A Presentation at Tools forHealthy Change for The Institute of Lifestyle Medicine 06/15/12 Stephan Esser MD www.esserhealth.com
Dollars and Sense: The Economics of Personal Choice Stephan Esser MD Institute of Lifestyle Medicine
Goals• Plant Seeds• Stimulate Dialogue• Harvest Ideas• Identify a Problem• Evaluate the Evidence• Unravel a Solution
Goals• Review the state of lifestyle-related disease in America• Understand the widening and graying of America• Unravel the related epidemic of chronic disease• Review the cost associated with management• Review the literature and identify possible benefits of LI
Lifestyle Medicine Therapeutic Intervention• Is it safe?• Is it efficacious?• Is it effective?• Is it cost effective?• Do the effects last?• How does it compare to conventional pharmacologic/surgical standards of care?
Foundational Questions• What are the most common chronic diseases?• How many people have them?• How much do they add to care costs?• Where is the most money spent?• Can LM improve health and save money?
A Paradigm Shift
“A global response to aglobal problem: the epidemic of overnutrition.” WHOIt is estimated that by 2020 2/3 rds of the global burden of disease will be attributable to chronic non- communicable diseases, most of them strongly associated with diet. The nutrition transition towardsrefined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other non-communicable conditions.Sedentary lifestyles and the use of tobacco are also significant risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and trade mechanisms, is necessary to address these matters.
Leading Causes of Death in US
Top Ten Causes of Death for Men in the United States
Actual Causes of Death in US
2 of 3
Associated Pathology• CVD: • Obstetrics: – Hypertension – Gestational DM – Congestive Heart Failure – Macrosomia – PVD – Inc. C Section rate – Impotence – Inc. Perinatal Morbidity – Inc. Pre/Eclampsia – Claudication • Cancer:• Endocrine: – Prostate – Diabetes – Colon DIABETES – PCOS – Breast – Hypothyroidism – Endometrial – Infertility – Renal Cell – Gallbladder• Orthopedics: – Esophageal Adeno. – Osteoarthritis • Other: – AVN • Hyperuricemia, Pancreatitis,• Hepatic: Gallstones, Sleep Apnea, Alzheimer’s, – #1 cause of liver dz in US Dyslipidemia, Metabolic Syndrome
Overweight ↑ risk of DM2 by 3 foldObesity ↑ risk by 9 fold
How did this Happen?
Perspective• We eat more – Sugar, Salt, Fat, Meat, Dairy – 1970-2006: • ↑ 24.5 % C/day ≈ 617K/day• We get less then ideal Physical Activity – 18.8% of adults achieved CDC reccs on Exercise – 10% of adults >65 y/o
Michelangelo’s David:12 month 20 city tour of the US
“A global response to aglobal problem: the epidemic of overnutrition.” WHOIt is estimated that by 2020 2/3 rds of the global burden Heart Disease of disease will be attributable to chronic non- Obesity communicable diseases, most of them strongly associated with diet. The nutrition transition towardsrefined foods, foods of animal origin, and increased High Blood Pressure fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other non-communicable conditions.Sedentary lifestyles and the use of tobacco are also significant High Cholesterol Diabetes risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and trade mechanisms, is necessary to address these matters.
The Problem1:9 adults
The Problem• High Blood Pressure: – 1 in 3 adults1:3 adults
Waist Circumference > 40” M > 35” W > 29% 34%Triglycerides > 150 HDL < 40 M or < 50 W of Americans BP ≥ 130/85 Fasting Glucose of ≥ 100
What we Know• Americans – Eat More – Exercise Less• 2012: – Obesity – Diabetes – Metabolic Syndrome – CV Disease
The Graying of America
The Graying of America
What we Know• Americans are: – Increasing in Width – Increasing in Age• The Result – Increasing Metabolic Syndrome – Increasing Diabetes – Increased Prevalence of “Heart Disease” – Increased Medication Use – Increased use of the Health Care System
HealthCare Spending = $2.7 trillion = 17.7% GDP
Associated Pathology• CVD: • Obstetrics: – Hypertension – Gestational DM – Congestive Heart Failure – Macrosomia – PVD – Inc. C Section rate – Impotence – Inc. Perinatal Morbidity – Inc. Pre/Eclampsia – Claudication • Cancer:• Endocrine: – Prostate – Diabetes – Colon – PCOS – Breast – Hypothyroidism – Endometrial – Infertility – Renal Cell – Gallbladder• Orthopedics: – Esophageal Adeno. – Osteoarthritis • Other: – AVN • Hyperuricemia, Pancreatitis,• Hepatic: Gallstones, Sleep Apnea, Alzheimer’s, – #1 cause of liver dz in US Dyslipidemia, Metabolic Syndrome
Top 35 leading diagnosis groups at ambulatory care clinics 1: Essential Hypertension 7: Diabetes Mellitus 15/17: Heart Disease
Number and rate of discharges from short stay hospitals 2009 2: Heart Disease 8: Strokes 11: Diabetes Mellitus 17: Essential Hypertension
Admission Diagnosis to Nursing Homes 2009 1: Disease of Circulatory System
What we know• Rising Tide: – Obesity – Lifestyle Related Disease – Population > 65 y/o• Healthcare Spending – All time High – Primarily on Chronic Disease
“A global response to aglobal problem: the epidemic of overnutrition.” WHO It is estimated that by 2020 2/3 rds of the global burden of disease will be attributable to chronic noncommunicable ……if…….Lifestyle is thediseases, most of them strongly associated with diet. Problem The nutrition transition towards refined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other noncommunicable conditions. Sedentary lifestyles and the use of What is risk factors. …….. A concerted tobacco are also significant the answer……..?multi-sectoral approach, involving the use of policy, educationand trade mechanisms, is necessary to address these matters.
Economics of LM• Corporate Wellness Models• Inpatient/Clinical Models• Contemporary Medical Studies
Motorola• Cost ≈ $6 mil/yr on wellness and work/life programs• Offerings: Health Screenings, Education, gym access etc• Cost-effectiveness: – $1 invested in wellness benefits, $3.93 saved – 2.4% increase in annual health care costs for participating employees vs 18% increase for non- participants – $6.5 million annual savings in medical expenses for lifestyle-related diagnoses (e.g., obesity, hypertension, stress) compared with non-participants
DaimlerChrysler• National Wellness Program – Targeted education programs, one-time workshops, multi-session classes, individual counseling, and self-directed modules, on-site services• Savings of: $16 per employee per month• Employees who completed one, two, or three health risk assessments on average had lower health care costs of $112.89, $134.22, and $152.29, respectively.• Employees who had completed at least one health risk assessment and participated in an additional wellness activity had an average cost savings of $200.35 per year.
Union Pacific• 1990: 29% spending on LR disease, $40mill.• The “Health Track Program”: Health Risk Assessment, follow-up intervention programs which are stage based, a Smoking Cessation Program called Butt Out and Breathe, over 500 contracted Fitness Facilities, an incentive program• 10 yr healthcare costs per employee decreased by 16%• 10% decrease in Health Care Costs due to Lifestyle Related Factors
Caterpillar• Healthy Balance Program: health assessment, risk stratification, individualized interventions, disease management phone counseling; serial tracking, online resources• Projected healthcare cost savings of $700 million by 2015.• To date reduced the aggregate health risk score by 6% for the "low-risk" population and 14% for "high-risk" subjects.• Participants who completed the high-risk program reduced their doctor office visits by 17%, and hospital days by 28%.
Northeast Utilities• 17% healthcare costs = Lifestyle related disease• WellAware program: financial incentives for participation, employees and spouses eligible, a health risk assessment, secondary coronary artery disease management program, phone contact and Internet site allows access at work and home, and a toll free hotline for materials and questions.• 1st 2 years: 1.6 return on investment, including a $1,400,000 reduction in lifestyle and behavioral claims and flat per capita costs for health care.• Participants demonstrated: 31% decrease in smoking, a 29% decrease in lack of exercise, a 16% decrease in mental health risk, a 11% decrease in cholesterol risk, an 10% improvement in eating habits, and a 5% decrease in stress.
Common Ground• Health Assessments• Risk Stratification• “High Touch”• High Tech and Low Tech• Family/Spouse Participation• Incentivization
Dean Ornish MD “Can Lifestyle Changes Reverse Coronary Heart Disease?”Lancet 1990 Regression of Atherosclerotic plaques $30,000 per patient in the first year “Intensive Lifestyle Changes for Reversal of Coronary Heart Disease” JAMA 1998 5 yr f/u showed continued atherosclerotic regression and ½ the rate of cardiac events “Angina Pectoris and Atherosclerotic Risk Factors in the Multisite Cardiac Lifestyle Intervention Program” AM J Card 2008 Reduced total health-care costs in those with By 12 weeks 74% were angina freecoronary heart disease by 50 percent after only one year “The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites” Am J Health Promotion 2010 Significant reductions in BMI/SBP/DBP/A1C/Tchol/LDL/Trig
Dean Ornish MD• High Mark BCBS : 2 years f/u post 1 year intervention• MI’s: 87 % in Ornish group, 48% for the control group.• Angioplasty: 84% in OG• Bypass Surgery: 80% in OG• Catheterizations: 64% in OG
Duke Rice Diet Program
Precedent• Pritikin et al. Effects of a high-complex-carbohydrate, low-fat, low- cholesterol diet on levels of serum lipids and estradiol AJM 1985 – 26 day inpatient stay 15-20% in TC• Pritikin et al Long-Term Use of a High-Complex-Carbohydrate, High-Fiber, Low-Fat Diet and Exercise in the Treatment of NIDDM Patients Diabetes Care 1983 – 26 day inpatient stay, 77% off Oral Hypoglycemics, 25% in TC• Effect of Short-Term Pritikin Diet Therapy on the Metabolic Syndrome Journal of Cardio-Metabolic Disease 2006 – 12-15 day stays, BMI 3%, SBP, SG, LDL 10-15% – 37% no longer met criteria for Metabolic Syndrome
58% Finnish Diabetes Prevention Trial Total 522: 172M 350W Av. age 55 Av. BMI 31 Randomized to standard of care or individualized lifestyle counseling“The reduction in the incidence of diabetes was Av. f/u 3.2 yrsdirectly associated with changesN in lifestyle” Engl J Med 2001;344:1343-50
Multi-Center Randomized Controlled Trialn=3234 non-diabetics w/ ↑plasma glucose3 Arms: placebo, Metformin (850BID), LifestyleInterventionLifestyle =7% weight loss/ healthy diet/150min wk exerciseAv. f/u = 2.8yrs Diabetes Incidence ↓’d by 31% in Metformin and by 58% in Lifestyle Intervention NEJM:2002
“Compared with the placebo intervention,the cost per QALY was approximately$1100 for the lifestyle intervention and$31300 for the metformin intervention.From a societal perspective, theinterventions cost approximately 8800dollars and 29,900 dollars per QALY,respectively. From both perspectives,the lifestyle intervention dominatedthe metformin intervention.”2005 intervention
Lifestyle Intervention was cost effective as compared to metformin 10 yrs: Incidence of diabetes reduced by 34% in the LM group and 18% in the metformin compared to placebo Cost Analysis: Direct medical costs of care outisde the DPP/DPPOS were least for lifestyle $24,563 vs $25,616 metformin vs $27,468 placebo Direct medical costs within the program were greatest for lifestyle $29,164 vs metformin $27,915 vs placebo $28,236 Features of Note: During DPPOS 60% of metformin and placebo groups participated in ≥ 1 LM session Calculated into costs travel to and from exercise and meeting, cost of exercise trainers, dietician, food, blenders, popcorn poppers etc… Diabetes Care April 2012
Participants: BMI ≥25, 3/5 components of Metabolic Syndrome Program: 12 weeks, 12-14 Sessions, 90 minutes each Results: 46.4% lost ≥5% and 26.1% lost ≥7% -87.5% and 66.7% sustained the In and 7%How Effective Were Lifestyle Interventions5% Real-WorldSettingsreduction, respectively, The Diabetes Prevention That Were Modeled On at the 6-monthProgram? Health Affairs 2012 reassessment. - 28 US based studies, Change in weight was similar regardless or more -43.5% experienced improvements in one of whether the interventionmetabolic syndrome component of was delivered by clinically trained professionals or lay educators. - 73.3% sustained this improvement at the 6-month reassessment.
30-day lifestyle modification program delivered by volunteers in a community setting. -5,070 participants (January 2006 to October 2009) -Outcomes: Reduction in body mass ( 3.2%), systolic anddiastolic blood pressure ( 4.9% and 5.3%, respectively), total cholesterol ( 11.0%), low-density lipoproteincholesterol( 13.0%), triglycerides ( 7.7%), and fasting plasma glucose ( 6.1%) p<0/001. Am J Cardiol 2011
CHIPIntervention: 28 video classes conducted in worksite, medical and community settingsSubjects: 763 middle-aged adults, ages 30–79 yearsFollow-Up: Four to 8 weeks after baseline
Robert Woods JohnsonNY Academy of MedicineTrust for America’s Health T2D, HTN by 5% = $5 billion annual savings T2D, HTN, CAD, Renal Dz, CVAby 5% = $19 billion annual savingsPrograms exist to achieve goals in2-5 years$10/person/yr1-2 yrs = $2.8 billion annually saved5 yrs = $16 billion ann. saved
What we know• What are the most common chronic diseases?• How many people have them?• How much do they add to care costs?• Where is the most money spent?
What we know• Lifestyle Interventions can be efficacious and effective• Lifestyle Interventions show great potential in reducing healthcare costs• Creativity is good
Remaining Questions• What are meaningful outcomes to measure?• What are the most effective/efficacious Lifestyle Interventions?• What are the most cost effective Lifestyle Interventions?• How and by whom are they best and most affordably delivered?
The Future• Broaden our knowledge• Advance the research• Expand the application• Engage creative models of care
References• http://aspe.hhs.gov/health/prevention• Prevention of Type 2 Diabetes Mellitus by Changes of Lifestyle Among Subjects with Impaired Glucose Tolerance. N Engl J Med 2001;344:1343-50.• Knowler, WC. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. NEJM 2002 Feb 7;346(6):393-403• Herman et al. The Cost-Effectiveness of Lifestyle Modification or Metformin in Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance. Ann Intern Med. 2005 Mar 1;142(5):323-32.• Crandall. J et al. The influence of age on the effects of lifestyle Modification and Metforming in Prevention of Diabetes. J Gerontol A Biol Sci Med Sci. 2006 Oct;61(10):1075-81.• Chopra M et al Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23.• www.cdc.gov/.../mmwrhtml/ figures/m846qsf.gif• www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf• Fox, Caroline. Et al. Trends in the Incidence of Type 2 Diabetes Mellitus: Circulation 2006:113;2914-2918.• http://meps.ahrq.gov/mepsweb/• http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf• http://care.diabetesjournals.org/content/early/2010/09/30/dc10-0879.full.pdf+html• http://www.ncbi.nlm.nih.gov/books/NBK91989/• http://meps.ahrq.gov/mepsweb/data_files/publications/cb11/cb11.shtml• http://www.cdc.gov/nchs/data/series/sr_13/sr13_169.pdfh• ttp://www.cdc.gov/nchs/data/nhds/2average/2009ave2_firstlist.pdfRankin, Am J Cardiol. 2012 Jan 1;109(1):82-6. Aldana et al., A video-based Lifestyle Intervention and changes in coronary risk. Health Education Research. 2008; 23:115-124.• Ali et al. How Effective Were Lifestyle Interventions In Real-World Settings That Were Modeled On The Diabetes Prevention Program? Health Aff January 2012 vol. 31 no. 1 67-75• Verhaeghe et al Effectiveness and cost-effectiveness of lifestyle interventions on physical activity and eating habits in persons with severe mental disorders : a systematic review Int Jrnl of Beh Nutr and PA 2011••
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