Health for life

Women who had sufficient amounts of vitamin D were 32 percent less likely to develop fibroids than women with insufficient vitamin D, according to a study from researchers at the National Institutes of Health.

Fibroids, also known as uterine leiomyomata, are noncancerous tumors of the uterus. Fibroids often result in pain and bleeding in premenopausal women, and are the leading cause of hysterectomy in the United States.

The study of 1,036 women, aged 35-49, living in the Washington, D.C., area from 1996 to 1999, was led by Donna Baird, Ph.D., a researcher at the National Institute of Environmental Health Sciences (NIEHS), part of NIH. Baird and her collaborators at The George Washington University and the Medical University of South Carolina screened participants for fibroids using ultrasound. They used blood samples to measure the primary circulating form of vitamin D, known as 25-hydroxy D. Those with more than 20 nanograms per milliliter of 25-hydroxy D were categorized as sufficient, though some experts think even higher levels may be required for good health. The body can make vitamin D when the skin is exposed to the sun, or vitamin D can come from food and supplements.

Study participants also completed a questionnaire on sun exposure. Those who reported spending more than one hour outside per day also had a decreased risk of fibroids. The estimated reduction was 40 percent. Although fewer black than white participants had sufficient 25-hydroxy D levels, the estimated reduction in prevalence of fibroids was about the same for both ethnic groups.

"It would be wonderful if something as simple and inexpensive as getting some natural sunshine on their skin each day could help women reduce their chance of getting fibroids," said Baird.

Baird also noted that, though the findings are consistent with laboratory studies, more studies in women are needed. Baird is currently conducting a study in Detroit to see if the findings from the Washington, D.C., study can be replicated. Other NIEHS in-house researchers, led by Darlene Dixon, D.V.M., Ph.D., are learning more about fibroid development, by examining tissue samples from study participants who had surgery for fibroids.

"This study adds to a growing body of literature showing the benefits of vitamin D," said Linda Birnbaum, Ph.D., director of NIEHS and the National Toxicology Program.

First study to report that proteins found in soybeans, could inhibit growth of colon, liver and lung cancers, published in Food Research International

Soybean meal is a bi-product following oil extraction from soybean seeds. It is rich in protein, which usually makes up around 40% of the nutritional components of the seeds and dependent on the line, and can also contain high oleic acid (a monounsaturated omega-9 fatty acid).

The study looked at the role soybeans could have in the prevention of cancer. Using a variety of soybean lines which were high in oleic acid and protein, the researchers looked to monitor bioactivity between the peptides derived from the meals of soybean and various types of human cancer cells.

The study showed that peptides derived from soybean meal significantly inhibited cell growth by 73% for colon cancer, 70% for liver cancer and 68% for lung cancer cells using human cell lines. This shows that the selected high oleic acid soybean lines could have a potential nutraceutical affect in helping to reduce the growth of several types of cancer cells.

People who are “apple-shaped” — with fat more concentrated around the abdomen — have long been considered more at risk for conditions such as heart disease and diabetes than those who are “pear-shaped” and carry weight more in the buttocks, hips and thighs.

But new research conducted at UC Davis Health System published in The Journal of Clinical Endocrinology and Metabolism provides further evidence that the protective benefits of having a pear-body shape may be more myth than reality. The journal article posted online January 10 and will appear in the March 2013 print edition.

The UC Davis study found that fat stored in the buttock area — also known as gluteal adipose tissue — secretes abnormal levels of chemerin and omentin-1, proteins that can lead to inflammation and a prediabetic condition know as insulin resistance in individuals with early metabolic syndrome.

Metabolic syndrome ers to a group of risk factors that occur together, doubling the risk for heart disease and increasing the risk for diabetes at least five-fold. Risk factors include having a large waistline, low levels of high-density lipoproteins (HDL), or “good” cholesterol, high blood pressure as well as high fasting blood sugar ( insulin resistance) and high triglyceride levels. According to the Centers for Disease Control and Prevention, metabolic syndrome affects 35 percent of American adults over age 20.

“Fat in the abdomen has long been considered the most detrimental to health, and gluteal fat was thought to protect against diabetes, heart disease and metabolic syndrome,” said Ishwarlal Jialal, lead author of the study and a professor of pathology and laboratory medicine and of internal medicine at UC Davis. ”But our research helps to dispel the myth that gluteal fat is ‘innocent.’ It also suggests that abnormal protein levels may be an early indicator to identify those at risk for developing metabolic syndrome.”

The UC Davis team found that in individuals with early metabolic syndrome, gluteal fat secreted elevated levels of chemerin and low levels of omentin-1 — proteins that correlate with other factors known to increase the risk for heart disease and diabetes. High chemerin levels, for example, correlated with high blood pressure, elevated levels of C-reactive protein (a sign of inflammation) and triglycerides, insulin resistance, and low levels of HDL cholesterol. Low omentin-1 levels correlated with high levels of triglycerides and blood glucose levels and low levels of HDL cholesterol.

“High chemerin levels correlated with four of the five characteristics of metabolic syndrome and may be a promising biomarker for metabolic syndrome,” said Jialal. “As it’s also an indicator of inflammation and insulin resistance, it could also emerge as part of a biomarker panel to define high-risk obesity states. The good news is that with weight loss, you can reduce chemerin levels along with the risk for metabolic syndrome.”

To conduct the study, Jialal and colleagues recruited 45 patients with early metabolic syndrome — defined as having at least three risk factors for metabolic syndrome including central obesity, hypertension, mild increases in glucose levels not yet in the diabetic range (<126 mg/dl), hyperlipidemia without cardiovascular disease or diabetes. A control group of 30 subjects had less than two risk factors for metabolic syndrome, with normal glucose and triglyceride levels. Both groups were matched for gender and age.

Complete blood counts, lipid profiles and blood glucose, blood pressure and C-reactive protein levels were measured in all participants. Levels of four proteins secreted by adipose tissue — chemerin, resistin, visfatin and omentin-1 — were also measured in plasma and in subcutaneous fat samples from gluteal tissue.

The researchers found that chemerin levels were increased and omentin-1 levels were decreased in both plasma and gluteal fat of subjects with metabolic syndrome compared to those in the control group. The abnormal levels of these two proteins were also independent of age, body mass index and waist circumference.

“Future large epidemiological studies should focus on evaluating the role of chemerin as a biomarker for the development of diabetes and cardiovascular disease in metabolic syndrome,” Jialal said.

New research that looked at whether two commonly prescribed statin medicines, used to lower low-density lipoprotein (LDL) or bad cholesterol levels in the blood, can adversely affect cognitive function has found that one of the drugs tested caused memory impairment in rats.

Between six and seven million people in the UK1 take statins daily and the findings follow anecdotal evidence of people reporting that they feel that their newly prescribed statin is affecting their memory. Last year, the US Food and Drug Administration (FDA) insisted that all manufacturers list in their side effects that statins might affect cognitive function.

The study, led by scientists at the University of Bristol and published in the journal PLOS ONE, tested pravastatin and atorvostatin (two commonly prescribed statins) in rat learning and memory models. The findings show that while no adverse cognitive effects were observed in rat performance for simple learning and memory tasks for atorvostatin, pravastatin impaired their performance.

Rats were treated daily with pravastatin (brand name - pravachol) or atorvostatin (brand name - Lipitor) for 18 days. The rodents were tested in a simple learning task before, during and after treatment, where they had to learn where to find a food reward. On the last day of treatment and following one week withdrawal, the rats were also tested in a task which measures their ability to recognise a previously encountered object (recognition memory).

The studys findings showed that pravastatin tended to impair learning over the last few days of treatment although this effect was fully reversed once treatment ceased. However, in the novel object discrimination task, pravastatin impaired object recognition memory. While no effects were observed for atorvostatin in either task.

The results suggest that chronic treatment with pravastatin impairs working and recognition memory in rodents. The reversibility of the effects on stopping treatment is similar to what has been observed in patients, but the lack of effect of atorvostatin suggests that some types of statin may be more likely to cause cognitive impairment than others.

Neil Marrion, Professor of Neuroscience at Bristols School of Physiology and Pharmacology and the studys lead author, said: "This finding is novel and likely lects both the anecdotal reports and FDA advice. What is most interesting is that it is not a feature of all statins. However, in order to better understand the relationship between statin treatment and cognitive function, further studies are needed."

I hate to say I told you so.  But I did.  Like a million times.  Yet, the fear of cholesterol continues.  What is it?  Is it the Lipitor ads?  Is it your cholesterol-phobic doctor, determined to get your cholesterol under 200 mg/dl at all cost?  Whatever it is, its about time we stopped worrying so damn much about high cholesterol.  This new study, entitled "Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid?  Ten years prospective data from the Norwegian HUNT 2 study.", shows us why.  Did anybody hear anything about this one in the media??  I didnt think so, not with a catchy title like that.  At least now the 3 people that read my blog will be aware of it.  The researchers followed 52,087 Norwegians aged 20-74 who were free of cardiovascular disease (CVD) for 10 years, then assessed the relationship of total cholesterol with total mortality, CVD mortality, and ischemic heart disease mortality (IHD).  (Just to be clear, CVD mortality signifies deaths from any disease of the cardiovascular system, while ischemic heart disease ers only to diseases involving restricted blood flow to the heart.)  Lets jump straight into the data then, shall we?  And another note:  since this study comes from Europe, the units for blood cholesterol are shown in mmol/L, rather than the mg/dL that we are used to.  The researchers classified the participants into four groups, based on their blood cholesterol.  Here are the converted unit values in mg/dL for the four groups...  <193, 193-229, 230-269, and >270


First, the least shocking data.  This graph compares the association between cholesterol levels and death from ischemic heart disease.  For the men, it looks like theres not much variation.  Deaths from heart disease rose slightly along with cholesterol levels, but nothing dramatic.  Women, on the other hand, yielded a much more interesting result.  Clearly, by a LARGE margin, cholesterol below 193 mg/dL was most predictive of death from heart disease.  All other groups, including the group with cholesterol over 270 mg/dL, showed significantly lower risk.  Yes, seriously.  On to the next graph!




This one here shows the association between cholesterol and cardiovascular disease, or CVD, which includes heart disease with stroke and any other disease of the cardiovascular system.  Again, lets begin with the men.  The lowest risk appears to lie in those with total cholesterol between 193 and 229 mg/dL, but a close second is the next range up, from 230 to 269.  If you know your erence ranges, you know that anything over 200 is considered dangerous.  Does anybody ever bother to check why this is considered dangerous, or do we just accept it without question??  Clearly, the data from this study suggests that a cholesterol level in men between 193 and 269 is optimal for CVD prevention.  As for women... oops, looks like they screwed up the data there!  They must have it backwards!  Except they dont... yes, the data shows that if youre a woman, the higher your cholesterol is, the lower your risk of death from CVD.  Id repeat it, but Ill be doing that again shortly.  Read on to all-cause mortality!


Here we are, all-cause mortality... the only statistics that really matter.  Deaths from IHD or CVD are cool, but not nearly as cool as all-cause mortality.  This one cuts through the bullshit.  Its not your risk of dying from one disease that really matters, its your risk of dying overall.  So, for men... the group with the HIGHEST risk of dying overall had the LOWEST cholesterol (below 193 mg/dL).  Even those with a cholesterol level over 270 fared better.  The sweet-spot, protective level here was shown to be 193-229, a level that, based on the current erence ranges, will likely get you prescribed a statin drug for being too high!  Its just not right I tell ya.  And for the women, we see another complete inverse relationship between blood cholesterol and all-cause mortality.  High cholesterol appears to be protective for the ladies!  Maybe I could incorporate that into a pickup line somehow... but I digress.

So, does this prove anything?  No.  Not really.  Although it happens to be in accordance with what I believe, its all just observation.  But this isnt the only study to show this kind of trend, just the most recent; there are at least 20 others like it if you just follow that link.  And it certainly makes a strong case for women... having low cholesterol, in the healthy erence range, mind you, just appears to be straight up deadly!  Despite the studys inability to conclusively prove anything, that didnt stop the researchers from letting loose a little on the drug industry.  And I quote from the conclusion of the paper... "Many individuals who could otherwise call themselves healthy struggle conscientiously to push their cholesterol under the presumed danger limit, coached by health personnel, personal trainers, and caring family members.  Massive commercial interests are linked to drugs and other remedies marketed for this purpose."  That may not seem so harsh, but for a group of researchers to say this and imply that massive commercial interests are wrongly influencing the clinical guidelines... thats a pretty strong statement.  And I agree wholeheartedly.  The guidelines need to be reassessed.

What does this mean, though, if having high cholesterol isnt a bad thing?  What are the implications?  Well, for one, maybe it will get people off these ridiculous statin drugs.  But even more significant, to me, are the implications for saturated fat consumption.  These days, everyone just "knows" saturated fat is bad.  But if I asked you, could you tell me why?  The standard answer is, because saturated fat raises your blood cholesterol.  Well... um... so what?  If you step outside of this cholesterol=bad paradigm for a while, things start to look a bit different.  What else is known about saturated fat?  Well, if you eat more of it, it makes up more of your cell membranes, and its highly resistant to oxidative damage.  So thats good, it protects your cells.  And... short-chain saturated fats like butyric acid, found in butter, are burned perentially as fuel and promote proper immune function.  And... saturated fats enhance calcium absorption, along with all the fat-soluble vitamins (A, D, E, K).  And dont forget, if youre a woman, having high cholesterol appears to be beneficial.  Wait a minute... could saturated fat be... healthy!?  So much for a French paradox...

A study that appeared in the March 6 issue of JAMA shed a favorable light on a diet that is, relative to USDA recommendations, lower in carbohydrate and higher in protein and fat.

Researchers randomly assigned overweight premenopausal women to one of 4 diets representing a range of carbohydrate intake: Atkins (low-carb), Zone, LEARN (follows USDA Food Guide Pyramid), and Ornish (high-carb). The women received instruction on the diets and were followed for a year.

They concluded:

"Women assigned to follow the Atkins diet, which had the lowest carbohydrate intake, lost more weight and experienced more favorable overall metabolic effects at 12 months than women assigned to follow the Zone, Ornish, or LEARN diets."

However, overall weight loss was minimal:



There was no difference in fasting glucose or insulin among the 4 groups. Women following the Atkins diet did experience a small reduction in systolic blood pressure relative to the other diets.

________
For the study (abstract):
Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women

News summaries:
And the Winner Is ... Well, Nobody
Atkins Beats Other Diet Plans In Study

New research at Oregon State University suggests the health benefits of small amounts of activity – even as small as one- and two-minute increments that add up to 30 minutes per day – can be just as beneficial as longer bouts of physical exercise achieved by a trip to the gym.

The nationally representative study of more than 6,000 American adults shows that an active lifestyle approach, as opposed to structured exercise, may be just as beneficial in improving health outcomes, including preventing metabolic syndrome, high blood pressure, and high cholesterol.

“Our results suggest that engaging in an active lifestyle approach, compared to a structured exercise approach, may be just as beneficial in improving various health outcomes,” said Paul Loprinzi, lead author of the study. “We encourage people to seek out opportunities to be active when the choice is available. For example, rather than sitting while talking on the phone, use this opportunity to get in some activity by pacing around while talking.”

Perhaps just as importantly, the researchers found that 43 percent of those who participated in the “short bouts” of exercise met physical activity guidelines of 30 minutes day. In comparison, less than 10 percent of those in the longer exercise bouts met those federal guidelines for exercise.

Loprinzi, who is an assistant professor at Bellarmine University, conducted the research as a doctoral student working in the lab of Brad Cardinal at Oregon State University. Cardinal, a professor of exercise and sport science, is co-author of the study, which is in the current issue of the American Journal of Health Promotion.

“You hear that less than 10 percent of Americans exercise and it gives the perception that people are lazy,” Cardinal said. “Our research shows that more than 40 percent of adults achieved the exercise guidelines, by making movement a way of life.”

Cardinal, who has studied the “lifestyle exercise” model for more than 20 years, said one of the most common barriers people cite to getting enough exercise is lack of time. He said the results of this study are promising, and show that simply building movement into everyday activities can have meaningful health benefits.

“This is a more natural way to exercise, just to walk more and move around a bit more,” Cardinal said. “We are designed by nature as beings who are supposed to move. People get it in their minds, if I don’t get that 30 minutes, I might as well not exercise at all. Our results really challenge that perception and give people meaningful, realistic options for meeting the physical activity guidelines.”

For example, Cardinal said instead of driving half a mile, try biking or walking the same distance; instead of using a riding lawn mower, use a push lawn mower. Instead of sitting through TV commercials, try doing some sit-ups, push-ups, or jumping jacks during the commercial breaks; and instead of sitting and being a spectator at a childs sporting event, try walking around during the halftime break.

The researchers said the participants in this study wore accelerometers, which is an objective tool to measure physical activity. Those who participated in the short bouts of activity could be moving as few as one or two minutes at a time. The people in the “short bouts” group had positive results in areas such as blood pressure, cholesterol, metabolic syndrome, and waist circumference.

For instance, the study showed those in the shorter exercise group who met physical activity guidelines had an 89 percent chance of not having metabolic syndrome, compared to 87 percent for those meeting guidelines using the structured exercise approach.

Loprinzi said the one area where small bursts of activity did not seem to equal the benefits of longer, sustained exercise was in Body Mass Index, or BMI. However, the researchers cautioned that these findings do not necessarily mean that short bouts of activity do not help with weight loss, especially since they did find a benefit on weight circumference.

“There are inherent limitations in BMI as a surrogate measure of fat and health in general,” Cardinal said. “People can still be ‘fit’ and ‘fat.’”

The researchers emphasized that for health benefits, people should seek out opportunities to be physically active.

“In our society, you will always be presented with things that entice you to sit or be less active because of technology, like using a leaf blower instead of a rake,” Cardinal said. “Making physical activity a way of life is more cost-effective than an expensive gym membership. You may be more likely to stick with it, and over the long term, you’ll be healthier, more mobile and just feel better all around.”

Ahhh it was a good day today when I read this article... "Study raises questions about dietary fats and heart disease guidance".  Heres the scoop... researchers from the United States and Australia have recovered missing data from an old study from the 1970s.  The study, known as the Sydney Diet Heart Study, was a randomized controlled trial in which the participants were told to replace the saturated fats in their diets with polyunsaturated fats from vegetable oil.  The 458 subjects were all men between ages 30-59 who had recently had a coronary event, defined as either a heart attack or angina (1). 

Why was this data missing?  Who knows.  I cant find a good answer.  But had these results been available in the mid 1970s as they should have been, it may have changed the course of the dietary guidelines on fat intake.

Okay so we had two groups, both groups are coming off of either a heart attack or angina.  Let me break it down right quick...

Group 1:  Control group

• Given no dietary advice at all

Group 2:  Intervention group, given the following instructions...

• Reduce dietary saturated fat (animal fats) to under 10% of calories
• Reduce dietary cholesterol to less than 300 mg/day
• Increase polyunsaturated fats (from safflower oil) to 15% of calories

The participants diets were reported through a daily food diary, and they reported to the lab for testing 2-3x per year for several years.  Here are the results for all-cause death, cardiovascular disease, and coronary heart disease...


Here you can see the cumulative death rate over the course of 5 years of follow-up.  The data is essentially the same for all-cause, cardiovascular, and heart disease deaths.  Its also statistically significant and very, very clear.  Those in the intervention group, who reduced their saturated fat and cholesterol intake while increasing their polyunsaturated fat intake, fared worse.  In other words, the people eating more saturated fat and cholesterol lived longer, and they had a lower rate of heart disease.

This shouldnt come as a huge surprise if youre a reader of this here blog.  You know saturated fat is wrongly accused... and that vegetable oils are the devil.  Just further evidence here.  But theres something else thats interesting about this study:  the cholesterol levels.  The data is only available for 1 year of follow up, and I had to make this graph myself for your viewing pleasure.  Check it out...


Sorry about the colors... theyre actually the opposite of the graphs above and I hadnt realized it til now!  But the point is that the intervention group in red, the group eating more vegetable oils, lowered their total cholesterol nearly 40 points!!  They ended up at 243.9 mg/dl by the end of the first year.  The control group?  Well they lowered theirs a measly 15 points to 266.5 mg/dl.  Both began at the same level.  (There were no significant differences between groups in triglycerides, body mass index, or systolic or diastolic blood pressure at baseline or during follow-up.)

So based on this, you would assume that the intervention group would be better off, right?  But they werent.  They died far more often of heart disease than the control group did, and with lower cholesterol!  Lesson #1:  Arbitrarily lowering your cholesterol by any means necessary does not and will not lower your risk of heart disease!!!  Cholesterol is just a semi-accurate risk factor...  it is not the cause.  Theore I dont necessarily give two shits if your diet lowers your total cholesterol. 

But the worst part of all this?  Replacing saturated animal fats with unsaturated vegetable fats has been a cornerstone of mainstream dietary advice for the past 40 years.  I could cite any number of different sources here, like...

• The 2010 Dietary Guidelines:  "Americans should replace solid fats with oils." pg. 40 (2)
• The American Heart Association:  "Replacement of saturated fat and trans fat with monounsaturated fat and polyunsaturated fat might even help lower LDL cholesterol when eaten as part of a healthy diet." (3)
• The My Plate fats and oils info sheet I was forced to teach to teenagers last semester in my community rotation:  "Replacing saturated fats with unsaturated fats lowers your cholesterol and reduces your risk for heart disease."

I, for one, have had enough of this shit.  Its time this changes, and maybe this is the study to put it over the edge.  Saturated fat isnt killing us.  Vegetable oil is.  Eat real food.  Peace Im out.

Consumption of fatty fish and fish-oil supplements linked to 71 percent higher risk

A second large, prospective study by scientists at Fred Hutchinson Cancer Research Center has confirmed the link between high blood concentrations of omega-3 fatty acids and an increased risk of prostate cancer.

Published July 11 in the online edition of the Journal of the National Cancer Institute, the latest findings indicate that high concentrations of EPA, DPA and DHA – the three anti-inflammatory and metabolically related fatty acids derived from fatty fish and fish-oil supplements – are associated with a 71 percent increased risk of high-grade prostate cancer. The study also found a 44 percent increase in the risk of low-grade prostate cancer and an overall 43 percent increase in risk for all prostate cancers.

The increase in risk for high-grade prostate cancer is important because those tumors are more likely to be fatal.

The findings confirm a 2011 study published by the same Fred Hutch scientific team that reported a similar link between high blood concentrations of DHA and a more than doubling of the risk for developing high-grade prostate cancer. The latest study also confirms results from a large European study.

"The consistency of these findings suggests that these fatty acids are involved in prostate tumorigenesis and recommendations to increase long-chain omega-3 fatty acid intake, in particular through supplementation, should consider its potential risks," the authors wrote.

"Weve shown once again that use of nutritional supplements may be harmful," said Alan Kristal, Dr.P.H., the papers senior author and member of the Fred Hutch Public Health Sciences Division. Kristal also noted a recent analysis published in the Journal of the American Medical Association that questioned the benefit of omega-3 supplementation for cardiovascular diseases. The analysis, which combined the data from 20 studies, found no reduction in all-cause mortality, heart attacks or strokes.

"Whats important is that we have been able to replicate our findings from 2011 and we have confirmed that marine omega-3 fatty acids play a role in prostate cancer occurrence," said corresponding author Theodore Brasky, Ph.D., a research assistant professor at The Ohio State University Comprehensive Cancer Center who was a postdoctoral trainee at Fred Hutch when the research was conducted. "Its important to note, however, that these results do not address the question of whether omega-3s play a detrimental role in prostate cancer prognosis," he said.

Kristal said the findings in both Fred Hutch studies were surprising because omega-3 fatty acids are believed to have a host of positive health effects based on their anti-inflammatory properties. Inflammation plays a role in the development and growth of many cancers.


It is unclear from this study why high levels of omega-3 fatty acids would increase prostate cancer risk, according to the authors, however the replication of this finding in two large studies indicates the need for further research into possible mechanisms. One potentially harmful effect of omega-3 fatty acids is their conversion into compounds that can cause damage to cells and DNA, and their role in immunosuppression. Whether these effects impact cancer risk is not known.

The difference in blood concentrations of omega-3 fatty acids between the lowest and highest risk groups was about 2.5 percentage points (3.2 percent vs. 5.7 percent), which is somewhat larger than the effect of eating salmon twice a week, Kristal said.

The current study analyzed data and specimens collected from men who participated in the Selenium and Vitamin E Cancer Prevention Trial (SELECT), a large randomized, placebo-controlled trial to test whether selenium and vitamin E, either alone or combined, reduced prostate cancer risk. That study showed no benefit from selenium intake and an increase in prostate cancers in men who took vitamin E.

The group included in the this analysis consisted of 834 men who had been diagnosed with incident, primary prostate cancers (156 were high-grade cancer) along with a comparison group of 1,393 men selected randomly from the 35,500 participants in SELECT.

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

Results of the PREDIMED study, aimed at assessing the efficacy of the Mediterranean diet in the primary prevention of cardiovascular diseases, have been published in The New England Journal of Medicine. They show that the Mediterranean diet supplemented with extra-virgin olive oil or tree nuts reduces by 30 percent the risk of suffering a cardiovascular death, a myocardial infarction or a stroke.

The study has been coordinated by the researcher Ramon Estruch, from the Faculty of Medicine of the UB and the Hospital Clínic -- affiliated centres with the health campus of the UB, HUBc -- and has had the collaboration of the professor Rosa M. Lamuela and her team from the Natural Antioxidant Research Group of the Faculty of Pharmacy -- located at the campus of international excellence BKC -- which determined the biomarkers of Mediterranean diet consumption.

The research is part of the project PREDIMED, a multicentre trial carried out between 2003 and 2011 to study the effects of the Mediterranean diet on the primary prevention of cardiovascular diseases. The study was funded by the Carlos III Health Institute by means of the cooperative research thematic network (RETIC RD06/0045) and the CIBER of Physiopathology of Obesity and Nutrition (CIBERobn).

A total of 7,447 people with major cardiovascular risk factors participated in the study. They were divided into three dietary intervention groups: a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with nuts (walnuts, almonds, hazelnuts), and a low-fat diet (animal and vegetable). A dietician visited the patients every three months and they attended dietary training group sessions, in which they received detailed information about the Mediterranean and the low-fat diet, and the food included in each one. Moreover, they were provided with shopping lists, menus and recipes adapted to each type of diet and each season of the year.

During the study, those participants who followed any of the two types of Mediterranean diet received freely extra-virgin olive oil (one litre per week), and nuts (30 grams per day; 15 grams of walnuts, 7.5 grams of almonds and 7.5 grams of hazelnuts).

After five years, it has been proved that participants who followed any of the two types of Mediterranean diet showed a substantial reduction in the risk of suffering a cardiovascular death, a myocardial infarction or a stroke.

According to the researchers, the results of PREDIMED study are relevant as they prove that a high-vegetable fat diet is healthier at a cardiovascular level than a low-fat diet. The authors state that the study has been controversial as it provides new data to reject the idea that it is necessary to reduce fats in order to improve cardiovascular health.

Hopefully, these results will provide new erences to prevent cardiovascular diseases. In addition, the design and methodology used can be easily transferred to the biomedical sector.

Researchers reporting in the July 17 issue of the New England Journal of Medicine published results of their two-year investigation into three popular diets: A low-carbohydrate diet (based on Atkins guidelines), a Mediterranean diet, and a low-fat diet (based on American Heart Association guidelines).

The full study can be found at:

Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet

Weight Loss

For weight loss, the low-carbohydrate and Mediterranean diets performed best, and were just about tied at 2 years:

• Low-carbohydrate Diet: 4.7 kg (approximately 10 pounds)
  
• Mediterranean Diet: 4.4 kg (approximately 10 pounds)
  
• American Heart Association (AHA) Diet: 2.9 kg (approximately 6 pounds)

Women did better on the Mediterranean diet, while men did better on the low-carbohydrate diet.

Diabetes

There was an unexpected finding that applied specifically to participants with diabetes. Fasting blood glucose of people with diabetes who followed the Mediterranean dropped an average of 32.8 mg/dl; while the fasting glucose of diabetics in the other groups increased by 1.2 mg/dl in the low-carb group and 12.1 mg/dl in the AHA group.

People with diabetes who followed the Mediterranean diet also had the lowest fasting insulin and lowest insulin resistance (HOMA-IR).

Differences Between Diets

All participants reduced their intake from baseline and were eating about the same amount of calories, 1500/day for women and 1800/day for men, regardless of group assignment. Physical activity also increased from baseline but was not different between groups.

The low-fat AHA diet derived about 30% of its calories from fat and 50% from carbohydrate. "The participants were counseled to consume low-fat grains, vegetables, fruits, and legumes and to limit their consumption of additional fats, sweets, and high-fat snacks."

The Mediterranean diet derived about 33% of its calories from fat and 50% from carbohydrate. This group had the highest ratio of monounsaturated-to-saturated fat, probably owing to olive oil and nut consumption: "the main sources of added fat were 30 to 45 g of olive oil and a handful of nuts (five to seven nuts, <20 g) per day." It was a diet "rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb." Members also consumed the greatest amount of dietary fiber.

The low-carbohydrate diet derived about 39% of its calories from fat and 40% from carbohydrate. Members consumed the least amount of carbohydrates (consuming about 120 g/day after the first 2 months and throughout) and the most amount of fat, protein, and cholesterol. It diverged from Atkins protocol by advising vegetarian sources of fat and protein. This was the only diet that was unrestricted in calories. However, participants averaged about the same amount of calories as the other groups. Notably, even though limits were not placed on how much members of this group could eat, the low-carb group had the highest drop-out rate.

Conclusion

"Mediterranean and low-carbohydrate diets may be effective alternatives to low-fat diets. The more favorable effects on lipids (with the low-carbohydrate diet) and on glycemic control (with the Mediterranean diet) suggest that personal perences and metabolic considerations might inform individualized tailoring of dietary interventions."

________

Todays question comes from college student Caitlin, who has finals coming up.

Q: What about healthy study snacks? i think i ate my weight in popcorn yesterday and definitely need an alternative!

A: Caitlin! Having been a carouser of the late-night cafeteria scene (read: mozzarella sticks, pizza, something called "broccoli cheesebake"), I understand your delicate, frommage-craving pain. Youd like something filling, but light. Tasty, but not time-consuming. And if its caffeinated, all the better.

This sounds lame, but fruit was always a good bet to start, with coffee acting as my beverage of choice. Energy drinks werent so popular back in 199X, but I might have avoided Monster and its ilk like a florescent green plague.

How about some all-natural granola bars? Or trail mix? Or, when all else fails, hummus, carrots, and pita will work wonders.

But I hand it over to you, sweet readers. What snacks will help Caitlin ace her semester-end tests?

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.

"I need to call someone..."

The Disease Management Care Blog apologizes in advance for a long post about an important study comparing two state-of-the-art weight loss interventions.  Get some caffeine and hang in there.  If you are interested in the science of disease management and its role in obesity, you will not be disappointed.

Talk to some of the Ayatollahs dominating the academic medical-industrial complex about telephonic disease management and theyll give you the same look that they give to something unsightly that they just discovered on the end of their finger after rubbing their nose.  The idea that some remote (ugh!), telephone-based (bleh!) for-profit (yuck!) company could contribute anything to their vision of the health delivery is health policy apostasy.

But what how does this ideology stack up against the evidence?  

Until recently, we haven’t really known because there were few head-to-head comparisons of traditional “disease management” vs. traditional patient counseling.  But now we have the just-published POWER (“Practice-based Opportunities for Weight Reduction” study that was funded by the NHLBI and (whoa!) Healthways.  The authors were from Johns Hopkins University, which has a long-term consulting agreement with Healthways. They had final say on the research methodology and the papers contents.

POWER was a prospective clinical trial that randomly assigned patients to one of three weight loss intervention strategies.  One consisted of “remote” telephonic treatment counseling, the second provided in-person counseling and the third was a control group.  The in-person sessions were provided by Johns Hopkins employees while the remote telephone counseling was provided by Healthways.

Study patients with obesity and at least one risk factor (hypertension, hyperlipidemia or diabetes) were recruited from six Baltimore primary care practices from 2008 through 2009.

All the interventions used basic nutritional and exercise guidelines that were delivered with state-of-the art “social cognitive theory,” "behavioral self-management,” “positive reinforcement” and “motivational interviewing.” Both of the intervention groups had access to a web site with learning modules plus feedback. If there was no log-on to the web site every 7 days, patients were sent a reminder email. 

Persons in the disease management-style remote support arm of the study got 12 weekly calls lasting 20 minutes for three months, which was followed by 3 monthly calls.   Persons assigned to the traditional in-person coaching arm got nine group sessions and three individual sessions over the 3 months followed by one group and two individual monthly sessions over three months. 

Participants’ weight loss was assessed at 6 and 24 months.

The patients primary care physicians received summary reports and encouraged their patients’ participation.

Readers should note that this was an “effectiveness” trial.  Unlike “efficacy” trials, the protocol dispensed with the usual run-in period or making sure patients were adherent to the protocol before or during the study.

1370 persons were screened and 415 were randomized.  64% were women, the mean age was 54 years, 41% were black, 97% had commercial insurance and the mean BMI was a hefty 36.6.

After randomization, there was some drop out: 366 were weighed at 6 months, 355 at 12 months and 392 at 24 months. 

At 6 months: the control group lost 1.4 kilograms (kg) while there was 6.1 kg lost in the remote support, and 5.8 kg. lost in the in-person group.  Thats 3.1 lbs vs. 13.4 lbs vs. 12.8 lbs.

At 24 months, the weight loss .8 kg in the control, 4.6 Kg in remote support and 5.1 Kg for in-person.  Thats 1.8 lbs, 10.1 lbs and 11.2 lbs. That translates to body weight changes of 1.1%, 5.0% and 5.2%.  The percent of persons hitting at least 5% weight loss was 18.8% in the control group, 41.4% in the in-person support group and 38.2% in the group getting remote support. 7.8% of controls, 27.5% and 18.8% of controls, remote and in-person support patients, respectively, reached a BMI less than 30  

There was no statistically significant difference in weight loss outcomes between the two intervention groups.  In other words, the small changes between the disease management and in-person counseling could have been the result of chance.

What can readers conclude?

1.  This was a solidly performed study with important implications for a still-evolving national strategy in the battle against obesity.  If an intervention can lead approximately 40% of persons to lose 5% of their weight over two years, maybe the science of non-invasive weight reduction has gotten to the point where insurers should cover it.  While the DMCB remains suspicious about “mandates” and “the minimum benefit,” there are other policy levers that could be pushed to make this happen.  This is doubly true when you think about the costly alternatives of drugs and weight loss surgery.

2.  Seen through the lens of a disease management vs. in-person counseling competition, the industry’s “best” (Healthways) went toe to toe with the health system’s best (Johns Hopkins) and it was a tie.  When it comes to weight loss, it now comes down to who can do it cheaper and who can scale it.

3.  While this was a solid study, readers should be aware of its imperfections.  Since there were so few patients on Medicare or Medicaid, we dont know how this would work in patients with public insurance. This was not double blinded, so it’s possible that the outcomes were skewed because patients and their doctors were aware of their assigned treatment arm. The drops-outs weights went unmeasured and their data could have changed the results.  There was a high reliance on group sessions in the "in-person" arm of the study, which may not be as effective as one-on-one counseling. The in-person sessions were also “remote” from the PCPs’ offices and may have been a poor substitute for the one-on-one counseling envisioned for a robust PCMH.  Successful weight loss is usually defined at 10% of body weight at one year instead of 5% at 2 years.  It’s also difficult to discern the relative contribution of the web site vs. the physician support vs. the nurse counseling.  We don’t know what happened to the patients’ blood pressure, cholesterol levels or their blood glucose control.  Finally, Hopkins had a doubtful but potential conflict of interest in a study that showed non-superiority vs. one of their customers.

4 While the DMCB doesn’t want to quibble, close scrutiny of the p-values in a table comparing the percent of persons reaching a BMI less than 30 for the in-person vs. remote support cohorts shows that it came quite close to being statistically significant at p = .07.  In other words, Healthways (27.5%)  almost beat Johns Hopkins (18.8%).  Using the same criteria in this study widely hailed as proving that Group Health’s medical home saves money, Healthways did beat Johns Hopkins.

5  Healthways deserves kudos for submitting to and committing resources to a clinical trial.  To the DMCB, the search for scientific truth is a price of doing business.  Their shareholders may think that cash is better spent on pursuing customers or driving efficiencies, but this research is an investment that will yield returns over the long run.  Other for-profits "get it" and so does Healthways.  The only question is why isnt this spashed on the companys web site?

6  If both interventions are equivalent, the DMCB suggests that they are not necessarily exclusive.  A truly enlighted approach to this would be to let patients choose which form of counseling they per.  Whats more, if patients were allowed to choose, the amount of weight loss for both groups would probably be even greater.

7. Last but not least, this is further evidence that "disease management" has grown up.  This "DM Ver 2.0" is based on far more sophisticated principles of behavior change than those used in the Medicare Health Support debacle.  Whats more, this Johns Hopkins paper reminds us that physicians, in the course of routine patient encounters, are simply not an option when it comes to weight loss counseling.  Theyre too busy and their job is to provide a supporting role.

"POWER" - one more acronym and one more piece of evidence to use in defense of disease and population-based care management.

A new study from Australia finds that people with diabetes who take metformin suffer more cognitive problems than those who dont take the drug:

Increased Risk Of Cognitive Impairment In Patients With Diabetes Is Associated With Metformin, Diabetes Care, October 2013

"Participants with diabetes had worse cognitive performance than participants who did not have diabetes. ... Among participants with diabetes, worse cognitive performance was associated with metformin use."

Why does metformin affect cognitive performance? Its thought that the drug interferes with the absorption of vitamin B12, by interacting with a B12 receptor in the distal ileum, and B12 is necessary for a well-functioning nervous system. Indeed, in this study vitamin B12 and calcium supplementation was associated with better cognition.

Dr. Adriaan Kooy from the Bethesda Diabetes Research Center in the Netherlands says:

"The malabsorption of neurovitamins like B12 in metformin users may contribute to neuronal dysfunction — potentially being misinterpreted as diabetic neuropathy."

The link between metformin and vitamin B12 isnt new, but the affect on mental function is becoming more apparent. The studys lead author, Eileen Moore, PhD, told Medscape Medical News:

"Since the 1970s, clinicians and scientists have been aware that metformin is associated with lower vitamin-B12 levels. The hypothesis that this may increase the risk of cognitive impairment seemed sound."

Moore advises:

"Vitamin-B12 levels in patients using metformin should be monitored at least yearly."

Dr. Kooys group published evidence of the link between metformin and vitamin-B12 deficiency a few years ago:

Long Term Treatment With Metformin In Patients With Type 2 Diabetes And Risk Of Vitamin B-12 Deficiency: Randomised Placebo Controlled Trial, British Medical Journal, May 2010

They had the same advice:

"Long term treatment with metformin increases the risk of vitamin B-12 deficiency, which results in raised homocysteine concentrations. Vitamin B-12 deficiency is preventable; therefore, our findings suggest that regular measurement of vitamin B-12 concentrations during long term metformin treatment should be strongly considered."

________

Individuals who have a high preference for sweets and a high aversion to bitter flavors may be at an increased risk of developing metabolic syndrome, according to a new study in the Journal of Food Science, published by the Institute of Food Technologists (IFT).

Researchers at the University of North Carolina at Chapel Hill analyzed how two tasting profiles, sweet likers (SL) and supertasters (ST), interact and affect dietary intake and health, particularly metabolic syndrome. Metabolic syndrome is a name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type-2 diabetes.

What researchers found is that those with both taste profiles or neither taste profiles were more likely to have an increased risk of metabolic syndrome compared to those who were only an SL or ST. The interaction between SL and ST was also significantly associated with fiber and beverage intake suggesting that tasting patterns may have an effect on both dietary intake and disease risk.

Trans-fat, like saturated fat and dietary cholesterol, has been found to raise LDL cholesterol, increasing risk for heart disease. Trans-fats may also increase insulin resistance in people with diabetes. (See Trans Fatty Acids And Insulin Resistance.)

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) recommends that people with diabetes limit intake of foods with trans-fat, such as snack foods and commercially baked goods.

But how healthy are the fats being used to replace trans-fats?

A study that appeared in the January 15th issue of Nutrition & Metabolism tested the effects of interesterified fats (IE fats), one of the leading contenders to replace trans-fats. Thirty participants consumed diets that were either rich in palm olein*, trans-fat, or IE fat. After 4 weeks:

• Those on the trans-fat and IE fat diets had higher LDL/HDL cholesterol ratios than those on the palm olein diet.
  
• Those on the trans-fat and IE fat diets had higher fasting plasma glucose than those on the palm olein diet. (Those eating trans-fat had a BG increase of about 5.2 mg/dl after 4 weeks, those eating IE fat had a BG increase of about 18.9 mg/dl.)

Manufacturers are still working to find a good replacement for trans-fats. What this study tells us is that not all apparently healthy alternatives to trans-fats are good ones.

*Palm olein is the fraction of palm oil that is liquid at room temperature. Palm olein is approximately 45% saturated fat and 55% unsaturated fat. (American Palm Oil Council)

________
For the study (full free access):
Stearic Acid-Rich Interesterified Fat And Trans-Rich Fat Raise The LDL/HDL Ratio And Plasma Glucose Relative To Palm Olein In Humans

The study, Online Disease Management of Diabetes: Engaging and Motivating Patients Online With Enhanced Resources-Diabetes (EMPOWER-D), was a prospective randomized clinical trial that is posted online over at JAMIA.

The Disease Management Care Blog summary:

Researchers at the Palo Alto Medical Foundation used the electronic health record (EHR) to look for active (seen once in the last 12 months) patients over 18 years of age with  Type 2 diabetes and an A1c greater than 7.5%.  If the primary physician approved, patients were then asked to complete a questionnaire and keep an appointment with a research assistant for additional review and discussion. Once patients agreed, they were entered into the study.

6,907 potential study subjects were identified, 1,594 agreed to complete the questionnaire and see the research assistant, 768 met additional research criteria. 415 agreed to be enrolled in the study, and 379 completed most of the 12 months of follow-up.

Patients were randomly allocated into one of two treatment tracks and followed for 6 and 12 months. The usual care (UC) track provided reminders about preventive care in addition to their usual visits with their physicians.  The intervention (INT) track had the usual physician visits, plus:

1. access to a "nurse care manager" (NCM) who provided advice and protocol-based medication changes,
2. Wireless uploads of glucometer readings into the EHR,
3. an EHR-based patient-specific summary "dashboard," that included risk scores, preventive care updates and a care plan,
4. web-based insulin, exercise & nutrition logs,
5. secure EHR-based messaging with the physician and NCMs and
6. patient-specific text and video offerings targeted by the NCMs.

The principal outcome measure was the A1c test, which is an indicator of overall blood glucose control. A level of 7 or lower is considered to be satisfactory control. At 6 months, INT patients statistically significantly decreased their A1c by 1.3 vs. 0.7 in the UC group.

At 12 months, there was still a difference favoring the INT group, but it did not achieve statistical significance: 1.1 vs. 0.7. 

Once the study was completed, the authors went back and looked at the proportion of patients that had decreased their A1c by at least 0.5.  At 6 months, it was 70% vs. 53% for  at 6 months, and 70% vs. 55% at 12 months for the INT and UC groups, respectively.  Both differences were statistically significant. 

Patients in the INT group were also more likely to lower their cholesterol, go through a medication adjustment, experience lower "treatment distress," have greater knowledge of their diabetes and be more satisfied with their care.  There was no difference in blood pressure control or the number of physician visits.  Overall health care costs or insurance claims expense were not measured.

Disease Management Care Blog take-aways:

You Want Evidence? Thanks to this high quality randomized controlled clinical trial conducted in a real world setting, the evidence base supporting the use of remotely placed nurse care managers continues to build.   Kudos to Palo Alto for simultaneously taking good care of their patients and conducting impressive research.

Patients At Risk: The combination of a) a steady percent of INT patients keeping their A1c 0.5 at 6 and 12 months plus b) a simultaneous overall average decline in the A1c makes the DMCB think that there was a subcohort of patients that "back-slid" and affected the group mean.  Commercial population health management service providers are working hard at prospectively identifying these higher-risk individuals for additional interventions.

Doing something is better than nothing: While the modest A1c decrease in the UC patients could have been due to regression to the mean, the DMCB wonders if they also benefited from being identified and monitored. 

Can Finally Point to Something Good About the EHR: While the EHR continues to disappoint in terms of consistently improving quality or reducing costs, this study demonstrates an important upside: it can be used to efficiently recruit potential research subjects.  Thats important because thousands of candidate patients are needed to find hundreds of study participants
 
Physician Utilization Did Not Decline: Unfortunately, this study did not address multiple measures of utilization, so the DMCB doesnt know what to make of any decrease in potential costs versus the cost of the the program.

ACOs Take Note: While the Palo Alto System is not representative of most health care settings in the U.S., it does hold important lessons for Accountable Care Organizations. Given their contractual responsibility to improve diabetes quality as well as managed insurance risk, this study says they ignore the potential of remotely-based and technology-backed nurse care managers at their peril