Nan Ottenritter feels a new sense of purpose these days when she walks down Connecticut Avenue to pick up something for lunch.

A pedometer provided by her employer, the American Association of Community Colleges (AACC), lets Ottenritter track how many steps she takes each day. Recording her steps is a habit she picked up this spring when she and several fellow staffers competed for awards the association offered as an incentive to its most peripatetic employees.

Ottenritter, 53, has long enjoyed weekend activities like bicycling and hiking. But it wasn't until she began wearing the pedometer throughout the day that she realized how sedentary she could be during the week.

"This contest -- with this silly little prize at the end -- it's got us thinking about how much we're walking -- or not walking, as the case may be," she said. "I didn't realize that on some days, I was only walking a few hundred steps. It's been a real eye-opener."

The view that employers can play a role in improving fitness among the rank and file is not a new one -- Sears, Roebuck and Co. was promoting healthy lifestyles among its retail workers in the early 1900s.

Nor is the belief, actively encouraged today by leading government health officials, that an employer's investment in workplace wellness programs can pay off by lowering health care costs, decreasing absenteeism and boosting productivity. Today some 95 percent of large employers -- those with 200 or more people on the payroll -- and about a third of smaller ones offer programs meant to improve the health of their workers (by helping them drop bad habits like smoking and adopt good ones like exercising and trimming excess weight) and curb rising health care costs.

Who could argue with such a demonstrably good idea, you ask? But it turns out the case for employer involvement in health promotion isn't yet clear-cut, say experts -- at least as concerns the bottom line.

Hard Case to Prove

Why isn't there more evidence of a dollar-and-cents payoff for employer fitness initiatives?

For starters, employees aren't exactly clamoring for wellness programs. On the contrary, worker interest in their employer's wellness initiatives is generally low, according to the Department of Health and Human Services (HHS). AACC's walking initiative may be a case in point. Despite initial enthusiasm, most employees lost interest after about a month, says Charisse Bazin Ash, AACC's human resources director.

But even long-standing programs haven't received the kind of scrutiny that allows a convincing business case to be built, say some public health advocates. The paucity of evidence was underscored in April when the federal Centers for Disease Control and Prevention (CDC) earmarked $14 million to study workplace wellness programs.

"What's lacking is clear data that [employer] intervention reduces costs," said Bill Dietz, director of CDC's Division of Nutrition and Physical Activity.

According to Charlotte Pratt, a researcher in the division of epidemiology and clinical applications at the National Heart, Lung, and Blood Institute (NHLBI), "there is some evidence that workplace programs can work." But most of the research has significant shortcomings. Most studies tend to be short in duration and aren't randomized, so their results might be skewed. The studies also generally lack a control group against which results can be compared, she says.

In addition, the value of even the most promising programs is limited if the results -- often largely dependent on specific workforce demographics, location and workplace culture -- can't be duplicated at another location.

"One has to look at results broadly to see if [they] can be generalized," said Pratt.

But the rigorous study of workplace wellness programs is costly.

A thorough analysis requires the collection and interpretation of huge amounts of data over time, according to Ron Z. Goetzel, director of Cornell University's Institute for Health and Productivity Studies. And while some costs, such as health care utilization and absenteeism, are easily quantified, others -- such as the impact of having sick workers show up for work but perform below par -- are not.

"It's complicated and expensive to do good applied research," he said.

And then there's the problem of researcher bias. Most employers who undergo the expense of studying the effectiveness of their wellness programs seem to have a bias in favor of the effort, according to Tee Guidotti, chairman of the department of environmental and occupational health at the George Washington University Medical Center. Studies that show little or no benefit for the employer are likely to get buried, he said.

The Weight of Evidence

But debate over the profitability of on-the-job health initiatives hasn't dampened many health advocates' enthusiasm -- or conviction -- that such programs are essential. Pratt says she's hopeful that better-designed studies, including some already underway at NHLBI, will show employers how to achieve the best results from their wellness programs -- particularly those directed at weight management.

"Sixty-four percent of the population is overweight or obese, and I think we have to tackle the epidemic on many fronts," she said. "The workplace may be a gateway for subsequent work outside the workplace."

Growing awareness of the costs linked to obesity adds weight, so to speak, to the case for workplace-based initiatives, according to HHS Secretary Tommy Thompson. Earlier this year, HHS pegged some $15.4 billion in employer costs -- including sick leave and health, life and disability insurance -- directly to the nation's expanding waistline.

Thompson -- who has dropped 15 pounds over the past few months and wants to lose 10 more to reach his goal of 185 -- is challenging employers to ramp up workplace wellness programs.

"Employer spending on prevention is a wise investment that pays off," said Thompson during a conference on obesity in June. "It pays off in lower health care expenses. It pays off in lower absenteeism and higher productivity. And we encourage all employers to make this investment so that they may reap big returns for a long time."

Healthy People 2010, the HHS blueprint for disease prevention and health promotion, aims to have 75 percent of U.S. work sites offering "comprehensive health promotion programs" by 2010.

HHS defines such programs as those incorporating five key elements: health education, screening programs, a supportive social and physical environment, integration of the health program into the organization's structure and links to related initiatives like employee assistance and work-life programs.

Thompson frequently points to Johnson & Johnson (J&J) -- awarded the 2003 C. Everett Koop National Health Award for health promotion by Stanford University -- as a model of employer-based health promotion. The company, which launched its wellness program in the 1970s, claims to have saved $38 million in health care costs between 1995 and 1999 by promoting healthy lifestyles.

After tracking its health care costs between 1990 and 1999, J&J researchers tied savings of about $225 per employee per year to early intervention programs aimed at employees with risk factors such as poor exercise habits, smoking, low fiber intake, or high cholesterol or blood pressure. Savings among high-risk employees were even higher. The findings were bolstered by an internal employee survey showing that those who took part in the J&J wellness program were more likely to have reduced their risk than those who didn't.

But even the study's own investigators -- who published their findings in the Journal of Occupational and Environmental Medicine -- acknowledge that the findings aren't beyond dispute. Enhancements to the J&J wellness program coincided with the company's shift to managed care -- a change that may have accounted for at least some of the dollar savings.

"I'll be the first to admit the research isn't perfect," says Goetzel, one of several consultants J&J paid to conduct the study.

Citibank provides another example cited by wellness advocates. The company claims a return of nearly five dollars for every dollar spent on preventive care.

The financial services company -- whose case study was reported in 1999 in the American Journal of Health Promotion -- offered workers a small financial incentive to complete a lengthy health risk appraisal. Those participants with risk factors like smoking, poor diet or a sedentary lifestyle received educational materials on how to reduce their risk and were called at least once by a health counselor who checked on their progress.

But that study's researchers also concede the savings they reported may be overstated since they lacked data to conclusively link the employer-sponsored interventions to behavior changes in those most at risk. Also, it was unclear whether the cost reductions were actually driven by those who did change their behavior.

Exercising Judgment

Despite the difficulty in measuring savings from employer wellness programs, Gary Lindsay of the Partnership for Prevention, a Washington-based nonprofit health promotion advocacy group, says the reasoning behind such programs remains strong.

"The promise of prevention stems directly from the fact that many of the leading causes of disability and premature death in the United States are potentially avoidable or controllable," said Lindsay, who heads up the organization's business partnership arm. "At its core, health promotion is an investment in human capital. Employees are more likely to be on the job and performing well when they are in optimal physical health. They are also more likely to be attracted to, remain with and value a company that obviously values them."

His sentiment is far from unique among employers who support wellness initiatives.

Fannie Mae, for instance, offers workers a range of wellness benefits, including risk assessments, exercise classes, discounts at Washington area gyms, various cancer screenings, flu shots and Weight Watchers classes provided on-site at a discount. The company also negotiated discounts for employees at local gyms.

Employee surveys show that about half of Fannie Mae's 5,200 workers participate in some aspect of the program, according to the company's human resources manager, Judy Dale. But the Washington-based mortgage financing company doesn't attempt to break out savings that stem directly from the offerings. Rather, says Dale, the value of the benefits is reflected in the company's historically low turnover rate and ability to attract high-quality workers.

"The more you focus on preventative wellness, the more there is going to be an impact downstream," she said.

Similarly, Bazin Ash of AACC says she wasn't watching for a measurable change in the bottom line when she handed out the pedometers or organized a lunchtime walking group to help workers get the most out of them. The case for the wellness initiative "is really just intuitive," she said.

Even at J&J, cost wasn't the driving force behind the wellness program, said Jennifer Bruno, who directs the company's worldwide health promotion program.

"The number-one reason is that it's the right thing to do," she says. "Over the years it's evolved to have a positive financial and health impact."

Beyond Fitness Centers

For all the debate surrounding employer-sponsored health programs, one area of consensus seems to be emerging: The company fitness center, once the hallmark of workplace wellness programs, isn't the only way to go.

"In the 1990s, employers began to realize that their fitness centers were mostly empty, and those who were using them were exactly the employees who needed intervention the least," said George Washington University's Guidotti. Today only about 10 percent of employees working for companies with wellness programs have access to an on-site fitness center, according to Labor Department statistics. Instead, education and behavior modification programs form the core of most corporate wellness programs.

The most successful programs address health risks such as smoking, diabetes and obesity through various initiatives, says Goetzel.

"Getting people to change their behavior is a very complicated process," he said. "I think a gym is great and wonderful. But health promotion is much more than providing a fitness center."

Company-sponsored wellness competitions have the potential to involve far greater numbers of employees than a fitness center would, says Wendi Bailey, who manages health promotion for Home Depot's 350,000 employees nationwide. While the company still negotiates discounts at local health clubs, the contests are a popular and low-cost alternative that might reach the many workers who would never consider going to a gym. Since 1978 Home Depot has launched various contests aimed at helping workers stop smoking, lose weight and increase their level of exercise.

"Our stores respond to competition," she said.

Bailey asks managers at each of the company's 1,500 stores to appoint a fitness coordinator -- someone outside management who's been enthusiastic about the company's wellness initiatives.

One recent weekday evening, Melissa Glover, fitness coordinator for Home Depot's Falls Church store, could be found scoping out the neighborhood around the Seven Corners Shopping Center in search of a route for this month's walking contest. Home Depot workers clocking the most mileage will be eligible for a prize.

"It never hurts to help people get motivated," said Glover, who works as a sales associate.

AACC'S Bazin Ash agrees.

"I just know that I'm more productive when I get exercise during the day," she said. "But I have a long commute and two kids. I know that when I get home I'm pretty much in for the night. So it has to happen during the work day."

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Rita Zeidner's most recent feature for the Health section described an experimental weight control technique called gastric pacemaker surgery.

American Association of Community Colleges staffers show pedometers used in an association-sponsored walking program, created by Charisse Bazin Ash, seated, center. At Fannie Mae, which offers workers discounts at local gyms, instructor Rich Tagiri Navies leads employees in a kickboxing class. Company fitness centers have become less popular with employers, which now seem to prefer education and behavior modification programs.