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A combination of diabetes, hypertension and dyslipidemia is the telltale sign of high risk
About 34% of adults meet the criteria for metabolic syndrome (MetS), a group of health conditions that put them at risk for diabetes, heart attack and stroke. And the prevalence of MetS is rising with the obesity epidemic in this country.
“A 2009 CDC (Centers for Disease Control and Prevention) report says that about one-third of the adults in this country meet the criteria for metabolic syndrome,” says Marc Jaffe, MD, clinical leader, Kaiser Permanente Northern California Cardiovascular Risk Reduction Program. “My suspicion is that these numbers underestimate the prevalence because in the last four years, we’ve become a little heavier, and we know that metabolic syndrome really correlates with obesity.”
“MetS” is a term used to describe patients with a combination of at least three of the conditions that put them at risk. The central-abdominal obesity risk factor is most concerning because overweight drives the other conditions. Obesity is the impetus for insulin resistance, and obesity and insulin resistance combined are the driving forces for the development of hypertension, diabetes and dyslipidemia.
“I’ve even seen some articles suggesting that maybe we should stop fixating on BMI [body mass index] and spend time measuring abdominal waist because there is such a strong correlation between the waist being greater than 40 inches in men leading to a much higher risk of diabetes,” says Derek van Amerongen, MD, regional chief medical officer for Humana of Ohio.
According to CDC, more than 68% of Americans-men, women and children-are overweight or obese, and public health officials consider it an epidemic. In fact, the American Medical Association recently declared obesity a disease.
“Obesity is the greatest risk factor for developing metabolic syndrome,” says Susan Kosman, RN, BSN, MS, chief nursing officer at Aetna.
In a screening program that Aetna conducted, it found that most of those with at least three criteria for MetS had a large waist circumference. Unfortunately, obesity is a complex disease in and of itself, which is tied into not only overeating, binge eating and lack of exercise, but also stress and depression.
“When you peel back the onion, there is more there than how many calories are in this cookie, and let me calculate whether I want to eat it,” Kosman says.
MetS is a warning system rather than an actual diagnosable disease with a diagnostic code, says Dr. van Amerongen.
Being told they meet the criteria for MetS indicates to patients that they are at risk for developing diabetes or having a heart attack or stroke, three of the top 10 killers in this country. But if they change their lifestyle early on, they can reduce the risk of these diseases.
“The good thing is we don’t have to invent some amazing or expensive treatment,” says Dr. van Amerongen. “It boils down to how do we get people to eat better? How do we get people to be more active, to stop smoking, and to manage their stress better? These are straightforward things.
“They are not easy. I don’t want to minimize how difficult they can be, but it is not like we need a brand new drug to cure pancreatic cancer or something like that. We already have the tools.”
Preventing the related diseases would go a long way toward lowering the overall cost of healthcare because the 1.5 million heart attacks and strokes that occur every year costs more than $312 billion in direct medical expenses and lost productivity, and diabetes cost about $245 billion annually. In addition, diabetes alone contributes to more than 231,000 deaths a year.
Each added risk factor for MetS a person has increases his or her healthcare costs by 25%.
“Beyond the health risks, the cost to individuals, employers and society is very high, which is why I think that there is so much concern about metabolic syndrome. We are talking about millions of people and the impact to the healthcare system and to the economy in general is substantial,” says Dr. van Amerongen.
Most employers are supporting wellness programs because they recognize that these health problems not only drive up insurance premiums, but drain productivity.
Even the best program or doctor won’t lower the risk factors unless patients are motivated and willing to do the work necessary to manage their health. Reducing these risks relies on people making lifestyle changes that enable them to lose weight, increase activity, reduce stress, and eat a nutritious diet.
But how do you motivate people to change their behavior? Van Amerongen says that everyone who provides care from doctors to insurers, and increasingly employers, struggle with this task.
The first step is getting individuals tested so they know their risks. But then, they need to understand the meaning of these numbers. It does no good to just tell a man his triglycerides are over 180 mg/dL. He needs to know what triglycerides are, how they put him at risk for a heart attack, what a normal level should be, and ways he can lower them.
To this end, Aetna has developed the Metabolic Health Advisor, which not only encourages members to be screened for MetS, but also helps members understand what the results mean to them and how they can lower their risk factors. Experts says that education is the key to making lifestyle changes.
Ultimately, that education should be life-long, and children should be learning about what constitutes a healthy lifestyle. They should be encouraged to eat healthy foods and exercise and be provided a safe environment to do so.
“We can talk about this when you already have heart disease and diabetes,” says Dr. Jaffe. “Or we can talk about it when you are at risk for developing heart disease and diabetes. But even better, would be to talk about this before you have metabolic syndrome. And that means talking to everybody.”
Preschool is not too early to talk about healthy lifestyle and wellness. In fact, communities, government and healthcare stakeholders are increasingly driving active-lifestyle programs for younger children.
“This is education that needs to be done from an early age,” says Dr. van Amerongen. “We need to do a better job about educating children and parents about what good nutrition is and what a good activity level is.”
Education must be done on a variety of levels and delivered in many different ways because individuals learn differently and react to different motivators. Some individuals like social media, others like one-on-one learning or support groups. Still others read brochures and booklets or visit websites. The Play 60 campaign by the National Football League is just one example of an engagement tool with a wellness message.
“One of the challenges we have is how do you keep messages fresh? How do you keep them understandable, and how do you make sure they relate to people’s lives?” Dr. van Amerongen says.
Typically insurers have many programs that promote wellness and help people live healthier lives from classes to coaches and nurses that are available for telephone consultation, but several stand out. For example, Aetna recently launched Metabolic Health in Small Bytes, which is an online program that uses a virtual classroom where participants can interact with each other and the instructor.
The program was developed after a research study that Aetna did with Duke University. In 2011, more than 600 Aetna employees participated in a 10-week study and were randomly assigned to one of the Small Bytes groups. They found that overall, participants lost an average of 8 pounds during the program and saw a reduction in BMI. They also saw improvements in activity and productivity.
The HumanaVitality program is a comprehensive wellness initiative that addresses all aspects of wellness, including the prevention of MetS. HumanaVitality is focused on physical activity, education, health screenings, tobacco cessation and nutrition. The effects of HumanaVitality are verifiable because it is a data-driven, empirical program, according to Dr. van Amerongen. The program offers incentives to motivate people to achieve their goals and enables them to connect online, by telephone or in person.
“It is very easy to tell someone to stop smoking and lose 50 pounds, but we need to customize that information into personalized paths that can help people make changes and improve their lives,” says Dr. van Amerongen.
Another issue with managing MetS or cardiovascular disease and diabetes is the disconnect when many clinicians and caregivers often are involved with a single patient’s care. He or she will see a primary care physician, a cardiologist, an endocrinologist, and maybe, a nutritionist and diabetes educator. This makes it difficult for comprehensive care coordination and patient evaluation.
The insurers hope that the patient-centered medical home and accountable care organizations, along with the push toward electronic medical records will help make sure that physicians see the total healthcare record and know the results of all tests and what medications the patient is taking.
Until that time, they say, it is incumbent on the patient to communicate their entire history.
The rates of obesity, heart disease and diabetes in this country are staggering and to really change them will take a concerted effort by public health officials, insurers, doctors, nurses and educators, as well as employers and individuals, these experts tell Managed Healthcare Executive.
“Metabolic syndrome is an important problem that we need to address globally as a community,” explains Dr. Jaffe. “The cornerstone must be the focus on lifestyle changes. We are talking about prevention, and the most effective method will be a partnership among individuals and their healthcare delivery system, as well as, the community that allows and encourages healthy lifestyle choices.”
The United States would benefit from a public health campaign similar to the tobacco cessation campaigns that began in the mid-1960s and helped reduce the rates of smoking from 42% to 18%.
Such campaigns were multifactorial and provided education about the health dangers, established smoking cessation programs and banned smoking in public buildings. But most importantly, they changed the mindset of Americans and made smoking culturally unacceptable, which enticed people to change their behavior.
“One lone physician or one lone health plan could not have reduced our dependence on tobacco, but when there was a partnership and a collaboration among industry, government, academia and healthcare delivery-when there was a shared mission-we were very successful,” says Dr. van Amerongen.
According to Kosman, “It will take a village to stop metabolic syndrome.”