Like no other event in our collective experience, the pandemic reminded us of the need for an integrative view of wellbeing beyond traditional measures of physical health. Focusing exclusively on cholesterol level and bone density, for example, would be hopelessly inadequate for the needs of today. 

I continued to be haunted by Zak Kohane’s description of the many children’s hospitals across the country that have stopped admitting patients for elective procedures.

This isn’t because the hospitals are overrun with COVID, Kohane says. Rather, the beds are filled to capacity with children whose mental health, exacerbated by the challenges of childhood in the era of COVID, now requires in-patient care. 

Many employers have apparently recognized the urgent health crisis. “Workplaces went through an accelerated digital disruption” as a consequence of the pandemic, Forbes columnist Brian Solis writes.  Corporate health and wellness offerings that used to be the sole provenance of HR are now getting the attention of senior leadership, talent management expert Josh Bersin explains. 

Particularly in the face of “the great resignation,” when many employees are seriously rethinking their priorities and commitments, keeping workers happy and physically healthy has become a top business priority.  The pandemic didn’t create today’s holistic view of employee health and wellness, but it dramatically accelerated and intensified employer interest. 

Today, let’s take a quick look at the evolution of workplace health and wellness, consider the dimensions of health and wellness that executives are now contemplating, and assess how well these efforts are likely to perform.

Evolution of Corporate Health and Wellness

The introduction of health and wellness to the workforce is generally traced to the 1950s, HR expert Cheryl Brown Merriwether explains. Early efforts tended to focus on “industrial hygiene” – monitoring “air quality and cafeteria sanitation.” 

In the 1970s, she explains, as the cost of healthcare assumed by companies climbed, employers looked to reduce these costs by promoting healthier lifestyles.

The first “modern” corporate wellness program is generally considered to be J&J’s “Live for Life.”  The effort launched in 1978 with two goals: encouraging healthy employees by promoting healthy behaviors, and reducing healthcare costs for the company.  

As Merriwether outlines, “Live for Life” was an onsite wellness program that

“included physical assessments, questionnaires, and provided employees with information on stress management, nutrition, and weight control.  The program also provided support for high-risk behaviors such as alcohol or substance abuse.”

Corporate wellness programs began to incorporate psychological wellbeing in the 1980s. Around that time, workplace fitness programs, sometimes including onsite fitness centers, became more widespread.

In the 1990s, the US Department of Health and Human Services advanced an initiative called Healthy People 2000, which encouraged employers to promote healthy behaviors. “It was widely believed during this period,” Merriwether says, “that workplace health and wellness initiatives benefited both employees and company, even though evidence and supporting data were hard to find.”

The deliberate focus on creating and fostering a positive corporate culture, which started to gain traction during 1990s, took off during the tech-fueled 2000s.

As Bersin explains,

“In 2007, Google created a course on mindfulness that was an overnight sensation. It was the most popular benefit on the Google campus and sparked the trend toward mindful thinking at work, in design, and even in engineering. We believe many of the new ideas about growth mindset, abundance mentality, yoga, and various other philosophies of growth prominent today stemmed from this root.”

Companies continued to look to health and wellness programs for healthcare cost-savings. Through the 2010s, companies increasingly searched for ways to persuade employees to avail themselves of perennially underutilized wellness services, and thereby unlock the (always elusive – see here) cost savings.

Corporate wellness programs continued to evolve in the 2010s. As Abraham and White describe in Health Affairs in 2017, there was a transformation in value proposition, from “return on investment (ROI)” to the more expansive concept of “value on investment (VOI).” 

As the authors explain, this means looking “beyond individually focused metrics of medical care cost savings or productivity gains,” and extending the scope “to include organizationally focused metrics such as employee engagement, turnover, retention, and satisfaction and even profitability.”

One health plan executive told Abraham and White that for employers, health and wellness may still be about healthcare costs, but it’s also increasingly about recruiting and retaining the most talented workers they can find. “It is way beyond ROI,” they say.

To address this need – a need obviously intensified by the pandemic – companies are creating “wellbeing care teams,” Merriwether reports. These teams are (or will be) staffed by “professional practitioners, both clinical and non-clinical, she says,” and “will include mental, behavioral, and integrative health practitioners working in partnership with health, wellness, and professional recovery coaches.”

Merriwether points out that the “market for health coaching services is $7B and growing,” and notes “there are currently more than 128,000 health coaches and educators who help clients establish lifestyle behavior changes.” (See here for my recent discussion of health coaches and technology.)  

Components of Health and Well Being

For some time, as Bersin notes, most companies have embraced a view of “wellbeing as a constellation of social, mental, physical, and behavioral health.” However, Bersin adds, over the last decade – particularly “as work has become ever more focused on always-on digital tools” – new dimensions have emerged: “sleep and rest, meaning and purpose, relationships with others, and even positive thinking.”

Bersin proposed a corporate health and wellbeing framework that includes six dimensions (plus enabling tech and HR capabilities); I’ve mapped this (imperfectly) onto the well being frameworks I’ve previously discussed (see here), and have also included a related but distinct set of six dimensions that McKinsey uses to categorize consumer interest in wellness.

Still Needed: Focus On Social Milieu

Today, Bersin points out, “nearly all companies have programs for resilience, wellbeing, mental health or stress reductions. Company leaders are adding new vacation policies, giving people apps and relaxation tools, and lavishing wellbeing benefits on their teams.”

So are these efforts working? If by “working” we mean creating a “healthy organization,” Bersin argues, then the answer is “no.” What’s needed, he says, is more than just “a set of benefits and wellbeing programs.”

Instead, he contends, what’s needed is “a top-down focus on job and work design, management, and rewards practices, a sense of psychological safety and fairness, and a commitment to listening to employees.”

What I think Bersin is getting at is a point that academic experts including Michael Kelly and Mary Barker have addressed as well: many well-intentioned “intuitive” solutions come up short because they fail to recognize and account for the complex social milieu from which behaviors originate.

In their instantly classic 2016 paper, “Why is changing health-related behavior so difficult?” Kelly and Baker highlight the failure of commonly-invoked approaches to behavior change. Among the examples they cite: “use common sense,” “it’s about messaging,” and “it’s about providing people with information.” They also explain why we can’t reliably be guided either by the assumption that “people act rationally” or by the view that “people act irrationally.”

What’s needed, they argue, is a view (called “social practice”) that “conceptualizes behavior not as something that can be reduced down to things that individuals do and think as if they were isolated from others.” 

Kelly and Baker emphasize the importance of “disaggregating broad behaviors” (like eating, drinking, smoking, etc), “breaking them down in time and place where different expression of these behaviors occur.” And of course, they remind us, more research is required.

Key Takeaways

For executives who need to help employees today, and for health-oriented entrepreneurs looking for a way to contribute, there are several takeaways.

First, it’s tremendously exciting and hopeful to see so many offerings targeting the many dimensions of health and wellness, a Cambrian explosion that would seem to increase the chance for the development of truly high-value products.  The diversity of wellness alternatives now available theoretically offers greater opportunity  for individual employees to find programs that best meet their particular needs.

But there’s a downside to this burst of activity. The volume of offerings makes it hard for employees to navigate the system and make good choices. (Full disclosure: I’ve worked in several large corporations and never managed to successfully navigate a benefits systems, which always seemed incredibly complicated, and to involve a series of nested options and endless passwords.)  

Apparently, I’m not alone. Bersin cites research that finds almost half of employees consider their multiple workplace wellness programs to be confusing. That’s a big roadblock that gets the way of using benefits. 

What matters most when it comes to corporate wellbeing solutions, Bersin says, are “simplicity and transparency.” 

Yet we should also not get so lost in the weeds of benefit deployment that we lose sight of what seems to be a really encouraging development – the increased recognition that our health and wellbeing is often closely tied to the environment we’re in: the nature of our work, the richness of our engagement with colleagues, the way in which our effort is recognized and valued. It’s also an area where genuine commitment and involvement by senior leaders can make a palpable difference.

Let’s dare to be hopeful for a moment. The increased availability of personalized corporate health and wellbeing options, from health coaches to fitness centers to mental health support, together with more integrative company-wide efforts that authentically promote and enable a healthy culture, offers exceptional promise.

We can begin to imagine what the future of work could, and arguably should, be.

Wellness, Not Woo Woo

One final point: it’s really important to recognize that the pursuit of wellness need not come at the price of hard work and exceptional performance. 

Phrased differently, wellness doesn’t have to be “woo woo.”

As the father of positive psychology, University of Pennsylvania professor Martin Seligman takes pains to explain, the “A” in his PERMA-V model  (a framework represented in column four of the previous table) represents “Achievement.”

Seligman further emphasizes that we feel best when we enter a state of complete absorption, termed “flow” by the late Mihaly Csikszentmihaly. We are most likely to experience “flow” when we are fully utilizing our core strengths. (Then again, when I took the test, my top three turned out to be “love,” “perspective,” and “curiosity,” so perhaps I should have become a rabbi.)

Flow may also explain why, as a recent WSJ article reported, entrepreneurs tend to be happier than wage-earning employees – even though entrepreneurs on average work longer, make less, and are more stressed. “All of those problems do take away from entrepreneurs’ happiness, of course,” the Journal acknowledges, “but the positives of running a business are so strong that they outweigh the negatives.”

The point: while it’s smart for companies to embrace health and wellness as a corporate value, it will be even smarter if leaders embrace and authentically support the remarkably diverse range of ways in which this worthy goal might be meaningfully pursued.

As we enter the holiday eating season – quickly followed by the New Year get-in-shape resolution season – let’s look at obesity challenge head-on. 

Expert physicians who study obesity recognize the condition as a complex disease associated with profound health consequences. It also represents, for many health tech entrepreneurs, a high-value problem to be solved.

Obesity has been ratcheting upward for decades, representing a corrosive threat to national (as well as global) health. (See the data below from the National Health and Nutrition Examination Survey and read the full CDC paper from February 2020):

More than four out of 10 adults in the U.S. meet criteria for obesity (Body Mass Index of 30 or higher), and nearly one out of 10  adults would be classified as suffering from “severe,” or “class III” obesity, with a BMI of 40 or higher. 

The increase in obesity during this time period, interestingly, occurs despite the decrease in physical inactivity reported during this same time.

In other words, although more Americans seem to be getting off the couch, obesity rates keep going up.

Obesity in adults “is associated with a striking reduction in life expectancy,” according to UpToDate (an authoritative reference used in clinical practice). In addition, UpToDate reports, “obesity and increased central adiposity are associated with increased morbidity,” noting that “obesity has surpassed smoking as the number one cause of preventable disease and disability.” Significant comorbidities related to obesity include diabetes, hypertension, osteoarthritis, cancer, depression – and of course, COVID-19.  As UpToDate summarizes, multiple (observational) studies “link obesity with increased morbidity and mortality” from COVID-19.

Not only are individuals with obesity at increased risk from COVID-19, but for many Americans, the pandemic seems to have prompted a hefty increase in weight. An American Psychological Association survey from March 2021 revealed that 42% of us reported undesired weight gain as a consequences of the pandemic; individuals in this category said they gained an average of 29 pounds; the median amount they gained was 15 pounds. 

If there’s a silver lining related to obesity, it’s that, according to UpToDate, most of the “over 230 comorbidities and complications of obesity” that have been identified will improve when people lose weight. 

The Brutal Challenge Of Weight Reduction

Yet durable deliberate weight loss remains an incredibly difficult challenge – staggeringly, almost incomprehensibly difficult.

One factor, according to MGH obesity medicine expert Dr. Fatima Cody Stanford relates to “the organ that’s most important with regard to regulating our weight – and that is our brain.”  In particular, she says, the brain actively defends a weight set point, and gets “quite angry” when you lose weight, to the extent, she says, that it pushes you to return to an even higher set point – a particular problem for “weight-cycling” (i.e. “yo-yo dieting”).

And it gets worse. For the vast majority of us – 97%, she says – the brain “doesn’t retrain” on a lower weight, no matter what you do. 

“Unless you do something that actually changes that brain-gut connection,” she says, citing the example of bariatric surgery, the brain “still wants to go back.” 

Consequently, outside of bariatric surgery – which Stanford describes “the most effective tool available for both children and adults that have severe obesity” – maintaining a healthy weight, for most people, is destined to remain a chronic, constant, difficult, daily battle; even those who have bariatric surgery generally must remain constantly vigilant, if they want to maintain the weight loss their procedure helps them achieve.

But wait – it (somehow) gets even worse. 

Six years after television’s “The Biggest Loser” competition, NIH metabolism researcher Kevin Hall, studied the 14 of the original 16 participants and discovered they had regained two-thirds of the weight they had lost during the show. 

Even more discouraging, Hall found that the people who continued to exercise the most (compared to original baseline) exhibited a lower(!) resting metabolic rate (RMR). Hall says he now believes these data may represent an extreme example of the “constrained energy expenditure model” proposed by Duke anthropologist Herman Pontzer.

Pontzer’s depressing insight – evident in Hall’s data – is that our bodies tend to exhibit metabolic adaptation, meaning that lots of physical activity seems to result in a disheartening decrease in RMR, with the apparent goal of keeping total energy expenditure fairly constant. In practice, this means that when intensive exercisers aren’t exercising, their bodies seem to burn calories at a slower rate – which seems like a miserable way for your body to thank you for exercising.

If there is any vaguely hopeful message from Hall’s study, it’s that the contestants who continued to exercise the most did better at sustaining weight loss (despite the compensatory decrease in RMR) than other participants. The reasons for this, he writes, “remain to be fully elucidated.”

Given the stubborn biology – not to mention the consequences of our often-obesogenic environment – it’s not surprising obesity remains a challenging and profound chronic health problem.

The Training Gap

What may be more surprising is that, despite the prevalence of obesity, and the fact that (at least according to a 2006 study from Australia), many patients preferentially look to physicians for advice on healthy eating and weight management, most doctors are apparently ill-prepared to step up.

In 2019, Stanford published a study she led examining obesity education in medical schools, residencies, and fellowships around the world, a report that concluded “there is a paucity of obesity education programs” for these trainees “throughout the world despite high disease prevalence.” 

Or as she has phrased it more colloquially, “nobody learns anything about obesity as a disease, which means that even though it’s the most prevalent chronic disease not only in the U.S. but around the world, no one knows how to treat it.” 

Stanford has recently extended these findings to medical specialties, and found:

“Even on medical board exams, obesity is not well covered. I can tell you that as a doctor, if it’s not on the test, we don’t think it’s important. So it’s not on the test, which means we’re not learning about it, which means that if you as a patient often are going into to your doctor and wondering why they don’t know much about the disease, it’s because they didn’t learn and it’s not necessarily their fault.”

While Stanford cites the “over 5,000 physicians in the country that are board certified in obesity medicine” as progress, she says “it won’t cut it” in the face of the “over 100 million adults that actually have the disease and the tens of millions of children that have the disease.”

Poignantly, Stanford pleads, “We need everyone to understand the complexity of the disease, especially anyone that’s on the treatment side: doctors, physicians, assistants, nurse practitioners, and the list goes on and on. Or we’re going to continue to fail our patients.”

One area where I recognize first-hand that physicians tend to lack training is in guiding patients through behavior change. I don’t know any internist who emerges from their education with a real sense of how to even think about this, beyond perhaps a conceptual introduction to the Prochaska “Stages of Change” model. While doctors consistently advise patients to undertake lifestyle modifications like reducing smoking, and pursuing diet and exercise, few in medicine expect their advice to be heeded, and it often seems to be offered more for the sake of documentation – and justifying more aggressive interventions – than based on any expectation of progress.

A physician-scientist colleague recently described a formative, and probably not that unusual experience from his own training as a medical student. A cardiologist he was shadowing would routinely try his best to scare patients, warning them they could easily die before their next visit if they didn’t shape up soon. This approach seemed to please the physician, but, predictably, resulted in minimal change in behavior.

The Promise of Health Coaching 1 – DPP Data

On the other hand, the somewhat unexpected triumph of the “lifestyle” arm of the Diabetes Prevention Program (DPP), a NIH-sponsored study first reported in the New England Journal of Medicine in 2002, highlighted the untapped opportunity associated with more intensive coaching efforts.

As I described in Forbes in 2012, this study examined whether several different interventions could forestall the development of type II diabetes in an at-risk population. The study included two medication arms (one of which was discontinued); one “usual care” counseling and education arm; and one “lifestyle” arm in which participants were intensively coached around diet and exercise. 

The big finding was that while participants who received the medication – metformin – saw their risk of progression to diabetes cut by about a third, the lifestyle intervention group experienced a massive 58% reduction in risk. 

The DPP data emphatically demonstrated what some have long believed: effective health coaching can make a real difference. At the same time, this required a Herculean effort from the coaches, who intensively and consistently engaged with the participants in this arm of the study. 

One question arising from the DPP: can this approach be replicated at scale? Early efforts using group counseling, administered through a YMCA, seemed encouraging. These results, coupled with the rise of powerful personal technology, led to the birth of startups like Omada Health and others, companies seeking to combine a DPP-style intensive coaching approach with emerging technologies to achieve similar benefits at greater scale.

The Promise of Health Coaching 2 – Expert Experience

While the success of intensive coaching may have stunned some physicians, I suspect many dedicated coaches were appreciably less surprised. Given the difficulty of motivating behavior change, it makes sense to consider the perspective and experiences of those who seem especially good at it.

One example here: Canadian John Berardi, whose passion for coaching and health led him to a successful career as a coach, entrepreneur (he co-founded Precision Nutrition, and in 2017 sold 80% of his ownership in the company, then valued at around $200M), researcher, and thought leader.  Berardi’s recently published book, Change Maker, offers particularly relevant insight to the unique challenges and opportunities of health coaching.  (Disclosure: I have recently reviewed course materials for Precision Nutrition; I have never met or interacted with Berardi.)

As Berardi points out, “we sometimes confuse our passion for health and fitness with actual skill in helping others improve their own health and fitness.” He emphasizes that “while having knowledge is a good and necessary thing,” for health professionals, the “desire to display knowledge” can be counterproductive, since “you’re not in a knowledge-first business but a people-first business.”

Doubling down on that point, which may make some physicians and other health professionals bristle, Berardi argues:

“Unless you’re a full-time researcher or a professional philosopher, you’re not in a knowing profession, you’re in a doing-stuff-with-people profession. That means you’re accountable for how you are with people and how often those people get results (as opposed to how much you know, how smart you sound when sharing it, or how elegant your solutions seem on paper).”

(This also relates to the need for medical therapies to deliver real-world performance, vs clinical trial performance, as I’ve discussed here and elsewhere.)

Berardi also explains the importance of deeply understanding the people you are trying to help, of “asking great questions and then deeply, actively listening to the answers,” and of building upon what someone is already good at, versus telling them, in effect, their success requires they become someone else. 

Also useful, he says: focusing on “behavior goals” rather than “outcome goals”; “approach goals” rather than “avoid goals”; “mastery goals” rather than “performance goals.”

In addition, he describes a “5S” approach for goals: simple, segmental, sequential, strategic, and supported, and takes a very long-term view towards getting results, building on small, achievable victories. 

“The irony here is that ‘all or nothing’ doesn’t get us ‘all,’ it usually gets us ‘nothing.’  Which is why I like to practice ‘always something’ instead,” Berardi says.

The point here isn’t that Berardi, the DPP investigators, or anyone else has figured out some magic formula for driving behavior change. Rather, the takeaway is that motivating behavior change is extremely difficult, and seems to represent a critically important health promoting capability that is both desperately needed and difficult to locate anywhere in our health system. Most doctors lack the training, time, and perhaps forbearance needed to guide patients effectively down this difficult route. 

This has created an opportunity for someone – maybe a profession, maybe a company – to step into this gap.

Hurdles Ahead

Three hurdles await:

• Driving durable healthy behavior change is intrinsically a wicked problem to solve.
• The business model needs to work. Someone has to pay for the cost of driving the healthy behavior change. It’s a real challenge given the historically low probability of success, and the need to tangibly (and credibly, as Quizzify’s Al Lewis unfailingly points out) realize the financial benefits of improved health – often in a relatively (perhaps unrealistically) short time frame.
• While technology offers the promise of scale, the power of health coaching seems closely tied to the close, trusted relationship and understanding that develops over time between coach and participant; while in theory, technology might offer the possibility of even more nuanced understanding and richer data collection, the power and intimacy of the personal relationship remains difficult to translate at scale.

This is the grand behavioral change challenge that brave health professionals, entrepreneurs, and technologists must now tackle, and upon which our collective health and well-being may depend.

Humility may not be the first word you associate with “genetics,” “precision medicine,” and “Harvard,” but it was unquestionably the theme of the day at a fascinating panel this week convened by the Harvard Data Science Initiative.

The discussion (video here), was remarkably grounded. It reflected hard-earned learnings from experts who have tried to implement data-driven, “precision” health solutions outside the academy, and had scars to show for it. 

Five themes stood out for me in this conversation:

• Appreciation for the successes of “precision medicine” – particularly in some cancers as well as in some monogenetic diseases;
• Recognition of the limitations of precision medicine – i.e genetics are often just not that determinative, and generally are not especially useful or impactful in the prevention and management of disease;
• Emphasis on the underappreciated implementation challenges associated with driving innovation into practice;
• An urgent plea for improved approaches for the identification and effective treatment of mental health conditions;
• A powerful sense that a key opportunity for improving health is the development of improved, ideally more precise, approaches to durable behavior change.

Because readers are likely familiar with my extensive discussion of precision medicine over the last 10+ years, I’m going to focus on the last three topics: implementation challenges, the mental health need, and behavior change opportunities.

Implementation Challenges

Tremendous advances in our scientific understanding and in the technologies we can deploy have invigorated researchers seeking to apply these advances to the study and treatment of human disease.  Yet the gap between theory and practice remains wide.

Foundation Medicine Chief Scientific Officer Priti Hegde described an early experience she had when she started out in the pharmaceutical industry at Genentech. 

”We had this vision,” she said. “We should collect data from every patient on our clinical trials, and that data will transform drug discovery.”

So what happened?

“You won’t believe it, but it took us over five years just to get systems in place where datasets can be put in place in a manner that allows us to analyze data; that we need to have cloud compute architecture, that we need to have data access policies. These things may be kind of boring for a scientist, but critically important for us to get to a place where we can actually start to analyze the data and make something out of it.”

(As I’ve written, the challenges Hegde saw have also been publicly discussed at Novartis – see here, here – and Lilly – see here.)

Hegde has taken this understanding to her current role. “At Foundation Medicine, I realized I can innovate ‘til the cows come home. But if the insurance providers don’t see value in what we’re doing, and if we can’t demonstrate value for patients, there is no point in innovating. So it always comes down to the practical, boring, mundane things that drive true innovation.”

(For more on the importance of implementation see here, here, here.)

Harvard’s Mark Namchuk, a pharma veteran, also spoke eloquently, and plaintively, about the challenges of moving from the “pristine biology” of the lab to the complexities of clinical trial design and execution. “There’s this practical world that you’re going to run into,” he explained, and urged students and trainees considering careers in translation to seek out the perspective of experienced clinical trialists.

Duke bioinformatician Jessie Tenenbaum, who is Chief Data Officer for the North Carolina Department of Health and Human Services, also highlighted the need for pragmatism.

“It’s the implementation,” Tenenbaum said. “It’s how do you build that into a workflow that’s extremely entrenched with clinicians and providers and genetic counselors and everyone doing what they do?  Make sure to get it in front of them in a way that’s going to be digestible in the busy day that they have.”

Tenenbaum also emphasized actionability – “what do we do” with the information, which requires a consideration of context. 

Tenenbaum shared an example from earlier in her career, when the genetics of warfarin metabolism were elicited. “When I was in grad school and learning about pharmacogenomics,” she said, warfarin was “the poster child for success” as researchers “figured out the genes and figured out the clinical guidelines based on the genes.” 

Her big revelation came afterwards, however, when she was at Duke. It arrived courtesy of cardiologist Rob Califf (who President Biden recently nominated to serve, for the second time, as Commissioner of the FDA).

As Tenenbaum tells it, Califf “made me get up at some ungodly hour, to round with him, to see the patients and how this [warfarin management] really worked. There was someone who was about to be prescribing warfarin, and Dr. Califf asked the doctor “did you think of doing the genetic test?” 

No, the doctor replied.

The patient “was an elderly person, had many other complicating factors…genetics just didn’t even play a role,” Tenenbaum recalled. 

(Indeed, most clinicians have found that dosing warfarin empirically, following the traditional “go low, go slow” advice, works well — especially since at least half the variation in dosing seems to depend upon factors besides the two genes implicated in warfarin metabolism.)

The point: it’s great to appreciate the ideal and abstract elegance of precision medicine, but to deploy it effectively, you also need to grapple with the messy reality of clinical care. 

The Mental Health Crisis

One particularly concerning reality of contemporary clinical care is the expanding mental health crisis sweeping the country in the wake of the pandemic.

The impact on children, in particular, was emphasized poignantly by Zak Kohane, a pediatric endocrinologist by training, who now chairs Harvard’s Department of Biomedical Informatics. 

“There is an unbelievable disaster happening in pediatric mental health right now,” Kohane explains.  “Our local hospital [i.e. Boston Children’s Hospital] is not accepting elective admissions — not because of COVID, not because of trauma, but because our psych wards are overflowing. And this is, by the way, not just us. It’s nationwide.”

Tenenbaum shares Kohane’s sense of urgency. Her research has focused on mental health, and she’s edited a forthcoming book, Mental Health Informatics. 

She points to several challenges in applying technology to mental health. 

First, she notes that “as opposed to cardiology, where we kind of understand how the heart works and how to quantify that, there’s just different epistemology of understanding what is knowledge.” 

She adds, “There are different concepts. They’re all self-reported and subjective, as opposed to something we can quantify. So there’s a huge number of challenges in that space.”

(There are some fledgling academic and industrial efforts to bring more quantitative data analysis to neuroscience R&D; see TR coverage of Neumora Therapeutics, Oct. 2021)

Tenenbaum also highlighted the profound need, in her current role in public health in North Carolina, to address mental health. It’s hard to make strides when essential data infrastructure is missing, she said.

When she started the role, she explains:

“We think about the sexy predictive analytics, machine learning, what can we do? And you get in and realize, ‘Oh my gosh, they’re using faxes, that’s where we’re at that.’ So data IT infrastructure, governance, quality automation — those are the things we need to get into place first, and then ask me next year about what we’ve managed to do with mental health and public health.” 

Tenenbaum hastens to add that many of the challenges in public health stem from efforts that “have been drastically underfunded for decades,” and notes that much of the fax reporting has now been automated.

John Quackenbush, a computational biologist at Harvard, also emphasized the unmet need represented by mental health, and expressed hope for the opportunities represented by “digital phenotyping,” a topic under investigation by the Onnela lab at the Harvard School of Public Health. 

The Onnela lab, Quackenbush said, was initially interested in the promise of wearables for neuropsychiatry, but more recently has focused on leveraging the passive data collected by smartphones. (I am somewhat cautious about this – multiple mental health startups were founded based on this exact principle, yet to the best of my knowledge, most ultimately pivoted away from it.)

Precision Behavior Change?

There was a strong emphasis from the panel on the urgent need to motivate healthier behaviors – precision behavior change, perhaps – but very little sense of how this can be done effectively, especially at scale.

All the panelists pointed out that for most people, you don’t need fancy assays to tell you how to live a healthy life. As Tenenbaum, put it, “I can tell you based on your genome what you should do. Eat right and exercise.”

Harvard’s Quackenbush tells me he offers people similar actionable advice based on their genomes: “Eat well, exercise, maintain a healthy weight, and don’t smoke.”

Obviously, we don’t need a genome sequence to tell us this.

Likewise, Namchuk emphasizes the lack of utility of microbiome analysis. He explains, “People are fascinated with the microbiome. I find the microbiome both fascinating and unbelievably frustrating because I have no idea what to do interventionally with the microbiome.”

Adds Tenenbaum, “So much of it comes down to eat right and exercise. And people can know that. And that doesn’t mean they’re going to do those things…we know in America there’s an obesity epidemic and we all know what we’re supposed to do, and it didn’t prevent myself and others I know from putting on that weight during COVID.”

The challenge, Tenenbaum says, is “figuring out the precision way to get people motivated to do it. I don’t know if we’ve cracked that nut yet.”

As Harvard’s Kohane summarizes:

“The sort of behavioral characteristics that we’re trying to modify turn out to be very hard. We don’t do it. Facebook knows a lot more than most of us know about how to modify behavior [see my discussion of ad-tech for health here], but the healthcare system doesn’t know how to modify behavior. Health insurance companies don’t know how to modify behavior.  They’ve tried all sorts of incentive programs for cigarette smoking, weight loss, and we just don’t know how to do that, and we’ve failed at scale.”

He adds, provocatively: “Do we have enough leverage to do behavior modification … or should we just say, you know, humans are weak-willed individuals, and if we really want to combat the biggest epidemic in our lifetime, namely obesity, we’re going to have to go pharmacologic?”

The takeaway: for most people, the key to improved health isn’t a diet or exercise program based on specious conclusions from sequencing your genome, analyzing your microbiome, or surveilling your smartphone. Rather, it’s figuring out how to motivate people to adopt and stick with basic healthy living behaviors. 

It’s really about consistent coaching, guiding people to lead healthy lives – in a customized fashion that maximizes the chances of success.

Companies like Omada Health, Virta Health, Noom, and Precision Nutrition, among others, are aspiring to do variations on this theme. (Disclosure: I’ve recently reviewed course materials for Precision Nutrition.) The challenge, from a business perspective, is finding a way to combine the power and value of one-on-one interactions with the technology that offers the potential for additional insight as well as the promise of solutions at scale. 

Hence health’s multi-billion dollar question: can technology truly enhance the power of health coaches, enabling health coaching to scale while providing customized insights and improving adherence? Or will the efficacy of health coaching inevitably be reduced and diluted in the insatiable drive to achieve exponential growth?

Our future health may depend on how this question is resolved.

“It’s been a busy few weeks for product announcements in the world of fitness,” industry observer Anthony Vennare recently commented, citing the latest offerings from the Peloton, Mirror, Tempo, and other digital fitness platforms.

On the one hand, these developments are encouraging, offering customers pursuing fitness — and who are willing and able to afford the steep premiums — a greater range of options.

At the same time, when you look at these products – and the slick ads that often accompany them – it’s pretty clear that the target market is the already fit, or at least the fit-adjacent. While certainly some previously sedentary people have been inspired to start riding a Peloton or rowing a Hydrow, the inactive do not appear to be the main customers these digital fitness companies are pursuing.

Which, from a health perspective, is really too bad.

Here’s why.

Minimal Exercise Is Unreasonably Healthy

There are plenty of data arguing that exercise is good for you, and a huge amount of ink that’s been spilt trying to define the ideal weekly threshold.  But if you are really looking for the most bang from your buck – the most benefit for the smallest change in amount of weekly exercise – the data seem remarkably clear. 

Going from inactive to exercising a little bit each week seems to result in a disproportionate boost in your health, including specifically years of added life. The amount you benefit if you make this relatively small change in weekly exercise is roughly equal to the benefit you can expect to receive if you then go from exercising just a little to exercising intensively, all the time.

As Andrew Yang might say, it’s just math – and in particular, the shape of the benefit curves. (See Figure 1 of this 2012 paper by Steven Moore and colleagues at the National Cancer Institute, and Figures 2 and 3 from this 2017 review by Warburton and Bredin of the University of British Columbia.)

Earlier this year, I discussed what seemed like an important opportunity for digital fitness companies to target these customers – a need for what investment banking analyst Aarti Kapoor called the “Planet Fitness of the Digital World.” 

For Kapoor, this opportunity reflected a market gap revealed by her economic analysis, but if you layer in the disproportionate health benefit from serving this population, the need for such an offering seems that much more compelling.

Motivating Small Activity Is A Big Challenge

So why haven’t more digital fitness companies seemed to have targeted this demographic?

One reason: it’s easier to persuade someone who’s already active to try out a different product than it is to convince an inactive person to get off the couch in the first place.

A second reason might be the intangibility of the benefits: a previously sedentary individual who now exercises a little every week might be significantly better off from a health perspective, but might not feel all that different, or look all the different, and might regard themselves as still fundamentally deconditioned.

A related challenge is the Peltzman Effect – the tendency to compensate for a reduced risk by feeling more comfortable engaging in riskier activities. You can think of it like permissioning; for some, wearing a seatbelt justifies driving faster; a skateboard helmet makes it easier to contemplate more dangerous tricks. In the area of health and fitness, I imagine this tendency might be renamed the “Diet Coke Effect,” since making one healthy choice (like opting for a calorie-free beverage) often seems to justify indulgences (say a package of Yodels) that can more than offset the potential benefits of the first decision. 

While this challenge impacts all of us – it’s easier to justify ice cream after an intense workout – it’s easy to imagine that any potential health benefit of slightly increased exercise might be lost if the activity made it easier to justify additional caloric consumption.

There are also a range of what might be termed structural obstacles, as Dr. Michael Joyner of the Mayo Clinic pointed out to me, ranging from challenges in the built environment (e.g. “neighborhoods that are either not safe or not walking friendly”) to economic factors to limited opportunity for active transportation.

No one ever said it would be easy.

At the same time, it’s difficult not to be impressed by the engagement of emerging digital fitness technologies; Peloton is arguably a leading example of this, as I’ve discussed –also here).

Who Will Figure It Out?

So, first question: where will the digital health company serving the inactive come from? Will it emerge from a sophisticated digital fitness player like Peloton developing a new offering that targets a different demographic (with all the attendant risks to the brand), or from a company like Planet Fitness, developing digital offerings that deeply engage and encourage the currently sedentary?

Alternatively, might it come from a wellness and mental health brand like Noom, Headspace Health, or Happify Health, seeking to extend their program with a fitness hardware component? Or might the winning entry be something yet to be created?

Second question: if a company does develop a compelling offering, will the benefits delivered be robust enough, and achieved rapidly enough, to meaningfully reduce health costs – what I often think of as the Al Lewis test. 

This deceptively simple goal represents a remarkably difficult challenge, as I’ve recently discussed, but one that, if met, would obviously be of exceptional interest to self-insured employers, as well as payors seeking to promote disease prevention and encourage health maintenance.

We may get some early visibility into the first question from Aarti Kapoor herself, who has recently left her investment banking job to become CEO of a SPAC — “VMG Consumer Acquisition Corp”— that went public just this week. The stated intention of this blank check company is ”to identify and complete a business transaction with a company in the high-growth consumer and retail industry.”

Given Kapoor’s previous interest in a digital fitness offerings focused on the less active, it’s exciting to contemplate the possibility that she might identify a promising high-growth company in this category.

Whether or not Kapoor invests here, the space remains compelling from both a business and health perspective. It represents an important opportunity for aspiring healthtech entrepreneurs.

The best concise summary I’ve seen of tech industry travails in healthcare comes from Blake Dodge, a reporter at Business Insider. Dodge had just written a piece about Apple Health, and took to LinkedIn to share an additional quote that didn’t quite make the final copy. 

“I think they came to it pure of heart, really thinking that they could design something that would be ultimately logical,” a source at Apple told Dodge. “But the problem is, is that the actual way that healthcare is delivered in the US is not a one size fits all experience. It’s actually incredibly heterogeneous.”

Bingo. 

What’s more, this heterogeneity is expressed on every level, from the services and care provided to the way health information is managed – as Google engineer Adam Connors recently discovered.

An unexpected illness brought Connors face-to-face with the healthcare system, an experience that shocked him as a patient and troubled him as an engineer who thinks about how to improve systems.  Writing at CNN, Connors described poignantly the very personal consequences of a system unable to consistently access coherent and complete data, deficiencies that delayed diagnosis and complicated treatment. Being sick was stressful enough; dealing with a dysfunctional healthcare system made it even more frustrating.

Connors wondered how much waste and confusion could have been averted if his healthcare providers had a longitudinal health record, which would include all of an individual’s health information, independent of where care had been received. (I couldn’t agree more, and at a recent seminar at Duke, I pointed to the need for a comprehensive account of our health journeys as the single most important requirement for data-driven medicine of the future.)

It’s easy to feel discouraged about information sharing. For those working in healthcare, the obstacles are all-too familiar.

Consider an example that emerged from a panel discussion I recently moderated on digital health and diabetes co-hosted by the Digital Medicine Society (DiME) and the Veterans Administration (video here).

To facilitate the care of diabetic populations, a startup called Glooko developed a platform to aggregate a range of diabetes-related information. Glooko’s hope is to integrate data in a way that enables healthcare providers remotely monitor the health of their diabetic patients based on the data the patients regularly collect. Dr. Varman Samuel, an endocrinologist at Yale University and the VA, highlighted two conspicuous compatibility problems for Glooko: data from Medtronic insulin pumps and from Abbott’s continuous glucose monitoring system. Moreover, it seems that Glooko used to have access to data from Abbott devices, until it was “unilaterally blocked” by Abbott, according to this Medscape report. 

An Abbott scientist on the panel defended the company, saying it collaborates with a number of manufacturers. Yet, as one of the panelists suggested, it appears Abbott has opted for a closed system, developing a data platform, LibreView, that’s analogous in intent to Glooko, yet which seems only to work with Abbott devices. It’s a familiar “walled garden” strategy utilized by a number of medical device manufacturers (for example, those who make ICU equipment), intended to motivate purchasers to remain loyal to the brand. Fellow residents of Apple’s walled garden will recognize the approach (as the Wall Street Journal’s Joanna Stern discusses here).

Harvard bioinformatics professor Dr. Zak Kohane has seen many such examples, where well-intended data sharing schemes collide with more parochial interests.

Kohane recently offered an especially thoughtful perspective on the challenges in healthcare data in a just-released podcast hosted by Apple AI expert Adriel Saporta and Harvard AI researcher Parnav Rajpurkar.  

The whole podcast is required listening, including an excellent, concise overview at the top of the show by the hosts of the history of health data legislation, moving briskly from HIPAA to HITECH to MACRA to 21^st Century Cures. 

In the subsequent discussion with Kohane, seven themes stood out.

1. Flying blind

According to Kohane, despite decades of lamentation, “we have an uninstrumented healthcare system” meaning that “things happen in our healthcare system and we don’t even count them.”  This matters, he says, because “you can’t have accountable care if you can’t count.” 

2. Data access

“The beginning of making our data work for us,” Kohane says, is to have our data “in a systematic, computable, form, or at least to have it,” so that various statistical methods can potentially “transform it into something computable” which can be used to generate “insights at a population level, and actions on the individual, clinical level.” In Kohane’s mind, while having computable data is helpful, he would absolutely prioritize gaining access to data in the first place, whether these data are immediately computable or not.”

3. Data silos and human behavior

Despite years of handwringing and public opprobrium, data silos remain a fixture of the healthcare landscape, as Google engineer Adam Conners’s experience painfully captures. The fundamental issue, Kohane suggests, isn’t technology, it’s people. 

“Lack of sharing,” Kohane says, “is core to the human condition,” and is exhibited by stakeholders throughout the system, from companies to healthcare systems to academic researchers to patient advocacy groups (yes, you heard that right). Kohane cites an example of “three different breast cancer groups not sharing data with one another,” an observation that would surprise no one familiar with the space. (I’ve discussed challenges of data sharing, including contrast between stated and revealed preferences, here.)

4. Challenge of incentives

From the perspective of patients, the benefits of improved health data sharing are clear. Kohane shared the published example from 2009 showing that fairly coarse hospital discharge data could be used to detect domestic abuse in emergency room patients. Yet according to Koahne, “twelve years after we published that study, no one is doing it.” It’s “a huge health issue,” Kohane points out, but “is not an obvious income generating thing.” 

Kohane also highlights the challenges faced by hospital CEOs, who might need to balance the desire of a physician to share data with what can feel like asymmetric downside risk, such as a data leak, that puts the executive on “the front page” of the paper. In other words, the risks associated with sharing data tend to feel larger (and certainly more palpable) to decision-makers than the consequences of not sharing. 

Thus, while data sharing may be something that clinicians, researchers, and hospitals should do, actually persuading people to do things they don’t perceived as serving their self-interest can be a challenge. As Upton Sinclair famously said, “It is difficult to get a man to understand something when his salary depends on his not understanding it.” 

Incentives impacting the adoption of emerging technologies have also been a preoccupation of thoughtful healthcare leaders including Stanford’s Dr. Kevin Schulman, who has emphasized the need for “innovative business models,” data that are “actionable by patients,” and an economic model that leverages data but focuses on service.

5. Multiple paths forward

Kohane discussed several potential paths forward, advocating the pursuit of all of them simultaneously. 

For starters, Kohane leads several  data sharing initiatives, such as the i2b2 consortium, and the 4CE consortium to evaluate COVID. By demonstrating the clinical and scientific value of data sharing, and learning what the sticking points are, the hope is to pave the way for broader changes. Kohane also highlights the role of regulation in compelling institutions to share data more substantively — as well as the need for institutions to understand and effectively manage the many regulations that seem to inhibit data sharing. 

But ultimately, Kohane seems to have the greatest faith in what he describes as an “end run” – consumerism.

“Our data may or may not be made to work for us by regulators, by medical leadership, and by other august leaders,” he says. “But the consumerist wave, which will continue to flow over healthcare” may drive progress. He cites the example of the ability to download information from an increasing number of hospitals to Apple Health using standard APIs (programming interfaces) as an indication of where the future may be headed. “In the long term, I think it’s all going to be in the consumer play because it’s where you have the scale and where you have alignment of interest.”

6. No database to rule them all

Asked whether he’d like to see a single, consolidated database with all healthcare information, Kohane said he much prefers a federated approach, meaning that data live locally, and can be selectively shared using agreed-upon standards. As Kohane and Dr. Ken Mandl wrote in 2016, a distributed model enables “each institution’s data” to be “maintained separately,” which “afford local control over data.”

Why the federated approach? As Kohane explained on the recent podcast, “Medicine itself is so heterogeneous… it’s a very labor intensive, still, artisanal practice in many, many ways that if you just shove things up into a shared database, you’re actually missing a lot of the differences in practice.” 

In essence, co-host Saporta summarized, “without having the context of where the data is coming from, you’re losing a lot of very important information.”

Instead, Kohane advocates the creation of “purpose-built” federated databases. He emphasizes that “no interpretation of clinical data … is universal for all purposes.” It’s critical to understand the context in which data are generated, he says, echoing a point that both Dr. Amy Abernethy and I have repeatedly made. Context matters.  

As Kohane explains, “It’s just like science: a good biologist who refuses to understand the system in which they measure the proteins is as unlikely to come up with an interesting and robust finding as a machine learning expert who doesn’t want to get down and deep into how the data was generated.”

7. Trust

The notion of sharing health data faces increasingly strong headwinds, as discussions of tech company’s questionable use of data and penchant for surveillance has increasingly attracted national attention. The opportunity, says Kohane, is “to leverage the intuition that many patients have, which is they trust their doctor and they trust their healthcare system more than they trust some anonymous large data company.” He suggests we should “focus on the sociology of where trust lies and maybe try to widen it to different spaces.” 

The importance of the trusted relationship between provider and patient, he noted, was evident in his experience assisting his elderly mother, who had struggled with her fluid balance and was hospitalized several times for diuresis. As Kohane had originally described to NPR, he had managed to help his mother stay out of the hospital simply by monitoring her daily weight, and, critically, engaging with her effectively when the numbers were off. 

The key, Kohane emphasizes, wasn’t the sophistication of his (incredibly basic) treatment algorithm, but rather, his relationship with the patient. He notes that while previous peer-reviewed studies of his approach had generally not been effective, he was able to succeed, he believes, because of the robust and daily dialog.

Bottom line: 

Healthcare is still struggling to effectively utilize technologies that have transformed other industries. It seems clear by now that the most significant hurdle isn’t technology, but people and human behavior. At the same time, the greatest hope for progress in health also lies with people. 

The challenge for technology is to leverage the best of medicine – including the often-powerful therapeutic relationship between caregiver and patient – while remaining cognizant of the very real anxieties. Most patients don’t want to be monitored all the time, or to continuously think about their health; hospitals want to provide excellent care but not reveal information that places them at a competitive disadvantage; researchers want to contribute to science but also manage their careers; companies have shareholders to consider. 

Emerging digital and data technologies continue to often exceptional promise for healthcare, but delivering on this potential remains elusive. Success will depend less on the elegance of a particular technology, and more on the emotional and organizational intelligence of the health technology team attempting to wield it.

Success will depend less on the elegance of a particular technology, and more on the emotional and organizational intelligence of the health technology team attempting to wield it.