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bluewatsons · 7 years

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Anna Kirkland, What Is Wellness Now?, 39 J Health Politics, Policy & Law 957 (2014)

Wellness as Buzzword

Wellness is a popular buzzword these days. One finds wellness programs, wellness centers, wellness contests, wellness conferences, wellness journals, wellness administrators, wellness awards, wellness tourism, and even a Wellness brand cat and dog food (complete with its own blog and website asking, “What is true wellness?”). Like “intersectionality” in feminist scholarship (Davis 2008), the rise of “diversity” over affirmative action (Kelly and Dobbin 1998; Edelman, Fuller, and Mara-Drita 2001), “sustainability” in approaches to the natural world and its use and development (Scoones 2007), and “sexual health” in place of panic over sexually transmitted infections (Epstein and Mamo 2011), the hegemony of the buzzword wellness signals its usefulness for framing consensus in contemporary American society. That consensus is that health is more than just the absence of disease, that health promotion and prevention of disease should be a top governmental and personal priority, and that each individual can and should strive to achieve a state of optimal functioning. But in typical buzzword fashion, the appeal of the term comes from its ability to float above thorny and contested details and to mean different things to different stakeholders so that it becomes viewed as an uncontroverted good.

The aim in this special issue is to pull wellness down from its buzzword height and to draw out all the political, legal, ethical, and practical controversies contained within it. The contributing authors define its variations with precision and locate them within the competing professions (the medical profession versus the alternative remedy world), domains of expertise (insurer or wellness coach), nations (the United States and other countries with different health care systems), and moral systems (holistic or pointedly individualistic and punitive) in which the term now proliferates. The articles focus on wellness as it is institutionalized and professionalized in the workplace. While much of the discussion throughout this issue addresses the economic rationale for wellness programs in profit-making private firms, the contributing authors understand the workplace to include the public sector (as municipalities have also taken up wellness and wellness programs) as well as organizations like colleges and universities, nonprofits, and other groups whose leaders understand them to have a stake in the health of their members or employees.

While wellness is not new or unstudied, we are at a uniquely critical point in the institutional and legal position of wellness in the health economy of the United States. The Patient Protection and Affordable Care Act established grants and technical assistance for small businesses to develop wellness programs and set up new regulations that increase the incentives employers can tie to employees' achievements of certain health benchmarks. Currently, workplace wellness programs are common and rapidly expanding, especially among larger employers, and they are generally voluntary rather than punitive (Mattke et al. 2013. That status may soon be changing, however. As a new survey by Aon Hewitt found, 83 percent of businesses surveyed offer incentives for employees to participate in wellness activities, but 58 percent reported that they planned to add penalties in the next few years for employees who “did not take appropriate actions” to improve their health (Mihelich 2013). The contributing authors argue that workplace wellness is the currently dominant variation of wellness in the United States, simultaneously more narrow and more powerful than its more holistic predecessors because of its tightened connection to economic interests. These collected articles explore what this new wellness regime will mean for law, culture, and justice and raise new questions for further research.

The Idea of Wellness over Time

Words become buzzwords because they capture something particularly salient about a culture at a moment in time and come to stand in for wide agreement about how something should be characterized. Wellness captures the sense that the era of combating diseases has given way to a more complex problem of success in modernity: living well, since so many more of us live long lives, entirely avoiding the diseases and accidents that killed our ancestors. Its emergence in the form we still know it today coincides with the rise of the notion that “health behaviors” were a large part of the explanation for health and disease, an idea that medical sociologist David Armstrong (2009) argues arose in the late 1950s and early 1960s in the United States and the United Kingdom. Today we would speak of health behaviors or risk factors, but these are simply the current terms for individualized explanations for health outcomes, ideas that have been with us a long time. The term wellness first came into usage in the post–World War II United States, but the roots of the concept extend far back into the history of American ideas about health, morality, and responsibility. In the nineteenth-century United States, religious and spiritual movements such as New Thought and Christian Science were founded on the idea that individuals' bodily health derives from their own achievement of a proper state of mind, usually understood as morally virtuous and often explicitly religious, not from outside medical intervention (Miller 2005). Christian religious ideas about sin and morality no longer have the central role in ordering American society that they did when early health movements began (Morone 1997, 2003), but the strong tie between proper attitude, correct practice, and individual responsibility for health remains a central part of wellness.

Halbert L. Dunn's 1959 article “High-Level Wellness for Man and Society” (the basis of his better-known 1961 book High-Level Wellness) first introduced the term, and his argument that health is about much more than the absence of disease remains a cornerstone concept of wellness today. Dunn (1959: 787) explained the need for this new turn to wellness as arising out of four features of modern life: interconnectedness through communications technologies, population boom and crowding, aging of the population, and rising tensions because of the “tempo of modern life.” Dunn's concept of wellness was designed to evaluate and prepare people and societies for a cacophonous, tense, and demanding new world in which everyone would be tied more closely together for longer lives. His concept was explicitly hierarchical: there were lower levels of wellness and higher ones, and the aim was to move everyone up from where they started to high-level wellness. Dunn's sense of a crowded, aging society is less prominent in wellness discourses today in those precise terms, but the sense that we have somehow gotten ahead of ourselves in modernity and cannot quite handle it all is still part of the turn to wellness. Now health professionals are more likely to point out that chronic diseases have become the biggest health problems, since we have improved so much in our abilities to combat infections and accidents.

Dunn (1961: 4–5) defined wellness as “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable.” Dunn's sense of individual striving from a certain starting point within a hierarchy of health possibilities is still salient in wellness discourses today. Donald B. Ardell's work in the 1970s and early 1980s clearly echoed Dunn's terms, but Ardell (1982: 17) defined wellness somewhat more individualistically though still holistically as “self-responsibility, nutritional awareness, physical fitness, stress management, and environmental sensitivity.” Definitions of wellness continued to vary somewhat but retained the form of roughly five dimensions covering vast areas of personal and social life. The Berkeley Wellness Letter, in print since 1984, defines it as “optimal physical, mental and emotional well-being, a preventive way of living that reduces — sometimes even eliminates — the need for remedies. It emphasizes personal responsibility for making the lifestyle choices and self-care decisions that will improve the quality of your life” (BerkeleyWellness.com 2013). Psychologists describing the “wheel of wellness” in 1991 outlined its “five life tasks of spirituality, self-regulation, work, love, and friendship” that “dynamically interact with the life forces of family, community, religion, education, government, media, and business/industry” (Sweeney and Witmer 1991: 529). Spirituality is at the center of the visual depiction of the wheel of wellness, and while physical fitness and nutrition appear as one component of the wheel's axes, moderate body weight is mentioned only in passing after much discussion of other elements such as humor, creativity, sense of worth, and emotional responsiveness. Health promotion and optimal health are terms often used interchangeably with wellness, as in Michael O'Donnell's (2009: iv) definition of optimal health as “dynamic balance of physical, emotional, social, spiritual, and intellectual health.” Gallup surveys several hundred thousand Americans nationwide each year (and will expand worldwide in 2014) to gauge well-being using its Healthways Well-Being Index Composite Score, assessing six domains: life evaluation, emotional health, physical health, healthy behavior, work environment, and basic access (Gallup-Healthways 2013).

An emphasis on preventing diseases rather than waiting for them to strike has always been central to wellness. But a close look at the intersections of prevention and wellness shows that not all prevention counts as wellness, and these points of dissociation are revealing. What are called disease management (DM) and medication management are certainly preventative, but they are usually situated in medical and pharmaceutical practice, controlled by experts, and administered as part of a larger bureaucratic program. Prevention controlled by outside experts loses the aspects of wellness that center individual responsibility for one's own striving and correct attitudes and thus may explain why wellness and prevention have not collapsed into each other and become synonymous. Value-based insurance design (VBID), for example, is a model of health insurance provision that attempts to change behaviors to both save money and spend it in acquiring the most health-promoting treatments for patients and that is also focused on prevention in a highly expert-driven, behind-the-curtain fashion (Chernew, Rosen, and Fendrick 2007). For certain categories of patients who already have medical problems, these programs have very specific goals, such as managing diabetes and avoiding an amputation or keeping an elderly person on his or her medication after release from the hospital. They target the person with risk factors and constitute him or her in a much more medical and actuarial frame than much wellness discourse does in its focus on the holistic person striving for self-improvement on his or her own, without expert intervention and highly technical guidance.

Wellness is prevention, but not the curing or treatment of any acute condition or specific health event. It is not associated with the design of complex actuarial schemes to shift population-level human behavior, such as in a new form of insurance design. It is the ongoing prevention of chronic diseases, aging, and disability at the site of an individual's body and is conducted in a self-aware manner by that individual starting well in advance of any particular medical problem. The sense of time here is critical — it must be a sustained effort of small actions and omissions that is descriptive of a lifestyle, not a highly medicalized or expert-driven management of a condition, no matter how much money it saves. This distinction is likely part of the heritage of wellness within the alternative medical community, with its emphasis on distance from doctors and diseases. (Recall the Berkeley Wellness Letter's definition, under which perhaps no use of remedies would be needed after wellness is embraced.)

So why, then, has accident prevention not been part of wellness discourse? It is personal, nonexpert-driven, and part of individual responsibility for health. (In the workplace context, preventing industrial accidents predates any wellness concerns and would be considered already addressed with other policies.) Storing firearms separately from ammunition and in a locked gun safe is not part of wellness, for example, nor is learning to swim or taking a defensive driving course. Accident prevention is too distant from the body and too isolated and abruptly temporal to count as wellness. Wearing a life jacket while boating or refraining from texting while driving are not lifestyles. A cynic might say that it is not wellness unless its achievement also advances one's ability to appear physically as an elite member of our society — thin, toned, and energetic at any age. I am interested in watching the direction of wellness in the future: Will it merge with techniques for cost saving and improvement of care such as VBID and become just a way of monitoring employees for the presence, emergence, and worsening of risk factors, or will it hold on to its more individualistic, holistic, and moralistic features? One conjecture is that it will do both within the corporate workplace, with the aspects that help with cost saving becoming firmly placed within systems of medical surveillance, while the workplace culture celebrates the parts of wellness that are employee perks (an on-site gym, for example) and which communicate striving, physically energetic individualism as a necessary part of being a good worker.

If the period of wellness blossoming from the 1960s to the managed care of the 1990s was the era of the five dimensions including aspects of the spiritual, intellectual, or emotional alongside the physical, the five data points of the current workplace wellness era would be body mass index (BMI), smoking status, glucose and cholesterol levels, and blood pressure. Wellness in the United States has become more focused on the attainment of specific biometric goals at the same time as it has become highly managerialized within the business world as employers seek to lower their health care costs. Even the Gallup yearly study on community wellness mentioned above focuses outside the workplace through a household telephone survey of individuals all over the world and is then used by its corporate partner, Healthways, to inform business clients who purchase its wellness programs aimed at those populations. This new version of workplace wellness is not a transformation but rather a paring down of some aspects of the definition that do not fit so well within the regimes of standardization that businesses use to measure wellness or which do not have a clear relationship to business goals. It is easy to measure employees' BMI and blood pressure, but not so easy to standardize the proper type and amount of their spirituality, nor articulate why an employer would care about it. The list of sessions at the 2013 National Wellness Conference (a meeting held yearly since 1977 in North America, organized by the National Wellness Institute [2013]) still contained panels on mindfulness and meditation, suggesting that they remain part of wellness discourses, but they were far overwhelmed by sessions on how to bring wellness programs into the business context, how to motivate and coach, and how to get a job in wellness administration.

As wellness programs have gone corporate, a big question has been whether they would yield much return on investment (ROI) for employers. Studies report that wellness programs can indeed return investments of about $3.00 for every $1.00 spent (Baicker, Cutler, and Song 2010). But many evaluation studies of wellness programs compare employees who enrolled in the program to those who did not, and consequently such studies suffer from significant selection bias (since healthier employees are much more likely to join and receive rewards for what they are already doing anyway). The trick is to show that wellness programs do more than just reward the already healthy or prompt improvements that will yield benefits only after the employee has moved on to another job. In a review of thirty-three wellness evaluation studies performed since 2000 on sites in the United States, random controlled trial designs showed that wellness programs produced positive effects (measured by a wide range of outcomes) about half the time, while the more biased observational designs claimed that three-fourths of programs had positive effects (Osilla et al. 2012. In addition, some of the studies had very short follow-up periods and small numbers of employees enrolled, and positive effects were small (especially for diet and exercise outcomes).

In short, a company or wellness program vendor could easily put together claims that a program is working well by comparing the health and expenditures of the signed-up group to those who did not join in, following them for just a year or two, and capturing just a few dozen or a few hundred workers. But this type of study design would not be considered strong enough to permit any causal inferences to be drawn in other scholarly areas, and so, not surprisingly, positive claims have not settled the question of the worth of wellness programs. One study of the long-standing (thirty-year-old) wellness program at Johnson and Johnson used propensity score matching to improve on this problem, comparing health outcomes and costs of Johnson and Johnson employees to similar employees at other companies with less well-established wellness programs. The researchers concluded that the Johnson and Johnson program returned an estimated $1.88–$3.92 for every dollar spent on the program as well as kept the company's health care costs lower (Henke et al. 2011. (I wondered whether such a strong health culture also draws health-conscious employees over time or drives out or bars unhealthy ones.) Longtime wellness researcher Dee Edington (2009, 2012) advocates taking a broader cultural and environmental approach in implementing a wellness program, looking to simply maintain health and prevent decline in employees, and resisting big claims about ROI. One question will be whether the distinction between wellness and other potentially cost-saving disease management programs will really hold up much longer, since they are likely to be pulled together by the employer's interest in saving money.

The New Wellness? Interrogating Wellness under the Affordable Care Act and Beyond

In my own contribution to this issue, “Critical Perspectives on Wellness,” I open up the question of what wellness programs do from the more commonly asked efficacy question (do they return on investment?) to the broader question of how they will operate in law, in organizational culture, and as a basis for social norms. The large majority of companies implement wellness programs without any plans to evaluate their effectiveness (i.e., their ROI in health care savings) (ADP Research Institute2012: 6). Perhaps wellness is worth having (from the perspective of those implementing the policy, of course) regardless of its economic payoffs. So, then, what does wellness do that is so important? What kind of wellness do companies want? I consider three main criticisms of what wellness, or certain forms of it, may do: (1) promote a conservative, individualistic health ideology, thereby undercutting communal, structural, redistributive, and sympathetic approaches to health; (2) promote workplace discrimination in programs as actually implemented within firms and organizations; and (3) promote homogeneity and prescribe one specific way of life for everyone, thus creating a problematic trend in a diverse democratic society. What the new workplace wellness means in practice will be influenced by the particular sites and people involved in implementing it, and wellness culture will surely have many positive features for some people. Nonetheless, I argue that some theoretical features of wellness ideology are troubling and that some predictable organizational paths it might travel along could produce undesirable consequences.

The next contribution in this special issue, “I'll Be Gone, You'll Be Gone: Why American Employers Underinvest in Health,” by Scott L. Greer and Robert D. Fannion, takes up the question of wellness programs from the perspective of the employer. Greer and Fannion first make the case that wellness can be viewed as an investment by the employer in the employee. Thinking about wellness as an investment helps illuminate many of the perplexing features of wellness spending (such as why it would be worthwhile to spend money extending an employee's lifespan when he or she will likely only work for the company for five years), and placing it within the scholarly literature on the level and variability of American employers' investment in their workforces allows Greer and Fannion to offer new explanations for these features. They introduce the terms positive wellness and negative wellness to capture the differences between investment (positive) and actuarial underwriting that raises insurance costs for at-risk employees (negative, and the type that the Affordable Care Act expands in 2014). The investment perspective is not encouraging for wellness as a positive investment. Greer and Fannion argue that public health, like most other forms of human capital in the United States such as education, is really only jointly produced by individuals and the state, with employers having no real incentive to invest much in producing it as well. They predict that employers will instead prefer to institute more symbolic forms of positive wellness as public relations and human resources tools while using negative wellness to save money.

The Affordable Care Act expanded the power of employers to incentivize participation in workplace wellness in order to promote health and preserve affordability while preventing discrimination. In “Using Reporting Requirements to Improve Employer Wellness Incentives and Their Regulation,” Kristin Madison, Harald Schmidt, and Kevin G. Volpp examine the regulation of workplace wellness programs and their use of incentives, focusing in particular on the improved evidence base needed for effective regulation. The first set of regulations from 2006 allowed for significant flexibility in program design and made no provision for systematic oversight. With the increasing popularity of incentive programs, however, perhaps the time has come to revisit these regulations. Do incentive programs work to improve health while avoiding discrimination and, if so, in what precise forms and for what kinds of people? Will data suggest that incentives differ in their effectiveness or that effects vary across groups of employees? What are the implications for fair treatment? The Affordable Care Act's provisions and new proposed regulations in 2012 allowing more intensive use of financial incentives provide an opportunity to do so. Madison, Schmidt, and Volpp describe how incentives are regulated and then detail the many unanswered questions about incentive program effects, at least some of which might have implications for regulatory design. They then identify ways to expand the body of knowledge about these programs through reporting requirements, describing the potential functions of reporting, discussing who should have access to reported data, and considering what data elements might be reported.

Perhaps the greatest point of tension in antidiscrimination law and wellness law is in the treatment of disability. Sick and unhealthy employees, such as those with chronic conditions, diseases such as cancer, or a history of having had such conditions, are protected from workplace discrimination under the Americans with Disabilities Act. Disability rights movements question whether health should be assumed to be so central to one's worth or happiness. Wellness programs hope to create healthy employees, or at least make each of them healthier, and the idea of a group of workers defined and protected by their unhealthy status would seem to be anathema to wellness goals. In “What's Bad about Wellness? What the Disability Rights Perspective Offers about the Limitations of Wellness,” Carrie Griffin Basas uses disability as a lens to explore the conflicts between the disability rights and wellness movements, tracing both their histories and their current intersections. Disability is a helpful perspective from which to critique wellness because it surfaces the underlying neoliberal tenets of wellness, for example, that health is within one's control, that it is a matter of behavioral choice and reform, and that the costs of illness should be borne by individuals, not the government or employers. One mission of the disability rights movement has been to describe health as a flexible, fluid state for everyone and to remove social stigma and moral reprimand for sickness. Wellness initiatives, however, can further marginalize people on the basis of health status by creating new categories of difference and inferiority and reifying old ones that are economically and socially disabling. They do this by vesting employers with new powers to regulate the private health information and decisions of their employees and to cast judgment with financial fallout that separates the healthy from the sick, the desirable from the unemployable.

If wellness is indeed a defining buzzword that captures so much about our relationships to health and personal responsibility, we should also ask how far the term has spread. Is it meaningful mostly in the US context of employer-sponsored health care, or does its neoliberal valence and lifestyle description travel well in other nations? In “Wellness as a Worldwide Phenomenon?” Heather Elliott, Jennifer Bernstein, and Diana M. Bowman focus on three distinctly different jurisdictions — the United States, Germany, and Australia — and examine wellness through the lens of employers, the health care system, employment and tort law, and the greater political economy. While the authors note that improving employee health, well-being, and productivity is common across the three countries and their respective cultures, they conclude that the focus on wellness as a distinct legal concept is unique to the United States.

Directions for Further Research

Refusing to use wellness as a buzzword means pressing for what its current meanings really are and asking how it is arranging power relations in specific settings. The contributors suggest a set of meanings and hierarchies in their essays, but more work needs to be done. One direction would be to continue work on evaluating the economic and health effects of wellness programs as they expand and perhaps take on more punitive forms under new regulations of the Affordable Care Act. Madison, Schmidt, and Volpp have pointed out many uses of regulatory information on wellness programs, and researchers could both independently gather and analyze some of that information as well as continue to direct policy makers about what exactly we need to know about how wellness actually operates and to point out persisting gaps.

Many of the essays collected here suggest that in its details and in its application, wellness will be discriminatory. The aim of contributors has been to lay out exactly why wellness is incompatible or at least in tension with equality norms and the exercise of personal freedoms and to point out where discriminatory practices are likely to be seen. A second area for new work will be to continue the ethical and moral arguments that treating people differently based on their health is indeed discriminatory. What counts as discrimination is highly contested, of course, and simple differential (and worse) treatment is certainly not always unlawful or unethical and is sometimes legally or ethically required. Some areas of US law stipulate that treating people differently based on their genes or health status may be illegal, but employment statutes generally only mention traits like race, sex, national origin, religion, ethnicity, disability, and perhaps sexual orientation. That mere measurement at an unacceptable level on a biometric screening constitutes a legally protected disability is unlikely, and weight discrimination is perfectly legal across nearly the entire United States except in Michigan and a few liberal cities such as San Francisco.

A third potential direction for further research on the discrimination question is to find out exactly how prevalent wellness-driven discrimination is, what forms it takes, and what its effects are. If business surveys are correct, workplace wellness programs under the Affordable Care Act are about to become even more common and much more punitive. Since most wellness programs up until now have been only participatory and not punitive, legal requirements for running a punitive wellness program has not been tested or extensively litigated. Health discrimination claims, either as disability discrimination claims or as claims about mistreatment under wellness incentives and punishments, could become a major site of employee dissatisfaction and litigation. The contributors to this special issue suggest that the law as written is not well poised to absorb these tensions, and it will be important for scholars to track and evaluate the new world of legal disputes over wellness.

References

ADP Research Institute. 2012. ‘‘Employers See Wellness Programs as Key to Containing Rising Healthcare Costs.’’ ADP Advisor 22, no. 2: 1–7.

Ardell, Donald B. 1982. Fourteen Days to a Wellness Lifestyle. Mill Valley, CA: Whatever.

Armstrong, David. 2009. ‘‘Origins of the Problem of Health-Related Behaviours.’’ Social Studies of Science 39, no. 6: 909–26.

Baicker, Katherine, David Cutler, and Zirui Song. 2010. ‘‘Workplace Wellness Pro- grams Can Generate Savings.’’ Health Affairs 29, no. 2: 304–11.

BerkeleyWellness.com. 2013. ‘‘What Is ‘Wellness’?’’ www.berkeleywellness.com/about-us.

Chernew, Michael E., Allison B. Rosen, and A. Mark Fendrick. 2007. ‘‘Value-Based Insurance Design.’’ Health Affairs 26, no. 2: w195–w203.

Davis, Kathy. 2008. ‘‘Intersectionality as Buzzword.’’ Feminist Theory 9, no. 1: 67–85.

Dunn, Halbert L. 1959. ‘‘High-Level Wellness for Man and Society.’’ American Journal of Public Health 49, no. 6: 786–92.

Dunn, Halbert L. 1961. High-Level Wellness: A Collection of Twenty-Nine Short Talks on Different Aspects of the Theme ‘‘High-Level Wellness for Man and Society.’’ Arlington, VA: R. W. Beatty.

Edelman, Lauren B., Sally Riggs Fuller, and Iona Mara-Drita. 2001. ‘‘Diversity Rhetoric and the Managerialization of Law.’’ American Journal of Sociology 106, no. 6: 1589–1641.

Edington, Dee. 2009. Zero Trends: Health as a Serious Economic Strategy. Ann Arbor: Health Management Research Center, University of Michigan.

Edington, Dee. 2012. ‘‘Interview with Dr. Dee Edington, PhD.’’ American Journal of Health Promotion 27, no. 1: TAHP-1–TAHP-6.

Epstein, Steven, and Laura Mamo. 2011. ‘‘Sexual Health as Buzzword: Competing Stakes and Proliferating Agendas.’’ Paper presented at the annual meeting of the Society for Social Studies of Science, Cleveland, November 3. Gallup-Healthways. 2013. ‘‘2012 State of Well-Being: Community, State, and Congressional District Well-Being Reports.’’ info.healthways.com/2012wellbeingindex.

Henke, Rachel M., Ron Z. Goetzel, Janice McHugh, and Fik Isaac. 2011. ‘‘Recent Experience in Health Promotion at Johnson and Johnson: Lower Health Spending, Strong Return on Investment.’’ Health Affairs 30, no. 3: 490–99.

Kelly, Erin, and Frank Dobbin. 1998. ‘‘How Affirmative Action Became Diversity Management: Employer Response to Antidiscrimination Law, 1961 to 1996.’’ American Behavioral Scientist 41, no. 7: 960–84.

Mattke, Soeren, Hangsheng Liu, John P. Caloyeras, Christina Y. Huang, Kristin R. Van Busum, Dmitry Khodyakov, and Victoria Shier. 2013. Workplace Wellness Programs Study: Final Report. Santa Monica, CA: RAND. www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR254/RAND_RR254.pdf.

Mihelich, Max. 2013. ‘‘More Employers Looking to Impose Wellness Program Nonparticipation Penalties in 2014.’’ Workforce, March 25. www.workforce.com /article/20130325/NEWS01/130329982/more-employers-looking-to-impose-wellness-program-nonparticipation-penalties-in-2014.

Miller, James William. 2005. ‘‘Wellness: The History and Development of a Concept.’’ Spektrum Freizeit, no. 1: 84–102.

Morone, James A. 1997. ‘‘Enemies of the People: The Moral Dimension to Public Health.’’ Journal of Health Politics, Policy and Law 22, no. 4: 993–1020.

Morone, James A. 2003. Hellfire Nation: The Politics of Sin in American History. New Haven, CT: Yale University Press.

National Wellness Institute. 2013. ‘‘2013 National Wellness Conference: Main Conference Sessions.’’ Annual conference held at the University of Wisconsin–Stevens Point, July 15–18. www.nationalwellness.org/resource/resmgr/PDFs/2013_Session_Descriptions.pdf.

O’Donnell, Michael. 2009. ‘‘Definition of Health Promotion 2.0: Embracing Passion, Enhancing Motivation, Recognizing Dynamic Balance, and Creating Opportunities.’’ American Journal of Health Promotion 24, no. 1: iv.

Osilla, Karen Chan, Kristin R. Van Busum, Christopher Schnyer, Jody Wozar Larkin, Christine Eibner, and Soeren Mattke. 2012. ‘‘Systematic Review of the Impact of Worksite Wellness Programs.’’ American Journal of Managed Care 18, no. 2: e68– e81.

Scoones, Ian. 2007. ‘‘Sustainability.’’ Development in Practice 17, nos. 4–5: 589–96.

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#wellness #health #the way we live now #health culture #rhetoric #buzzwords

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hamzaasp · 5 years

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The 10 Healthiest Dog & Cat Food Brands

As much as we love our pets and need them to be healthy, we sometimes forget that one among the simplest things we will do for them is to form sure we’re giving them food that gives optimum nutrients, minimal fillers and therefore the slightest of artificial ingredients. It’s easy to grab whatever name-brand dog or cat chow is handy, because pet food is pet food, right? Well, not really. It seems that what we feed our beloved pets can have an immediate impact on their overall health. Here’s a roundup of the ten healthiest dog and cat foods on the market.

For Dogs:

Blue Buffalo

The Blue Buffalo brand produces several different sorts of pet food, each geared to satisfy specific health needs for dogs. one among the more reputable dog foods around, Blue Buffalo may be a grain-free brand that uses a good amount of meat as its main source of protein, with quite 30 percent protein per serving. With no corn, wheat or soy in its recipes, that’s excellent news for dogs with food allergies. Plus, Blue Buffalo doesn’t use artificial colors, flavors or preservatives.

Castor & Pollux Organix

Castor & Pollux Organix pet food line was the primary certified brand to satisfy all the wants of the USDA’s National Organic Program. Its favorite ingredient is free-range chicken, along with side chicken meal, organic rice, and organic peas. With 26 percent protein, 14 percent fat and 4.5 percent crude fiber, this is often a healthy option for those pet parents who want to stay it organically.

Kirkland Signature Nature’s Domain Organic

Costco’s Kirkland brand has become an enormous name player within the grocery market, and pet food is not any exception. Their Nature’s Domain Organic petfood contains certified organic ingredients, including chicken, peas, sweet potatoes and lentils. it's grain-free and contains an omega carboxylic acid blend for optimum health.

Taste of the Wild

Real meat is that the favorite ingredient in Taste of the Wild brand dog foods, which are available more wide-ranging varieties than other brands, including boar, bison, and roasted venison, roasted lamb, roasted fowl, salmon and more. Their grain-free foods include the “Prey” line, which is GMO-free with no artificial colors, flavors or preservatives.

Natural Planet

Natural Planet dog foods are available several varieties, including rabbit and salmon, chicken and oats, and duck and whitefish. All feature organic, non-GMO ingredients and most have quite 25 percent protein per serving.

For Cats:

Natural Balance Limited Ingredient Diets

For cats with allergies or other health issues, Natural Balance Limited Ingredient Diets cat chow sticks to simple formulas for optimum nutrition. With top quality chicken, garden pea protein and Omega 3 and 6 fatty acids, Natural Balance support healthy digestion and overall nutrition. Each serving has 30 percent protein, 14 percent fat and 4 percent fiber.

Castor & Pollux Organix

In addition to their pet food line, Organix also makes the list for healthy cat chow. made up of premium certified, non-GMO organic ingredients, they need both grain-free and natural-grain foods. Organic chicken is their first ingredient, alongside a mix of superfoods like flaxseed, cranberries and copra oil. Each serving features a hefty 32 percent protein, 14 percent fat and three.5 percent fiber.

Nutro Grain Free

Made with no grains or glutens, Nutro Grain Free cat chow is another good option for cats with digestion issues or food sensitivities. With essential antioxidants like vitamin E, Omega 6 fatty acids and vitamins B and C, also as many natural meat and vegetable products, Nutro promotes heart health and powerful immunities. Nutro is additionally a winner when it involves protein, with 33 percent protein in each serving. Acana Meadowland Inspired by the Kentucky region they hail from,

Acana Meadowland

cat chow features free-run poultry, whole nest-laid eggs, and seafood. freed from any plant proteins, Acana is 75 percent meat-based, with 50 percent of its ingredients consisting of fresh or raw meats. They also incorporate organs and cartilage in ratios set to mirror those in nature, which provides extra calcium, vitamins, and minerals.

Instinct Original

The Instinct line focuses on raw food for pets, and their Instinct Original cat chow contains quite 70 percent real animal ingredients along with side vegetables, fruits, and natural oils. It is grain-free and ready employing a freeze-dry method that avoids any quite heat or cooking, which is claimed to preserve nutrients and keep the food as on the brink of its original form as possible. Instinct also offers a frozen raw variety which will be served as a meal or added to kibble as a supplement.

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forlovedogs11 · 5 years

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You and I have something in common. I guarantee it. We both love dogs, and we both want what’s best for them. On this latter point, I decided to start looking at healthy, fresh food options for my pups. But let’s face it – as much as I love them and want what’s best for them, I just don’t have time to cook homemade meals for them everyday. For those of you that make this happen, I applaud you. But for the rest of us, I wanted to see if there was an option. A healthy, easy option. Delivered to my door.

Video for a little background on NomNomNowand why I’m doing this.

I currently feed my dogs Kirkland Signature Nature’s Domain Dog Food. The ingredients seem to be mostly healthy. They have a good record without recalls. I feel like it’s a well-balanced food for them. I’m sure everyone will have an opinion about my choice, but this is what I feed my pups. But I know it’s not the best.

So I started doing some research online for companies that prepare fresh food for dogs – sort of like Home Chef for humans. I was surprised to find a handful. Some of the criteria I used to narrow down my search were:

The Search Criteria

Quality Ingredients (transparency) – Do I understand the ingredients list? Is every ingredient there for a reason AND beneficial to my pup? Is it all sourced here in the USA?

Recipes – Will this be food my dog will like? Are there options for dogs with allergies, like gluten-free?

Track Record – Have there been any recalls or health scares associated with the food/company?

Price – Pricing for all the home delivery, fresh dog food services was comparable. I can tell you that for NomNomNow and the other companies, the price will depend upon how much your dog weighs and activity levels. NomNomNow is great because they offer price breaks if you order bi-weekly or monthly, as opposed to weekly.

Convenience – Home delivery is key. Plus, I don’t want to measure food – pre-portioned, individual meals are key.

With this in mind, I finally came to the conclusion that NomNomNow checked all the boxes. They had great sounding recipes, and based on the pictures (which also turned out to be real – see the video). The recipes are all formulated and tested by a board-certified veterinary nutritionist – NOT just a vet. Apparently, there are less than 100 veterinary nutritionists in the US. They are vets, but they also spend additional time studying animal nutrition. Who better to come up with healthy food for your dog. I was satisfied.

NomNomNow has facilities in California and Tennessee, which is a big deal, especially when you’re talking about fresh food that’s being shipped. I’m in Washington, so my food arrived within just a few days of placing my order. 4 to be exact. NomNomNowalso prepares and cooks all of the food in their own facilities. Nothing is farmed out. They have total control.

Signing Up.

This was pretty easy and straightforward. I simply went to the NomNomNow website, answered a few questions about each of my dogs (weight, age, birth date), selected the foods I wanted and entered shipping & payment information. That was it. NomNomNow also has a product called Insights, which is a microbiome testing kit for dogs and cats. You collect a fecal sample, send it back to NomNomNow. They analyze the sample and provide insights on your dog’s gut bacteria. I didn’t opt for this, but I wish I had. I think it would have given me an even better look at the health of my dogs prior to trying the fresh food program. It’s not absolutely necessary, but it would have been nice to know how my previous dog food was performing.

Food is Shipped.

After I had completed my online order, the first food shipment arrived pretty quickly. It took about 4 days from order day to arrival. It was two weeks worth of the four varieties NomNomNow offers:

Heartland Beef Mash

Porkalicious Potluck

Tasty Turkey Fare

Chicken Chow-Wow

The Food.

Let’s talk a little about the food. There are photos on the website. Glamour shots, right? Well, what I received looked exactly like the photos. It wasn’t a mashed up version. It’s whole food ingredients. I could see the meat, the egg, peas, everything – to be honest, it looked like something I would make and eat myself. As a retired firefighter, I’ve cooked my fair share of meals, so I am no stranger to criticism when it comes to food. This stuff actually looked really good. I mentioned how each meal was formulated by a veterinary nutritionist, and it shows. In fact, the NomNomNow foods exceed the standards set by the AAFCO. They’re charged by law to regulate the sale and distribution of animal feeds (including dog and cat foods) and animal drug remedies. So they set standards, and NomNomNow exceeded that. That made me feel pretty good. One other point of interest, the food came pre-portioned for each meal. There was no measuring. No storage of partially used food. It’s what we call in the business – firefighter proof. Simple.

Check out the video of the 1st shipment unboxing.

Day 0 – Pre-Challenge Check Up – The Vet

Before I started the 30-day challenge/test with my pups, I wanted to take my pups to the vet for their annual check-up, as well as a full blood work up and fecal test. I wanted to make sure there weren’t any underlying issues beforehand. As expected, they were in relatively excellent health. I was told my female, Sandy, was a little over normal weight – but nothing serious. The look test results would take a few days for results.

Day 1 – It Begins!

The food arrived yesterday. Time to unpack the box and get started. I was very pleased with how it was packed – definitely cold – which is huge considering you’re dealing with pork, chicken and other fresh ingredients. Included in the box were 2 free bags of single ingredient dog treats – I’m big on single ingredient treats. Also in the box, I had all 4 varieties of NomNomNow foods. Some additional literature and explanation of the transition period feeding was included, as well. For the first week, I’ll be giving my dogs a 50/50 mix of NomNomNow food and their regular kibble. This just helps their tummies adjust to the new food. I have to say, I’m really please with 1.) the small 50% pre-portioned bags and 2.) the labels on these bags which note that they are for the transition period. The food smelled and looked really good. Like something I would eat. Even my picky son wanted to have a bite. No surprise – my dogs gobbled it up. 30-day challenge…we’re off to a great start.

Watch my pups try NomNomNow for the 1st time!

Day 3 – Dogs Love NomNomNow

I got the blood test results back from a few days ago. Nothing to note – nothing abnormal. So that’s good! I haven’t really seen much of a change in the dogs – which to be expected this early…except the dogs are cracking me up. They are really digging the NomNomNow food. Each morning (and evening) they gather in the kitchen where we prep the food. They sit (without being told) like good little pups. So good. Waiting! They LOVE this stuff.

Day 8 – Transition Period Ends

With the transition period over, today I’m feeding my pups 100% NomNomNow fresh food. The previous week was really easy thanks to the pre-portioned transition packs. The dogs are still very excited each meal for their NomNomNow. It could just be the new food, but they definitely seem to be more energetic, especially around meal time. Go figure. I was a little worried that there would be an issue with diarrhea since I was changing up the food my dogs were used to, but I’m pleased to announce that there haven’t been any issues or accidents.

Day 11 – Potty Talk

Okay, so we’re into the test over a week and 3-days post transition, and I can say one thing I have noticed – the dog’s stools are smaller. Not weird small, but it just seems like they’re processing more. The poop is also super easy to pick up. Very firm. Okay, no more talk about poop. I don’t want to gross anyone out, but this seemed noteworthy for sure.

Day 15 – Puppy Love

So we’re a little over 2-weeks into the test. Both dogs definitely seem to be more energized. Puppy-like. They are only 5 years old, but I’ve noticed them bounding around more and playing with each other – wrestling. A lot more. It’s actually pretty fun to watch. I’m trying to keep an open mind, so I’ve been relying on my kids to give their opinions, as well. They’re funny – they talk as if we have different dogs. So maybe not the best sources.

Day 20 – I Might Be In Trouble

For almost 3-weeks my furry little friends have been devouring the fresh NomNomNowfood. It is clear to me that this will have to be a permanent change, I’ll be facing a mutt mutiny! Stools are still smaller and firmer (for those keeping track). Energy levels are definitely higher. I know I’m not imagining this. I have to say, their coats also seem a little shinier.

Day 27 – Big Changes

Scheduled my follow-up vet appointment today. I’m excited to see what, if anything has changed. I’ve definitely noticed Sandy seems a little more fit. She’s definitely more active, so that’s great! I don’t feel like the photos really do justice to the change I’ve seen in my dogs. I’m not a professional photographer, and I shot these photos on my phone. But I really see a difference in my dogs. Their coats are shinier and softer. And as I mentioned, they are so much more active.

Day 30 – The Last Day

The final day! Wow, that was easy. I’ve already got my next two weeks of food in the refrigerator. I just didn’t have the heart to return my dogs to the old food I was using. I can’t even imagine the outrage. My pups are just as excited for mealtime today as they were on Day 1. I am sold. Fresh food is the way to go. I love NomNomNow. Maybe not as much as my dogs. I know some will say – of course, fresh food is best – but this challenge wasn’t about just fresh food. It was about getting my dogs healthy, fresh food – that I didn’t have to make. If you have time to make food, by all means, go for it. It’s all about giving our dogs the best we can.

What Did I Learn?

The final vet check-up came back great. The vet commented that the dogs still are in excellent health. Sandy lost 2 pounds. So she’s closer to her healthy weight. I think the healthier food and increased activity are definitely to credit for this. Overall, I am really happy with the NomNomNow fresh food. It was really easy – pre-portioned bags made this so simple, and the home delivery was so convenient. No more lugging big bags of food from the store. Not once did I question whether or not this was good for my dogs. I really appreciate the work that went into coming up with these recipes. It’s comforting knowing that I am giving my dogs great tasting, healthy food.

It’s worth mentioning that NomNomNow also has a great guarantee. If you don’t think your pup benefited for the NomNomNow fresh food, just contact them within 10 days of your 30-day trial, and they’ll reimburse you up to $40 for your next food purchase. I like stuff like this. it gives me peace of mind. Plus, it tells me NomNomNow is confident in their product. And they should be. Over the past 30 days, my dogs have definitely benefited. Mind you, they were in good health to begin with, so I am not claiming some miraculous transformation. But from their appearance to their activity levels, I definitely see improvements. I can only imagine how this fresh food could benefit a less healthy pup.

Don’t take my word for it. Give NomNomNow a try. You won’t be disappointed, and they have a great deal right now for 50% off your first order. So give it a try and see the difference it makes in your dog

0 notes

naivepets · 3 years

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Who Makes Kirkland Dog Food? (Canned, Wet, Organic, Grain Free, Healthy Weight)

5/5 - (1 vote)

Have you ever wondered who makes Kirkland cad food ? Look no more. We´ve got you covered.

Kirkland has a stove of dry and wet food for all ages, sizes, and lifestyles of dogs. Kirkland aims to provide quality to compete with the finest of pawl food brands but at a divide of the price.

so, who makes Kirkland cad food? Kirkland dog food is manufactured by Nature´s Domain Pet Food which belongs to the Kirkland company named Diamond Dog Food. However, Kirkland Signature has been operating for almost 50 years under the manufacturing of the Diamond Dog Food company.

As such, the post has successfully managed to expand its list of pawl food products to include the grain-free, high-protein product Nature ’ randomness Domain.

Reading: Who Makes Kirkland Dog Food? (Canned, Wet, Organic, Grain Free, Healthy Weight) – RV and Playa

In this article, we will be discussing the manufacturers of Kirkland Signature ’ s dog food, plus the nutrition rate, and ingredient sources. Whether you ’ ra debating switching to new dog food, or precisely looking for more data on your current one, read on.

Who Makes Kirkland Dog Food?

Kirkland Signature is just one of the products under the company named Diamond Dog Food. The cad food, Nature ’ south Domain, belongs to Kirkland Signature but denotes the mark to Diamond Dog Food to make affordable, yet high-quality dog food.

Many people are confused by Kirkland ’ s relation to Diamond Dog Food, as it is assumed that Kirkland Signature is entirely associated with Costco. Until recently, Nature’s Domain was only sold at Costco, but then it became available to other purchasing sources, most notably Amazon.

Who Makes Kirkland Canned Dog Food

Kirkland canned frump food is made by Diamond Dog Food company .

Who Makes Kirkland Healthy Weight Dog Food

Kirkland healthy weight unit frank food is made by Costco by Simmons Pet Food .

Who Makes Kirkland Lamb and Rice Dog Food

Kirkland lamb and rice pawl food is manufactured by Diamond Pet Foods. They are a U.S.-based pet food manufacturer with plants located in Meta, Missouri, California, and Gasto .

Who Makes Kirkland Wet Dog Food

Kirkland wet pawl food is made by Diamond Pet Foods in the USA .

Who Makes Kirkland Grain Free Dog Food

Kirkland grain free cad food is made by Diamond Pet Foods under the Kirkland brand name

Who Makes Kirkland Mature Dog Food

Kirkland Mature cad food is manufactured by Simmons Pet Food .

Who Makes Kirkland Organic Dog Food

Kirkland grain organic andiron food is made by Diamond Pet Foods which is owned by Schell and Kampeter, Inc .

Where is Kirkland brand dog food manufactured?

All of Kirkland ’ s dry frump food products are made in five different company-owned fabricate facilities by Diamond Dog Food. All of which are in America, however, vary in regions . Two of the facilities are based in Arkansas, California, one is in South Carolina, and the final one is in Missouri.

Most of the ingredients also originate from the United States, nonetheless, there are some critical ingredients that cannot be sourced domestically on American soil at the high quality that the company strives for.

Therefore, certain ingredients are sourced from overseas such as dried chicory root from Belgium, and potato protein from Germany .

The nutritional value of Kirkland Signature dog food

The nutritional prize of Kirkland ’ s frank food can vary between each product, depending on the chase they ’ rhenium target, and the kernel subject used. Below is a graph of the alimentary capacity between some of their dry food products.

Dog Food Type Protein Calcium Fibre Glucosamine Calories Healthy Weight Dog Formula 20% 1.70% 13% 750mg 275kcal/cup Adult Dog – Chicken, Rice, and Vegetable Formula 26% 2.5% 4% 300mg 393kcal/cup Puppy – Chicken, Rice, and Vegetable Formula 28% 1.20% 3% 0% 390kcal/cup Adult Dog – Lamb, Rice, and Vegetable Formula 23% 2.20% 4% 300mg 373kcal/cup Small Dog – Chicken, Rice, and Vegetable Formula 27% 2.50% 4% 0% 362kcal/cup

Is Kirkland dog food good or bad?

It is the lawsuit with any individual label brands that information is hard to come by. Since Kirkland Signature does not have a direct web site, and Costco doesn’t thymine immediately advertise information about the product, finding reliable sources can be difficult.

Nonetheless, Kirkland’s dog food range has had great success throughout its many years of service and has built up a good reputation with dog breeders and dog show exhibitors.

No company is perfective, and Kirkland has had their partake of recalls on two break occasions. The first remember happened in 2007, when a hole in the system brought concerns of melamine contents in the latest batch of food .

To err on the side of caution, the caller recalled all of the recent products .

Whilst no traces of melamine were always found, nor was any pawl ever affected who ate this batch, the company wanted to be absolutely certain .

The moment remember occurred in 2012. It was a similar situation where there was a suspected contamination leak, and the company couldn’t metric ton be 100 % indisputable that the products had not been infected with salmonella .

Again, no traces were ever found, and no dogs were harmed. The contamination leak proved false, and the products proved to be fine.

Read more: When Should You Worry About Doggy Diarrhea? | Diamond Pet Foods

From this unfortunate position, the company has become very diaphanous with its ingredients, manufacturing process, and tamp down standards.

They have made up for it through their proactive behavior, aiming to stop problems before they have arisen.

On trip adviser, Dogfoodadvisor Kirkland Signature Dog Food has earned the top rating of 5 out of 5 stars.

The ratings are high on other sites besides, with an median of 4.1 stars on Consumeraffairs, and an impressive average of 4.9 at Costco itself.

Summary

Kirkland frank food has high ratings and reviews amongst customers. The stigmatize has been manufacturing under Diamond Dog Food successfully for 50 years, striving to provide high-quality food at low-cost prices.

Diamond Dog Food is a US-based company, with five different manufacture facilities based around different locations in America . The majority of the ingredients put into cad food are besides sourced from within the state

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Lindsey

Lindsey graduated with an MBA in 2001. Since then, Lindsey has worked as a leader for wholly Foods market for over 2 decades. Lindsey has dined at some of the finest restaurants from seashore to coast and has had the honor of meeting such a celebrated chef as Hubert Keller. Lindsey is a senior staff writer and manage editor at Rvandplaya.com. Lindsey is based in Morgantown, West Virginia .