It's not that Santa Claus hasn't notice the Jane Fonda exercise tapes and the "Heavy Hands" weights, the bulky books on cholesterol, high-fiber and low-sugar diets. After all, he's the one who has to maneuver them down the chimney. But those were always for other people, not for the jolly old man with a twinkle in his eye.
Still, he's not oblivious to the fact that his "life style" is not exactly recommended by the U.S Public Health Service: those late nights, the pipe smoking, the chimney soot, the cookies-and-milk meals, the demand for perfection in a high-pressure job. He acknowledges, without the euphemism of "a bowlful of jelly," that he is fat. Although he knows when he's been bad or good, this year those terms have been quantified.
It was his health insurance company that sought to make a list (and check it twice) of Claus' suspiciously hazardous health behavior. To assess his medical status, the gnomes at the insurance company used a specially designed instrument called the "health risk appraisal." It consists of a 16-page booklet of questions that range from weight and blood pressure levels to job attitudes and personality types. The answers, of course, were guaranteed to be "eyes only" -- for a computer and Claus himself, and not seen by any red-nosey reindeer. But word has started to leak out.
Question: Have you had any reason to wonder if you were losing your mind, or losing control over the way you talk, think, feel, or of your memory (during the past month)?
Answer: Yes, around Dec. 22, when the elves mutinied with the arrival of a new weather forecast map for Christmas eve.
Question: Do you have a strong need to be the best in most things you do? Do you let children win on purpose when you play games with them, e.g. Monopoly?
Answer: Yes. Yes.
Question: As a driver or passenger of a car, truck or motorcycle, how many miles do you travel each year? Think about it. Include travel to work, shopping, business, school, church, pleasure, recreation. 10,000 miles is average. Do not underestimate!
Answer: 21,534. All on one night a year. All on "Thirty-two Feet and Eight Little Tales" sleigh.
"Most of the time," he answered to "Has your daily life been full of things that are interesting to you?" "Some of the time," to "Have you felt tired, used up or exhausted?" "Yes, I wear my seat belt; yes, I have six to nine friends I can talk to about personal matters; no, I have never had radiation treatment for ringworm of the head."
Several weeks later, Claus' "personal health report" from the health risk assessment company arrived at the North Pole.
It didn't start off on a promising note: "Doesn't regularly eat fresh fruit, vegetables, whole grains or bran," the report said. Highlighted was a "personal history of high blood pressure and overweight." What's more, his driving record turned out to be a major problem. "Miles per year in car is 20,000," the report said. "10,000 or less is ideal. Can you use public transportation?"
The report concluded on Claus' driving: "Goes consistently over the speed limit, drives a sports car; Wrecks in your size car are dangerous -- drive carefully."
Another problem was Claus' Type A personality -- the report counted him among the prime examples. Type A's, the report said, tend "to feel guilty when relaxing and measure their success in terms of numbers, such as swimming 50 laps or closing four deals" . . . or delivering 5 billion presents.
Work pressures, the report went on, "seem to cause you great anxiety -- seek professional help to learn coping and
relaxation skills . . . Do some soul searching. What's behind your distress? Are you getting enough sleep? Do you feel ignored or taken for granted? Are you reacting to bad news? Are you irritated by a family member? How long have you been feeling troubled?"
The risk analysis concluded that, at the chronological age of 71, Claus' "risk age" -- how old he really is, given his bad habits -- is 75. His risk of heart attack or stroke, the report noted, is 10.13 percent, compared to the average for a 71-year old man of 6.68 percent. The bottom line on Claus, according to the computer, is an "estimated life expectancy" of 80 years, and an "attainable life expectancy" of 85 years if he changes some of his habits.
So he'd been bad for goodness sake!
To be sure, the report added a few caveats to all this dire news: "These 'odds' are statistically computed through a program that compares you with a national mortality data base and makes adjustments according to the unique combinations of risks you have," it said. "This data base is the product of all reported deaths throughout the country each year. The goal here is for you to become aware of how your personal characteristics, habits and overall life style affect your 'odds' of being healthy -- or in fact, your 'chances' of dying. Hopefully this information will help you live by choice, not by chance. Life is a risk. We are always 'playing the odds,' but it's advantageous to know how to manipulate those odds."
Health risk appraisals (HRAs) may provide a bit of fantasy about future health or disease, but their presence is far from mythical. Since the 1950s, when "health hazard charts" were designed to aid physicians with preventive efforts, the resulting HRAs have become widespread in a society eager to quantify future risks. HRAs have become a major tool for businesses and prepaid medical plans to assess the health status of individuals and predict their risk of disease. And their potential for use by health insurance companies is significant.
For more than 10 years, these computerized appraisals have been the bread and margarine of General Health, a Washington firm that engages in "health risk management" with small businesses as well as corporate clients. With over half a million individual records in its data base, General Health was among the INC magazine 500 fastest-growing privately held companies for 1985-86.
Since 1981, more than 200 organizations, including Ford Motor Co., IBM and AT&T have administered some version of the HRA to its employes. The Carter Center at Emory University recently established the "Health Risk Appraisal Development and Dissemination Program" to encourage the use of health risk appraisals in every state health department and school of public health.
The appeal of the HRA, which is a kind of pop quiz of death and disease, lies in its apparent simplicity. It can provide a physiological "state of the nation" report to the chief executive of the body being appraised. Meshing self-reported responses with mortality statistics, the computer calculates: 1) average risk of dying per 100,000 in the next 10 years based on age, race and sex; 2) current risk age and 10-year risk of death based on the answers to the questionnaire; and 3) the "achievable" age assuming a person makes appropriate behavior changes.
Health experts hope that a personal health risk appraisal will help motivate people to alter their life style as a way to reduce their risk of disease. If a person is impressed by what one researcher calls this "aura of authoritativeness," a computerized report telling a woman that her "risk level" of breast cancer is 10 on the "mortality index" may spur her to have a mammogram and do regular breast self-examination.
"One of the exciting things about HRAs," says epidemiologist Sabina Dunton, president of the Tucson-based "Well Aware About Health" company, "is that it can be a layman's course in epidemiology."
At best for the consumer, HRAs may appear to be a bit of quantifiable fun for those who enjoy comparing themselves to others (albeit dead). At worst, it's a doom-and-gloom-a-gram.
But according to a 1986 research report to the National Center for Health Services Research and Health Care Technology Assessment (NCHSR), health risk appraisals are far from benign and have prompted questions in the medical community about their use.
"One of the concerns we have," says Dr. Edward Wagner, director of the Center for Health Studies at the General Health Coop of Puget Sound in Seattle and one of the authors of the NCHSR report, "is that it's not hard for the respondent or the computer to make a mistake."
Wagner cites what he describes as a whole series of "ferocious anecdotes about computerized reports claiming that people were pregnant or having some problem when this clearly was not the case."
Researchers also know that self-reporting tends to be highly inaccurate. In a 1977 study to assess behavior change in a smoking cessation program, respondents filled out the same HRA six months apart. Researchers found, according to the NCHSR report, "almost as much change in responses that should not change as in responses that should . . . Clients resurrected their parents, caused their rheumatic heart disease and diabetes to disappear, shrank their frame and added five years to their history of virginity."
Another problem is that the HRA computer is programed to fill in the answer to any question left blank by the respondent. If a person doesn't know his or her cholesterol level, the appraisal report will substitute an average cholesterol level, for example. Which is where Claus made his mistake.
For the space he left blank, the computer substituted a cholesterol level of 220, the average given his age and sex. Since the average cholesterol is high among Americans, the report then admonished him to lower it, pointing out in Claus' words: "My cholesterol is high and this is an important contributor to my high risk of dying from a heart attack."
"The use of a population average can seriously misrepresent the client's true measures," write William Beery, Victor Schoenbach and Edward Wagner in the government report, especially "for the middle-aged client," for whom "blood pressure is one of the most important ingredients in the overall risk prediction." The researchers also point out, for example, that "an error in reporting diabetes can cause as much as 10 years difference in appraisal age."
Even if all the data reported is correct, how the computer arrives at a "risk age" is subject to speculation. One program encountered problems with truck drivers whose "risk ages" were miscalculated because they drove so many more miles than the average person.
Besides, the risk of death is hardly determined by numbers alone. Kenneth McLeroy, assistant professor in the department of public health education at the University of North Carolina at Greensboro, writes in a recent Health Education Quarterly that in "the Pooling Research Project, only about 10 percent of men with two or more heart disease risk factors actually developed heart disease within a 10-year period. Ninety percent of men with two or more risk factors did not develop problems, and 58 percent of those who developed heart disease had one or fewer risk factors . . . We know some of the things that people in the aggregate can do to stay healthy, but . . . for individuals, health is uncertain. Society must certainly be less sanguine about inferring the causes of disease from the behavior of affected individuals."
There also are serious questions about the pyschological ramifications of, as Wagner puts it, "handing out mortality data." For many older Americans, the computerized results may be far from tidings of comfort and of joy.
"I've never been a fan of HRAs," says Anne Kiefhaber, coordinator of the Health and Human Services Department's Worksite Health Promotion Project. "I think they're misused if they're sent back in the mail. If you send it back to an older couple and you say one is going to live a long life and the other one is going to die, what good have you done?"
Age is also a factor in the usefulness of HRAs. "For the elderly, risk is so high and life expectancy so low," noteBerry, Schoenbach and Wagner, "that to have these explicitly stated can be discouraging and depressing. A death- and fear-oriented approach appears to be particularly inappropriate for this group for whom accepting the inevitability of death may be as important as postponing its occurrence."
To many experts, consumers do not have the medical knowledge to be able to evaluate their own health risk.
"It's being widely misused by those who would give it to peope without a careful preparation," says Indianapolis physician Lewis Robbins, 77, considered to be the father of the HRA. "When you're careless and just give this tool willy-nilly without the kind of supervision a physician can give, you're apt to be in trouble."
Kiefhaber tells of taking an HRA with a colleague "who had about the same health habits" but who "came out much worse because her mother died at an early age." Another time she took an HRA and imitated a very depressed person with no friends. "I got this thing back in the mail and I thought it would show I was really depressed," says Kiefbaer, "but it said, no, you're normal; everybody is depressed, but you should see a counselor. It made you feel terrible because everybody else was just as depressed as you but you should spend money on a psychiatrist. I thought, boy, if I weren't depressed before, I sure would be now."
In a study of 26 employes at NASA-Ames Research Center who used HRAs three times over four years, Joseph LaDou and colleagues showed that the group had reduced its overall health risk. The researchers also indicated, however, that "patients increasingly disagreed with the conclusions regarding their health" and some patients "find it unsettling to be presented with changes in risk factor counseling that are beyond their control."
The very thesis of the HRA, as stipulated by the Carter Center in Atlanta at a recent HRA symposium, is "the assumption that, given the necessary information, individuals can and will act in their own self interest by assuming responsibility for their personal health behaviors."
Yet there is a growing consensus that changing behaviors such as smoking, drinking alcohol or eating a high-fat diet is more complex than filling out a questionnaire.
"I think there is somewhat more responsible use of health hazard appraisals now," notes Wagner, "than, say, five or six years ago," when people were setting up trailers in the parking lots of shopping malls and spewing out results. "People said that somehow the process of filling out the questionnaire, in and of itself, was a potent stimulus to doing good. But what we've found is, that ain't enough."
Notes Wagner: "My sense for a consumer is that they should use it in settings where they have access to some more knowledgeable person who can discuss it with them. In that context, the specific HRA may be less important than the person they're talking to."
For more than 10 years, the Centers for Disease Control (CDC) has operated an HRA program for its employes. In addition, an HRA research and evaluation program and computer health risk computations were offered to other public health agencies. With one of CDC's 1,500 HRA software packages and a computer, almost anyone can practice armchair epidemiology.
Great Performance Inc., a Chicago company, sells a $595 "Lifescan Health Risk Appraisal Software," which allows users to predict their own or their neighbor's mortality.
In the future, HRAs may well be used as a method of setting health insurance rates for individuals and groups.
""We have the capacity to do that," says Dr. James Bernstein, president of General Health in Washington, D.C.. "Nobody complains about having auto insurance rates high for single men under 25."
So far, notes Bernstein, health insurance companies have shown little enthusiasm for using HRAs as a rate-setting tool. Most of the interest in risk appraisals has come from health maintenance organizations (HMOs) that want to know the individual health risks of the people they are taking care of.
At the same time, insurance companies are encouraging consumers to take a greater responsibility for their own health and are forcing them to shoulder an increasing share of medical costs.
Just last week, TK a sentence or two on the recent AIDS decision in the District that will permit health and life insurance companies to raise rates for AIDS patients.
In an era of budget cuts, Santa Claus is not the only one who'd better watch out for the health risk appraiser.
Still, Claus, who does get exercise at least once a year, thought he scored particularly well on the section called "Attitudes Towards Your Health."
Question: How vulnerable do you think you are to sickness and disease?
Answer: Not Very. I'm tough, I've been around for centuries, I'm one of the best-known men in the world. I don't eat right, but I have good genes.
Marta Vogel is xxxx xxxx xxxx xxxx xxxx xxx.