Cardiometabolic disease costs associated with suboptimal diet in the United States: A cost analysis based on a microsimulation model

Diet quality improvement and 30-year population health and economic outcomes: a microsimulation study

OBJECTIVE

Diets closer aligned with nutritional guidelines could lower the risk of several chronic conditions and improve economic outcomes, such as employment and healthcare costs. However, little is known about the range, order of magnitude and timing of these potential effects.

DESIGN

We used a microsimulation approach to predict US population changes over 30 years in health and economic outcomes that could result from a substantial (but not impossible) improvement in diet quality - an improvement from the third to the fifth quintile of US scores on the Alternate Healthy Eating Index, 2010 version.

SETTING

Risk ratios from the literature for diabetes, heart disease and stroke were used to modify the Future Adult Model (FAM) to simulate outcomes from a higher-quality diet. Model parameter uncertainty was assessed using bootstrap and sensitivity analysis examined the variation in published risk ratios.

PARTICIPANTS

FAM simulates outcomes for the US adult population aged 25 and older.

RESULTS

Improved diet quality initially leads to very small changes in chronic disease prevalence, but these accumulate over time. If diets improved beginning in 2019, after 30 years diabetes prevalence could be reduced by 5·9 million cases (11·5 %), heart disease prevalence by 4·0 million cases (7·2 %) and stroke prevalence by 1·9 million cases (10·3 %). These reductions in disease prevalence would be accompanied that same year by fewer deaths (88 000) and healthcare cost savings of $144·0 billion (2019 USD).

CONCLUSIONS

This microsimulation study suggests that improvements in diet are likely to improve health and economic population outcomes over time.

Health-care spending attributable to modifiable risk factors in the USA: an economic attribution analysis

BACKGROUND

There is a robust understanding of how specific behavioural, metabolic, and environmental risk factors increase the risk of health burden. However, there is less understanding of how these risks individually and jointly affect health-care spending. The objective of this study was to quantify health-care spending attributable to modifiable risk factors in the USA for 2016.

METHODS

We extracted estimates of US health-care spending by condition, age, and sex from the Institute for Health Metrics and Evaluation's Disease Expenditure Study 2016 and merged these estimates with population attributable fraction estimates for 84 modifiable risk factors from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 to produce estimates of spending by condition attributable to these risk factors. Because not all spending can be linked to health burden, we adjusted attributable spending estimates downwards, proportional to the association between health burden and health-care spending across time and age for each aggregate health condition. We propagated underlying uncertainty from the original data sources by randomly pairing the draws from the two studies and completing our analysis 1000 times independently.

FINDINGS

In 2016, US health-care spending attributable to modifiable risk factors was US$730·4 billion (95% uncertainty interval [UI] 694·6-768·5), corresponding to 27·0% (95% UI 25·7-28·4) of total health-care spending. Attributable spending was largely due to five risk factors: high body-mass index ($238·5 billion, 178·2-291·6), high systolic blood pressure ($179·9 billion, 164·5-196·0), high fasting plasma glucose ($171·9 billion, 154·8-191·9), dietary risks ($143·6 billion, 130·3-156·1), and tobacco smoke ($130·0 billion, 116·8-143·5). Spending attributable to risk factor varied by age and sex, with the fraction of attributable spending largest for those aged 65 years and older (45·5%, 44·2-46·8).

INTERPRETATION

This study shows high spending on health care attributable to modifiable risk factors and highlights the need for preventing and controlling risk exposure. These attributable spending estimates can contribute to informed development and implementation of programmes to reduce risk exposure, their health burden, and health-care cost.

FUNDING

Vitality Institute.

Perspective: Guidelines Needed for the Conduct of Human Nutrition Randomized Controlled Trials

Guidelines for designing, conducting, documenting, and reporting human nutrition randomized controlled trials (RCTs) have as yet to be developed and disseminated as reference for investigators, funders, regulators, institutions, assessors, trainees, and others involved in human nutrition research. Diet-related interventions can include diet and/or behavioral manipulation, provision of foods or entire meals, or delivery of dietary components in individual food items or supplements. This Perspective introduces a series of papers that outline core principles for the design and conduct of human nutrition RCTs, documentation and reporting of all aspects of clinical trial management, and data analysis and reporting of results. Human nutrition RCTs have unique considerations delineated in these papers. Conducting them with the highest scientific rigor is essential to the development of evidence-based dietary guidance for promoting optimal health and advancing health care.

Point-of-Decision Prompts Increase Dietary Fiber Content of Consumers' Food Choices in an Online Grocery Shopping Simulation

Only 5% of Americans consume the recommended amount of dietary fiber. In an online simulated shopping experiment, we examined whether a fiber-focused point-of-decision prompt (PDP) would influence consumers to choose food products that were higher in this important nutrient. We hypothesized that participants exposed to the dietary fiber PDP would choose products with more dietary fiber/serving than those who were not exposed to the PDP. The experiment was completed by 753 participants. Participants were randomly assigned to a condition in which they were not exposed to a PDP (the no-PDP condition), a personalized PDP, or PDP without personalization. Choices in the two PDP conditions were not significantly different. Therefore, the PDP conditions were pooled together into one condition and compared with control participants that did not receive the fiber-focused PDP. Across the three product categories, participants in the PDP condition chose products that had a greater amount of dietary fiber/serving (cereal: 22% increase; bread: 22% increase; crackers: 26% increase; p < 0.01) and products that had a greater healthiness rating (cereals (odds ratio (OR): 1.45, 95% confidence interval (95% CI): (1.10, 1.92)), bread (OR: 1.44, 95% CI: (1.09, 1.91)), and crackers (OR: 1.66, 95% CI: (1.25, 2.21)). Overall, the fiber PDP influenced participants to choose healthier products that contained greater amounts of dietary fiber.

Relationship between Dispositional Mindfulness, Psychological Health, and Diet Quality among Healthy Midlife Adults

Mindfulness, a practice of non-judgmental awareness of present experience, has been associated with reduced eating psychopathology and emotion-driven eating. However, it remains unclear whether mindfulness relates to diet quality. Thus, the purpose of this study was to examine whether dispositional mindfulness is associated with diet quality and to explore psychological factors relating dispositional mindfulness to diet quality. Community-dwelling adults (N = 406; M_age = 43.19, SD = 7.26; M_{body mass index [BMI]} = 27.08, SD = 5.28; 52% female) completed ratings of dispositional mindfulness, depressive symptoms, perceived stress, positive affect (PA), and negative affect (NA). Dietary intake was assessed using the Block Food Frequency Questionnaire, from which the 2015 Healthy Eating Index was derived. Analyses were conducted using the "lavaan" package in R with bias-corrected bootstrapped confidence intervals (BootCI). Age, sex, race, education, and BMI were entered as covariates in all models. Higher dispositional mindfulness was associated with higher diet quality (β = 0.11, p = 0.03), and this effect was mediated through lower depressive symptoms (indirect effect β = 0.06, p = 0.02, BootCI = 0.104-1.42, p = 0.03). Dispositional mindfulness was negatively correlated with perceived stress (β = -0.31, p < 0.01) and NA (β = -0.43, p < 0.01), as well as positively correlated with PA (β = -0.26, p < 0.01). However, these factors were unrelated to diet quality. These cross-sectional data provide initial evidence that dispositional mindfulness relates to diet quality among midlife adults, an effect that may be explained in part by less depressive symptomatology. Given that lifestyle behaviors in midlife are leading determinants of risk for cardiovascular disease and neurocognitive impairment in late life, interventions to enhance mindfulness in midlife may mitigate disease risk. Additional research assessing the impact of mindfulness interventions on diet quality are warranted.

Associations between Governmental Policies to Improve the Nutritional Quality of Supermarket Purchases and Individual, Retailer, and Community Health Outcomes: An Integrative Review

Supermarkets are natural and important settings for implementing environmental interventions to improve healthy eating, and governmental policies could help improve the nutritional quality of purchases in this setting. This review aimed to: (1) identify governmental policies in the United States (U.S.), including regulatory and legislative actions of federal, tribal, state, and local governments, designed to promote healthy choices in supermarkets; and (2) synthesize evidence of these policies' effects on retailers, consumers, and community health. We searched five policy databases and developed a list of seven policy actions that meet our inclusion criteria: calorie labeling of prepared foods in supermarkets; increasing U.S. Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) benefits; financial incentives for the purchase of fruit and vegetables; sweetened beverage taxes; revisions to the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package; financial assistance for supermarkets to open in underserved areas; and allowing online purchases with SNAP. We searched PubMed, Econlit, PsycINFO, Web of Science, and Business Source Ultimate to identify peer-reviewed, academic, English-language literature published at any time until January 2020; 147 studies were included in the review. Sweetened beverage taxes, revisions to the WIC food package, and financial incentives for fruits and vegetables were associated with improvements in dietary behaviors (food purchases and/or consumption). Providing financial incentives to supermarkets to open in underserved areas and increases in SNAP benefits were not associated with changes in food purchasing or diet quality but may improve food security. More research is needed to understand the effects of calorie labeling in supermarkets and online SNAP purchasing.

Cardiometabolic medicine - the US perspective on a new subspecialty

The high prevalence of cardiovascular disease and worldwide diabetes epidemic has created an ever-increasing burden on the healthcare system. This calls for the creation of a new medicine subspecialty: cardiometabolic medicine. Using information from review articles listed on PubMed and professional society guidelines, the authors advocate for a cardiometabolic medicine specialization training program. The curriculum would integrate relevant knowledge and skills of cardiology and endocrinology as well as content of other disciplines essential to the optimal care of cardiometabolic patients, such as epidemiology, biostatistics, behavioral science and psychology. Cardiometabolic medicine should be seen as an opportunity for life-long learning, with core concepts introduced in medical school and continuing through CME courses for practicing physicians. To improve care for complex patients with multiple co-morbidities, a paradigm shift must occur, transforming siloed education, and treatment and training to interdisciplinary and collaborative work.

Cardiovascular Healthcare Cost Savings Associated with Increased Whole Grains Consumption among Adults in the United States

Little is known about the potential health economic impact of increasing the proportion of total grains consumed as whole grains to align with Dietary Guidelines for Americans (DGA) recommendations. Health economic analysis estimating difference in costs developed using (1) relative risk (RR) estimates between whole grains consumption and outcomes of cardiovascular disease (CVD) and a selected component (coronary heart disease, CHD); (2) estimates of total and whole grains consumption among US adults; and (3) annual direct and indirect medical costs associated with CVD. Using reported RR estimates and assuming a linear relationship, risk reductions per serving of whole grains were calculated and cost savings were estimated from proportional reductions by health outcome. With a 4% reduction in CVD incidence per serving and a daily increase of 2.24 oz-eq of whole grains, one-year direct medical cost savings were estimated at US$21.9 billion (B) (range, US$5.5B to US$38.4B). With this same increase in whole grains and a 5% reduction in CHD incidence per serving, one-year direct medical cost savings were estimated at US$14.0B (US$8.4B to US$22.4B). A modest increase in whole grains of 0.25 oz-eq per day was associated with one-year CVD-related savings of $2.4B (US$0.6B to US$4.3B) and CHD-related savings of US$1.6B (US$0.9B to US$2.5B). Increasing whole grains consumption among US adults to align more closely with DGA recommendations has the potential for substantial healthcare cost savings.

A Mixed Methods Evaluation of a Randomized Control Trial to Evaluate the Effectiveness of the Pure Prairie Living Program in Type 2 Diabetes Participants

The primary objective of this randomized control trial was to evaluate the effectiveness of the Pure Prairie Living Program (PPLP) in a primary care setting. Adults with type 2 diabetes were randomized into intervention (PPLP, n = 25) and wait-listed controls (CON, n = 24). The PPLP group participated in education sessions. The intervention yielded no significant within-group changes in HbA1c at three-month (-0.04 (-0.27 to 0.17) and -0.15 (-0.38 to 0.08)) or six-month (-0.09 (-0.41 to 0.22) and 0.06 (-0.26 to 0.38)) follow ups in either CON or PPLP groups, respectively. Dietary adherence scores improved in the PPLP group (p < 0.05) at three and six months but were not different in the between-group comparison. No changes in diabetes self-efficacy scores were detected. In the qualitative analysis, participants described the program as clear and easy to understand. Knowledge acquired influenced their everyday decision making but participants faced barriers that prevented them from fully applying what they learned. Healthcare professionals enjoyed delivering the program but described the "back-stage" workload as detrimental. In conclusion, while some positive effects of the PPLP intervention were observed, they were not comparable to those previously attained by our group in an academic setting or to what the guidelines recommend, which reflects the challenge of translating lifestyle intervention to real-world settings.