Health for life

Change in Weight More Important Than Where You Start

Some overweight older adults don’t need to lose weight to extend their lives, but they could risk an earlier death if they pack on more pounds.

In fact, the nationwide study found that people who were slightly overweight in their 50s but kept their weight relatively stable were the most likely to survive over the next 16 years.

They had better survival rates than even normal-weight individuals whose weight increased slightly, but stayed within the normal range.

On the other hand, those who started out as very obese in their 50s and whose weight continued to increase were the most likely to die during that period.

Overall, the results suggest that about 7.2 percent of deaths after the age of 51 are due to weight gain among obese people, at least among the generation in this study, said Hui Zheng, lead author of the study and assistant professor of sociology at The Ohio State University.

“You can learn more about older people’s mortality risk by looking at how their weight is changing than you can by just looking at how much they weigh at any one time,” Zheng said.

While some extra weight seemed protective in this study, Zheng cautioned that these results applied only to people over 50. His previous research, published in Social Science & Medicine, suggests that being overweight may not be helpful for younger people.

“Our other research suggests that the negative effect of obesity on health is greater for young people than it is for older people, so young people especially shouldn’t think that being overweight is harmless,” he said.

This new study was published online this month in the American Journal of Epidemiology. Co-authors are Dmitry Tumin, doctoral student, and Zhenchao Qian, professor, both in sociology at Ohio State.

The researchers used data from the Health and Retirement Study, a nationally representative survey of Americans born between 1931 and 1941. This study analyzed 9,538 respondents who were aged 51 to 61 when the survey began in 1992. They were re-interviewed every two years until 2008, and the researchers had information on how their body mass index (BMI) changed at each interview and whether they died at any point before December 2009.

Body mass index measures weight relative to height and is often used to evaluate obesity.

Zheng and his colleagues classified respondents into six groups, depending on their BMI at the beginning of the study and how it changed over the 16-year period they were surveyed.

While slightly overweight people (BMI of 25 to 29.9) whose weight was steady had the highest survival rate, those who moved from overweight to obese (BMI 30 to 34.9) were close behind.

“This suggests that among overweight people at age 51, small weight gains do not significantly lower the probability of survival,” Zheng said.

The third highest survival rate among the six groups was normal weight individuals (BMI of 18.5 to 24.9) whose weight increased slightly, but stayed within normal range.

Next came the Class I obese (BMI of 30 to 34.9) whose weight was moving upward.

“You can learn more about older people’s mortality risk by looking at how their weight is changing than you can by just looking at how much they weigh at any one time.”

Next to last were normal weight individuals who lost weight. Although the study attempted to control for illnesses among those studied, it may be that many of these individuals dropped weight because of illness.

The most obese individuals (BMI of 35 and over) who continued to add weight had the lowest survival rate of the six groups.

There weren’t enough people who started out as overweight and obese and lost weight to include in this analysis, Zheng said.

“We can’t really evaluate the effectiveness of planned weight loss on mortality. Even in the normal-weight people in this study, there was no way to tell whether weight loss was planned,” he said.

Zheng noted that the study took into account a wide variety of demographic and socioeconomic factors that may play a role in both weight and mortality among Americans. The researchers also controlled for whether the respondents smoked, whether they had a variety of chronic illnesses and even how they rated their own health. The results stood even after all of these factors were taken into account.

Why is being slightly overweight protective for older people?

“It is probably because the older population is more likely to get illnesses and disease, especially cancer, that cause dangerous weight loss,” he said. “In that case, a small amount of extra weight may provide protection against nutritional and energy deficiencies, metabolic stresses, the development of wasting and frailty, and loss of muscle and bone density caused by chronic diseases.”

Younger people are less likely to get many of the diseases that afflict older adults, which is one reason extra weight is not good for them, he said.

But Zheng said the main message for everyone, including older adults, is that packing on the pounds, especially if you’re obese, can be hazardous to your health.

“Continuing to put on weight can lower your life expectancy,” he said.

Every Saturday, we post a piece from the CHG archives. This one comes from June 2009.

Though it might seem intuitive, determining a recipe’s cost and nutritional value can get pretty complicated, pretty quickly. Ingredient prices can add up before you know it, and a combination of fats, meats, and cheeses will take a toll on your calorie count without even registering on your radar. And sometimes, even the most harmless-looking dishes, like All Recipes’ Greek Pasta Salad with Shrimp, Tomatoes, Zucchini, Peppers, and Feta, can run you $2 and 42 grams of fat per serving.

So, how can you tell if a dish is good for you, just by looking at it? How can you avoid the pitfalls of secretly fatty and financially unsound food? How can you err on the side of caution when it comes to cooking?

Look no further, sweet readers. We’ve got you covered. If your recipe source doesn’t give a nutritional breakdown and you’re unsure of the potential cost, these tips will help you decide whether the money/waistline expenditures are worth the trouble. If you have any suggestions, be sure to include them in the comment section.

DO choose your source wisely. Man, I love Paula Deen. Her food looks stupendous and she’s endlessly entertaining – like Yo Gabba Gabba if it was a charmingly cackley southern woman. That said, her concoctions might not be the best choice for those concerned about weight. If you know you’re looking for healthier recipes, sources like Everyday Food, Cooking Light, and Eating Well will generally be more helpful than the Neelys or the Two Fat Ladies. Likewise, reproducing a dish from Grant Achatz’s Alinea cookbook will probably run you a pretty penny compared to the average Cook’s Illustrated meal. Starting your search with a website, cookbook, or blog aimed at your requirements is half the battle.

DO check the number of servings. Once you have a recipe in mind, before you do anything else, check how many people it’s supposed to sate. Fourteen ounces of flank steak does little damage split among eight eaters, but can destroy diets if it’s meant only for two.

DO read the ingredient list caully. After the serving size, the ingredients are the most important determinant of the cost and nutritional value of a recipe. Scan the rundown, look for a few keywords (many of which are listed below), and be extra aware of extravagant or difficult-to-find foods for your area, which will drive up the price.

DO consider recipes with one or two out-of-the-box ingredients. In small doses, odds are it/they won’t break the bank, and you can incorporate new flavors into your repertoire. Lemongrass? Meyer lemons? Lemon basil? Sure, why not?

DON’T dismiss a long list of ingredients outright. Lighter foods like Bon Appetit’s Turkey Chili with Beans frequently require multiple, inexpensive spices and flavorings to make up for the absence of fat. While their sheer number can seem pretty intimidating, don’t fret. Oftentimes, these foods can be found right in your pantry for minimal cost.

DO count the number of ingredients already in-house. Speaking about that pantry, recipes based on dry goods will usually be cheaper than ones requiring a trip to the supermarket. Look for meals that use rice, beans, pasta, and other staples as jump off points, and go from there.

DO opt for whole food ingredients. If it can be found in the outer aisles of your supermarket, it’s probably a good start to a meal. Fresh fruits, veggies, and lean meats give recipes more bang for the buck, and almost guarantee a healthier overall experience. Fewer preservatives and extra-excellent flavor are just bonuses.

DON’T choose recipes made from processed food. The less ingredients are handled by humans, the better. Why? Well, in general, heavily processed and pre-cut edibles are more expensive and worse for you than the aforementioned whole foods. Semi Homemade-style meals may be convenient, but when you’re sacrificing money, nutrition, and taste, is it worth it?

DO watch out for lots of meat and cheese. In moderation, neither of these is anything to fear. But prices and calories rise when a meal centers on multiple cups of frommage or large cuts of beef or pork. Instead, search for recipes where meat and cheese are add-ons instead of the main event. You’ll save all around.

DO calculate about 12 or 13 grams of fat per tablespoon of butter or oil. When doing a cursory scan of any recipe, I take extra care to check the total cooking fat. If there’s a lot, but it can be easily reduced (like in sautés), I keep going. If there’s a lot, but the amount is set in stone (as in some baking), I move along to the next dish.

DON’T rule out all fatty ingredients. Nuts, olives, avocados and certain oils aren’t low-fat foods, but they’re healthy ones because of the vitamins and minerals they offer. Relatively inexpensive and often pivotal to a dish’s overall flavor, they should be incorporated into any diet in moderation.

DO look for words like: baked, roasted, steamed, grilled, or sautéed. These cooking techniques tend to use less fat than others while still producing flavorful foods. Steaming and boiling are good keywords as well.

DON’T choose recipes with the words: fried, au gratin, cream sauce, bisque, bacon-wrapped, or lard. Each of these terms implies one thing: fat. If you’re serious about watching your weight, there are lighter recipes for certain dishes (Spaghetti Carbonara, etc.), but straight-up lobster bisque will do a number on your numbers.

Confusing? Maybe. Do-able? Definitely. With some practice, these rules will get easier to use. And in the end, you’ll have no problem telling the difference between the recipe you really want and the recipe you thought you wanted.

Readers, fire away in the comment section.

~~~

If you liked this article, you might also dig:

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• Frugal Food Hacks: 10 Tricks to Simplifying Online Recipe Searches
• The Dos and Don’ts of Buying a Cookbook

While the national mainstream media focuses on Obamacares dimming prospects, internecine Republican conflicts over the merits of a government shutdown, pugnacious Democratic debates over government price controls and who should take credit for the drop in health care cost inflation, check out this local city paper article on the One Simple Idea (that) Could Revolutionize Health Care. As the reporter pointed out, there was no press release, no touting and no awards.  Simply results.

The DMCB agrees.

Barbara Schneider and her team work with Philadelphia health insurer Keystone Firsts community outreach and care coordination programs to intervene on the "sickest of the sickest" diabetics.  These are 35 patients who are admitted on average more than twice a month.  Patients who are on a first-name basis with all the local emergency rooms nurses on all the shifts. Patients who live in run-down boarding houses on a good day.  Patients who are lucky if their blood sugar is only 600 mg%.  Were talking hundreds of thousands of dollars in health care costs.

Dr. Schneiders lay community health workers (more info on the science here) are seeing these individuals in parking lots, McDonalds, row homes and halfway houses  to cajole, coach, text, call, shuttle and haggle with patients, families, social workers, pharmacists and insurers to dismantle barriers one patient at a time.  If a patient isnt ready to stop abusing drugs, that doesnt mean he cant be taught to use a glucose meter.  While living circumstances may be chaotic, that doesnt mean she cant use a cell phone instead of just going to the emergency room.

As Dr. Gawande noted in his The New Yorker article about the super-utilizers, those kinds of interventions can add-up significant savings.

While Keystone has yet to release an analysis on the impact on claims expense for these patients, a cursory review of the data shows emergency room visits have been cut by a third, while inpatient stays declined by more than half.  Even with the DMCBs limited background in analytics, it suspects that when the return on investment is finalized, Keystone will conclude that the program was an unqualified success.

To the DMCB, this is what its all about.  Washington DC can continue its partisan scorched earth battles while, in the meantime, small regional community minded health insurers like Keystone First are figuring out how to do right by patients using novel programs like this. 

Image from Wikipedia

The right definition was there all along!

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over "population health."

The Disease Management Care Blog says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing "population health" for an entire geography. 

Between the here of "improving chronic care" and the there of "population health," Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term "population health" in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

In short, they dont believe ACOs, as currently configured, are up to the new task.  Thats because ACOs would need to collaborate with social service organizations, be responsible for a geographically defined service area and improve long term public health outcomes.  According to the authors subtitle, the answer to the question "should they try" is "no."

The Disease Management humbly disagrees.  Thats because Drs Noble and Casalino, the editors of JAMA and the manuscripts peer reviewers seem to be ignorant of the the correct definition of population health. Its right there on the Care Continuum Alliances web site, in this longstanding page that describes the "population health model of care."  When the DMCB did a simple Google search on "population health definition," it had little difficulty finding the link.

The CCA helpfully describes population health as:

a delivery model characterized as a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.

Was that so hard?

And how is that accomplished?  According to the CCA, the ingredients to that make for population health include:

• Population identification strategies and processes;

• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;

• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;

• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;

• Self-management interventions aimed at influencing the targeted population to make behavioral changes;

• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;

• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health

Accordingly, if an CMS-contracted ACO can identify its assigned Medicare population, perform needs assessments, promote awareness of health risks, offer education as well as support, increase self management, use data feedback and evaluate outcomes, its offering "population health."  By using that playbook, an ACO will capitalizing on the experience of a community of population health service providers that have been doing precisely this for over a decade.

This vision is far more compact than the overreaching, misinformed and muddled definition of "population health" offered in JAMA.  It is also, if ACOs invest in the right resources and partnerships, well within reach.

The DMCBs answer to the question "Should they try?" is "yes."

The Disease Management Care Blog has really been trying to not pay attention to the trial of Conrad Murray MD, the infamous propofol-wielding personal physician for pop legend Michael Jackson.  Unfortunately, the whole thing is so lurid, its difficult to not gawk.

While no one should come to any conclusions about any allegations until all the facts are known, one thing is certain: Mr. Jackson is a poster child for the downsides of having unfettered access to all the health care anyone could ever want.  Dissatisfaction with a first round of plastic surgery and insomnia are common place, but few patients have the resources to go on to decimate their nose and turn their bedroom into an anesthesia suite.

Which brings up a good point.  Regular DMCB readers are well aware of this graph from the Kaiser Family Foundation report on Trends in Health Care Costs and Spending:

Michael Baum, Professor emeritus of surgery at University College London says that, while deaths from breast cancer may be avoided, any benefit will be more than outweighed by deaths due to the long term adverse effects of treatment.

He estimates that, for every 10, 000 women invited for screening, three to four breast cancer deaths are avoided at the cost of 2.72 to 9.25 deaths from the long term toxicity of radiotherapy.

These figures contrast with an independent report on breast cancer screening, led by Sir Michael Marmot and published in November last year. Marmot and his committee were charged with asking whether the screening programme should continue, and if so, what women should be told about the risks of overdiagnosis.

They concluded that screening should continue because it prevented 43 deaths from breast cancer for every 10,000 women invited for screening.

The downside was an estimated 19% rate of overdiagnosis: 129 of the 681 cancers detected in those 10,000 women would have done them no harm during their lifetime. However, those women would have undergone unnecessary treatment, including surgery, radiotherapy and chemotherapy.

But despite this higher than previous estimate of overdiagnosis, they concluded that the breast screening programme should continue.

The report also judged that screening reduces the risk of dying from breast cancer by 20%. But Professor Baum disputes these figures, saying the analysis takes no account of improvements in treatment since these trials were done, which will reduce the benefits of screening. Nor does it make use of more recent observational data.

With these data included, estimated rates of overdiagnosis as a result of screening increase to up to 50%, he argues.

This is important because it can change the decisions women make when invited for screening. In a study also published today, researchers at the University of Sydney explored attitudes to screening in a sample of 50 women. Many of the women were surprised when they were told about overdiagnosis and most said they would attend screening if overdiagnosis rates were 30% or lower, but a rate of 50% made most of them reconsider.

An accompanying editorial points out that the harms of screening will reduce as more effective diagnostic processes develop to inform less harmful and more personalised treatments. In the meantime, it says women need up to date and transparent information about the benefits and harms of screening to help them make informed choices.

In the modern diet world, there are so many different theories and ideas on nutrition that it can sometimes be overwhelming. We have diets that dont allow carbs, diets that restrict fat, diets in which you eat exclusively fruit, diets in which you cant eat animal products, diets based on "superfoods"... whatever that means. Whichever food or food group is targeted, most of these diets fall victim to the same fallacy: if a little is good, more is better. Or, in many cases, if too much is bad, then none at all must be best.

Allow me to elaborate. Eating too many carbs can be detrimental, so restrict them all... too much dietary fat can be bad, so get it as low as possible... eating fruit is healthy, so lets eat nothing but fruit. You see the pattern? I dont think I need to go on. None of these diets get at the foundation of a healthy eating plan, and none come close to establishing a healthy relationship with food. What they lack is a sense of balance. Along with a misunderstanding of how biology works.

The U-Shaped Curve
Too much isnt good, but neither is too little. That is the idea of the U-shaped curve. Take, for example, this graph that I just found in a quick Google search...


See the U shape? This graph is a simple depiction of the relationship between sleep duration and risk of mortality. Those who get too little sleep have a higher risk of death; this is common sense. But does that mean we should get as much sleep as possible? Not exactly. People who get too much sleep also have a higher risk of death. The lowest risk lies at the bottom of the U; according to this graph, seven hours of sleep per night is associated with the lowest rate of mortality.

We see this type of U-shaped relationship in nearly every aspect of nutrition and biology. Too little water and well die of dehydration, but too much and well die of overhydration. Too little exercise isnt good, but working out for 8 hours a day isnt so great either. A little Snookie in our lives is good to instill confidence in ourselves and remind us that hey, at least were not Snookie... but too much Snookie can lead to a hostile attitude towards others and a tendency to speak like a faux-Italian Jersey girl. See? The U-shaped curve applies to more than you realize.

Moderation and Balance
Theres a time and place for total restriction of food groups, and I see that being most useful for people with serious medical conditions like food allergies. It can also be beneficial as a short-term cleanse type of diet for those who need a kick start to their healthy lifestyle. But that does not mean that any of these things should be taken to the extreme, nor do they need to be permanent or long-term. Just because reducing your carbohydrate intake may be beneficial for you, that does NOT mean that eliminating them entirely is even better. The same goes for grains, fat, sodium, sugar, gluten, meat, fruit, dairy, vegetable oils, etc. Balance is key.

When youre walking through Barnes and Noble and you take a glance at the diet section, just remember the U-shaped curve. There are very few cases in which this U-shaped relationship is not true, unless were talking about straight up toxins like lead or mercury. Dont be gullible. Achieving health is never as easy as eliminating one food.

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.