All posts by blackfriar

healthy habits, nutrition, quantified self, rapid learning health systems

PACT – tool to motivate exercise

Larger fines fund smaller rewards. Perfect!

http://www.medicalobserver.com.au/news/money-a-motivator-in-exercise-app

Money a motivator in exercise app

6th May 2014

Dr Rosemary Atkinson   all articles by this author

PACT is a good tool to recommend to the techno-savvy patient needing motivation to get out and moving.

Created by a pair of Harvard students, it purports to help 92% of users live a healthier life by using money as a motivator.

Pact requires users to set the number of exercise sessions they will complete in the coming week. They then agree to a fine ($5–50) for every session they miss. Those who meet their goals are rewarded by receiving money paid by those who fail (25–60 cents per workout).

In order to verify that the exercise is being done, visits are logged at a gym via GPS check through the app, or for physical activity outside of a gym by measuring activity with a ‘motion tracker’, or in conjunction with partner apps such as Run-Keeper, Fitbit, Jawbone Up, MapMyRun or MyFitnessPal.

Users can access the number of workouts completed and money earned via the profile page. The settings screen allows you to set and modify your workouts for the next week, withdraw rewards and schedule a break.

Pact uses a carrot and stick approach to promote positive behaviour change and although the monetary reward is small, it may be enough to provide motivation for at least a proportion of patients.

App: Pact

Cost: Free 

Compatibility: iPhone, iPod touch, iPad

Requirements: iOS 6.0 or later

Registration required: Yes 

The verdict: 3 stars

1=optional 2=useful 3=recommended 4=must have

iTunes: https://itunes.apple.com/au/app/pact-earn-cash-for-living/id456068701?mt=8

facts & data points, health market quality, healthcare, policy, politics, rapid learning health systems

Anne-marie lays down the case in The Conversation

 

 

http://theconversation.com/the-state-of-australia-health-25920

The state of Australia: health

We’re unlikely to solve persistent challenges to the health system, such as ensuring equitable access to well-coordinated care, with quick fixes. AAP Image/Quentin Jones

In the lead-up to the budget, the story of crisis has been hammered home, but there’s more to a country than its structural deficit. So how is Australia doing overall? In this special series, ten writers take a broader look at the State of Australia; our health, wealth, education, culture, environment, well-being and international standing.

In the lead up to this year’s federal budget, the government has been telling us short-term budget pain is needed to secure our long-term economic future.

The release of the National Commission of Audit report last week reinforced the government’s message that we need to do something more than tinker around the edges to get our economy back into shape.

But is Australia’s health system so bad it needs some kind of shock therapy to ensure it meets our future needs?

How are we doing now?

In 2011-12, Australia spent 9.5% of GDP on health, just higher than the OECD average of 9.3%. Twenty years ago, Australia spent 7.1% of GDP on health, which was about the OECD average. These figures somewhat undermine the argument that we have a crisis in health spending.

When you take a look at the headline indicator for health status, life expectancy, Australians are doing fairly well by global standards. In 2011, the average life expectancy for all Australians was 82 years, making us the seventh longest-living people among OECD nations.

There are some concerns, however, that we might not be living such long lives in the future. In 2011, Australians drank a little more alcohol than the OECD average (ten versus 9.3 litres per person per year). And we’re also a lot fatter: 21% of the population report being obese, compared with an OECD average of 15%.

While these indicators and global comparisons are useful high-level measures of our health system’s effectiveness, we need to get beyond averages to find the true picture.

 

More Australians are obese than the OECD average. Olivier Le Moal/Shutterstock

 

Most people know – whether from personal experience or just watching the news – that our health system does not serve us all equally well. Some people cannot get access to essential health care, such as pharmaceuticals, general practitioners or dentists, when they need it simply because of cost.

Other people, especially those living in rural and remote areas, struggle to get access to services close to home.

And with some types of elective surgery and cancer services now predominately done in private hospitals, people without private health insurance can find themselves waiting for an excessively long time for treatment.

If the care you get depends to some extent on where you live, what you earn or whether or not you have private insurance, we have a problem with equitable access to care. And it’s a serious one too because there is strong evidence showing the people in most need of health care are the ones least able to afford it.

Getting timely access to care is one thing, but the quality of it matters too. In aninternational survey by the Commonwealth Fund, Australia’s performance was patchy on a series of quality measures.

When compared with seven other developed countries (including the United States, United Kingdom and New Zealand), Australia ranked sixth overall on a series measures looking at medical errors.

We ranked fourth on how well care was coordinated between different health professionals and third on how well care was centred around patient’s needs and preferences.

How we got here – past reforms

Medicare is the foundation of the Australian health system. The scheme, now 30 years old, is funded partly through our progressive tax system, and this is one of the key reasons our health system is considered to be relatively equitable. While Medicare has served us well, the time is right to consider reforms.

Medicare was originally developed to help people get access to basic medical and hospital care; in the 1960s when the scheme was conceived, most people suffered from relatively straightforward acute health conditions (infections, for instance, and traumatic injuries). Treatment from GPs, medical specialists and public hospitals was often all people needed to be cured.

Now, with more than seven million Australians having at least one chronic disease, people’s health needs are more complex. For some, a basic level of care might mean being treated by a GP, physiotherapist, dietitian, occupational therapist and an array of medical specialists. Medicare now funds a limited range of non-medical services, but much of what people need still falls outside its scope.

 

Australia’s 30-year-old Medicare system needs reform. AAP Image/Dave Hunt MEDICARE

 

Medicare also works on an insurance model, with patients reimbursed for each visit to the doctor, and doctors paid largely on a fee-for-service basis. This model works reasonably well for one-off visits to the GP, but provides few incentives for health-care providers to work co-operatively and ensure patients receive coordinated care.

Over the last 20 years or so, federal and state governments have tried many different ways of improving the coordination of care. Some focused on reforms to financing health care, for example, the coordinated care trials of the 1990s.

Others have tried to improve coordination by making changes to the governance of the health system at the local level – the more recent establishment of Medicare Locals is an example.

In some areas, the long struggle to improve the coordination of care is starting to pay off, but these successes have yet to be replicated cross the country.

What’s next?

The National Commission of Audit report recommended some major changes to the structure and operation of our health system, and a 12-month period to review some of the proposals it outlined. But before the government looks at them in any detail, it’s important to recognise the limits of what Medicare, or any health system, can do to improve the length and quality of people’s lives.

It is well established that health services are just one of many factors that influence health outcomes. Other important determinants of health include the social, economic and physical environment, and people’s individual characteristics and behaviours. To improve the health of Australians, governments will also need to make gains in some of these other areas that determine health outcomes.

Health systems, however, do have an influence on health outcomes. A large study of 136 countries found that there was a correlation between rates of death and certain health system variables. Countries with more doctors, lower out-of-pocket costs, and higher total expenditure, for example, had lower premature death rates at the national level.

 

When you take a look at the headline indicator for health status, life expectancy, Australians are doing fairly well. Mercy Health/Flickr, CC BY-NC-ND

 

While this study includes many less wealthy countries than Australia, it shows that the design and operation of our health system does matter, even to headline indicators such as mortality.

The Australian health system clearly has some problems that need to be addressed, but they are long-standing ones, and ones shared by most other OECD countries.

We are unlikely to solve persistent challenges, such as ensuring equitable access to well-coordinated care, with quick fixes (we have tried most of them before). Nor are they likely to be solved by reforms naïvely borne out of economic theory, or imported holus bolus from other countries.

To improve Australia’s health system, we need to carefully consider a range of reforms and evaluate their potential to solve the most important problems we face (and this is not overall health expenditure).

If we don’t, we will simply add to the growing pile of overly ambitious reform proposals that have fallen by the wayside and made no difference at all.

health market quality, healthcare, healthy habits, management and leadership, policy, politics, rapid learning health systems

Polypill Barriers

 

https://www.mja.com.au/insight/2014/16/polypill-barriers-remain

Polypill barriers remain

Nicole MacKee
Monday, 12 May, 2014
Polypill barriers remain

BARRIERS to the global availability of a polypill to prevent cardiovascular disease remain despite growing evidence of its clinical potential, according to former BMJ editor and long-term advocate of the polypill, Dr Richard Smith.

Dr Smith, who was in Melbourne last week to attend the Cardiovascular Combination Pharmacotherapy Global Summit, in conjunction with World Congress on Cardiology, said momentum was starting to gather with growing evidence of increased adherence and clinical benefit with the polypill — a fixed-dose combination of commonly used blood pressure and cholesterol-lowering medications, and aspirin.

“But in terms of actually getting it made available to lots of people, the progress is fairly slow because, although the big drug companies are the people who know how to get a drug on the market, they’re generally not interested”, Dr Smith told MJA InSight.

Dr Smith, director of the Ovations Chronic Disease Initiative, welcomed findings from the Single Pill to Avert Cardiovascular Events (SPACE) project that showed the polypill was associated with a 43% boost in patient adherence to medication at 12 months. (1) (2)

“That’s tremendously dramatic”, he said, of the research that was presented at the cardiology congress. “Generally, if you have people taking treatment for life … after a year [of starting therapy], you’ve only got about 50%̄60% of people [still] taking the treatment, so anything that can increase adherence is really important.”

The SPACE project, led by researchers from the George Institute for Global Health, analysed data from three clinical trials involving 3140 patients, including the Kanyini-GAP trial in Australia. (3)

Dr Ruth Webster, of the George Institute, said the polypill’s capacity to prevent cardiovascular events was “potentially massive”.

“In Australia, 50% of people who should be taking these combination medications don’t take them”, she said. “Globally at least 90% of people in lower income countries who would potentially benefit from these medications are not taking them.”

Dr Webster said the affordability of the polypill could ensure that its benefits were felt in low- as well as high-income nations.

“One of the key aims of the polypill has always been … to make it cheap so that patients can afford it”, said Dr Webster, adding that governments and health care organisations could use their buying power to ensure a cheap and effective pill was available globally.

Although a polypill is available in some Latin American and Asian countries, the UK, the US and Australia do not yet have one on the market.

Dr Webster said the George Institute was actively involved in efforts to have a polypill made available in Australia.

Dr Smith said that Iran was trialling providing the polypill to everyone over the age of 50 years who had at least one risk factor for cardiovascular disease. “The future is going to come not from Australia or Britain or the US, but from these kinds of countries, where … there’s much more to gain … as there are many people not being treated [at all]”, he said.

In addition to regulatory hurdles, cardiologists were also a barrier to polypill development, said Dr Smith, who recently wrote about the key barriers to polypill uptake in his BMJ blog. (4)

“[Cardiologists] think … that constantly titrating the drugs you give people, measuring their blood pressure regularly and their lipids … is a better way of doing things. But the problem is that we have this famous rule of halves — of all of the people at risk, half are not diagnosed; and of the half that are diagnosed, half are not treated; and the half that are treated, are not treated adequately”, he said. “So you end up with a very high proportion of people who are at risk who are not getting good treatment.

“The strongest argument for the polypill is how bad things are at the moment. Not just in low- and middle-income countries where, on the whole, they are terrible, but also in high-income countries because a lot of people are not getting adequate treatment.”

Dr Smith said the polypill had also faced opposition from public health experts concerned that giving people such a pill would discourage improvements in lifestyle and diet.

“But I think that’s a myth that’s been laid to rest because in three trials that have looked at lifestyle, people on the polypill don’t get fatter, they don’t smoke more, they don’t eat unhealthier diets”, he said.

1. Nature 2007; 450: 494-496
2. George Institute for Global Health: SPACE Project
3. BMC Public Health 2010; Online 5 August
4. BMJ Blogs 2014; Online 1 May

 

health market quality, healthcare, healthy habits, management and leadership, policy, politics, quotes & aphorisms, rapid learning health systems

Peter Baume on Money in Medicine

Former senator, doctor and colleague, Professor Peter Baume, used to say that:

“matters of principle usually turned out in politics to be matters of money, while matters of high principle usually turned out to be matters of lots of money.”

He could have been talking about matters of health policy.

Quoted by Steve Leeder

https://www.mja.com.au/insight/2014/16/stephen-leeder-policy-means-people

 

Stephen Leeder: Policy means people

Stephen Leeder
Monday, 12 May, 2014
Steve Leeder

SHOULD we pay more from our pockets for health care and less from the public purse?

What current institutions in health can we do without? Should prevention be a major concern of government or should it be left to the individual?

These questions should be addressed by a national government elected to oversee — among many things — the health of the nation.

Much health care in Australia is paid for from taxes. A long history explains why this is so, much of it expressing humane concern for people who are sick and assuring access to care for those who are not so well off financially.

Our politicians have choices — they can leave the health system as it is or they can try to change it by changing the underpinning policy. In seeking to make change they inevitably provoke the interest of those who stand to lose or gain as a result — doctors, nurses, patients, managers, insurers, pharmaceutical companies and many others.

So, whether they leave the system mostly in place and merely fiddle, or propose branch and root changes, politicians are engaging in policy decisions whether they recognise it or not (policy in this case being deciding how to apply resources available for health care).

These policy decisions affect people’s lives and are not trivial. For example, increasing theprivatisation of health care, as has been proposed in Queensland, carries costs for those least able to pay.

The more privatised the system, the less the needs of the poor and the marginal are met. This in turn means that society is changed and the values that it expresses — a fair go for all and concern for the weak — are hammered in the promotion of profit.

The results of a two-tiered health system are rapid access to quality care for the rich, who pay privately, and inferior care with long waiting times for the poor through a publicly funded safety net, a system well known in less developed countries.

Because it involves money, the health policy debate occurs in the context of other public policy discussions, most notably those that have to do with the Budget. Former senator, doctor and colleague, Professor Peter Baume, used to say that matters of principle usually turned out in politics to be matters of money, while matters of high principle usually turned out to be matters oflots of money. He could have been talking about matters of health policy.

As the word implies, policy has to do with the polis — the people. In a democracy the people expect their voices will be heard, alongside those of experts in health, the financial controllers and other interest groups. They also expect that changes to the system are canvassed with them before being announced and that they have a chance to have their say.

Optimally, a competitive, comprehensive statement of intent for health care would be provided by contestants for our vote at each election. This did not happen at the last federal election and we have not been canvassed about proposed changes.

Instead we have been bombarded in the past few weeks by government and the media about proposed cuts in tomorrow’s federal Budget, rumours of extinctions (eg, the Australian National Preventive Health Agency and Medicare Locals), increased costs to visit GPs and nothing much about our public hospital system.

It would be healthy if tomorrow’s Budget acknowledged the need for people-based health policy.

We should be presented with options that emanate from clear-headed policy thinking as well as a sound budget. The publication recently of the National Commission of Audit report is not reassuring. It focuses heavily on the supply side of the cost equation for health care but does not provide any insights into what can be done to achieve real efficiency through structural change. Instead, we just hear about rising charges through copayments and by forcing high-income earners out of Medicare and into private insurance schemes.

How to achieve more efficient (and generally more effective) care is left unconsidered. For example, in the Western Sydney Local Health District in the past 2 years, we have cut millions of dollars from our recurrent budget with an 8% increase in activity by attending to contracting, procurement and not using expensive part-time staffing from a budget of a mere $2.4 billion.

Let’s have less haste and hysteria, and more speed towards an efficient and humane health system, thank you.

 

Professor Stephen Leeder is the editor-in-chief of the MJA and professor of public health and community medicine at the University of Sydney. He chairs the Western Sydney Local Health District Board.

complex adaptive systems, cool, storytelling

LNL: The Reading Brain – Proust and the Squid

 

 

http://www.abc.net.au/radionational/programs/latenightlive/the-reading-brain/3276794

The reading brain

Wednesday 2 April 2008 10:40PM

The development of reading brought radical changes to the functioning of the human brain, as well as to the evolution of human society.

What does our move into a digital and visual culture mean for the brain and its capacity for transformation?

Guests

Maryanne Wolf
Professor of Child Development and Director of the Center for Reading and Language Development at Tufts University, Boston.

Publications

Title
Proust and the Squid: The Story and Science of the Reading Brain
Author
Maryann Wolf
Publisher
Harper Collins
Title
Proust and the Squid: The Story and Science of the Reading Brain
Author
Maryanne Wolf
Publisher
HarperCollins

Credits

Researcher
Sarah Kanowski
healthy habits, meaning, musings, nutrition, policy, politics

Katz on attitudes to wealth vs health

Lots of quotable quotes…

https://www.linkedin.com/today/post/article/20140330140626-23027997-health-wealth-and-wisdom-be-serious

Health, Wealth, and Wisdom? Be Serious!

March 30, 2014(Note: some content adapted for use in this column originally appeared on the Huffington Post on 3/9/12.)

As my newly published review article, “Can We Say What Diet is Best for Health?” makes the media rounds, some questions arise more commonly than others- and some are just more interesting than others. One that stands out in both categories is: what’s the problem? Why, if we really do (and yes, we really do!) have knowledge of the basic theme of eating that could do so much to promote health- adding years to life, and life to years– don’t we embrace it and put it to that excellent use for ourselves and those we love?

There are a number of answers, and different ones received particular emphasis in different interviews. But several of the most important start along distinct trajectories only to wind up at exactly the same place: money.

One such trajectory has to do with those entities – Big Food, Big Publishing, Big Pharma, Madison Avenue, Big Weight Loss industry- that profit enormously from the status quo. Many in this space would be well within the bounds of reason, if not propriety, to wish fervently for our dietary pseudo-confusion and related health travails to last forever. Maybe they do- but I won’t presume to say. I will say: it’s much about the money being made.

But it’s about our hard-earned, carefully tended money as well, and that’s the more interesting part of the story. Because if most of us in our culture treated our money and wealth in any manner vaguely comparable to how we treat our health we would be, in a word, morons. Or, at best, suckers. That’s the problem, right there. Fix this, and a world of opportunity would open up before us.

What’s the case?

Over nearly 25 years of patient care, I have seen — far too many times, painful to recall — people reach retirement age with nicely gilded nest eggs, and disastrously scrambled health. I have never met anyone seriously willing to trade their capacity to get out of bed for a large bundle of cash. I have known many people who would gladly give up large fortunes for the chance to get out of bed one more time, or get out of a wheelchair or be free of weekly dialysis.

But now we enter the Twilight Zone, where what’s real and important, and how we behave, part company. We value money (i.e., wealth) before we have it, while we have it and if ever we had it. We want it if we can’t get it. It’s a crime when someone takes it from us. We fight to keep it.

Health is more important, but most of us — and our society at large — value it only after it’s lost.

Consider that one of the more significant trends in health promotion is providing some financial incentive for people to get healthy. This strategy is populating more and more programs in both real space and cyberspace, and is incorporated into many worksite wellness initiatives.

I have no real problem with it — whatever gets us to the prize is okay with me. But it is… bizarre. We have to be paid to care about getting healthy.

Consider if it were the other way around. You could do a job, and you would get money for doing the job, but then you demanded an “incentive.” Money is not an incentive? No! We insist on being provided “health” to incentivize us to work for the sake of wealth. Unless you, my employer, can guarantee that working for you will help make me healthy, you can take this job and paycheck and…

Ludicrous, right? It doesn’t even sound rational to insist on getting paid in health to accept benefits in wealth. And yet, we all accept that it’s perfectly rational to require payment in wealth to accept benefits in health. We all accept it, that is, until health is gone, we realize what really mattered all along, and we say: What the %#^$ was I thinking? Too late.

I have a real problem with this, not because I want to be in charge of anyone else’s life, but because I know that people want to be in charge of their own lives. Once health is gone, so is control. Your life is governed by medications, procedures, doctor visits and emergencies. You are the very opposite of in charge.

Our society makes it quite clear that responsible adults take care of their money. They don’t spend it as they earn it — they put some into savings. They anticipate the needs of their children, and their own needs in retirement. Wealth — or at least solvency — is cultivated. If you neglect to take care of your budget and your savings, you are, in the judgment of our culture, irresponsible.

But our culture renders no such guidance for those who routinely neglect their health. Those who don’t have time today to eat well, but will have time tomorrow for cardiac bypass. Those who don’t have time today to exercise, but will have time tomorrow to visit the endocrinologist. Those who get, and apply, mutually exclusive recommendations dosed almost daily by daytime television. Prevailing neglect of health costs us dearly, individually and collectively, and it costs us both health and wealth. Being sick is very expensive — in every currency that matters: time, effort, opportunity cost, legacy and yes, dollars.

What if health were more like wealth?

  • If health were like wealth, we would value it while gaining it — not just after we’d lost it.
  • If health were like wealth, we would make getting to it a priority.
  • If health were like wealth, we would invest in it to secure a better future.
  • If health were like wealth, we would work hard to make sure we could pass it on to our children.
  • If health were like wealth, we would accept that it may take extra time and effort today, but that’s worth it because of the return on that investment tomorrow.
  • If health were like wealth, society would respect those who are experts at it- and not substitute the guidance from those who are not.
  • If health were like wealth, young people would aspire to it.
  • If health were like wealth, we would be serious about it.

But health is not like wealth. We venerate wealth, and all too often, denigrate health. People are routinely willing to lose weight fast on some cockamamie diet to look good for a special event. It’s not healthy, but what the heck? Well, it would be like cashing out your 401(k) to show up at the special event in a flashy car you can’t really afford. It would feel good for a day, and bad for the rest of your life. We know this, and responsible people don’t treat wealth this way. But we mortgage health to the point of foreclosure as a matter of routine.

Health is not like wealth. It is vastly MORE important. Just ask anyone who has one but not the other.

We are raised to aspire to wealth, while health is often left to languish in that space where stuff just happens. Wealth is its own prize; we need an incentive in another currency to recognize health as such. We watch sitcoms to laugh at get-rich-quick gullibility, then apply that very delusion ourselves to promises of get-thin-quick, get-healthy-quick, or stay-young-forever. We look to genuine experts for advice in almost any field, and certainly when it comes to managing our money- but if some Hollywood celebrity tells the world “I lost weight by eating only pencil erasers while being thrashed about the elbows with wilted artichoke leaves”- we get in line and reach for our credit cards.

To the extent we own wisdom or at least common sense, we are encouraged at every turn to apply them to our careers, and our bank accounts. But they lapse into a coma with every weight loss infomercial.

The result is an endless appetite for an unending parade of “my diet can beat your diet” contestants, rather than a sensible devotion to applying the fundamentals of healthful eating. It’s exactly analogous to frittering away all of our money on a comparable parade of get-rich-quick schemes, while ignoring the readily available, reliable information about sound investing. Or, if you prefer: it’s shopping for fiddles while Rome burns.

Wise is wonderful, but probably sets the bar too high. We could be both healthy and wealthy- or at least exercise comparable control over both- if we were just comparably sensible about both. We don’t even need to be wise to be healthy- we just need to be serious about it, rather than silly. What’s the problem? When it comes to eating well and being healthy, we are not serious people. Silly prevails.

-fin

Dr. David L. Katz has authored three editions of a nutrition textbook for health care professionals. He is editor-in-chief of the peer-reviewed journal, Childhood Obesity, and President of the American College of Lifestyle Medicine. He was commissioned by Annual Review in Public Health to write the review article, Can We Say What Diet is Best for Health? He is the author, most recently, of Disease Proof.

www.davidkatzmd.com
www.turnthetidefoundation.org

http://www.facebook.com/pages/Dr-David-L-Katz/114690721876253
http://twitter.com/DrDavidKatz
http://www.linkedin.com/pub/david-l-katz-md-mph/7/866/479/

Photo: Stefan Holm/Shutterstock.com

facts & data points, healthy habits, nutrition, policy

Katz on Butter

 

http://www.linkedin.com/today/post/article/20140327141338-23027997-bittman-butter-and-better-than-back-to-the-future

Bittman, Butter, and Better than Back to the Future

March 27, 2014

I generally appreciate the work and writing of Mark Bittman. But on one prior occasion, I was obligated to highlight his erroneous interpretation of an epidemiologic study about sugar, obesity, and diabetes. Mr. Bittman responded cordially and graciously when I pointed out his error, and more generally, his want of training or qualifications to offer up seemingly expert opinion to the public on research studies. I was pleased and gratified by the exchange that ensued between us, including a phone conversation and plans to meet for lunch, which alas, never came to fruition.

But old habits, it seems, die hard- and in this week’s New York Times, Mr. Bittman is indulging again in intellectual mission creep, with predictable consequences. While not trained as a chef, Mr. Bittman has established himself among the foodie elite, and is thus qualified to opine expertly on the culinary merits of butter. Or, at least, I am not qualified to say he is unqualified to do that- I defer to Jacques Pepin.

But Mr. Bittman is absolutely not qualified to assert the health effects of butter based on arecent meta-analysis I rather doubt he read in its somewhat excruciating detail. (In fact, he doesn’t even seem inclined to pretend he read it; he references the work several times, but in each case, the links he provides lead to someone else’s blog about the study, each reaching a conclusion- surprise- aligned with his own.) He should restrain himself from such inclinations to impersonate an expert, and the New York Times should set the bar higher. Experts should earn the rarefied real estate of New York Times pages only for their domain of actual expertise; the public probably expects, and certainly deserves, no less.

Mr. Bittman’s writing is, as ever, engaging and stylish. Overall, his column entitled “Butter is Back,” which turns out to be much about other things, such as limiting our overall intake of meat for ecological and humane reasons, is balanced, and thoughtful, and reaches generally reasonable conclusions about a diet of real foods, mostly plants – for the benefit of human health, our fellow species, and the planet alike. This is a topic near and dear to my heart, and one to which I have devoted considerable, recent effort.

But speaking of hearts, his conclusion that butter has now been exonerated of all harms formerly alleged is, in a word, wrong.

Since the study Mr. Bittman cites was about fatty acids, not foods, and only headlines in pop culture said anything about butter or cheese, we might begin with: what, exactly, are the saturated fatty acids in butter, and how did they fare specifically in the meta-analysis in question? I am betting you don’t know or care-but my point is, I bet the same of Mr. Bittman.

We could, perhaps productively, wade into just such weeds of the meta-analysis, but I’ve done that already, and see no value in redundancy here. My prior column is accessible to you. Note, as well, that colleagues have identified potentially quite important flaws in the actual analysis, the investigators themselves have conceded those flaws, and an outright retraction of the paper is at least being discussed.

But we can leave all of that alone and grind better grist altogether. Consider that the meta-analysis, even if sound, showed only that Western diets with lower and higher levels of saturated fat still produced roughly comparable levels of heart disease. It actually showed slightly less heart disease with lower saturated fat intake, but statistically speaking, that’s picking a nit, so we can let it go. Let’s accept that without addressing at all what replaces the saturated fat, a fairly typical Western diet produces about the same amount of heart disease whether higher or lower in saturated fat content. Substituting in Mr. Bittman’s leap of faith, this might mean that typical Western diets with higher or lower amounts of butter produce about the same amount of heart disease.

On this basis, Mr. Bittman says: bring back the butter.

Before you do, consider these points, in no particular order:

1) All ‘Western’ diets produce very high levels of heart disease, at least 80% of which has been shown to be outright preventable by a litany of studies spanning decades.

2) The new meta-analysis did NOT consider what was replacing the saturated fat in the diets of those who ate less, but others have told us that: mostly refined starch and sugar. Importantly, then, despite Mr. Bittman’s assertions that these are the ‘real’ culprits in our diets- diets lower in saturated fat did NOT show higher levels of heart disease, as we might expect if we were replacing a false culprit with the real ones (i.e., cutting saturated fat, adding sugar). So, the new study might just as well be interpreted to show that ‘adding sugar and starch to the diet in the place of saturated fat’ does not increase heart disease rates. So on what basis does this study indicate these are the ‘real’ culprits? Mr. Bittman just brought his preconceived notions along for the ride. (My view? Excesses of saturated fat, sugar, and refined starch are in on it together, and all still wanted for further questioning.)

3) The new study did show lower rates of heart disease with higher intake of omega-3 fat. There was a favorable trend with polyunsaturated fats in general, but this was not significant.

4) Overall, then, the study showed that some dietary fats can be beneficial to health, butsaturated fats as a class were not among them. The best the study said of saturated fats is:they don’t seem to make things worse than the prevailing status quo.

5) But to rephrase point 1: the status quo stinks!

6) Other studies have blown the status quo away. In his famous study years ago, Dean Ornish showed a relative 70% reduction in the rate of heart attack with a plant-based, low-fat diet that certainly did not feature butter.

7) Perhaps of more general interest: the Lyon Diet Heart Study showed exactly the same, impressive, relative 70% reduction in heart attack rates. But in this case, the intervention diet had no ascetic overtones; it was a Mediterranean Diet. The control diet, which resulted in standard –and thus appallingly high- rates of heart attack was a typical Western diet. But the Lyon Diet Heart Study, as the name suggests, was centered in Lyon, France- and conducted in European countries. The ‘typical’ diet was not American junk- it was the real-food diet of Northern Europe, dripping in, among other things, butter. Other Mediterranean Diet studies have shown much the same.

8) Combining point 7 with the new study could be said to show this: saturated fat (and therefore, maybe, butter) may not be bad for hearts and health compared to other things that are bad for hearts and health. But there is no evidence they are good for hearts and health. That hardly seems cause to start shmearing.

9) In contrast, a balanced portfolio of monounsaturated and polyunsaturated fats-characteristic of all of the world’s most healthful diets; particularly associated with the Mediterranean diet; and derived from foods such as olives, avocadoes, nuts, seeds, with or without fish and seafood- is decisively associated with lower rates of all chronic disease, dramatic reduction in the rate of heart attack, and reduction in the rate of premature death overall. And that’s without buttering it up.

10) Well, I guess I’m done. Just reread 1-9, and there you go.

I don’t think butter is poison. Go ahead and have some if so inclined. But do it for pleasure, not health. The new study was not about butter, but had it been, it could have concluded that there are things we can eat instead that are just as good, or just as bad. Either way, there was no hint that adding butter to our diets would improve our health. Since other studies do show us how to do just that, why would we settle for a lateral move, and stay mired in a place where coronary disease is practically a middle-aged rite of passage? There are places around the world that get the healthy living formula right where heart disease is all but unknown.

I have opinions about cuisine-but they are just opinions. I cannot, and do not, claim culinary expertise. Mr. Bittman, by popular affirmation, can-and I, like many of you, am happy to listen and learn when he does so. But he is no scientist, and when he forgets that, he becomes a potential danger to public heath, misdirecting his considerable influence, and exploiting the faith of his followers. When it comes to clear messaging about nutrition and health, we all should be a bit more careful about which side of the bread is being buttered, and who wields the knife.

If you don’t mind living in a world where everyone you know over age 50 is on multiple medications to fix what lifestyle as medicine could fix far better, by all means add back the butter. If you think it’s normal that most adults of a certain age have had their chests opened up or their coronaries ballooned open, butter away.

But we certainly know how to do far better than such variations on the theme of eating badly. Even in the home of the famous French paradox, replacing butter with olive oil –among other things- slashed rates of heart disease. In my unprofessional opinion, cold-pressed, extra virgin kalamata olive oil on fresh, whole grain bread is sublime. In my professional opinion, it’s good for me. I’m sticking with it for both reasons.

Butter is not, and never was, a singular nemesis– any more than sugar is, or wheat is. But butter never did our health any favors either- however it may treat our taste buds. Advice to add it back takes us back, not forward, to our nutritional future. We know how to do far better.

-fin

Dr. David L. Katz has authored three editions of a nutrition textbook for health care professionals. He is editor-in-chief of the peer-reviewed journal, Childhood Obesity, and President of the American College of Lifestyle Medicine. He was commissioned by Annual Review in Public Health to write the review article, Can We Say What Diet is Best for Health? He is the author, most recently, ofDisease Proof. He likes olive oil.

data saving lives, health market quality, policy, politics, rapid learning health systems

US Physician Payment Data

Great opener in this article:

The days of building electronic medical record software are over. Oh sure, EHRs will continue to get built, improved, “skinned,” perhaps even reimagined. But with the EHR incentive program beyond its peak, attention is shifting to other important aspects of the healthcare technology spectrum.

Really belies where these guys are coming from…

http://www.healthleadersmedia.com/content/TEC-303683/Physician-Payment-Data-is-Where-the-Action-Is

Physician Payment Data is Where the Action Is

Scott Mace, for HealthLeaders Media , April 22, 2014

 Look beyond the EHR incentive program. A national effort to turn CMS’s recent release of Medicare physician payment data into useful, actionable data visualizations is the hottest HIT challenge right now.

The days of building electronic medical record software are over.

Oh sure, EHRs will continue to get built, improved, “skinned,” perhaps even reimagined.

But with the EHR incentive program beyond its peak, attention is shifting to other important aspects of the healthcare technology spectrum.

Last week in this space, I described how entire communities are engaging in friendly competition to leverage the many digital breadcrumbs that make up today’s total population health picture.

The Way to Wellville effort is a five-year marathon. Health Datapalooza’s Code-a-Palooza is an opportunity for a variety of stakeholders, healthcare systems included, to step forward and compete in a national one-month sprint to turn CMS’s recent burst of Medicare physician payment data into useful, actionable information for patients and payers alike.

While this data gives patients the opportunity to compare and contrast physician-level data on charges, it is a lot of information to sift through.

That is the challenge for Code-a-Palooza entrants. A collaboration among Health Data Consortium, the ONC and CMS, developers are invited to use the newly released data to create a data visualization that improves consumer decision-making when it comes to selecting a physician or procedure, in turn helping to potentially reduce costs and increase value to the patient.

Health Data Consortium will award $35,000 to three top teams at Health Datapalooza on June 3.

To learn more, I spoke with Health Data Consortium CEO Dwayne Spradlin. Last year, Spradlin reminded me, an earlier competition used a specially prepared CMS data set that had not been made public. This year, for the first time, the competition is based on public data. That should drive lots of discussion, and no small amount of controversy.

Last year, the competition winner was a team of doctors who had coding chops. You never know where in healthcare such tech talent may be waiting.

“I would be floored, in fact, if we don’t have quite the diversity of individuals and teams registered,” Spradlin said.

I responded that there is this conventional wisdom that healthcare is so far behind the technology curve that mere doctors cannot be expected to be the leading technology innovators, but instead must be rescued by the rocket scientists, Wall Street quants and otherBrainiacs who populate so many venture-backed healthcare startups, parachuting in as if their ignorance of the healthcare system is some sort of advantage.

There may be some truth in such thinking. “There’s an adage in the field of open innovation, which is some problems are too big to leave to the experts,” Spradlin said. “Very often, if the expert in a particular field could solve a problem, they would have already.” So, will there be contenders from outside of healthcare? You bet.

And yet, Code-a-Palooza may continue to put the lie to this stereotype.

“You do need the people who are the subject masters to really come in and say take this data set from CMS and make it do things that really matter to healthcare,” Spradlin said.

But as Spradlin reminded me, last year’s winners “did not represent your father’s healthcare system. They were fearless, unafraid. They had been brought up in the develop arena as well. They saw a need to do some things differently.”

But just to set expectations, remember that the recently released CMS data is all about cost, not quality. The full matching set of quality data is locked up still somewhere in CMS, and since I understand the agency operates at least four separate data warehouses, it could be some time before we see a truly complete coding competition.

That will invite in the controversy, because just looking at cost without the associated quality measures is bound to be taken out of context by someone somewhere. To some extent, because the newly released data hasn’t been poured into apps as easy to use as Yelp, some of that controversy hasn’t erupted yet. And there’s always the possibility that a Yelp-style app won’t capture the nuance or the inherent value of a medical encounter. The ensuing outcry could simply be added to all the other perceived outrages of our public healthcare debate.

Still, Spradlin pointed out that in the initial flush of reportage after April 9, reporters and healthcare critics were able to go after apparently inflated costs.

“It took all of about a day for them to start finding which providers had the highest billing numbers,” Spradlin said. “But it certainly won’t be the last word.” Geographic variations, socioeconomic variables and other deep population analysis “may be the most interesting of all. Some of that could come out of this competition. People will be analyzing this data for months and months. I think the least interesting thing is actually what got published on April 10.”

Every time more of this data gets released, a network effect will kick in, with new opportunities to correlate previously-released data with the new.

In a world where consumers can spend five hours picking out their latest smartphone, and less than 20 minutes picking a physician, this kind of information will fundamentally change healthcare, Spradlin said.

“The AMA is right, in that there is a lot of context that’s important to understand,” Spradlin said. “As we get a little bit smarter, and the consumer population gets a little bit smarter about understanding and parsing a lot of this, we’ll get better at correlating the quality measures in these cases.

“I also think we could see some unexpected attempts at driving some that, even here. When you look at claims data, you can’t help but look at readmission rates. Are readmission rates potentially a strong signal of quality? I think for certain procedures, probably.”

Code-a-Palooza visualization proposals are due on April 25. (Don’t worry, the coding doesn’t all have to be done by then.) As competitors and other healthcare luminaries assemble in Washington June 1–3 and I’ll be there again to cover it—then the real fun begins.

Scott Mace is senior technology editor at HealthLeaders Media.