Sunday, May 27, 2018

Intermittent Fasting Can Benefit Weight Loss, Type 2 Diabetes and the Cardiovascular System

Investigations such as the Diabetes Prevention Program (DPP) trial and the Look AHEAD study have shown that a low calorie diet, physical activity of at least 150 minutes per week, and lifestyle modification can lead to beneficial weight loss. Both these studies highlight the importance of diet and physical activity. But it appears that diet is more important than physical activity – at least in the early stages of a weight loss program. Since diet is a key element in weight loss, weight maintenance, and overall health, a lot of research has gone into looking at different types of diets. One diet approach that has received much attention in the past years is the intermittent fasting (IF) diet.

Usually in the IF diet, an individual follows a very low or zero calorie plan for some days of the week, and a normal eating plan for the other days of the week. The IF diet has been shown to lead to weight loss, improvement in type 2 diabetes and cardiovascular disease. One very popular version of the IF diet is presented in the book, "The FastDiet," sometimes referred to as the 5:2 diet.

In the book, Michael Moseley, the author, concludes that a man, trying to lose weight, can achieve weight loss by restricting his diet to 600 calories a day for two days. And that a woman, trying to lose weight, can achieve weight loss by restricting her diet to 500 calories a day for two days. On the remaining five days of the week, both the man and the woman should eat normally. This form of IF is apparently effective for some individuals as indicated by the reviews of Moseley’s book on

Another version of IF is called alternate day fasting (ADF). In ADF, a person follows a very low calorie diet on alternate days of the week, while following a normal diet on the remaining days of the week. ADF may enable an individual to lose weight. Further, one study suggests that ADF might not only lead to weight loss, but the dieting approach can lead to improvements in type 2 diabetes.

And finally, a recent study has indicated that the 5:2 diet allows an individual to lose weight and lower the risk of cardiovascular disease. In fact, the study’s investigators “found that following weight loss, participants in the 5:2 group continue to eliminate fats (triglycerides) faster and more effectively than other volunteers. Scientists have also noticed a greater reduction in arterial systolic pressure associated with decreased risk of heart attack and stroke.”

So, healthcare providers might want to include IF among their weight loss tools. Not only could IF enable some patients to lose weight, but the weight loss approach might lead to improvement in type 2 diabetes and cardiovascular conditions.

Sunday, May 20, 2018

Why are US Healthcare Costs So High and What Can We Do about it?

Frequently, there are stories in the news related to the rising US healthcare costs, and the low quality of US healthcare compared to many other industrialized countries. It is often stated that US healthcare costs are high because of over utilization of healthcare services. But one study questions the validity of the over-utilization assertion as a reason for the high costs. Also, one approach to lowering the cost of healthcare in the US is gaining momentum. The approach is to form partnerships between healthcare organizations and community organizations to deliver healthcare services.

In 2014, The Commonwealth fund, a private organization that promotes high-quality healthcare, concluded that the US had the worst healthcare system among 11 developed nations. These nations were the United Kingdom, Switzerland, Norway, Sweden, New Zealand, the Netherlands, Canada, France, Australia, Germany, and the United States. Not only is US healthcare quality a problem, but the high cost of healthcare in the US is also a great concern.

So the US healthcare quality is poor and the cost is high. But is the cost high because of over healthcare utilization? At least one study concludes that the answer is no. The investigators assert that healthcare providers in the US are paid too much. US healthcare providers are paid twice as much as providers in some other countries.

Now some experts would argue that providers are paid more in the US because of the physicians' medical school debt. But according to the above-mentioned study, this is not the case. The investigators indicated that “taking into account tuition costs didn’t explain the difference in earnings.” This might mean that healthcare providers’ salaries should be lowered and that less expensive providers should be sought in many instances.

This also might mean that the move by some healthcare organizations to lower costs and improve outcomes by aligning themselves with community organizations might be a promising approach to the US healthcare cost and, perhaps, the quality problems. Medicare, for example, is partnering with the YMCA and other organizations to provide a diabetes prevention program (MDPP). The approach used to deliver the prevention program has been shown to be effective and less costly than the treatment offered in the normal clinical environment.

Partnerships between healthcare organizations and community organizations may be feasible for other illnesses – especially in the treatment of chronic illnesses such as obesity. In fact, the CDC is suggesting that more research be directed at community programs, such as Weight Watchers and Jenny Craig along with randomized controlled trials (RCTs), to come up with practical methods for dealing with overweight and obesity.

Friday, April 27, 2018

Primary Care Can Fight Obesity with the Help of the Community

In a recent post, we discussed the MDPP or the Medicare Diabetes Prevention Program. In our discussion, we indicated that the program’s purpose is to treat Medicare beneficiaries who are prediabetic. Further, we said that the program would be administered in community settings such as YMCAs. Based on past studies, it has been concluded that a partnership between healthcare organizations and community organizations can effectively address prediabetes in Medicare beneficiaries. This kind of partnership could also be cost effective in addressing obesity.

Cost-effectiveness is of the utmost importance in healthcare. Weight loss and weight loss maintenance are extremely difficult to accomplish. It requires frequent interventions with the obese individual. And it is costly for a healthcare provider, such as a physician, nurse practitioner or physician assistant to engage the patient in a way that causes the patient to lose and maintain weight loss on a long-term basis. This is where partnerships between healthcare providers and community organizations could make a difference.

Indeed, in an article entitled “Collaborations Between PCPs, Community, Needed to Tackle Obesity Epidemic,” a primary care physician indicated how he set up a weekly obesity class with community help. He used a high school coach to give weight loss related pep talks at each one of the weekly sessions. The physician said that 25% of the program’s participants lost at least 6 pounds during six months, and that he received Medicare reimbursements of $19,000 during the first year of the program.

The AAFP (American Academy of Family Physicians) recognizes the importance of partnerships between healthcare providers and the community. In an article entitled, “Integration of Primary Care and Public Health,” the AAFP indicated that “Family Medicine within the Primary Care specialties must co-align with the public health sector, two fields with a common interest yet functioning independently for the last century.”

Since obesity is one of the biggest problems facing our society, it makes sense to create relationships between healthcare organizations and community organizations to address the problem. These relationships will benefit PCPs, patients, and the community as a whole.

Tuesday, April 24, 2018

The Importance of Protein in Our Diet

We all know that macronutrients are important components of any diet. The macronutrients are protein, fat and carbohydrates. One must consider the quantities of these nutrients when trying to determine the most effective diet. Experts often delineate the amount of fats and carbohydrates that one should consume on a daily basis for good health. Some experts will weigh the merits of a low fat diet compared to a low carbohydrate diet for example. But while there is some question as to what a high or low protein diet is, with few exceptions, experts don’t often recommend a very low protein diet. That’s because there is agreement that protein confers many health benefits on an individual.

There are at least two ways to determine the amount of protein required for good health. It can be done with respect to body weight or with respect to daily food intake. With respect to body weight, the recommended daily protein allowance for a person is .8 grams of protein for each kilogram (2.2046 lbs.) of body weight. That means that for a sedentary woman weighing 140 pounds, the recommended protein daily allowance is a little over 50 grams of protein. With respect to daily food intake, a healthy diet should consist of between 10 and 35% of a person’s intake. 

A high protein diet is considered by some to be conducive to weight loss. In one study, consisting of 105 participants, 51 of the participants were on a standard protein diet, and 54 of the participants were on a high protein diet. It was determined that the high-protein participants lost more weight than the standard-protein participants.

Another study indicated that a 35% protein diet, which is considered to be a high protein diet, will lead to improved triglycerides. And in one study, the researchers reasoned that whey protein promoted weight loss in female patients who were regaining weight after gastric bypass surgery. Indeed, the researchers stated that “Whey protein supplementation promoted body weight and FM [fat mass] loss in women with long-term weight regain following RYGB [Roux-en-Y gastric bypass].”

Finally, in a study looking at protein intake for patients in ICU settings, it was found that critically ill patients (CIPs) often don’t receive the amount of protein needed to maintain health.  Investigators determined that “energy and protein intakes in CIPs are low, disproportionate to their requirements. Therefore, actual dietary intake records, individual dietary requirement calculation, and individual dietary planning in relation with the patients' disease and stress should be considered. Such an accurate nutritional care process can promote patient safety.”

Based on the studies mentioned above, both health care providers and patients should pay close attention to daily protein intake.

Monday, March 26, 2018

The Medicare Diabetes Prevention Program

The National Institute of Diabetes and Digestive and Kidney Diseases (NIKKD) conducted a study to determine if weight loss could prevent type 2 diabetes. The study was called the Diabetes Prevention Program (DPP). The researchers concluded that a relatively small amount of weight loss can prevent type 2 diabetes for those people with prediabetes. Because of positive results from the study and other studies related to the DPP study, Medicare will offer its own type 2 diabetes prevention program. That program is called the Medicare Diabetes Prevention Program (MDPP).

The Diabetes Prevention Program or DPP trial was initiated in 1996 by the NIKKD to determine if weight loss could be used to prevent type 2 diabetes in persons with prediabetes. The study was a randomized trial consisting of three groups. All three groups contained prediabetic subjects that were overweight but not obese. Results from the trials were reported in 2002.

Subjects in one of the groups received placebo treatment for type 2 diabetes treatment. Subjects in another group were given the diabetes drug metformin. And subjects in the third group were provided intensive lifestyle intervention, with the goal of a 7% weight loss using diet, exercise and lifestyle modification.

The specific goal of the study was to determine if individuals with prediabetes could avoid type 2 diabetes by losing 7% of their weight through diet, exercise, and lifestyle modification. Actually, all three groups lost weight. At one point in the study, the subjects in the intensive lifestyle group lost 15.4 pounds, compared to 5.5 pounds for the metformin treatment group, and about 2.2 pounds for the placebo  group.

During the 2.8 years of the study, it was found that the intensive lifestyle subjects experienced a 58% reduction in the incidence of type 2 diabetes, and the metformin group experienced a 31% reduction compared to the placebo group. And after ten years, the type 2 incidence "was reduced by 34% ... in the lifestyle group and 18% .. in the metformin group compared with placebo." Furthermore, another study, looking at results from the original DPP study and  a follow-on study called the DPP Outcomes Study (DPPOS), concluded that DPP treatment was cost-effective when compared to metformin or placebo treatment.

And finally, a study called the Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA  or DEPLOY, was carried out in  two YMCAs in greater Indianapolis. The researchers concluded that "YMCA wellness instructors can be trained to deliver a group-based DPP lifestyle intervention and achieve changes in body mass after 6 and 12 months that are comparable to the DPP study."

Based on the DEPLOY positive results, Medicare carried out its own test to determine if the DPP method could be cost effective for Medicare beneficiaries. The MDPP test program was implemented in 17 YMCAs in the U.S. Based on positive results from its study, Medicare decided to expand the program to all prediabetic Medicare beneficiaries who satisfy criteria established by Medicare. That program is set to start in April of 2018. The program is called the Medicare Diabetes Prevention Program or MDPP.

The program uses CDC trained coaches to engage with the beneficiaries to help them adhere to the guidelines of the program. The settings for the MDPP could be within a typical healthcare organization or within some community organization, such as the YMCA. Healthcare providers can refer Medicare beneficiaries to organizations offering the MDPP.

Since Medicare will reimburse organizations that provide the program, there is an opportunity for primary care physicians, who want to improve the outcomes of their prediabetic patients, to play an important role in their patients' care.

Thursday, March 22, 2018

It Is Possible to Lose and Maintain Weight Loss Long-Term

It is believed by most people that no one can lose weight and maintain weight loss long-term. Further, it is often stated that there is no way to predict who will be successful at losing weight. However, a long-term study, called the Look AHEAD study, showed that it is possible to lose weight and maintain the weight loss long-term. The study results also showed that it is possible to predict who will be the most successful at losing weight.

“The Look AHEAD (Action for Health in Diabetes) study [was] a multi-center, randomized controlled trial, designed to determine whether intentional weight loss reduces cardiovascular morbidity and mortality in overweight individuals with type 2 diabetes.” The study consisted of over 5000 subjects, and ran for about ten years.

It was found that for 42% of the persons, who lost at least 10% of their weight during the first year of the weight loss program, were able to maintain the weight loss for at least four years. Further, it was concluded that those participants who lost at least 5% of their body weight, at the end of the first month of a weight loss program, were more likely to lose at least 10% of their weight after one year compared to those participants who lost less than 2% of their weight at one month.

At any rate, it appears that providers should resist the temptation to tell people that weight loss and long-term weight-loss maintenance are virtually impossible. It is possible to lose and maintain weight loss as the above mentioned study shows. And those individuals most likely to lose appreciable weight can be identified early in the weight loss program.

Finally, weight loss lessens the risk of negative cardiovascular outcomes. A study, which was a follow-on study to the Look AHEAD study, found that 85% of the Look AHEAD subjects experienced a significant reduction in cardiovascular events as a result of the weight loss. Although 15% of the subjects did experience negative outcomes, for those subjects, the negative outcomes may be associated with depression. Also, the subjects' "substantially poorer compliance with the exercise portion of the intervention" may have played a role in the negative outcomes.

At any rate, it is possible to lose weight and maintain the weight loss for a long period of time.

Monday, February 26, 2018

Weight Loss and Arthritis

Weight loss through diet and exercise may be an effective treatment for arthritis, specifically, rheumatoid arthritis and are osteoarthritis. First of all, there are important differences between rheumatoid arthritis (RA) and osteoarthritis. “RA is an auto immune disease. That means the immune system attacks parts of the body.” Whereas “osteoarthritis results from “wear and tear” on your joints ... .“ Osteoarthritis can result from injuries, age or obesity. Weight loss, or at least, maintaining a healthy weight can improve the symptoms of RA and osteoarthritis.

For a time, it was believed that obesity actually lowered the risk of death from rheumatoid arthritis. However, that belief may be in error based on one study. Indeed, maintaining a healthy weight may be warranted when a person has rheumatoid arthritis. One of the researchers of the study indicated that healthy weight loss may be beneficial to RA patients.

And with respect to osteoarthritis, one report suggested that "obese individuals have significantly more severe joint degeneration in the knees compared with normal weight or underweight individuals." Further, the report concluded that "Weight loss can prevent onset of osteoarthritis, relieve symptoms, improve function and increase quality of life."

And in another study, where 380 overweight men and women were investigated in a 96 months analysis, it was found that "cartilage degeneration was significantly lower among people who lost weight through diet and exercise or diet alone. [However,] weight loss through exercise alone showed no significant difference in cartilage degeneration..."

So, weight loss and maintaining a healthy weight can be beneficial in the treatment of arthritis. Healthcare providers can use this information in counseling sessions. The providers can advise patients that weight loss and weight maintenance can improve the symptoms of arthritis -- especially rheumatoid arthritis and osteoarthritis. Knowing that there is something that patients, suffering from arthritis, can do to relieve the symptoms of arthritis can be very helpful to the patients.


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