosophy that many have been championing for decades. The Health Enhancement Research Organization (HERO), where I work, has a vision that “all workplaces will positively influence the health and well-being of employees, families and communities.” The Roundtables pronouncements read as if written 20 years ago by HERO’s founders. Another more recent, but no less aligned example comes from the “Culture of Health as a Business Imperative” program, a joint effort between the Harvard Business School and the Harvard T.H. Chan School of Public Health, led by Dr Howard Koh with the support of The Robert Wood Johnson Foundation (RWJF). I have the pleasure of serving as an advisor on the project and on faculty for an executive education course derived from this RWJF grant. Our curriculum includes engaging business executives in strategic direction setting exercises relating to whether and how to increase the role of the private sector in community health. These executives readily identified that more such collaborations between business schools and schools of public health are needed if future business leaders are to be predisposed to seeing social problems as business opportunities.

Another of many deliverables from Harvard’s effort came from Business School scholar Dr John Quelch who, together with his coauthor Emily Boudreau, wrote the book, Building a Culture of Health: A New Imperative for Business.⁸ Consistent with the Roundtables’ commitments, Quelch and Boudreau examine the interface of social and business trends and argue that 4 pillars are needed if business is to accrue the advantages of leading with a culture of health. Taken directly from their book, the pillars are:

Consumer health: How organizations affect the safety, integrity, and healthfulness of the products and services they offer to their customers and end consumers.

Employee health: How organizations affect the health of their employees (eg, provision of employer-sponsored health insurance, workplace practices, and wellness programs).

Community health: How organizations affect the health of the communities in which they operate and do business.

Environmental Health: How organizations’ environmental policies (or lack thereof) affect individual and population health.

Regarding the “employee health” pillar, in a recent editorial I reviewed results from the Workplace Health in America Survey to make the point that few businesses have risen to the challenge of providing the kind of comprehensive approach needed to achieve exemplary results. Specifically in 2018, 12% of companies took a comprehensive approach to employee health promotion which is up from 6.9% sponsoring comprehensive approaches in 2004.⁹ Like the nature of the mêlée over red meat among nutrition experts, it is fair to say the workplace health promotion movement was spawned more by expert recommendations than by consumer values and demands. But that’s been changing fast in the past decade with more businesses owning up to the effects of their cultures on employee health rather than merely putting the onus of high health-care costs on employee lifestyles. Yet, if following best practices recommendations in the employee health pillar is still uncommon, how many companies are engaging in activities that support all 4 pillars? Gladly, a team of researchers have examined that very question and their results produced some echoes from the early days of the employee health promotion era. Michael Anne Kyle and colleagues recently published “Toward a Corporate Culture of Health: Results of a National Survey” in the Milbank Quarterly,¹⁰ research that offers detailed data about how companies, large and small and across sectors, are addressing each of the 4 pillars. These findings offer what I hope becomes the baseline for a movement that broadens the private sector’s commitments to improving lives and protecting the environment.

As investors, consumers, and employees, we need to reward companies that invest in health and, as constituents, we need to demand that our elected officials create conditions that do so too.

Sara Singer

Growth in the employee health pillar has been spurred by a mix of scientific evidence, employer paternalism, competition for talent, and efforts to contain the cost of employee health benefits. I anticipate an employer’s intent to build business strategies for each of the other pillars will also derive from diverse views about the purpose of a corporation and the business advantages that can accrue relative to each pillar. For perspective on such, I turned to Dr Sara Singer who also serves as co-principal investigator and is on faculty for the aforementioned Harvard culture of health initiative and was a coauthor on the Milbank Quarterly paper about the results from the national culture of health survey. Dr Singer is a Professor of Medicine at the Stanford University School of Medicine and Professor by courtesy at the Stanford Graduate School of Business and She remains an Adjunct Professor at Harvard Chan. Before Stanford, Dr Singer developed and taught courses at the Harvard T.H. Chan School of Public Health, entitled “Health Care Organizations and Organizational Behavior” and “Leadership and Innovation in Health Care Organizations.” She also taught in the Harvard PhD in Health Policy core course and conducted leadership training programs for the Brigham and Women’s Hospital and the Massachusetts General Physician Organization on topics related to organizational culture, leadership, and teamwork.

Dr Singer’s research productivity is extraordinary with more than 100 articles published in academic journals and books on health-care management, health policy, and health system reform. Singer’s publications have won numerous awards, including best paper awards from the Academy of Management’s Health Care Division 4 times and was the recipient of the Avedis Donabedian Healthcare Quality Award from the American Public Health Association. Singer shared the results of the national culture of health survey as a keynote speaker at HERO’s Forum19, and the following interview builds on questions and comments she fielded from the audience. Additional reflections from Singer on the study’s findings can be found at a publicly available HERO webinar.¹¹

Q, Paul Terry: Many readers of this journal are familiar with the role the private sector has played in advancing community health and employee health, and your team’s national survey offers insights into how much the private sector invests in those areas. Yours is the first study I know of where you bring an equal focus to the role companies can play in improving consumer and environmental health. Advocating for all 4 pillars seems both audacious and admirable. Why did you weight the 4 pillars equally in your study?

A, Sara Singer: Thanks for your question, Paul. First, I’d like to point out that while your readers may be accustomed to thinking about the private sector as playing a role in advancing community and employee health, even these roles are not widely appreciated. Private sector companies are often seen as profit maximizers, first and foremost. I’m glad your readers appreciate the potential value private sector businesses can bring to communities and employees. That suggests they’re already pretty forward-thinking. Our survey examined potential contributions of businesses in 4 areas—community, employee, consumer, and environmental health—because we wanted to acknowledge the potential for businesses to contribute in the broadest possible sense. In addition to any benefits and well-being programs for employees and community-based programs, all businesses impact health of consumers through their products and services, and they all lay down an environmental footprint that impacts all of us.

You’re familiar with the Workplace Health in America Survey results that we published in this journal showing that relatively few companies took a comprehensive approach to employee health promotion in 2018, though at 12% it nearly doubled the percentage of companies that were sponsoring comprehensive approaches back in 2004. Your team found that few companies are being strategic about all 4 of the Culture of Health pillars. Is it fair to draw parallels between employee health in America in 2004 and the employer’s role in a Culture of Health in America in 2019?

Well, in our recently published research, what we found is that only 8% of businesses report having a strategic plan for promoting a culture of health that included all 4 pillars. We also asked about whether businesses took 38 specific actions to promote a culture of health across the 4 pillars, and we found that only 2% of businesses were in the top quartile for action-taking in all 4 dimensions. Another 5% of businesses were in the top quartile for 3 of 4 dimensions. Almost 60% of businesses weren’t in the top quartile for any of the pillars. The businesses that had a more comprehensive strategic plan were more likely to take health-related actions: 78% of them were in the top quartile for action-taking. So yes, I agree, it’s still a pretty small proportion of businesses taking a comprehensive approach when it comes to promoting health and well-being.

Can you react to worries some may have about employee health and culture of health opportunity costs? That is, given we’re making relatively slow progress toward using best practices to support employee health, do you have any concerns that adding 3 more pillars as a business imperative for employers will slow progress even more?

Interesting question. Actually no, I believe that businesses will derive a return on their investment in health and well-being. Investors, consumers, and employees are becoming increasingly aligned in rewarding businesses that do well by doing good, which means that businesses can create a virtuous cycle by investing to promote a culture of health. I’m also optimistic that if businesses work toward culture of health comprehensively, for example, by bringing together those responsible for the 4 pillars—human resources, product development, sustainability, and community outreach—they will find synergies across the pillars.

Can you say more about the business case in support of employer leadership in all 4 pillars rather than a select 1 or 2? Specifically, can you suggest a logic model that positions 4 pillars as synergistic or as accelerators rather than as scope creep relative to the private sector’s role in a culture of health?

Let me answer your questions by giving you an example of the synergy I think is possible. Say a company decides to stop selling unhealthy products or to embark on efforts to reduce its greenhouse gas emissions. Not only might these initiatives attract consumers who value health and climate but they might also make employees feel better about their opportunity to contribute meaningfully, making it easier for the business to hire and retain top talent. Likewise, investing in the health and well-being of employees positions them to participate in efforts to enhance community.

In national surveys about employee health programs, we find wide variation between large and small companies, with large companies much more likely to sponsor a comprehensive approach. I was surprised that the variation in investing in consumer or community health didn’t seem that great between large and small companies in your survey. Your thoughts on expected differences in considering all 4 pillars by company size?

We were a little surprised by our findings regarding size as well. We assumed that larger businesses would have more resources for investing in a culture of health. One thing to keep in mind is that—because we assumed really small businesses wouldn’t have these resources—we excluded from our survey businesses with fewer than 50 employees, still, we found pretty modest differences; businesses with fewer than 100 employees took about 9 of the 28 actions we queried, while businesses with more than 5000 employees took about 12. Adjusted for industry, these differences basically disappeared. So, size and industry together are accounting for some of the differences in action-taking we observed, rather than size or industry alone. We did find that larger businesses were more likely to play a leading role (vs just participating or sponsoring programs financially) in community programs, so maybe it’s in anchoring community initiatives where size matters most.

You make reference to CVS Pharmacy’s strategic business decision to stop selling cigarettes and the tremendous impact this had on consumer health. And you prognosticate that the food industry may be recognizing the business advantage of factoring in consumer health in their strategy. You found on average that companies in America are taking 38% of the actions you asked about across all 4 pillars. Plenty of room for improvement or an indication that all 4 domains is a bridge too far?

There’s clearly room for improvement. If the businesses in the lowest quartile performed as well as the ones in the top quartile, that would be a tremendous shift. Having said that, even the businesses that are performing at the top still have room to improve. Even they only took 62% of actions, so they could also do better. I don’t think that progress on all 4 domains is a bridge too far. The fact is, we need businesses to engage in all 4 pillars in order to achieve and maintain this country’s health goals. The medical care system alone isn’t going to do that. I think our biggest challenge is getting businesses to see the return on investment for action-taking. This means that, as investors, consumers, and employees, we need to reward companies that invest in health and, as constituents, we need to demand that our elected officials create conditions that do so too.

Listening for Truth in an Echo Chamber

In the executive education course mentioned above, I asked participants the same question I asked Dr Singer—whether working toward all 4 pillars was synergistic or a bridge too far? One of the business groups in attendance had just generated strategies related to how their services could have a more positive impact on consumer health and a member of the group said: “We need to offer our employees the same great benefits we’re considering for our customers. You know, the cobbler’s kids also need shoes.” Yes! When we turn the same passion for satisfying customers to pleasing employees, we’re likely on to more than just a morale boosting strategy. That we treat different stakeholders differently may be the root cause behind the food fight. On one side of the fight, consumers are casualties of misinformation. As the New York Times writer suggested: “While the new findings are likely to please proponents of popular high-protein diets, they seem certain to add to public consternation over dietary advice that seems to change every few years.”¹²

But on the other side of the fight is the tension between scientific progress, consumer preferences, and business interests. How is it that a journalist would suggest that the findings from one study would override the consensus guidance from the world’s leading scientific organizations? The Executive Director of the True Health Initiative, Jennifer Lutz, summarized this tension well when she wrote: “We live in a culture that leads us toward preventable illness and in an echo chamber that keeps telling us we don’t know how to be healthier. Except we do. The latest “research” is a distraction, an irresponsible gust of wind that threatens to steer us off course.”¹³ A key word in Lutz’s rebuttal is “us.” The Business Roundtable seems intent on being a part of “us,” not deemed per usual as the “them” that buyers need to beware about.

Business leader Steve Denning harkened back to 1954 and Peter Drucker’s philosophy when he wrote the article “Making Sense of Shareholder Value: The World’s Dumbest Idea.”¹⁴ For Drucker, creating customers was the one and only purpose of a corporation. Per Drucker: “For it is the customer, and he alone, who through being willing to pay for a good or for a service, converts economic resources into wealth, things into goods… What the customer thinks he is buying, what he considers ‘value,’ is decisive—it determines what a business is, what it produces and whether it will prosper.” Such seems to be the call back to business basics that Koh, Quelch, Singer and, finally, the Business Roundtable is invoking. Following the NYT article about the food fight, the leading “NYT Picks” from the comments section came from “the last generation” who wrote:

“The evidence is too weak to justify telling individuals to eat less beef and pork” excuse me? The damage the meat industry does to the earth, it’s impact on climate change, is only second to the US military’s devastating impact on climate change. If people don’t stop eating a significant amount of meat my generation will be the last. HOW DARE YOU tell people the “evidence is too weak to justify telling individuals to eat less beef and pork.”

What’s not to love about a good food fight? If it serves to highlight the ascendency of consumer influence on business practices, the evidence about which foods are rotten may well be beside the point. What’s more, if the food flinging hits some scientists upside the head and has them pause to consider the role of consumer preferences and values in decision-making, well, hand me a slimy slab of red meat.

Paul E. Terry, PhD Editor in Chief, The American Journal of Health Promotion, Senior Fellow, The Health Enhancement Research Organization (HERO).

References

Johnston

Zeraatkar

Han

, et al. Unprocessed red meat and processed meat consumption: dietary guideline recommendations from the Nutritional Recommendations (NutriRECS) Consortium. Ann Intern Med. 2019. doi:10.7326/M19-1621. https://annals.org/aim/fullarticle/2752328/unprocessed-red-meat-processed-meat-consumption-dietary-guideline-recommendations-from. Accessed October 2, 2019.

Kolata

. Eat less red meat, Scientists said. Now some believe that was bad advice. New York, NY. New York Times; 2019. https://www.nytimes.com/2019/09/30/health/red-meat-heart-cancer.html. Accessed October 2, 2019.

Terry

. Mindful Eating (Not the Kind you Think) and an Interview with Dr. Kevin Walker. Am J Health Promot. 2019;33(7):984–990. Sage Publications.

Terry

. Could a broader social and educational diagnosis inform fairer food policies? Am J Health Promot. 2016;30(4):301-303. doi:10.1177/0890117116639016e.

The Business Roundtable Our Commitment. The Purpose of a Corporation. 2019. https://opportunity.businessroundtable.org/ourcommitment/. PDF of Statement. https://opportunity.businessroundtable.org/wp-content/uploads/2019/09/BRT-Statement-on-the-Purpose-of-a-Corporation-with-Signatures-1.pdf. Accessed October 3, 2019.

Tzelepis

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. The business roundtables recipe for confusion. Wall Street Journal. 2019. https://www.wsj.com/articles/the-business-roundtables-recipe-for-confusion-11568760132. Accessed October 3, 2019.

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. Building a Culture of Health: A New Imperative for Business. New York, NY: Springer Publishing; 2016. https://www.springer.com/gp/book/9783319437224.

Terry

. Workplace health promotion is growing up but confusion remains about what constitutes a comprehensive approach. Am J Health Promot. 2019;33(6):845–849. Sage Publications.

10.

Kyle

Seegars

Benson

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Singer

. Toward a corporate culture of health: results of a national survey. Milbank Quarterly. 2019. https://www.milbank.org/quarterly/articles/toward-a-corporate-culture-of-health-results-of-a-national-survey/. Accessed October 10, 2019.

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Dr Sara Singer. Results from a National Culture of Health Survey. HERO webinar hosted by Paul Terry. 2019. https://hero-health.org/webinars/webinar-archives/.

12.

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13.

Lutz

. The truth about meat and health: don’t be confused by misleading media reports. Opinion. New York Daily News. 2019. https://www.nydailynews.com/opinion/ny-oped-the-truth-about-meat-and-health-20191001-imjyumxaavhwbgmtccaezy7bue-story.html. Accessed October 2, 2019.

14.

Denning

. Making sense of shareholder value: ‘The world’s dumbest idea’. Forbes. 2017. https://www.forbes.com/sites/stevedenning/2017/07/17/making-sense-of-shareholder-value-the-worlds-dumbest-idea/#5e5b7fdb2a7e. Accessed October 3, 2019.