Health for life

With atypically little fanfare, the Disease Management Care Blog gazes into the crystal ball and offers ten health care predictions for 2012:

1.  After Mitt Romney secures the Republican nomination for President, he and Mr. Obama will mutually try to find ways to avoid debating the issue of health care orm.  Both will calculate that there’s little advantage to reminding voters of the messes they’ve made.

2.  As a result of 1 above, the election will not hinge on health care orm, which, thanks to an improving economy, will otherwise be very close and not be a erendum on Obamacare.

3. Yet, the U.S. Supreme Court will stir things up with a ruling that the Affordable Care Act mandate is unconstitutional because, among other reasons, Congress should have used its power to tax, not impose a penalty.

4.  There will be no generalizable and published peer reviewed studies on the Patient Centered Medical Home or the electronic health record that conclusively demonstrate that either reduces health care costs.

5.  Even though CMS will have trouble providing timely claims data feeds to its newly established ACOs, we’ll hear little about it in the public domain.  ACOs have every incentive to not cross CMS.

6. Speaking of ACOs, the least recognized Achilles heel as they start up will be a pervasive physician culture that trumps patient perence over shared savings.

7.  We will learn that, thanks to their complexity, the deadlines for implementation of health information exchanges will need to be pushed back.

8.  Congress will "kick the can" of the Sustainable Growth Rate conundrum down the road and past the 2012 election with another temporary patch.

9.  More academic medical center faculty will find that it’s far more professionally rewarding to post on line than to publish in paper-based journals.  Department Chairs will reluctantly find ways to use web statistics in promotion and tenure.

10. Piqued by Mr. Obamas recent recess appointments, the Republicans will respond by holding the up the appointment of Ms. Tavenner as CMS Administrator.

While the Disease Management Care Blog is pretty good at spotting current health policy silliness, its track record at predicting the future has been rather spotty.  Regular readers have undoubtedly forgotten this brazen attempt at 2012 health care augury, but the transparent DMCB uses to bury its mistakes.

So how did it do with its Ten 2012 Predictions?

1. Mitt Romney will win the Republican nomination and avoid discussing health care.  The DMCB got some of this right, but who would have predicted that the President would cleverly upend his opponents by embracing the term "Obamacare?"

2. A close election will hinge on an improving economy, not on Obamacare. In the end it wasnt really that close, but the DMCB was correct in foreseeing that Mr. Romneys candidacy would be undermined by dropping unemployment levels and the bottoming out of the comatose housing market.

3. The Supreme Court will rule Obamacare unconstitutional: Boy, the DMCB got that wrong.  But in its defense, few foresaw that SCOTUS would ignore the Affordable Care Acts statutory language and rule that a penalty was really a tax all along.

4. There will be no generalizable and published peer-review studies on the electronic record of the medical home that conclusively show that either saves reduces health care costs.  "Bingo!" says the DMCB.  It hopes 2013 is different and that a p value is < 0.05.

5. ACOs will not criticize CMS about the tardy delivery of claims data necessary to manage its assigned populations. The DMCB says the silence over this issue is deafening, which means either a) CMS has overcome its dismal track record on providing timely information or b) the ACOs are reluctant to go public with any concerns.  The DMCB has heard rumors that the latter is true.

6. Speaking of ACOs, their physicians will trump patient perences over savings.  The DMCB says the jury is still out on this, but time will tell if its call about this ACO Achilles heel is as important as it thinks it is.

7.  Health exchange deadlines will be pushed back. To the DMCBs knowledge, CMS is holding firm on the fall 2013 implementation date.  The DMCB takes some credit, however, for being among the first to spot this issue and bring it to its readers attention.

8. CMS will kick the Sustainable Growth Rate (SGR) down the road. "Bingo again!" says the DMCB.  It got his one right and looks forward to how Congress will deal with this in 2013.

9. Medical academics will increasingly turn to social media instead of print to make their mark on the scientific world. The DMCB believes this trend is continuing but has yet to reach a tipping point.

10. CMS Interim Administrator Tavenners status will remain in recess limbo.  OK, it wasnt all that hard to bank on continued partisan bickering, but the DMCB got this one right too.

Will the DMCB offer up predictions for 2013?  Stay tuned!

And Im back for part 2 of my AHS 2012 review.  Read part 1 if you missed it.  And no, this blog is not about AHS, the leader among home warranty providers.  Its the Ancestral Health Symposium.  Only the biggest event in the paleo nutrition world, everyone knows that.  Now read......

Can you believe Mark Sisson is 60?  I guess this paleo thing works.

Mark Sisson and Robb Wolf Q&A
This was another highlight of the weekend, in which Mark and Robb took questions from the audience.  It was only a 40 minute session, but I could have listened to this for hours.  I honestly dont remember what any of the questions were, so I guess I dont have much to talk about here, but they were very engaging and hilarious.  Great stuff.  I would love to spend a night socializing with these guys over NorCal margaritas.



Gut Health and Obesity
Stephan Guyenets talk on gut health and obesity was just fascinating.  Hes been one of my favorite people in the paleo community for a while now, Ive learned so much valuable information from his blog.  The gist of his talk, from what I can remember, was on how your intestinal health affects your propensity to gain weight.  And he made a major distinction between visceral fat and subcutaneous fat (visceral being the fat gained within the abdominal cavity, and subcutaneous fat being fat located under the skin).  Theres a big difference.  A person with more visceral fat will be at much higher risk for metabolic abnormalities and chronic disease, while someone with mostly subcutaneous fat is likely to be metabolically healthy, regardless of the fact that theyre obese.

Ill certainly need to go back and watch Stephans presentation again to really take in the information (once they get the lectures online, that is).  But as I recall, the most interesting part to me was about gut bacteria and obesity.  He talked about a few studies in rats, in which they performed fecal transplants to transfer gut bacteria from one rat to another.  Yes, that means taking the poop from one rat and sticking it up the butt of another rat.  We do it in humans too.  But the basic idea was that the gut flora differed between lean and obese mice.  But when the gut bacteria from the obese rat was transferred to a lean rat, that lean rat then became obese.  There was much more to it than this, but as I said, I need to go back and watch it again and take notes.  But its very intriguing to me that simply changing the gut flora of an animal could make them become obese.  It sounds like this area has a lot of potential for future study, and its definitely something Ill be following.

On another note, on the last night of the conference I was able to meet Stephan and chat a little bit.  He was super nice and down-to-earth.  We talked about beer and other manly things, apparently he brews beer.  But I also talked with him about probiotics.  Probiotics can be found in either food or in supplement form, but they are essentially healthy bacteria for your gut.  The idea is that they make it to your large intestine, set up shop there, and do good things for your digestion and your body.  But according to Stephan, and I suspected this to be true, probiotics dont significantly change your gut bacteria, and they dont really have any effect at all.  Most of the bacteria get killed on the way to the large intestine, and the few that are left just dont make a dent in the billions of bacteria that are already there.  Ill be sure to look into this more in the future as well.

Maybe the best part of Stephans talk though... the opening.  "Hi, Im Stephan Guyenet, and Im not going to talk about carbs."  Loved it.


Lustig and His New Research
Dr. Robert Lustig gave one of the better talks at AHS as well, about sugar (as if he ever talks about anything else).  It was really great though.  Even though Ive seen his lecture Sugar: The Bitter Truth, and Ive seen his 60 Minutes special on sugar, I still learned something.  He discussed the danger of fructose overconsumption, per the usual, but one thing he stressed this time was that fructose is only toxic if it is consumed in the context of a hypercaloric diet.  Translation:  if youre in caloric balance, or caloric deficit, fructose doesnt exhibit the same dangerous effects on insulin sensitivity, weight gain, etc.  Only if you are overconsuming calories will it exhibit these toxic effects.  I had read this on Stephans blog as a criticism of Lustigs work, so I was happy to see Lustig evolve his information.  In a real life situation though, it seems as though many people who consume a lot of sugar would be in caloric excess, especially those who consume a lot of sugar-sweetened beverages.  High-sugar foods typically arent satiating and can lead to overconsumption.


Dr. Lustig also revealed some data on a new sugar/fructose/metabolic syndrome study that hes working on getting published.  He asked the audience not to take any pictures of his slides since this study isnt published yet, and as a result, I have no way of remembering any of the details.  However, he was very pleased with the results, and as you can guess, it made sugar look pretty shitty.  Cant wait for that one to be published.


Okay, thats it for this edition of my AHS review.  Ive still got much more to talk about, so come on back for part 3 tomorrow!

So this past weekend, I was able to attend AHS 2012 in Cambridge, MA.  For those of you who dont know, the Ancestral Health Symposium is an annual event that began last year, and it brings together all of the most well-known people in the paleo community for a weekend full of lectures, debates, paleo food, and apparently, large amounts of free chocolate and coffee.  Or maybe it was only me who spent half the conference eating free dark chocolate samples and drinking americanos.  Oh well, coffee is life.

Caveman chocolate.

It was a great weekend, and I got to meet some great people who Ive learned so much from over the past couple of years.  Stephan Guyenet, Chris Kresser, Mark Sisson, just to name a few.  Also got to meet Laura from Ancestralize Me, which was great because shes also on the RD track and I love bitching about My Plate.  I did NOT get to meet Robb Wolf, which I was really disappointed in since hes sort of the ring leader of this whole paleo movement.  Maybe next time.  I was so pleasantly surprised to learn how down to earth and approachable these people were.  Despite their status in the community, they were willing to socialize with everyone and blend in.  I really appreciated their everydayness.

Anyway, over the next few days Ill be discussing my thoughts on some of the main topics from AHS this year, and also talk about the event as a whole and what it means for the future of the paleo community. So without further ado...


Safe Starch Debate
One of the best presentations of the weekend was the safe starch debate involving Paul Jaminet, Chris Kresser, Cate Shanahan, and Ron Rosedale.  Let me first just say how ridiculous it is that were even asking the question "Is there such a thing as a safe starch?"  Im sorry but its stupid.  Especially when it followed Chris Masterjohns great presentation, which explained very clearly how humans, as compared to apes, have evolved the ability to digest greater amounts of starch through salivary amylase.  This is not debatable.  Of course starch is safe.  The question is, how much starch is safe for a given person?  Well, according to Chris Masterjohns data, humans have varying abilities to produce salivary amylase.  So there is a spectrum in terms of the ease at which humans digest starch.  Some can handle it very easily and perhaps in large quantities, while others may have a hard time digesting a lot of starch.

Chris Kresser (middle) dominating the safe starch debate

The obvious answer to safe starch debate is... it depends.  One person may be just fine on a diet high in starch from potatoes and sweet potatoes, while another person may be better off limiting their potato consumption.  There is no one diet for everybody, which is why I think Chris Kresser clearly came out on top in this debate, because he understands this concept.  Ron Rosedale came off as a complete idiot, in my opinion, although he did make some interesting points.  He advocates a low-carb, ketogenic diet for everyone, which I completely disagree with.  Cate Shanahan was on the low-carb side as well, although she was not as militant about it, and I was happy to hear her conclude with the idea that eating real food is what matters most.  Not to forget about Paul Jaminet, I thought he was great in this debate as well, but having read his book, I know he is of the opinion that the optimal human carbohydrate intake is fixed at between 100-150g per day.  Any more, according to him, is toxic.  I just cant agree with that.  So Kresser for the win.

Oh, and theres also that pesky fact that nearly all 7 billion people on earth eat a starch-based diet.  I know that doesnt mean its optimal, Im just saying.  Theyre not killing us.


LDL-P
The concept of LDL-P seemed to be a theme this past weekend.  LDL-P stands for LDL particle number.  In a typical lipid panel from your doctor, they are measuring LDL-C, or LDL concentration.  According to Peter Attia, and Robb Wolf mentioned it in his talk as well, LDL-P is a much better predictor of heart disease than LDL-C. 

From Dr. Attias presentation.  This graph compares LDL-C levels with incidence of heart attack.  Most heart attacks occurred in people with what is considered a "normal" level of LDL-C.  What would conventional medicine do?  Lower the erence range and prescribe more statins.  What should we do?  Get a new fucking risk factor.

Lets make up an example.  Say you have a healthy LDL-C, as measured by your doctor, at 120 mg/dl.  Thats a good thing, as far as hes concerned.  But LDL can vary in size.  If all those particles are small LDL particles, then there must be a lot of them to make up that concentration of 120 mg/dl.  If you have a lot of LDL particles, youre at high risk of heart disease, regardless of what your LDL-C says.  On the other side of the coin, you may have large LDL particles.  In this case, you have fewer total particles that make up that 120 mg/dl.  Here, you would be at low risk.  Of course, you could also look at someone with high LDL-C, say 200 mg/dl, and you could make the case that he or she may or may not be at risk, depending on the size and total number of LDL particles.

I  have been familiar with the LDL particle size idea for a while now.  But according to Dr. Attia, particle size is largely irrelevant in its own rite.  Small, dense LDL particles are very much associated with a higher risk for heart disease, but it is not the small LDL that are causing disease.  It is because small LDL often indicates a large particle number that explains the association with heart disease.  It is not the small, dense LDL itself.  In a situation where someone might have low LDL-C, low LDL-P, and small particles, the risk of disease remains low.  Or if someone has high LDL-C, high LDL-P and large particles, their risk of heart disease is high.

I realize this may be confusing.  But heres the take home message:  It looks like the LDL-C measurement, the one doctors are currently using, is largely useless.  While higher LDL-C may increase the chances that youve got a high LDL-P (only makes sense, right?), the two are not necessarily connected.  We need to start measuring LDL-P if were ever going to get an accurate measurement of heart disease risk.


Thats it for part 1 of my AHS review.  Ive got much more to talk about, so stay tuned for the next part!

Futures so bright, gotta wear shades!

Optimism.  Enthusiasm.  Bullishness.  Who can blame the Care Continuum Alliance for describing the future as "bright" in a ebullient 2012 population health management "Industry Outlook" white paper?  Based on a survey of unnamed "industry leaders,  the CCA found that practically every high visibility health policy initiative out there is relying on the principles of care management.

Theyre right.  Given growing recognition that "health care as usual" cannot continue, companies, vendors and organizations (and blogs) that offer new approaches will thrive.  Have a good idea on reducing chronic illness and improving health and the value proposition will follow.  Have a value proposition and the business model will follow.   Have the business model and an early comfortable retirement will follow. 

The report can be downloaded here.  No company or individual resource knowledge library is complete without it.  The Disease Management Care Blog also thinks that forwarding the report to colleagues, co-workers, bosses, underlings, friends and enemies will demonstrate two key traits:

1) your situational market business awareness is second to none
2) reading the DMCB is a competitive advantage

A DMCB summary review is below

ACOs and Shared Savings: the industry has a host of necessary  risk assessment, predictive modeling, information technology, analytics, patient engagement and condition management tools that can be built and tailored. Provider organizations that seek to make money from "upside gainsharing" ignore these resources at their peril.

Electronic and Mobile Health: remote physiologic monitoring, app based coaching and "pull" style  social media engagement are all reaching a tipping point.  Or rather, are all eReaching an eTipping ePoint. The Disease Management Care Blog, sharing in the eEnthusiasm, has initiated a remote "eSpouse" offering. More on the ePerils of that eBusiness model in a future ePost.

Reducing Readmissions: Come Oct. 1 2012, outlier hospitals with more than their fair share of heart failure, heart attack and pneumonia readmissions can look forward to a painful revenue cut.  "Pay us now or pay later," says the industry, with too numerous-to-count proven care management strategies that have been described at the Care Continuums annual meetings for years.

Medicare Advantage Bonus: Thats right, MA plans will be eligible for bonuses from CMS based on HEDIS inspired commercial insurance outcomes that have been the bread and butter of the care management service providers since the beginning of time.

Dual Eligibles:  This highly vulnerable population has been trapped in a twilight zone of overlapping and uncoordinated benefit plans thanks to a well-meaning but typical Washington-style mishmash of Medicare and Medicaid.  The good news is that the Feds have finally woken up to this and are interested in funding many of the coordination strategies that the population health industry stands ready to offer.

Prevention and Wellness: The Feds have money to put into this and employers are increasingly willing to invest in it.  Medicare covers annual wellness visits and covers obesity counseling.  The controversial ham-fisted involvement of HHS in calculating the MLR has thankfully correctly slotted the cost of wellness programs.  Wellness and prevention are one of the ten essential benefits.  The industry is poised and ready to go.

And what about "build" versus "buy" and the notion that providers already know how to do all this stuff?   The DMCB points to the sine wave of on-again off-again in and outsourcing that has been the norm for the commercial insurer-disease management vendor relationship for years.  The DMCB suspects the same will occur for providers, hospitals, delivery systems and ACOs that have to operationalize complex programs that achieve measurable accountability.  The difference is that, up until now, they havent had to do that at all.  Based on a mix of in-house competencies, interest, speed to market needs and cost comparisons, many will buy. 

The population health industrys outlook is very bright indeed.

Image from Wikipedia

And were back for part 3 of the AHS talk.  Again, thats the Ancestral Health Symposium, not the American Hemerocallis Society, the American Helicopter Society, nor the American Headache Society, all of which come up ahead of Ancestral Health Symposium in a Google search.  That needs to change.  On to the discussion...


Two Ways of Looking at a Food: Nutritionism vs. A Whole Foods Perspective
This wasnt a topic that was covered specifically at the symposium, but some of the presentations touched on it, and that made it a frequent topic of discussion with my friends and I (Amanda at Inspired. and Matthew at whatever-he-will-call-his-new-blog.com).  First there was Mat Lalondes talk about his new system for measuring nutrient density, in which he made bacon look pretty darn nutritious.  Cool with me.  I liked it far more than the ANDI score system used at Whole Foods, or the NuVal system used at conventional grocery stores, but it was very apparent by the end of his talk that there is no perfect system to quantify the nutrient density of food.  Then there was Peter Ballerstedts talk about grass-fed meat, his main point being that the nutritional differences between grass-fed and grain-fed meat are negligible.

So these two talks generated some discussion about this reductionist perspective of nutrition.  Or "nutritionism", if you will.  You can measure the nutrients in a food and try to rank its healthiness, but what ultimately matters is the effect this food has on your body as a whole.

A couple of examples... Firstly, I appreciated Dr. Ballerstedts point, that the nutritional difference between grass-fed and grain-fed meat is insignificant.  He mainly focused on the difference in omega-3 fatty acids.  And he may be right, there isnt that much more omega-3 in grass-fed meat.  But does it matter?  A 2011 study, for example, found that eating grass-fed beef significantly increases the composition of omega-3 fatty acids in plasma and platelet, while eating grain-fed beef actually reduced their omega-3 content (1).

Then theres the whole grain thing, which I blogged about recently.  Despite being high in antioxidant nutrients (vitamin B6, folate, selenium, zinc, magnesium, and cysteine), whole grains have zero effect on your bodys total antioxidant capacity (2). 

So, you can talk all day about a food being more nutritious or less nutritious than another, but at the end of the day youre guessing.  Okay, thats not quite fair.  Its an educated guess.  But nutrient composition isnt everything.  We dont really know how food acts in our bodies until we study it.  Nutrient density can be a great guide, but its not the end-all-be-all.



Denise Minger is Hilarious/Adorable/Really Super Smart
Denise Minger was great as always.  No blogger makes me laugh like Denise does, and I think I nearly died of laughter during her AHS presentation.  She brought up the cholesterol-fed rabbit model, which many of you are probably familiar with.  A study from the early 1900s fed rabbits cholesterol and observed a rise in their cholesterol levels.  But rabbits dont eat cholesterol; theyre herbivores. 

Do rabbits eat carrots?  Or babies?

Point made.  Anyway, Denises presentation was about the negative aspects of meat consumption.  Many in the paleo world tend to assume we can eat as much meat as we want, but hopefully Denises presentation will bring us back to earth a bit.  She brought up a few ways meat can be harmful, including overcooking, but the most interesting part to me was on organ meats.  Ive been thinking about this a lot lately, so this presentation came at a perfect time.

If you really think about it, its just common sense that we should incorporate organ meats into our diet.  In hunter-gatherer times, we would have eaten plenty of organ meats, and in fact, traditional societies always place a high value on foods like liver.  We eat far too much muscle meat, and too little organ.  Denise explained that muscle meat is very high in the amino acid, methionine, which can be problematic.  Foods like liver, heart, and bone broths are higher in glycine, and apparently we should avoid an imbalanced intake of these amino acids.  This is something Ill be researching more in the near future, for sure.  And in the mean time, Ill be eating more organ meats!  Heres a little stew I made recently with beef heart and marrow bones:

Mmm, coronary arteries...

Terry Wahls and Multiple Sclerosis
Terry Wahls is just an inspiration.  Long story short, just a couple years ago she had debilitating MS, to the point where she could barely walk, and only with the assistance of two canes.  Since adopting a strict paleo diet, not just any paleo diet, but one with a very high intake of leafy greens and specific micronutrients, she has improved her symptoms so much that she recently biked 17 miles.  Absurd.  And whats more, she is currently conducting research on others with MS, putting them on the same diet she eats, and the preliminary results are astounding.  I was not able to get any pictures of the data, since she asked us not to, but when this information is published it will definitely be groundbreaking.  You can check out her TED talk here and learn all about her story.




Phew, thats it!  The end of my review of the 2012 Ancestral Health Symposium.  I may write another in the coming days talking about what it meant to me to be able to attend this amazing event.  And maybe Ill talk about the paleo movement as a whole and how excited I am for the future.  But until next time, ciao!