If less is more and we're dealing with already tight employer budgets (which is ironic considering that more than 70 percent of sick care costs are driven by health habits), then the one and only thing to invest heavily in and do really well is exercise. Why?

Exercise is best

There are many things that don't add much value in wellness programs yet we spend money on them year after year. Tools such as health risk assessments, biometric screenings, biggest loser competitions and smoking cessation programs are just a few examples of money spent for little, if any, return beyond the cost of the program. Quite often the return doesn't even come close to the cost of the program and can even be negative (smoking cessation programs not only often fail, but they can leave smokers feeling targeted and demotivated towards employers).

We already know almost everyone should be exercising, including those suffering from chronic diseases or are in recovery from most medical procedures. We don't need to "know our numbers" to know that.

Why focus on exercise rather than the whole range of issues that arise in wellness? Surely the obesity and diabetes epidemics are more pressing, more expensive problems to address? But they're not. Here is the evidence:

• Exercise prevents (or, in a very real way, treats) more conditions than any single medication, therapy, procedure or medical intervention. At least 45 diseases (and counting) are less likely to arise, or be less severe and less costly, for those who are fit versus those who are unfit. Exercise treats or prevents depression, GORD, chronic MS pain, headaches, impotence, heart disease, high blood pressure, diabetes and many other diseases often (but not always) more effectively than the leading drug in each therapeutic class. And with mostly positive side effects (see below).

Exercise is a catalyst

Exercise works very quickly. According to the Physicians Committee for Responsible Medicine, more than 90 percent of patients on oral diabetic medications and 75 percent of patients on insulin were able to get off their medications after 26 days on a proposed diet and exercise regime.

According to research, people who exercise:

• Have greater will power to resist the temptations of unhealthy food.
• Exercise improves heart rate variability (a good thing), reduces cravings, boosts will power and so increases people's persistence with new tasks including adopting healthier diets.
• Have increased energy, the core source of motivation to put other healthy habits into action
• Sleep better and this in turns helps with appetite control
• We didn't say a good diet is not important, just less important. Remember, we have a limited budget and we're trying to maximize our return. The least fit 20 percent have five times the prevalence of diabetes as do the most fit 20 percent but the apparent range based on nutrition habits alone is narrower. We can't do everything and our goal is to do something that will have the greatest impact and to do it well.
• The impact on other health habits from exercising is not limited to diet. Starting or increasing exercise has been shown to be one of the most effective ways to quit smoking. So starting with exercise is often the "gateway drug" to other good habits. The fittest 20 percent of people include only 5 percent of smokers. The least fit 20 percent include more than 30 percent smokers.
• This is especially true when you consider that most people who've tried and failed to lose weight or quit smoking have left the experience with a loss of faith that they'll ever succeed. So much so that many succumb to the "what the hell effect" and stop trying. Yet, many of these people remain somewhat active each day, and getting them to exercise is a matter of degree and something about which they have created fewer personal "stories" that get in their way.

Exercise is the key driver of positive performance

The lens through which we often compare wellness initiatives is the likely impact on claims costs. Through that lens, exercise massively outperforms disease management, drug therapy of risk factors such as hypertension and cholesterol and many other treatment-based modalities. Yet, when we look at the impact on positive performance, exercise really outperforms. Consider this:

• Students that are the most fit get up to 30% better grades in English, Math and other subjects. They have better discipline and attendance records. More interestingly, there appears to be no difference in academic performance based on body mass index.
• 40 minutes of walking, three times per week, improves episodic memory and executive control functions by 20 percent
• In one study, complex decision-making improved by 70 percent in response to exercise
• Mental errors in concentration and memory tasks fell 27 percent for fit workers
• Stamina improves by 100 percent for those who exercise in the last two hours of each day. That's a 12.5 percent improvement in productivity.

Any sober look at the data makes it easy to confirm the hypothesis that exercise is overwhelmingly the single most important health habit. Yet two problems persist.

First is that we're in love with broad rather than deep. Wellness vendors, and wellness buyers want programs that "have something for everyone" and that address all possible aspects of health, health management and wellness. But at what price comes this breadth and choice? It comes at the price of not being able to do well the one thing that makes a world of difference, getting people to exercise effectively almost every day.

And that brings us to the second problem. How do we actually get people to do that, to love exercise, to be addicted to exercise and to support others in doing so? That's the nut to be cracked. Here are five keys to successful employee engagement in this area:

1. Keep it simple. What we mean here is that the value proposition should be obvious for the employee and easy to understand. Don't clutter your program with so many different ways to engage (eat well, sleep more, get fit, do digital coaching, take your HRA, get your biometrics, say hello to your coworker, etc.).  People think they want choice but more options result in a difficulty to commit.  Simple and focused.
2. Make honesty/integrity an important part of the "game." How many employees wait until the last day of the period to "log" all of their activities for the prior quarter just so they can clear the bar to earn that $100 gift card.  For employers who say, "That's okay, at least we know they are thinking about it" should rethink their strategy. Find a partner that has integrated the mobile health tracking apps and devices that will not only provide more verifiable data but actually make your analytics make sense. Employees actually get motivated by their daily accomplishments, provided there is no "friction" or little effort involved with tracking their activity.
3. Liberate your employees. This is a big one. We often use the phrase, "meet your employees where they are at." Find a partner that liberates your employees to engage in activity with friends that might be other than their colleagues.  If an employee is more engaged when being active with their spouse our outside (work) friends, great. If an employee likes to play basketball vs. walk, great. If an employee wants to keep their data private, fine. In other words, don't try to prescribe. Rather, provide your employees with the ability to connect with you in a fashion that works for them. The most important thing is that you are there as a      partner to recognize and value that activity and to build a bridge for each employee to exercise more.
4. Closely correlate any rewards with the action you want to incent. In behavioral economics there's a term called hyperbolic discounting. Hyperbolic discounting suggests we tend to significantly discount the value of a future reward vs. a smaller reward we might get today or right now. Meaning $100 at the end of the quarter might be just as powerful as $10 per month or $1 right now. Most health rewards are too distant from the  actual act of achievement that employees don't assign the level of value that you think they should. Give more frequent but smaller value rewards to reinforce the behavior.
5. Market  a consumer experience, not an employer experience. There are too many "wellness" vendors out there that have been built for the employer to allow them to "check the box" on offering programs. Find a partner who's built their solution for the consumer first and layered on an employer module once that's done well.  In this way the employee won't feel like they're receiving another top-down employer-centric program but rather they're engaging in a consumer experience that's better because of you, not worse.

Next year is the year to crack the code. There's much at stake and employers are heavily focused on engaging their employees in healthy activity. The answer is clear. Do one thing and do it well. Exercise is the top of the engagement funnel. Don't miss the opportunity.

Andrew Sykes, Chairman of Health at Work, is a qualified actuary, a licensed health insurance broker, an HIAA managed health professional and an accomplished speaker on the topic of consumer-directed health care and wellness. To learn more about Health at Work visit www.healthatwork.com or email Andrew at [email protected].

Russell Benaroya is the co-founder and CEO of EveryMove, a health rewards program that allows consumers to turn their active lifestyles into rewards from their health plan, employer and brands. To learn more about EveryMove visit www.everymove.org or email Russell at [email protected].