Health for life

Before I leave the topic of vitamin B12 (yesterdays post: New Study Links Metformin To Cognitive Impairment, via inadequate vitamin B12), its important to know that you dont have to be taking metformin, or have diabetes at all, to risk a vitamin B12 deficiency.

The National Institutes of Health (NIH) say between 1.5% and 15% of the US population experience vitamin B12 deficiency. Most people over the age of 50 have such poor absorption of the vitamin that the NIH recommends older adults supplement with B12, either by eating fortified foods or taking dietary supplements.

From the NIH Office of Dietary Supplements:
Quick Fact Sheet on Vitamin B12
Professional Fact Sheet on Vitamin B12

Groups that may not be getting enough vitamin B12 or that have trouble absorbing it:

• Many older adults, who do not have enough hydrochloric acid in their stomach to absorb the vitamin B12 naturally present in food. People over 50 should get most of their vitamin B12 from fortified foods or dietary supplements because, in most cases, their bodies can absorb vitamin B12 from these sources.
• People with pernicious anemia whose bodies do not make the intrinsic factor needed to absorb vitamin B12. Doctors usually treat pernicious anemia with vitamin B12 shots, although very high oral doses of vitamin B12 might also be effective.
• People who have had gastrointestinal surgery, such as weight loss surgery, or who have digestive disorders, such as celiac disease or Crohns disease. These conditions can decrease the amount of vitamin B12 that the body can absorb.
• Some people who eat little or no animal foods such as vegetarians and vegans. Only animal foods have vitamin B12 naturally. When pregnant women and women who breastfeed their babies are strict vegetarians or vegans, their babies might also not get enough vitamin B12.

Low levels of vitamin B12 show up as numbness or tingling in the arms and legs, weakness, and loss of balance - symptoms similar to diabetic neuropathy. Other symptoms include constipation, loss of appetite, weight loss, soreness of the mouth or tongue, and megaloblastic anemia. And as we saw in yesterdays post, vitamin B12 deficiency affects cognition, leading to depression, confusion, poor memory, and dementia.

A vitamin B12 deficiency can be detected by a blood test. Also, an elevated mean corpuscular volume (MCV) in a blood test can indicate low B12 status and justifies measurement of serum B12 directly.¹
________¹ Diagnostic Value Of The Mean Corpuscular Volume In The Detection Of Vitamin B12 Deficiency, Scandivavian Journal of Clinical and Laboratory Investigation, February 2000.

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.”

The look of cooperation

Medicare continues to move forward with its PRQS "value-based" fee schedule modifier that will adjust physician payments up or down by 2% and 1%, respectively. 

As the Disease Management Care Blog understands it, 2013 physicians quality and cost data will be compared to peers, and the docs who are above and below the mean will be correspondingly financially rewarded or dinged starting in 2015.  While the American Medical Association continues to quibble over the details, this Affordable Care Act pay-for-performance (P4P) train has left the station.

Unfortunately for CMS, plenty of research suggests that it remains an open question whether PRQS will have much of an impact. For example, findings from this Ontario study indicate that incentives tend to reward physicians who have already achieved the quality thresholds, doing little for the docs who are behind.  Additional research shows physicians may not agree with the underlying methodology and distrust the reliance on insurers data, leading to a willful disregard of the incentives.  And then theres this expert survey that suggests that the effort it takes to achieve low single digit digit changes in income may be viewed as not worth the trouble.

The DMCB also thinks there may be another under-recognized issue at stake. While fee schedule changes in the 1% to 2% range can make a big difference to large hospital-physician organizations, that money, thanks to these organizations byzantine internal accounting and transfer pricing, is unlikely to trickle down in a meaningful way to their employed physicians paychecks. 

Ouch.

Physicians and P4P may turn out to be like cats and going for a walk.



Image from Wikipedia