Suboptimal Diet May Drive $50 Billion in Cardiometabolic Costs

Debra L. Beck

December 31, 2019

Of the estimated $276.3 billion spent yearly on the treatment of cardiometabolic disease in the United States, $50.4 billion is related to suboptimal diets, a new study concludes.

Researchers used a microsimulation model to estimate annual costs associated with the treatment of ischemic heart disease, stroke, and type 2 diabetes and found that $18.2% of those costs went to pay for care related to suboptimal intakes of 10 common dietary factors associated with cardiovascular benefit or harm.

"So, looking at the adult population from 35 to 85 and their consumption patterns, if they were to turn their consumption into what we consider the ideal diet for these 10 nutrients food groups that we describe in the paper, up to $50 billion in healthcare savings could be realized in terms of reduced need for cardiovascular and diabetes care," said senior author Thomas A. Gaziano, MD, Brigham and Women's Hospital, Boston, Massachusetts.

The study by Gaziano and colleagues, with first author Thiago Veiga Jardim, MD, PhD, also from Brigham and Women's, and co–senior author Renata Micha, PhD, from Tufts University, Boston, was published online on December 17 in PLOS Medicine.

On a per capita basis, annual diet-related costs of cardiometabolic disease were $301 per person. The largest annual per capita costs were attributed to underconsumption of nuts and seeds ($81 per person) and seafood omega-3 fats ($76 per person).

For "good" foods, optimal consumption amounts were something to strive for: more consumption for more benefit. For other food groups (red meat and sodium), decreased consumption was linked with more benefit, and the "optimal" amount was a maximum not to be exceeded.

In the case of nuts and seeds, the researchers estimate that Americans, on average, consume only about 19.5% of the optimal amount of 20 g/day.

On the flip side, eating too much red meat was associated with only $3 in costs per person. The consumption limit was low — just 14.3 g/day — and 37.5% of individuals were at or below that level. "The cardiometabolic risk associated with red meat is limited, so there isn't that much to gain from it," Gaziano explained.

For two "bad" foods — processed meats and sugar-sweetened beverages — the optimal consumption level was zero. "We found that 48% of the population were at zero for sugar-sweetened beverages, and 32% of the population avoid eating processed meats regularly," said Gaziano.

"There were some reductions in medical costs — mostly this means drug costs — but a large amount, about 80%, of the savings are from reductions in hospitalization for acute care, which would be mostly reduced risk of myocardial infarction and stroke," Gaziano explained in an interview.

Sara Machado, PhD, a health economist at the London School of Economics, who was not involved in the study, expressed an interest in better understanding the population-attributable risk related to diet and other factors.

"I think that unless we map out the attributable risk and cost of all the factors for cardiometabolic disease, we have to be a bit careful about how to interpret these results, because they leave 82% of costs related to cardiometabolic disease unstudied," she told theheart.org | Medscape Cardiology.

"And if we think about attributable risk, we're assuming here that only 18% of costs for cardiometabolic disease are really attributable to diet."

Grist for Policy Change?

Individual annual costs were stratified by cost type (acute, chronic, drug), and by sex, age, race, education, body mass index, and health insurance.

The highest individual costs were for men ($380), individuals aged 65 years or older ($408), blacks ($320), those with less education ($392), those with Medicare ($481), and those who had dual eligibility for Medicare and Medicaid ($536).

"On the policy level, we can see that there's a lot of money that's being spent on people not eating the right things in this country," said Gaziano.

"People who were older and poorer were more adversely affected by poor diets, and government was the major payer of much of these costs, which really makes the case that if we can use incentives that serve to encourage a healthier diet, the government should really think about getting behind that," he added.

One suggestion is to spend more on helping individuals, particularly those with lower incomes and at greater risk, afford healthier food choices.

"If Medicare and Medicaid is paying an extra $500 per person in healthcare expenditure, if that money was shifted towards programs that encourage improved healthy food choices, then it could be a revenue neutral exchange," explained Gaziano.

Machado thinks it's premature to assume that money spent reducing the $50 billion in diet-related spending would provide the best bang for the buck.

"To say a health policy intervention should zone in on these 18% of costs, we need to know what is driving the other 82%, because there might be more cost-effective policies with higher cost utility related to those other costs," she suggested.

"If there is low hanging fruit in the other 82%, that's where we should be putting the money," she said. She noted that there might be more benefit in providing preventive medications or other interventions.

Not a Simple Analysis

The researchers used a validated microsimulation model called CVD PREDICT to estimate costs related to suboptimal diets. The model uses updated longitudinal data on real people and considers their dietary habits and age-adjusted estimates of effect sizes for the association of different food and nutrients with heart disease, stroke, and type 2 diabetes.

"A lot of work went into this analysis to make sure that our estimates are as solid as possible, and taking account of all the risks and trends," noted Gaziano, a claim supported by the 22 supplements of supporting information that accompanies the article.

The 10 food groups considered (fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages, polyunsaturated fats, seafood omega-3 fats, and sodium) included those for which there was probable or convincing evidence for causal relationships to cardiometabolic health, either positive or negative.

Dietary consumption patterns were estimated using nationally representative data from multiple NHANES (National Health and Nutrition Examination Survey) cycles. Intakes were assessed from up to two standardized 24-hour dietary recalls per person to account for within-person variation. The authors note that this method is subject to recall bias and measurement errors and that it likely underestimated dietary consumption.

All dietary factors were adjusted for energy intake to reduce measurement error and to account for potential differences in body size, lean mass, metabolic efficiency, and physical activity.

Costs attributed to a particular dietary grouping were driven by two factors — the relative risk reduction per unit change in consumption, and how far an individual is from optimal intake.

Healthcare costs were collected from validated sources, including American Heart Association statistics, said Gaziano.

"The optimal consumption data came from an analysis from our Tufts group that looked at a series of nutritional surveys and studies where they followed different populations and saw no additional benefit in a reduction in risk for CV disease beyond that amount of intake," explained Gaziano. Further consideration was given to feasibility and consistency with major dietary guidelines.

The researchers were clear that theirs is not a cost-effectiveness study but rather an attempt to provide estimates of the potential healthcare savings based on a hypothetical situation of optimal intakes. As such, they did not consider the implementation costs or feasibility of achieving said intakes.

The investigation was conducted as part of the Food Policy Review and Intervention Cost-Effectiveness (Food-PRICE) Project and was funded by the National Institutes of Health. Gaziano reported research funding from Novartis unrelated to this work and personal fees for consulting from the World Health Organization and Amgen, both outside the submitted work. Micha is principal investigators of a research grant from Unilever on an investigator-initiated project to assess the effects of omega-6 fatty acid biomarkers on diabetes and heart disease.

PLoS Med. Published online December 17, 2019. Full text

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