Health for life

Researchers from New England found that men who slept either less than 6 hours, or greater than 8 hours, increased their risk for type 2 diabetes. That risk remained after adjustments were made for age, hypertension, smoking status, self-rated health status, education, and waist circumference.

These results suggest that even though you have a handle on your weight, blood pressure and smoking, you may still court a diagnosis of diabetes if your sleep is consistently short-changed, or over-indulged.

The study included 1564, primarily white men, aged 40 to 70, who were enrolled in the Massachusetts Male Aging Study (MMAS), and who did not have diabetes at baseline. The men were followed for up to 15 years. Similar, although less marked results were found in women who partook in the Nurses Health Study.

The study appears in the March 2006 issue of Diabetes Care.

________
For the MMAS study:
Sleep Duration as a Risk Factor for the Development of Type 2 Diabetes

For a summary of the MMAS study:
Diabetes Risk Raised By Too Much Or Too Little Sleep

For the Nurses Health Study:
A Prospective Study of Self-Reported Sleep Duration and Incident Diabetes in Women

"I  think I need to go back to the hospital....."

The Disease Management Care Blog remembers her very well. She had come to the United States after escaping on foot from post-war Hungary.  She liked to have sliced pears and cognac for lunch. As her health began to fail, her stubbornness began to exceed her self-sufficiency, leading to multiple hospitalizations. One time, despite making sure she had a post-discharge outpatient appointment, a fresh pile of prescriptions and home visiting nurse services, her illness flared and she had to come back to hospital.

She was not only my patient, but she represented one of Medicares dreaded readmission statistics.

By now, DMCB readers know that CMS, buoyed by its value-based purchasing program, has targeted readmissions by reducing payment levels to hospitals that fall outside the expected norm. Threatened by the loss of income, it’s assumed that hospitals will respond by developing higher quality discharge planning and care programs that keep patients from having to come back.

An important part of reducing readmissions is to identify those patients that are at greatest risk. That would help on two levels:

1) if a hospital had more than its fair share of patients at risk, it could argue that an increased number of readmissions is the result of a sicker patient population and not quality of care. As a result, the hospital could be held "harmless;

2) hospitals would be able to focus extra care resources on those patients who are spotted early as likely to come back, thereby reducing the readmission rate.

In other words, patients like the lady from Hungary would not necessarily lead to a cut in hospital payment rates and, for example, she could be proactively given extra care, such as a doctor appointment within 48 hours, a week’s supply of free medications and twice a day home nurse visits.

Which is why this just published JAMA article "Risk Prediction Models for Hospital Readmission" by Devan Kansagara, Honora Englander, Amanda Salanitro David Kagen, Cecelia Theobald, Michele Freeman and Sunil Kripalani is important.  The authors set out to see what the evidence-based published scientific literature had to say about predicting readmissions.   They filtered thousands of erences, reviewed 286 publications found 30 rigorous studies that described 26 models. 

To the DMCBs delight, the authors applied a “c statistic” to the 30 publications to assess a wide variety of retrospective and concurrent prediction methodologies using a host of data inputs such as age, gender and past diagnoses. According to this article, the c (or "concordance") statistic measures how well a test can predict the presence or absence of a "condition" which, in this case, was being readmitted to the hospital.  One way to think of this is the likelihood of correctly identifying a condition when there are two people, one with it and one without it.  If the likelihood is 50%, thats no better than random guessing.  If its 100%, thats perfect.  By the way,if this sounds a lot like the area under the receiver operator curve, youre right.

And what did the all-seeing "c statistic" say?  All of the published models had disappointingly similar levels of performance that ranged between the extremes of .52 to .83 with most in the .50 to .7 range. Whats more, only one study examined the most important question of all: is it possible to find patients with preventable readmissions?

What does the DMCB think?

1) This may be another area where national health policy has gotten out in front of the scientific evidence.  If we cant reliably assess or predict readmissions with sufficient accuracy, there is a distinct likelihood that statistical variation, not quality of care, will lead to some hospitals being victimized by CMS with lower payment rates. Whats more, if hospitals cant tell which patients are likely to come back, how are they supposed to target their expensive care management programs at those who are most likely to benefit?

2) There are undoubtedly some proprietary predictive models that havent been reported in the literature that claim to have higher levels of accuracy.  Yet, without the scrutiny of successful peer-reviewed publication, itd be difficult to believe that theyre really any better than the mainstream published range of .5 to .7.  The next time the DMCB runs into one of these outfits, its going to ask about the "c statistic" and if they havent published their results, why not.

3) Last but not least, while the hospital payment rates are being held hostage by CMS, its the doctors that are making the call on readmissions based on the best interest of their patient.  The c statistic suggests that that will be the most important determinant in the readmission rate.

Women who exercise regularly spend as much time sitting as women who don’t, according to a new Northwestern Medicine study.

Emerging research shows that prolonged sitting has significant health consequences---and the new Northwestern study suggests that being a dedicated exerciser doesnt prevent women from spending too much of their day sitting.

This research is the latest indication that public health recommendations should be established to encourage Americans to limit the amount of time they spend sitting every day, said Lynette L. Craft, first author of the study and an adjunct assistant professor in preventive medicine at Northwestern University Feinberg School of Medicine.

“We all know someone who gets a good workout in every day, but then spends a large portion of their day sitting in front of a computer with few breaks,” Craft said. “If these people could replace some of the sitting with light activity---just getting up, moving around, maybe standing up when talking on the phone, walking down the hall instead of sending an email---we do think they could gain health benefits.”

The Northwestern research was done in collaboration with Ted Zderic, of the Pennington Biomedical Research Center and was published in the International Journal of Behavioral Nutrition and Physical Activity.

Past studies have shown that people who sit for extended periods of time---even those meeting exercise recommendations---are more likely to develop chronic conditions such as diabetes, obesity, cardiovascular disease and some cancers.

This was the first study to use an objective measuring device to examine the relationship between the type of exercise recommended in the government’s Physical Activity Guidelines for Americans and sitting. The guidelines recommend adults engage in a minimum of 150 minutes of moderate intensity aerobic activity every week. Previous studies on physical activity and sitting have primarily relied on self-reported data.

While many of the women in the study met or exceeded 150 minutes of physical activity per week, in reality only a fraction of the women’s days were spent being physically active. The women in the study spent an average of nine hours a day sitting. That number is consistent with previous results from much larger studies that examined the number of hours Americans spend sitting every day.

“I think some people assume, ‘If I’m getting my 30 to 40 minutes of physical activity a day, I’m doing what I need to do for my health,’” Craft said. “Of course, exercise is very important and is associated with many positive health benefits, but negative health consequences are associated with prolonged sitting, and this study shows that just because you’re physically active doesn’t mean you’re sitting less.”

For the study, 91 healthy women ranging in age from age 40 to 75 wore an activPAL activity monitor device during waking hours for one week. The device, which was worn on the thigh, recorded time spent sitting, standing and stepping, and engaging in sustained 10-minute bouts of moderate-to-vigorous physical activity.

Trying to replace some sitting time with more light activity throughout the day---along with the recommended bouts of moderate and vigorous exercise---is an approach more Americans should try to take, Craft said.

Future studies are needed to further examine the relationship between the type of exercise recommended in the Physical Activity Guidelines for Americans and sitting. For example, various subgroups such as men, children and the elderly should also be studied, Craft said.

The Lynn Sage Breast Cancer Foundation, the Avon Foundation and the Edward G. Schlieder Educational Foundation supported the study.

Olive oil

Fearing that it would have to write about the Oscar award shows vulgar Hollywood humor or Washingtons budgetary caterwauling, the Disease Management Care Blog was happily distracted by a flurry of splashy news reports on a just-published primary prevention trial:

"Mediterranean diet....showed 30% lower risk of having a heart attack, stroke or dying of heart disease....."

"Tasty diet cuts heart disease, study finds."

" ....diet rich in olive oil, nuts, beans, fish, fruits and vegetables prevents about 30% of heart attacks, strokes and deaths from heart disease..."

Fighting the urge to run to the pantry and add years to its life by ingesting some olive oil-drizzled walnuts, the DMCB did something that mainstream news reporters seem incapable of doing: it asked what the diet actually entails and whether the impact was really all that.

Heres the original New England Journal of Medicine study. Disappointingly, the absolute risk reduction was quite small and, for the typical DMCB primary care patient, would involve a major lifestyle change.

The DMCB explains.

The PREDIMED trial ("Prevención con Dieta Mediterránea") was a prospective and randomized clinical trial in which male (age 55 to 80 years) and female (age 60 to 80 years) volunteers with either:

1) diabetes or

2) three other risk factors, such as tobacco use, high blood pressure, abnormal cholesterol levels, obesity and a worrisome family history of premature heart disease,

were randomly assigned to one of three treatment arms:

1) A "Mediterranean diet" supplemented with extra-virgin olive oil (a liter was delivered to the home each week), or

2) A "Mediterranean diet" supplemented with nuts (30 grams of almonds, walnuts and hazelnuts per day) or

3) A control diet.

Whats just what is a Mediterranean diet?  According to the authors:

A) lots of olive oil for cooking and dressing dishes;

B) consumption of ≥ 2 daily servings of vegetables (at least one of them as fresh vegetables in a salad), discounting side dishes;

C) ≥ 2-3 daily servings of fresh fruits (including natural juices);

D) ≥ 3 weekly servings of "legumes" (kidney beans, pinto beans, black beans, chickpeas, lima beans, black-eyed peas, split peas, and lentils);

E) ≥ 3 weekly servings of fish or seafood (at least one serving of fatty fish);

F) ≥ 1 weekly serving of nuts or seeds;

G) selecting white meats (poultry without skin or rabbit) instead of red meats or processed meats such as burgers and sausages;

H) cooking regularly (at least twice a week) with tomato, garlic and onion adding or not other aromatic herbs, and dress vegetables, pasta, rice and other dishes with tomato, garlic and onion adding or not aromatic herbs. This sauce is made by slowly simmering the minced ingredients with abundant olive oil.

I) the limitation of cream, butter,margarine, cold meat, pate, duck, carbonated and/or sugared beverages, pastries, industrial bakery products (such as cakes, donuts, or cookies), industrial desserts (puddings, custard), French fries or potato chips, and out-of-home pre-cooked cakes and sweets.

By the way, the study organizers used genuine olive oil, not this fake stuff.

Patients assigned to the diet had to see a dietitian at the outset of the study and participate in every 3 month group education sessions.  There were no recommendations to lose weight or participate in exercise.

The results?

8713 persons were screened and 7447 were assigned to one of the study arms.  After a median of 4.8 years, 523 persons were lost to follow-up. 288 persons had either a heart attack, stroke or
cardiovascular death.  There were 96 deaths in the extra virgin olive oil group, 83 in the nut group and 109 in the control group. The calculated percents were 3.8%, 3.4% and 4.4%, respectively.  Versus the control group thats an absolute difference of 0.6% and 1.0%. There didnt appear to be any surprises in the subgroups outcomes.

Using a number needed to treat analysis, these data basically mean 100 to 166 persons would need to live on fish, nuts, lima beans, and olive oil without burgers, starches or soda for 5 years to prevent a single heart attack, stroke or death.

The DMCBs take:

1. The small amount of benefit is not enough, in the DMCBs estimation, to warrant routine inclusion of a "Mediterranean diet" in disease management care planning for persons with diabetes or multiple cardiac risk factors.

2. The diet was "all or none."  There is no evidence, based on this trial, that substituting crab cakes for that steak once a week and using olive oil on your iceberg lettuce tonight will help you live longer.

3. The "number needed to treat" of 100-166 over 5 years is in the same performance range as statin drugs with a NNT that, according to this study, ranges from 77 to 150 over four years.  No wonder many persons choose to continue with their more tasty burgers and fries along with a daily pill.

4. Its unlikely that persons who are not already on a Mediterranean diet will chose to switch, and given the amount of sacrifice involved and the small reduction in risk, the DMCB cant blame them.

Image from Wikipedia

Today, a CHG-related question I can’t believe we’ve never asked before.

Q: How much do you spend on food?

A: Husband-Elect and I live in a not-upscale hood in Brooklyn, New York. For groceries, we usually blow somewhere between $50 and $60 per week, all meals included, except for maybe one office lunch and one night of takeout/restaurant dinner.

Sweet readers, how about you? If you could include your general location, the number of people you feed, and your average weekly/monthly food bill, it would be fab. I’d love to get a general idea of what kind of expenditures others are looking at. Thank you!

Want to ask the interweb a question? Post one in the comment section, or write to Cheaphealthygood@gmail.com. Then, tune in next Tuesday for an answer/several answers from the good people of the World Wide Net.

When it comes to cooking, theres no doubt about it: time is the chief obstacle to getting started. If you’re pressed for it, whipping up a three-course meal can seem as overwhelming as running a marathon in a bunny suit.

That’s why it pays to know some tricks. Some cheap tricks. Specifically, ten cheap tricks. (Note: not including this Cheap Trick, though they are also quite enjoyable.)

Some might find the following time-savers, like, “Oh, duh. I was born knowing this information. Get a job!” Others may be all like, “Oh, duh. I never thought of this. This is the most informative literature I’ve ever read, and that includes the ‘You’re a Woman Now’ pamphlet I got from my gym teachers in sixth grade.” Either way, they’re my story, and I’m sticking to em.

Readers, what did I miss? What are your easy shortcuts? Add ‘em in the comment section.

1) Wash fruit and veggies as soon as you get home from the supermarket.
It takes ten minutes and you can pick freely from your stash for the rest of the week. Don’t forget to dry the food completely, and include a paper towel in your storage vessel, perably lining the insides. This should extend the life of your produce by a few days, at least. And hey - if you want to chop, slice, or dice to prep for future dinners at the same time, more power to you.

2) Read the recipe (at least twice) beforehand.
Who here has been gotten all psyched up to make a delicious dinner at 6pm, only to find Step #4 takes two hours? (*raises hand*) Or that you’ve forgotten the tomatoes? (*raises both hands*) Or that you have no idea how to braise? (*raises both hands and foot*) Scanning the instructions can save you infinite failed meals, plus a few bucks on last-minute emergency purchases.

3) Set out all your ingredients before you begin to cook.
Not only does it make reaching for stuff much simpler, but it ensures you have all the ingredients on hand. If you want to measure and chop as well, go crazy. Chefs and Frenchy types call this “mise en place,” and it streamlines the whole cooking process. Pretty prep bowls (a la Alton Brown) can make it look professional, too.

4) Take care of long-cooking items (rice, roasted veggies) first.
When I first began cooking, one of my biggest problems was timing every dish so they finished together. The chicken was ready 15 minutes before the broccoli, and the rice wouldn’t be good to go for another half-hour. Nowadays, I take a minute or two to think of cooking intervals: What will take the longest? What can be prepared relatively quickly? Then, I get going on the food that requires the many-est roasting/braising/steaming minutes. Dinner doesn’t always time out perfectly, but at least we’re not eating in installments anymore.

5) Learn how to chop an onion.
Onions are the basis for … every dish, ever. In history. Seriously. I can’t think of an ingredient I use more frequently. And in the olden days, dicing one would cost me ten minutes and two Kleenex. Mincing one? Fuggedaboudit. Now that I know the correct technique, it takes less than 60 seconds. I’m much happier. So are my sinuses.

6) Do dishes as you go along.
Let’s face it: if recipes listed “Dish Washing Time” along with “Cooking Time” and “Prep Time,” they would practically double in duration. (30-Minute Meals – ha!) And for those of us without dishwashers, scrubbing plates, pots, and forks can take all the fun out of cooking. However: if you clean as you go along, you’ll reduce back-end soaping tremendously. (Maybe entirely, even.) And then your night can be your own again. (For Lost, presumably. Did you SEE last night? Husband-Elect has been in the fetal position ever since.)

7) Fear not the eyeball.
We’re using the Rachael Ray-approved definition of “eyeball” here, meaning: approximating ingredient measurements based on what they look like in your hand, rather than precise recipe quantities. As you cook more frequently, you’ll get a feeling for how much chili powder or olive you need. Even better, you’ll be better able to customize to your tastes. Of course, if you’d rather go by specifics…

8) Memorize measurements.
How many teaspoons are in a 1/4 cup? (Twelve.) How many cups are in a quart? (Four.) When a recipe calls for 2/3rd cup of flour, but you’re only making half a batch, how many tablespoons do you need? (A little less than six.) Knowing simple measurements by heart will make the scaling process go much faster. If this seems like too much to commit to memory…

9) Keep a calculator in the kitchen.
It could come in useful for a bunch o’ other things, anyway: estimating grocery bills, projecting portions, showing your roommates how much they owe you in back rent, etc.

10) Have a super-basic erence cookbook at the ready.
Whether it’s Betty Crocker or Better Homes and Gardens, owning a How To tome is invaluable. A good one will give you technique tutorials, cooking times and temperatures, measurements, substitutes, and plenty of pictures. And when you’re stuck, a quick flip-through will solve just about any problem.

BONUS
Get a garbage bowl.
Rachael Ray was right on this one, too; during your prep period, keep a large bowl at your side for scraps and garbage. It cuts down hugely on trips to the trash bin, plus a lot of leaning over. Great for people with bad backs and/or finite patience.

And that’s a wrap. Readers, the comment section awaits. Let’s compile the world’s greatest shortcut thread.

~~~

If you like this post, these might also delight you:

• Cheap Healthy Master Recipes: Eight Versatile Dishes Entirely Adaptable to Your Tastes
• Frugal Food Hacks: 10 Tricks to Simplifying Online Recipe Searches
• Overcoming Your Cooking Obstacles

Even if you didnt eat your veggies or drink your milk as a child, your height is still in your hands, reveal new findings by economists from the University of Southern California, Harvard University and Peking University.

Using unique data from a new massive longitudinal survey of 17,708 adults beginning at age 45, the researchers show for the first time that lifestyle choices we make in adulthood — and not just the hand were dealt as children — influence how tall we stand as we age.

"Had we only examined the correlations between measured height and health, we would have missed this important insight," said John Strauss, professor of economics at USC, and an investigator on a study published in the April 2013 issue of the American Economic Journal: Applied Economics. "The evidence shows that it is not only early-life events that are associated with how we age, but health decisions in later life as well."

While prior work has looked for the connection between height and health — both in childhood and adulthood — the researchers are the first to examine height loss as we age. They show that regardless of your maximum height, the loss of height over time is also an important indicator for other health issues as we age.

For example, the research reveals an especially strong relationship between height loss and cognitive health. Those who had lost more height were also much more likely to perform poorly on standard tests of cognitive health such as short-term memory, ability to perform basic arithmetic and awareness of the date.

Among the socioeconomic factors that correlate to height loss, urban dwellers had much less height loss than those in rural areas, the researchers found, in a country where there has been significant migration to urban areas in the last few decades. In addition, having completed primary school, rather than being illiterate, is associated with 0.9 cm less height shrinkage in men — a large difference when considering that overall average height loss for men is 3.3 cm. Completing high school meant an additional 1 cm less in shrinkage.

For women, having completed primary school was the difference in 0.6 cm of shrinkage, compared to average overall height decrease of 3.8 cm.

"Height has been recognized as an acceptable proxy for childhood health conditions, but there are complications there," says USC economist Geert Ridder, a co-investigator on the study. "Some of adult health might be determined by childhood circumstances, but people shrink differentially, and that shrinkage is also a measure of adult health conditions."

All humans go through physical changes with age, including an increase in body fat and decrease in bone mass. But a decrease in height can be further exacerbated by certain kinds of arthritis, inflammation of spine joints or osteoporosis, which other studies have shown are associated with such lifestyle choices as diet, exercise and smoking.

The researchers used new data from the China Health and Retirement Longitudinal Study, a groundbreaking sampling project led by USC economist Strauss, Yaohui Zhao of the China Center for Economic Research (CCER) at Peking University and Gonghuan Yang of the Chinese Academy of Medical Sciences and Peking Union Medical College, that covers 150 counties randomly chosen throughout China.

The baseline for the survey was collected from June 2011 to March 2012 and includes both subjective self-reported responses to survey questions as well as objective physical measurements such as blood tests. These physical measurements and personal interviews will be followed-up with the same 17,708 people every two years — capturing, for the first time, critical data about human aging in the most populous and most rapidly aging country in the world.

For example, recent changes in social security policy and health insurance in China provide a valuable opportunity for researchers to study how health care actually affects health and aging in a large population, with insights for other developing health care systems worldwide, as well as an opportunity to identify possible under-diagnosis of various chronic conditions.

The researchers will also be able to examine the role specific historical events in China may have had on long-term health, including whether there are health and aging differences among those who were "sent-down" during the Cultural Revolution.