Health for life

Three new studies involving tree nuts (almonds, Brazil nuts, cashews, hazelnuts, macadamias, pecans, pine nuts, pistachios and walnuts) were presented this week at the Experimental Biology Meeting in Boston, MA. Tree nut consumption was associated with a better nutrient profile and diet quality; lower body weight and lower prevalence of metabolic syndrome; and a decrease in several cardiovascular risk factors compared to those seen among non-consumers.

First, the Adventist Health Study looked at the effect of nut intake on the risk of metabolic syndrome (MetS) in a population with a wide range of nut intake ranging from never to daily. Researchers at Loma Linda University studied 803 adults using a validated food frequency questionnaire and assessed both tree nut and peanut intake together and separately. "Our results showed that one serving (28g or 1 ounce) of tree nuts per week was significantly associated with 7% less MetS," stated lead researcher Karen Jaceldo-Siegl, DrPH. "Interestingly, while overall nut consumption was associated with lower prevalence of MetS, tree nuts specifically appear to provide beneficial effects on MetS, independent of demographic, lifestyle and other dietary factors."

The second study looked at 14,386 adults participating in the 2005-2010 National Health and Nutrition Examination Surveys (NHANES). Intake was from 24-hour recall data and tree nut consumers were defined as those who consumed more than ¼ ounce of tree nuts (average consumption was about an ounce/day). As seen in previous research, tree nut consumers had higher daily intakes of calories (2468 v 2127 calories) and nutrients of concern: fiber (21v 16 grams [g]); potassium (3028 v 2691 milligrams [mg]); magnesium (408 v 292 mg); monounsaturated fats (36 v 29 g), and polyunsaturated fatty acids (21 v 17 g), but lower intakes of added sugars (15 v 18 teaspoons), saturated fats (25 v 27g), and sodium (3197 v 3570 mg) than non-consumers. Tree nut consumers also had lower weight (80 v 82 kg; p=0.0049), BMI (28v 29; p<0.0001), and waist circumference (96 v 98 cm; p=0.0006) than non-consumers. In addition, those who consumed tree nuts had lower systolic blood pressure (120 v 122 mmHg; p=0.0120) and higher HDL-cholesterol (the good kind) (55 v 53 mg/dL; p=0.0020). On a population basis, these reduced risk factors could lead to better health. "Consumption of tree nuts should be encouraged to improve diet quality, nutrient intake, weight status, and some cardiovascular risk factors," according to Carol ONeil, PhD, MPH, RD, lead author on the paper and Professor at Louisiana State University Agricultural Center.

Finally, a third study looked at several markers for cardiovascular disease risk. In 2011, researchers from the University of Toronto and St. Michaels Hospital in Toronto, Canada, published the largest study to date on nuts and diabetes (Jenkins, D.J.A., et al., 2011. Nuts as a replacement for carbohydrates in the diabetic diet. Diabetes Care. 34(8):1706-11.), showing that approximately two ounces of nuts a day, as a replacement for carbohydrate foods, can improve glycemic control and blood lipids in those with type 2 diabetes. The researchers looked at the effects of nuts on various cardiovascular markers. "We found that nut consumption was associated with an increase in monounsaturated fatty acids (the good fats) in the blood, which was correlated with a decrease in total cholesterol, LDL cholesterol (the bad kind), blood pressure, 10-year coronary heart disease risk, HbA1c (a marker of blood sugar control over the previous three months) and fasting blood glucose," explained Cyril Kendall, Ph.D., of the University of Toronto. "Nut consumption was also found to increase LDL particle size, which is less damaging when it comes to heart disease risk." According to Dr. Kendall, this study found additional ways in which nut consumption may improve overall cardiovascular health.

"These three new studies, independent of one another, support the growing body of evidence showing that consuming nuts can improve your health," states Maureen Ternus, M.S., R.D., Executive Director of the International Tree Nut Council Nutrition Research & Education Foundation (INC NREF). "In 2003, FDA (in its qualified health claim for nuts and heart disease) recommended that people eat 1.5 ounces of nuts per day—well above current consumption levels—so we need to encourage people to grab a handful of nuts every day."

Dr. Smith* was well known among the hospitals medical directors. Thanks to his superb training and busy clinical practice, this busy physician was convinced, thank you very much, that he had all the knowledge necessary to manage his patient population.

Summary quality reports, feedback and best practice advice he did not need.  He also loved pointing out that he wasnt being adequately reimbursed to deal with administrative hassles, many national Clinical Guidelines were based on faulty research, his patients were not "average," and his duty to his patients was to "first do no harm."  He believed in patient education but resented administrators meddling.

The medical directors werent about to use a "stick" and "de"credential Dr. Smith and kick him out of the network. The "carrot" financial P4P incentives they offered for quality measures were modest and comprised a only a small percentage of the physicians income.  They. Were. Stuck.

Enter the Affordable Care Acts Patient Centered Outcomes Research Institute (PCORI). Writing in the latest issue of Health Affairs, RAND researchers Justin Timble, Eric Schneider, Kristin Van Busum and Steven Fox reassure frustrated medical directors everywhere that PCORI will come to their rescue by ushering in a new dawn of clinical trial research.  The studies will be so good that Dr. Smith will change his passive-aggressive ways.

Dr. Timble et al point out that the reluctance of physicians like Dr. Smith to change their clinical practice is not surprising.  Payment mechanisms incent questionable treatments, much of the published medical science is riddled with ambiguities, even expert scientists succumb to a host of biases when they interpret study results and doctors are more interested in avoiding the risky downsides versus the upside benefit of new medical advances.  Last but not least, clinic-based electronic record decision support never fails to disappoint.

Fortunately, says these RAND authors, the PCORI is on it. Its sponsored research will transparently solicit stakeholder input and investigate all meaningful outcomes, including side effects.  When this high octane knowledge is combined with a dollop of rigorous guideline development, more gigabytes of information tech decision support and the luster of Obamacares payment reforms, uncooperative Dr. Smith will be transformed into compliant Dr. Smith.

Sounds good, but the DMCB doubts that sprinkling PCORI pixie dust on docs is the cure to what ails the health care system. In its estimation, the RAND authors and the editors of Health Affairs are only telling half the story.

The DMCB to the rescue.

Despite the authors enthusiasm, PCORIs well-meaning stakeholders will have to make real-world compromises on study scope, data collection and completeness. Their research methods and findings will never be completely immunized against healthy skepticism.  And while RAND scientists and the readers of Health Affairs are professionally invested in PCORI, how well it competes for the attention of practicing docs like Dr. Smith remains to be seen.

Financial carrots and sticks can be used to change physician behavior, but Dr. Smith will ultimately stay in the drivers seat thanks to a) a looming physician shortage and b) the prospect that total physician reimbursement will go down, leaving no room for incentives. While integrated delivery systems, accountable care organizations and physician-hospital alliances may (or maybe not) wring some dollars out of PCORI-based efficiency and quality studies, it remains to be seen how these big capital-intense organizations will share any precious leftover dollars with their docs.

The population health management (PHM) service community has a better answer.

While high quality research conducted under the supervision of an expert professional class has its place, they know its ultimately up to the informed patient to make decision.  A considerable body of research, much of which would pass PCORI muster, has shown that shared decision making using a personal physicians advice is remarkably adept at reconciling imperfect research with patient values and preferences.  This, in turn, increases quality and reduces unnecessary costs.

The DMCB has seen countless physicians like Dr. Smith welcome the help of team-based nurses who can help his patients. He may call it "education," but theyre engaging patients in science based decision-making and taking a lot of work off of Dr. Smiths hands.