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An Ounce of Prevention

By Leslie Hast
July 2009

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According to the Centers for Disease Control and Prevention statistics, chronic diseases such as heart disease, cancer and diabetes are the leading causes of death and disability in the United States, accounting for 70 percent of all deaths – or 1.7 million each year. The good news is chronic diseases, the most common and expensive health problems, are largely preventable. Physicians will play a key role in attaining widespread effective prevention, which, for now, remains far in the future.

Shari Barkin, M.D., Marian Wright Edelman Professor of Pediatrics and chief of the Division of General Pediatrics, emphasizes the pressing need for prevention when considering pediatric obesity.

“If we’re effective at prevention,” she said, “we can change the frightening statistic that one in three children born in the year 2000 will have diabetes. We can change the frightening prediction that this generation of children will die before their parents. This is a time when we are the most technologically advanced, but we might reverse our life expectancy, completely counter to our notion of evolving as a species. If we continue to have obesity at the rates we do now, we won’t have a workforce that is healthy to maintain our economy. We won’t have a workforce that is healthy to participate in the military to defend our nation. People won’t be able to pass the test.”

F as in Fat, an obesity report from the Robert Wood Johnson Foundation, found that “if we keep on the current course, 75 percent of Americans will be overweight or obese by 2015.” The document ranks Tennessee No. 6 on its list of states with the highest obesity rates.

With obesity, the adage holds true: an ounce of prevention really is worth a pound of cure.

Juan Carlos Mondragon, holding his daughter, Leah, and his wife, Suyapa Flores, with daughter, Shayla, watch as Chef Majid “Magic” Noori prepares a healthy snack. The family participated in a Nashville Collaborative program to build skills and increase healthy lifestyles while decreasing pediatric obesity. Photo by Joe Howell.

Juan Carlos Mondragon, holding his daughter, Leah, and his wife, Suyapa Flores, with daughter, Shayla, watch as Chef Majid “Magic” Noori prepares a healthy snack. The family participated in a Nashville Collaborative program to build skills and increase healthy lifestyles while decreasing pediatric obesity. Photo by Joe Howell.

“Once someone is overweight, even if they can’t achieve their ideal weight, just a modest amount of weight loss does decrease the risk of a number of diseases. It does make a huge difference to stay at a manageable weight,” said Joan Randall, M.P.H., administrative director of the Vanderbilt Comprehensive Obesity Research Program.

“It took a long time for us to become this bad, and it will take a long time to turn it around,” Randall said.

The Physician’s Role
“It’s critical that primary care doesn’t disappear. Maybe decades down the line there won’t be such a need for it, but for the next several decades there will be, and even a larger role, for the primary care folks to help get a handle on this. I think primary care physicians have a huge role to play because people listen to them,” Randall said.

According to a 2008 Association for American Medical Colleges (AAMC) Center for Workforce Study, there will be a greater shortage in primary care than in any other specialty. “In fact, the projected shortage in primary care accounts for more than a third of the total projected shortage in 2025 (37 percent of the overall physician shortage, or about 46,000 fulltime equivalent primary-care doctors),” the study indicates.

Barkin said the pediatrician’s office is also a primary player in prevention.

“We have this great window of opportunity to bring up to the surface a level of awareness about how important parents are in their children’s health. We do have that opportunity to promote children’s health with information, with skills building,” she said. “We don’t in one large leap change anybody’s mind with information. It’s over time working in partnership together, demonstrating results in improved health that you change things.”

David Meltzer, M.D., Ph.D., warns that prevention on a broad scale won’t come cheaply.

David Meltzer, M.D., Ph.D., warns that prevention on a broad scale won’t come cheaply.

The Teaching Kitchen is a skills building program sponsored by the Nashville Collaborative, of which Barkin is executive director, and is a partnership between Nashville Metro Parks & Recreation and the Monroe Carell Jr. Children’s Hospital at Vanderbilt. While a physician can say children should eat healthy foods, the Teaching Kitchen actually shows parents how to prepare the foods and make them affordable.

While Barkin and Randall see the importance of primary care fighting on the front lines for prevention, Carlos L. Arteaga, M.D., sees an increasing need for specialization.

Arteaga, professor of Medicine and Cancer Biology and director of the Vanderbilt-Ingram Cancer Center Breast Cancer Program, said the history of medicine shows that physicians become increasingly specialized, and more specialization means better care.

A recent study—conducted for the American Society of Clinical Oncology (ASCO) by the AAMC’s Center for Workforce Studies—found that “demand for oncology services is expected to rise 48 percent between 2005 and 2020. During the same period, the supply of oncologist services is expected to grow only by 14 percent, translating to a shortage of between 2,550 and 4,080 oncologists.”

“Keep in mind that we have not seen a decline in cancer rates. We’re seeing a prolongation of survival of patients with all kinds of cancer,” Arteaga said.

Many studies are under way in cancer prevention, but even with the best prevention strategies cancer is inevitable in the long run because of DNA aging, Arteaga said.

“You’ve got to die of something. We can’t stop DNA turnover and aging; something has got to eventually go wrong,” he said. “Cancer is probably inevitable. It’s part of the process of aging. We’re going to live longer, and there will always be cancer that we will have to treat. Sometimes we’ll cure it, but other times we’ll turn it into a chronic disease. Somebody who is trained in cancer care, perhaps not a general practitioner, will have to take care of these folks.”

A Collaborative Approach
Whether specialized or focused on primary care, everyone can agree that the burden of prevention lies with more than just physicians.

“A medical sector is very important and necessary, but not sufficient,” Barkin said. “We have to include schools, food and beverage companies, the media and policymakers. Health is not in the hands of only physicians. Health is in the hands of you and me, of parents, of grandparents, schoolteachers, basketball coaches. This is a group effort.”

Randall is involved in the Tennessee Obesity Taskforce, which unites leaders from health care, the government, universities and the non-profit sector. It is charged with developing a viable state plan for obesity.

“The issue around these plans is that many of them are very, very good, but they have not included implementation or evaluation strategies. The goal is to develop a plan that’s not only great on paper but will make a difference because we have identified resources or organizations that have agreed to be accountable for making certain that very basic things, such as healthy food in the schools, are achieved, and, of course, then measured,” she said.

One of the biggest challenges in obesity prevention right now, Randall said, is the lack of evidence that programs are effective and sustainable.

Shari Barkin, M.D., says that pediatricians play a key role in prevention. Photo by Susan Urmy.

Shari Barkin, M.D., says that pediatricians play a key role in prevention. Photo by Susan Urmy.

“We only have promising practices that hopefully will work,” she said. “We don’t know, for example, if putting P.E. back in schools will make a difference. When I grew up, of course we had P.E. all the time and we moved around at recess, but we didn’t eat out for meals 40 percent of the time either, which the average American is doing now. So even if we get kids moving again, we don’t know what the impact will be because we don’t have data on that. There isn’t evidence that it’s going to work. Because of this lack of evidence, policymakers are reluctant to fund many of the policies that are being proposed.”

The Economics of Prevention
Prevention requires resources – both personnel and financial – and prevention on a broad scale won’t come cheaply, says David Meltzer, M.D., Ph.D., a leading health care economist at the University of Chicago.

“There are very few forms of real prevention that save money. Most prevention ends up costing money,” Meltzer said.

Those costs include the direct cost of the treatment along with costs incurred later because the patient lives longer.

If prevention is thought of as an investment, the way an investment is measured is its stream of returns, and most prevention efforts do not yield immediate returns.

“Sometimes you can see in short trials that if you’ve had a heart attack, lowering your cholesterol can make you healthier quite soon, but for many of these things, you’re preventing complications that are way in the future,” he said.

Meltzer has studied the stream of returns on intensive diabetes therapy and found that the average duration from the time a patient starts therapy to the time they actually see a lot of the benefits can be measured in decades.

Photo by Joe Howell

Photo by Joe Howell

“In the presidential election,” Meltzer said, “there was a period where a number of the candidates were very fond of talking about how prevention was going to save money and be the cure to our health care system’s problems. No way, not realistic. It’s not a realistic solution to controlling health care costs, but is it an important part of the health care system? Absolutely. Prevention is often a great form of health care, but it is not a form of cost containment.”

In the end, Meltzer, along with Barkin, Randall and Arteaga, insist that the true value of prevention is not in investment returns, saving resources or solving the physician shortage. It is in creating a healthy person who can make a significant contribution in life.

“Whatever the cost, it is going to be outweighed by the productivity of the individual,” Arteaga said. “That person is going to be able to raise a family, start a company, create new knowledge and capital, run a business, etc.”

Barkin often uses this observation of Frederick Douglass’: “It is easier to build strong children than to repair broken men.”

“If you look at where our spending is,” she said, “it is on a latter end, when health has gone wrong and disease has set in. We benefit the patient, the family and society by focusing on prevention.”

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