The Japanese figured out the concept of a successful change a long time ago-a little goes a long way. "Kaizen" is a Japanese word constructed from two characters. The first represents change, and the second symbolizes goodness or virtue.

Kaizen equals uninterrupted, ongoing, incremental change. Change that is so subtle, anyone can do it.

As folks involved in the case management business in one way, shape, or form, changing people and their health-eroding behaviors drive a lot of our focus. I personally believe we have made the required adjustments too overwhelming.

I am writing to you today as a clinical physiologist who worked with clients who ranged from obese children to pregnant women to injured workers to Olympic and elite athletes. My time spent in work-hardening and industrial rehabilitation coupled with my current focus on working with employers to assist them in maximizing workforce productivity, as well as helping people remain at work or return to work as quickly as possible following an injury or illness, color my thoughts and my attention.

The article outlines four steps that I believe we should consider when approaching success with our colleagues, our employees, our clients, and ourselves.

Before we get started, we must get one thing out of the way. We must stop labeling people.

We place labels on people all the time. The only reason we get people to pay attention to health and disability issues is that, in the words of Dr. Dee Edington from the University of Michigan's Health Management Research Center, "health is free but health care costs."

Because we care about medical expenses, we get down to root causes. The root causes turn out to contain easy labels: smokers, alcoholics, obese people, slugs, people with depression, and so forth.

When we label people, they tend to get defensive. They spend lots of time telling us all the reasons why they are not going to modify their ways. Yes, these characteristics are often associated with increased healthcare costs, absenteeism, and presenteeism. But the people are not bad. If we are going to get people to correct their course, how do we put in interventions that separate the people from our categorization of their less than optimal behaviors?

Think about it. Seventy percent of smokers want to stop. Five to ten percent try to quit every year. Only 3.7% of them enjoy lifetime success. How do we approach smokers? We send them outside in the cold to smoke huddled in doorways or clustered together at the edge of the employer's campus. We unwittingly create environments of smoker support networks. We may give them extensive physical support services that often include nicotine patches and hypnosis, but we give them no emotional support. In fact, when someone quits, we rip him or her away from his or her main support group. They leave people behind. Is it not the Marines who never leave a soldier behind? Have we ever thought about developing initiatives in which we literally welcome smokers back in from the cold?

We also need to think about how we are delivering root-cause information to our audiences. Have we given them license to judge people? No one wants to be judged.

If we want to convey a message that is different, we need to think about delivering the entire message. Not only do we need to identify the behaviors we want to alter and programs that can help individuals with change, we have to figure out a way to support people both physically and emotionally. We cannot just isolate the behaviors from the people. Not if we want to be successful.

Here are the four steps I recommend we consider. It is a process we might have to go through as both individuals and case managers to adjust the route we are on.

Step 1: Facts Do Not Change Behaviors

Smoking is bad for you. So is too much alcohol. In fact, too much food and too little exercise are not good for you either. Eat at least five servings of fruits and vegetables every day. Remember to get 8 hours of sleep every night. And cheer up, will you? The way you are headed, your lifetime risk for some form of a mental illness, probably depression, is 50%.

You know every one of those facts. You probably said at least one of them in the past 12 months. But the reality is, knowing statistics and applying them in our lives are two different things. Facts do not change people's behaviors.

Take a look at these statistics from the April 2005 issue of the Archives of Internal Medicine. Twenty-four percent of American adults still smoke. Most of us were born knowing smoking was bad for us. Merely 40% of us are in the optimal weight range. There is a reason why airlines are offloading luggage on sold-out flights. Just 23% of us eat all our veggies and fruit. How are we ever going to get to the new "9-a-day" target that the National Cancer Institute set? Barely 22% of us exercise regularly. It is pretty easy to find an empty treadmill at your local YMCA on Fridays.

Worse yet, only 3 of every 100 Americans exhibit all four healthy lifestyle characteristics described above, with women being twice as compliant as men. Yikes!!

Why are we trying to do the impossible? Why are we trying to change adult behaviors in the first place? We believe that there is a correlation between these choices and escalating healthcare costs. According to the Centers for Disease Control and Prevention and RTI International, an obese person will spend $900 more on annual medical costs and a smoker will, on average, add $1,600 to annual healthcare costs when compared with their slim and nonsmoking counterparts.

If facts do not permanently change behaviors, what does? Nothing short of an epiphany. But there is something we can do. Simply maintain. As a classic Rodgers and Hart song declares, "don't change one hair for me, not if you care for me."

Research from Dr. Dee Edington indicates that we fall into one of three categories: low-, medium-, and high-risk individuals. Low-risk people exhibit zero to two risk factors such as smoking, alcohol overuse, and overweight; medium folks have three to five risks, and he describes high-risk people as living with more than five risks. Eighty percent of low-risk people stay low-risk, 60% of medium-risk people remain there, and 50% of high-risk people stay the same. The rest of the population is shifting back and forth among risk levels.

One of the most effective strategies employers can put in place to keep healthcare costs down is to keep low-risk people at low risk. Dr. Edington says,

It's hard enough getting people to maintain healthy behaviors, let alone change unhealthy ones. I really do believe that our best opportunity for success is in low-risk maintenance[horizontal ellipsis]. These are the people we need to spend time with, because if you stop the flow of high-risk people, then you win.

In other words, although we tend to focus solely on high-risk employees, we are missing all the people who move from low-or medium-risk to high-risk. We have more people in the end who move to high-risk than people who reduce their risk. Costs generally follow risks, so it may be more important to concentrate on those who have the potential to become high-risk and high-cost.

What further substantiates the low-risk focus is that high-risk individuals who successfully tackle one risk factor tend to develop another one.

How do we keep low-risk employees low? Many people believed that incentives, especially financial incentives, were the key to success. America on the Move points out to employers that you can at least double initial participation rates in a health promotion program if they pay upfront costs and add even more employees if they add further incentives. But within 3 months, about 70% of employees drop out of behavior change programs. Money is like oxygen to a flame. It keeps the candle burning, but eventually the fire dies out.

Is there something else we can do to maintain our low-risk clients? Evidence exists that people who are satisfied with their jobs and are happy with their lives in general cost less money. A 2005 Journal of Occupational and Environmental Medicine study indicates that job satisfaction is one of the most important factors influencing employee health. Identifying and eradicating work practices that cause the most job dissatisfaction provide the greatest impact on employee health.

Happiness, not facts, may be the best way to keep health in check. Employers have the capacity to provide happy, healthy, and productive lives for their employees through the environments they create and their personal commitment. We must seize the chance to help employers and our clients, their employees.

"Happiness," Aristotle said, "more than anything is absolutely final. For we always choose it for the sake of itself and never for the sake of something else."

Step 2: Make It Personal

Dr. Raphael Levey, founder of the Global Medical Forum, states that five behaviors drive 80% percent of the healthcare budget: smoking, drinking, eating, stress, and not enough exercise. Facts such as these cause us to make the uncomfortable leap of getting involved in our clients' personal lives. Once inside these uncharted waters, we may find ourselves making unwelcome phone calls to clients' homes. The consequences do not often hit us until our own telephone rings.

If only 1% of men and 2% of women are living all the recommendations espoused by the researchers, we are as much a part of the problem as the people we coach. But, how many of you revealed your own health or behavior challenges as you talked with someone about his or her habits? Probably, not many. Do not be too hard on yourself-you are not alone.

The Partnership for Prevention hosts a wonderful program called, "Leading by Example." Nineteen CEOs and governmental leaders spend time reaching out to senior management at other companies to explain how they make health promotion and disease prevention part of their business strategy. Only one of the featured individuals, however, talks about his personal journey-Mike Huckabee of the state of Arkansas. The now-famous former governor used his 110-lb weight loss to first inspire his state constituents through his Healthy Arkansas program, which includes his own tip sheet on how to make behavior changes. As the chair- man of the National Governors Association, Governor Huckabee expanded the program nationwide under the banner of Healthy America: Wellness Where We Live, Work and Learn. Leadership like this is hard to find.

So, let me get personal. I talk about behavior change all the time, but I am generally blessed with good genes and good habits. I have started telling audiences that. I mean, what the heck do I really know about losing more than 10 pounds? But, I finally stumbled on a story I could tell, and it was not easy.

The New England Journal of Medicine published an article titled "Unhealthy Alcohol Use." No, I am not an alcoholic, but, according to the definitions described in the article, I sometimes dabble in "risky use." For me, that generally means drinking seven alcoholic beverages in a 7-day period. This easily happens on a weeklong business trip with dinners every night. If I kept up this pattern long-term, I risk cirrhosis and certain cancers. So, I tell people that. I also let them know I am conscious of what I drink and enjoy sparkling water with lime now, as often as I do a good glass of wine. And that has gotten people to pay attention to their own consumption.

Here is my challenge to you. Get personal, too. Take a deep breath, step forward, and tell your clients, when appropriate, your own story. Share your struggles and your passion. They will pay attention.

A set of four studies released in March 2006 out of Stanford, Northwestern University and New York University reveal two aspects to successful health communication: relating to the emotional state of the listener and focusing on the consequences of an illness for the individual or the impact on his or her close family or friends.

Touch people's emotions with your story.

As Governor Huckabee says, "Leaders cannot ask others to do what they're unwilling to do."

More to come next issue!!