1. A Presentation at Tools for
Healthy Change for The Institute
of Lifestyle Medicine 06/15/12
Stephan Esser MD
www.esserhealth.com

2. Dollars and Sense: The Economics of
Personal Choice
Stephan Esser MD
Institute of Lifestyle Medicine

3. Disclosures
None

5. Goals
• Plant Seeds
• Stimulate Dialogue
• Harvest Ideas
• Identify a Problem
• Evaluate the Evidence
• Unravel a Solution

6. 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

7. 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?

8. 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?

9. A Paradigm Shift

10. “A global response to a
global 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 non-
communicable diseases, most of them strongly
associated with diet. 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 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.

11. Mortality Statistics

12. Leading Causes of Death in US

13. Top Ten Causes of Death for Men in the United States

14. Actual Causes of Death in US

15. 2 of 3

17. 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

18. Overweight ↑ risk of DM2 by 3 fold
Obesity ↑ risk by 9 fold

22. How did this Happen?

26. 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

27. Michelangelo’s David:
12 month 20 city tour of the US

28. “A global response to a
global problem: the epidemic
of overnutrition.” WHO
It 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 towards
refined 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.

29. The Problem
1:9 adults

30. The Problem
• High Blood Pressure:
– 1 in 3 adults
1:3 adults

31. 1:6 adults

32. 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

34. What we Know
• Americans
– Eat More
– Exercise Less
• 2012:
– Obesity
– Diabetes
– Metabolic Syndrome
– CV Disease

35. The Graying of America

36. The Graying of America

42. 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

43. Spending

44. HealthCare Spending = $2.7 trillion = 17.7% GDP

50. 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

52. Top 35 leading diagnosis groups at ambulatory care clinics
1: Essential Hypertension
7: Diabetes Mellitus
15/17: Heart Disease

53. Number and rate of discharges from short stay hospitals 2009
2: Heart Disease
8: Strokes
11: Diabetes Mellitus
17: Essential Hypertension

54. Admission Diagnosis to Nursing Homes 2009
1: Disease of Circulatory System

55. What we know
• Rising Tide:
– Obesity
– Lifestyle Related Disease
– Population > 65 y/o
• Healthcare Spending
– All time High
– Primarily on Chronic Disease

56. “A global response to a
global 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 the
diseases, 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, education
and trade mechanisms, is necessary to address these matters.

57. =
+

58. Economics of LM
• Corporate Wellness Models
• Inpatient/Clinical Models
• Contemporary Medical Studies

59. 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

60. 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.

61. 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

62. 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%.

63. 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.

64. Common Ground
• Health Assessments
• Risk Stratification
• “High Touch”
• High Tech and Low Tech
• Family/Spouse Participation
• Incentivization

65. Inpatient/Outpatient/Clinical Models

67. 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 free
coronary 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

68. 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

69. Duke Rice Diet Program

71. 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

72. Additional Studies

73.  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 yrs
directly associated with changesN in lifestyle”
Engl J Med 2001;344:1343-50

75. Multi-Center Randomized Controlled Trial
n=3234 non-diabetics w/ ↑plasma glucose
3 Arms: placebo, Metformin (850BID), Lifestyle
Intervention
Lifestyle =7% weight loss/ healthy diet/150min wk exercise
Av. f/u = 2.8yrs
Diabetes Incidence ↓’d by 31% in Metformin
and by 58% in Lifestyle Intervention
NEJM:2002

77. “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, the
interventions cost approximately 8800
dollars and 29,900 dollars per QALY,
respectively. From both perspectives,
the lifestyle intervention dominated
the metformin intervention.”2005
intervention

78. 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

79. 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-World
Settingsreduction, respectively, The Diabetes Prevention
That Were Modeled On at the 6-month
Program? 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.

80. 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 and
diastolic blood pressure ( 4.9% and 5.3%, respectively), total
cholesterol ( 11.0%), low-density lipoprotein
cholesterol( 13.0%), triglycerides ( 7.7%), and fasting plasma
glucose ( 6.1%) p<0/001.
Am J Cardiol 2011

81. CHIP
Intervention:
28 video classes conducted
in worksite, medical and
community settings
Subjects: 763 middle-aged
adults, ages 30–79 years
Follow-Up: Four to 8 weeks
after baseline

82. A Pause

83. Robert Woods Johnson
NY Academy of Medicine
Trust for America’s Health
 T2D, HTN by 5%
= $5 billion annual savings
 T2D, HTN, CAD, Renal Dz, CVA
by 5%
= $19 billion annual savings
Programs exist to achieve goals in
2-5 years
$10/person/yr
1-2 yrs = $2.8 billion annually saved
5 yrs = $16 billion ann. saved

84. 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?

85. What we know
• Lifestyle Interventions can be efficacious and
effective
• Lifestyle Interventions show great potential in
reducing healthcare costs
• Creativity is good

86. 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?

87. The Future
• Broaden our knowledge
• Advance the research
• Expand the application
• Engage creative models of care

88. Thank you!

89. 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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