Time for Docs to Get Out of the Food Wars

In Food Fad Fantasyland, rotund patients can see their primary care physicians and discuss the merits of Atkins versus South Beach vs. [insert name here].  Armed with the latest nostrums, patients go forth and diet until the next twerk comes along.

Bleh.

While physicians and the for-profit care management vendors can disagree about many things, one thing they can agree on is the ability of their corpulent patients to swear by an endless number of diets.  Whether its "low carbs" or "Mediterranean" or "mini-fasts," docs and coaches alike are expected to not only endorse these fads, but deploy insider jargon like DMCB spawn watching the MTV Video Music Awards. Taylor Swift was crooning about... who?

Which is why, after reading this JAMA Viewpoint article, the Disease Management Care Blog agrees that it's time call a time-out.  It's also time for the DMCB primary care colleagues to exit.

The DMCB explains.

Drs. Pagoto and Appelhans point out that when it comes to weight loss and risk factor reduction, there is no research that convincingly proves that one dietary approach is superior to any other.  Outside of individual preference, the mix of nutrients makes no real difference.  Instead, say the authors, what's important is adherence.  In other words, once patients embark on their preferred diet, they have to stick to it.

Unfortunately, that message has been lost in the multi-billion dollar faddism that has come to dominate the food industry marketplace.

Skeptics will point out that getting persons to stick to a particular diet is a fool's errand.

Not so, say the JAMA authors. Pointing to the Finnish Diabetes Prevention Study, The Da Qing Diabetes Prevention Study and the Diabetes Prevention Program, they note that long-term behavior change that includes behavioral modification and lifestyle change is very possible. 

"Hear hear!" says the DMCB.

As most doctors are aware, most health insurers (including Medicare) don't really reimburse enough to meaningfully cover the true costs of life-style related counseling.  What's more, selective memory recall means that physicians generally remember just how often their counseling leads to their individual patients being as fat as ever.  Most of us physicians are not that good at coaching anyway.

Which is why the DMCB thinks dietary counseling should be outsourced outside of the doctors' offices.  The good news is that wellness and health promotion programs are becoming more adept at focusing on patients' adherence to lifestyle change, mostly by finding those with a willingness to change. It's then a matter supporting those individuals over the course of a year or more. 

This is just one example of the approach.  There are more to come.

The DMCB conclusion

1. Docs should be "agnostic" when it comes to one diet fad vs. another.  It's patient preference.  Next.

2. What really counts is adherence to long-term lifestyle change.  Since many physicians are not good at that kind of long-term coaching, better to let other programs offer their wares to insurers.  The key for these programs is to focus on lifestyle change for those patients who want it and can accomplish it.

More on Penn State's Wellness Woes and The Evolving Science of Evaluating Health Promotion Program Outcomes: There Is No Gold Standard

Aside from keeping up to date with work buddies, the Disease Management Care Blog doesn't really use LinkedIn all that much. But when "Support our Penn State Colleagues in their Fight to Prevent Coercive Junk-Science Wellness Programs" postings began to appear in a Discussions board, the DMCB couldn't resist. It rose in support of its alma mater (College of Medicine, '77) faster than a med-mal attorney can calculate a contingency fee.

 As noted in this prior DMCB posting, Penn State University launched a rather routine health promotion program that prompted some nasty and very public teaching faculty resentment. Calls for "civil disobedience" and sinister references to "eugenics" made the DMCB wonder how much of the reported push-back was mainstream employee opinion vs. mainstream media's biased reporting. That distinction didn't stop the LinkedIn board from running a mostly one-sided dialogue on the matter.

So, undeterred by the unfairness of so many vs. just one, the contrarian DMCB naturally jumped right in.  Among the issues raised:

The RAND Study on wellness casts doubts on the merits of employer sponsored wellness programs:

Actually, RAND found employer-sponsored programs lead to statistically significant increases in exercise levels as well as reductions in tobacco abuse and body weight.  To the disappointment of wellness vendors everywhere, however, these programs did not lead to statistically significant reductions in health insurance claims expense.  The ever-optimistic DMCB points out that that means that these health improvements occurred without an increase in health care costs.

While cost neutrality alone is good news, the DMCB also believes that an emerging generation of wellness programs will do a far better job of identifying persons with 1) actionable risk and 2) who are willing to take action.  By husbanding wellness resources for subpopulations where it will have the greatest "bang," program costs will go down and claims savings will achieve statistical significance.

The author of the widely quoted Health Affairs paper on the merits of employer sponsored wellness programs has back-pedaled away ("too early to tell") from her study's original conclusions.

Actually, the original Health Affairs paper said that the finding of a $3.27 return on every dollar spent is subject to:

 "(f)urther study.... to elucidate the time path of return on investment.... The assumption of a linear trend in savings from the beginning to the end of program evaluation may not reflect the reality of behavior change within organizations."

The point is that nuanced and calibrated conservatism is typical of excellent peer-reviewed research and, taken in context, the authors are being quite consistent in-print and on-air.  Academics will always say more research is needed.  Skeptics will over read that.

There are powerful arguments against the common wisdom that "wellness saves money," suggesting that the health promotion industry has been intentionally ripping employers off.

Actually, when it comes to wellness outcomes, there is no agreement on "the" measurement "gold standard." Without any consensus on which assessment approach (for e.g., this vs. this) is truly "better," only one thing is certain: much like the Betamax vs. VHS wars, the future owner of "the" standard stands to reap a consultant's bonanza. Until we declare a winner, assessing the truth will be a messy mix of triangulating on means, medians, confidence intervals, imperfect reference controls, suspect generalizability, human judgment, moving targets and evolving interventions.

What about [insert name of wellness program here] that is an obvious sham?

There have been women who have had mammograms with missed cancer, victims of car crashes who have died despite seat belts and times when the DMCB did something really dumb despite the advice of the DMCB spouse.  That doesn't mean mammogram, seat belts or advice are worthless.  The plural of anecdotes is not data.

Coda: By the way, the statistically significant "value of  0.05" is more of a consensus than a gold standard.  Why is a 5% chance that an observed result is not the result of randomness wiser than a 6% chance or a 4% chance?

Does Worksite Wellness Work? A Critical Look at the "Wellness Incentives In the Workplace" Article

A waste of money and
a basis for discrimination?

The answer to the "Does Worksite Wellness Work?" question depends on your frame of reference.

If you read this 2010 review by Baicker, Cutler and Song, you'll see that there are 32 peer-reviewed published studies from work settings that a) transparently described the intervention and b) used a valid parallel control group - persons who did not receive the intervention - as a comparison. When interventions like these were deployed, impressive reductions in medical costs and absenteeism like these were achieved in the intervention groups, compared to the groups that did not receive the wellness programs.

If you read this just-published 2015 review by Jill Horwitz, Brenna Kelly and John DiNardo, you'll see that it's possible to use a "conceptual framework" to completely trash the notion that worksite wellness programs offer any benefit.  Oh, and by the way, they also result in discrimination.

How is that you ask?

This framework asks:

1) Do employees with chronic conditions or health risks spend more?  The authors' answer is that most studies for most conditions indicate the answer is yes.

2) Do financial incentives change behavior? The authors' answer, based on a review of the literature, is that obese persons tend to gain weight and many persons who quit tobacco relapse.  The impact on high blood pressure and lipids is less certain.

3) Do health improvements lead to employer savings? The authors' brief three paragraph answer, based on two references (here and here), is "uncertain," "depends" and "erroneously assuming."

The authors also

a) point to the abundant literature that questions the relationship between "process" and "intermediate" outcomes (blood glucose testing or control in persons with diabetes mellitus) versus long-term outcomes (like mortality - an example is here),

b) note that aggressive treatment can lead to unintended consequences (an example is here), and

c) suggest that wellness programs disproportionately benefit persons from higher socioeconomic classes who suffer from less disease. It's frankly difficult for the Disease Management Care Blog to follow the authors' logic, but as it understands it, anything that benefits one segment of a population is a zero-sum loss for the remaining segment.

The DMCB's two-fold take:

1) The 2010 review examines state-of-the-art clinical trial data, while the 2015 "conceptual framework" interprets the underlying published literature and finds it wanting.  According to the framework authors, the value of any counseling is ultimately unproven.

Big deal. The DMCB would like to point out that a similarly conducted review of primary care (where there are no randomized control clinical trials), Medicare (a social experiment if there ever was one) and parachutes (to combat "gravitational challenges") could also conclude that there's no proof.

Bottom line: Lack of proof for a benefit is not the same as proof that there is a lack of any benefit.  What's more, the business persons that run worksite wellness programs know that evidence based medicine is necessary, but not sufficient.  They don't demand proof, they use reasonable assurance.  The 58% of large employers that are offering worksite wellness are using seasoned logic in a world of conflicting data.  Good for them.

2) The Homer Simpson-inspired DMCB doesn't quite "get" the framework's socioeconomic argument.  If persons from lower socioeconomic classes have a higher burden of obesity, diabetes, high cholesterol levels and poor fitness, anything that offers increased access to a higher level of care is not only good policy but a proportionately noble thing.

What's more, if worksite wellness results in no economic benefit and doesn't shift costs in any direction, how does that result in any discrimination?

While economic incentives in a zero sum game can be problematic, the DMCB believes that Horwitz, Kelly and DiNardo's logic is overlawyered worksite nihilism run amok. Their ultimate unspoken conclusion is that when it comes to employees, all should be treated to the same level of neglect.

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