Behavioral Economics for Healthcare

POSTED: Thursday, November 29, 2007

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healthA new article in JAMA suggests policymakers can use the science of behavioral economics to dramatically improve the health of Americans. The commentary, published in the Nov. 28 issue of the Journal of the American Medical Association posits behavioral economics — a decision-making model that recognizes individuals are prone to biases that impede or undermine their ability to make good or rational choices –-can be used to steer individuals toward good physical and improved mental health.

The paper was written by researchers at Carnegie Mellon University, the University of Pennsylvania, Aetna Inc. and the Philadelphia Veterans Affairs Medical Center.

The authors believe the new approach can counter one of the underlying causes of major health problems in the United States and other developed nations — bad decision-making on the part of individuals.

Tobacco use, obesity and alcohol abuse account for nearly one-third of all deaths in the United States. What’s more, the full benefits of many medical advances — such as medication to control blood pressure, lower cholesterol and prevent strokes — go unrealized because people fail to adhere to their treatment.

For example, the authors note that one year after suffering a heart attack about half of patients prescribed drugs to lower cholesterol have stopped taking them.

So, why do people make choices they know are bad for them, or fail to do things, like take medication, which they know will be helpful?

Unlike conventional economics, which assumes that when presented with adequate information people will make decisions that are in their own best interests, behavioral economics recognizes that individuals are prone to biases that impede their ability to make good choices.

The authors advocate exploiting these decision-making biases to help people make better decisions — without taking away their freedom of choice — a strategy they label “asymmetric paternalism.”

Take weight loss. Many of us, around the holidays, resolve to lose weight starting after the New Year. But when the time comes, many people fail to make good on this resolution. Rather than a simple lack of willpower, the authors explain that this is an example of a present-biased preference: the tendency of individuals to place disproportionately greater weight on the costs and benefits of their choices in the present than in the future.

The cost of giving up food one enjoys is immediate, while the benefits are realized in the future. Without a mechanism to enforce self-control, a person’s resolve often fails.

Another common decision-making bias is the tendency to favor the status quo or default option. This bias explains, for example, why the organ donation rate in the United States is so much lower than in France, where almost everyone is an organ donor: In the United States, a person must sign-up to be an organ donor, but in France, a person is automatically registered as a donor unless they choose to opt out.

These biases can be exploited by making the healthiest choice the one that follows the path of least resistance.

For example, fast food restaurants that now offer soda as the default choice with a combo meal can instead make a bottle of water the default option, with soda being a substitution available only on request.

A cafeteria line could be arranged so that the healthiest foods appear first, with unhealthy foods requiring the most effort to select. Employers can provide chilled bottles of water within easy access of workers, while placing soda machines in out-of-the-way locations.

Vending machines could be installed in workplaces with access codes that an individual must activate to buy snacks or soda on the following day. Present-biased preferences, meanwhile, can be utilized by providing patients with up-front rewards for healthier behavior.

Such incentive-based approaches have been found to be effective in areas such as smoking cessation and even abstinence from drugs such as cocaine.

“We’ve only scratched the surface of potential applications. The possibilities for using decision errors to improve health behaviors and thereby improving the health of the population is enormous,” said study author George Loewenstein, the Herbert A. Simon Professor of Economics and Psychology at Carnegie Mellon.

Asymmetric paternalism can be used to help people get better medical care, give up bad habits such as smoking, or even exercise more. Gym visits or routine lab tests, such as cholesterol screenings, can be automatically scheduled so that the patient has to incur added inconvenience to cancel them rather than, as is currently the case, to schedule them.

People often miss out on routine but life-saving medical tests simply because they fail to schedule appointments. Health care providers should automatically schedule the next test when the patient comes in for the current test.

The potential for these approaches to improve health is immense, and some of the up-front costs of incentive programs could be paid by employers or insurers in anticipation of improvements in health and productivity that likely would follow.

The paper was co-authored by Kevin Volpp, a staff physician at the Philadelphia Veterans Affairs Medical Center and an assistant professor at the University of Pennsylvania School of Medicine and the Wharton School; and Troy Brennan with Aetna Inc.

“Modifying health behaviors such as smoking is an enormous and important public health challenge. Despite tremendous progress, smoking still causes more than 400,000 preventable deaths per year. But these approaches have the potential to be more effective than many approaches that have been used to date,” Volpp said.

Source: Carnegie Mellon University

Knowing heart risk may prompt healthy change

Thu Nov 29, 2007 2:11pm EST

NEW YORK (Reuters Health) - Adults at risk for developing coronary heart disease seem to respond better to preventive treatment when their doctor tells them exactly what their risk is and how they can help lower their risk, results of a study suggest.

In the study, people who had frank discussions with their doctor about their coronary risk profile achieved greater improvement in their cholesterol levels than those who did not have these discussions.

It is well known that lowering levels of "bad" LDL cholesterol and raising levels of "good" HDL cholesterol reduces the chances of a heart attack and heart-related death. Yet patients don't always stick to recommended lifestyle changes or their cholesterol medications.

The results of one recent study suggested that about one-third of people who stop taking their cholesterol medications do so because they are not convinced they need them.

This made Dr. Steven A. Grover of McGill University in Montreal, Quebec, and colleagues wonder whether boosting patients' knowledge of their heart risk profile might help boost their adherence to heart-healthy ways.

To find out, they randomly assigned 3,053 adults being treated for cholesterol problems to usual care or to receive a 1-page computer printout displaying their probability of developing heart disease in the next 8 years based on their current lifestyle, blood pressure, cholesterol levels, and other risk indicators.

During the study, reported in the Archives of Internal Medicine, the printout group also received ongoing feedback on how much they could cut their risk through lifestyle modification and drug therapy.

A total of 2,687 patients completed the 12-month study, and the researchers saw that those in the intervention group who kept track of their heart risk profile had small but significantly greater improvements in their cholesterol profiles.

The patients who were better educated about their heart risk profile were also more likely to reach cholesterol targets, the investigators found.

Given the public health burden of heart disease, prevention is key, Grover and colleagues note in their report. "Communicating risk is consistent with many of the recommendations to improve adherence, including enhancing self-monitoring and using the support of family and friends."

SOURCE: Archives of Internal Medicine, November 26, 2007.

© Reuters2007All rights reserved

The Scary Truth About Influenza

The Flu Kills More Than 36,000 People Each Year -- Here's How to Protect Yourself
By SALLY H. HOUSTON, M.D.

March 28, 2007 —

Flu has been one of the most devastating infections in human history. In 1918 and 1919, the flu killed 50 million people worldwide in just a few months.

Fortunately, flu seasons this dangerous are rare. According to the Centers for Disease Control and Prevention, 5 to 20 percent of Americans get the flu each year. That is 15 to 60 million people in the United States alone.

Approximately 200,000 are hospitalized because of flu complications, and 36,000 die. Many of these deaths could be prevented if people got their flu vaccine in the fall each year.

There are hundreds of possible strains of flu virus, and getting the flu once does not protect you from getting it again.

Each year scientists determine which strains of flu are the most likely for the next flu season. Then they make a vaccine to protect against those strains.

Even if you get infected with a different strain, the flu vaccine will help your body fight off the infection more quickly, and you will not get as sick.
What Is Flu?

The flu is caused by the influenza virus, a potentially life-threatening respiratory tract infection that can be prevented by getting vaccinated and avoiding exposure. Preventing the spread of influenza is everyone's responsibility.

Flu symptoms include sudden onset of high fever, dry cough, sore throat, stuffy nose and severe muscle pains in the legs and low back. People with the flu usually do not experience a runny nose, vomiting or diarrhea.

Most people with flu will feel terrible for five to seven days and then recover completely. However, the very young, elderly or those with chronic illnesses are at greater risk of developing complications that may lead to hospitalization or even death. These patients develop life-threatening complications such as pneumonia, respiratory failure or heart failure.
What Do I Do If I Get the Flu?

The most important thing any flu victim can do is to stay at home. This will help prevent spread of flu to others.

A quick call to your doctor is also important because there are medicines that will shorten the course and decrease the severity of flu symptoms, but they must be started within 48 hours of the first symptoms.

Rest, drink plenty of fluids and take acetaminophen, ibuprofen or aspirin to help with the fever and muscle aches. But never give aspirin to children with the flu because serious and deadly complications can develop.

Tylenol is a very safe medication for treating fever and pain, but high doses or even normal doses taken with alcohol can cause liver failure. Check over-the-counter medication labels to be sure that you do not take more than 4000 mg of acetaminophen in 24 hours. Ibuprofen should be taken with plenty of liquids and some food to prevent stomach upset.
How Can I Prevent Flu?

Vaccination is safe and effective. There are two kinds of vaccine: an injection and a new nasal vaccine.

The injection is made with killed flu virus and is safe for people 6 months old and older. The nasal vaccine is administered directly into the nose and is for healthy people between the ages of 5 and 49 years.

You cannot get flu from the injected vaccine. There is a small risk that people with weakened immune systems could become sick from the nasal vaccine, which is made with a weakened form of the flu virus.

Some people still get flu after vaccination, but they are much less likely to become seriously ill than those who have not been vaccinated.

There may not be adequate supplies of flu vaccine to vaccinate everyone against flu every year. In that case, vaccine manufacturers and public health authorities will work together to assure those at greatest risk receive vaccines first.

Priorities for flu vaccination include individuals at high risk for complications and their caregivers. This includes children 6 months to 5 years old, pregnant women, those over 50 years old, people who live in nursing homes and those with chronic illnesses.

Complications associated with flu vaccine are very rare and include pain and swelling at the injection site, fever and aches (more common in children), and allergic reactions to components of the vaccine.

Medicines used to treat flu can also be used to prevent flu, but these work best when used in addition to the vaccine. Otherwise, they must be taken for the whole flu season, which spans fall and winter.

Some people cannot take vaccine and may need to take these medications to prevent flu. Check with your doctor if you have questions about flu prevention.

Keeping sick people at home, washing hands frequently, covering nose and mouth with tissue when coughing or sneezing will prevent flu, as well as ward off other germs that cause colds, vomiting or diarrhea.

Dr. Sally Houston is an associate professor at the University of South Florida College of Medicine and chief of staff at Tampa General Hospital.

Copyright © 2007 ABC News Internet Ventures

The Salt Threat

Too Much Sodium in Diet Harmful to Americans' Health

Nov. 29, 2007 —

It's recommended that Americans eat a teaspoon or less of salt per day. But most of us eat about twice that much.

Later today, the Food and Drug Administration will hold hearings to discuss whether it should create warning labels or even set limits for sodium in packaged foods.
Hidden Culprit

It's not the table salt you sprinkle from your shaker, but the salt hidden in everyday foods that's the real danger.

Experts say 75 percent of the sodium we consume comes from packaged foods. There are obvious ones, like salty snacks. But did you know bread, chicken broth, cheese and chocolate can be high in salt? Some TV dinners contain several times the recommended daily dose.
Serious Health Concerns

Too much sodium can raise your blood pressure and lead to heart disease. In fact, the American medical association says cutting people's sodium intake in half could save 150,000 lives a year.

The Center for Science in the Public Interest wants the government to limit the amount of sodium manufacturers can put in various categories of food. And it wants warning labels on high sodium products.

The food industry says it is already taking steps on its own, such as offering low sodium versions of popular products and even secretly removing sodium without telling consumers.

The FDA hasn't indicated whether it will take any action on sodium. By contrast, the British government is setting reduced sodium targets for foods and even running catchy educational ads.
What Can You Do?

Start by paying more attention to how much salt you're eating. Read labels at the grocery store and choose low-sodium alternatives.

Avoid certain foods that are notorious salt culprits, such as canned soups and meats, salted nuts, frozen dinners, salad dressings and snack foods like pretzels, potato chips and cheese.

Be careful when you cook. Substitute fresh meat and vegetables for canned alternatives. Skimp on the salty seasonings like soy and steak house. If you have to use canned products be sure to rinse and drain them first.

Lastly, if you can bare it, take the salt shaker off the table.

The good news though is that it might be one of the easiest habits to kick. According to "GMA's" consumer correspondent, Elisabeth Leamy, it could take just a few weeks to wean your taste buds off salt. One month of reducing your salt intake and your former favorites will taste too salty.

For more on the dangers of salt and tips on how to beat your salt habit head to the American Heart Association online.

Copyright © 2007 ABC News Internet Ventures

A New Way to Control Weight?

Scientists Say Just Standing Up May Be as Important as Exercise
By LEE DYE

Nov. 28, 2007 —

Scientists have found intriguing evidence that one major reason so many people are overweight these days may be as close as the seat of their pants. Literally. According to the researchers, most of us sit too much.

In most cases, exercise alone, according to a team of scientists at the University of Missouri, isn't enough to take off those added pounds. The problem, they say, is that all the stuff we've heard the last few years about weight control left one key factor out of the equation. When we sit, the researchers found, the enzymes that are responsible for burning fat just shut down.

This goes way beyond the common sense assumption that people who sit too much are less active and thus less able to keep their weight under control. It turns out that sitting for hours at a time, as so many of us do in these days of ubiquitous computers and electronic games and 24-hour television, attacks the body in ways that have not been well understood.
The Need to Putter

"It was hard to believe at first," said Marc Hamilton, associate professor of biomedical sciences at the University of Missouri-Columbia and leader of the research team. He said the team didn't expect to find a strong signal when they began researching what happens to fat when we remain seated. But the effect, both in laboratory animals and humans, turned out to be huge.

The solution, Hamilton said, is to stand up and "putter."

The research was published this month in the peer-reviewed journal Diabetes, and it will be presented by Hamilton's post-doctoral researcher, Theodore Zderic, at the upcoming Second International Congress on Physical Activity and Public Health in Amsterdam.

Hamilton is not suggesting that anyone quit exercising. But he says his work shows that exercise alone won't get the job done. We have to pay more attention to what's happening when we aren't in the gym, because the body's ability to dispose of fat virtually shuts down, he says, at least if we're sitting down.

Hamilton recruited a few laboratory rats and pigs, as well as about a dozen human volunteers, including himself, to learn more about the physiological effect of sitting. The lab animals laid the foundation for the research in two different experiments. The animals were injected with a small amount of fat that contained a radioactive tracer so the researchers could determine what happened to the fat.

"What's the fate of that fat?" Hamilton asked during a telephone interview. "Is it burned up by the muscle?"

The radioactive tracer revealed that when the animals were sitting down, the fat did not remain in the blood vessels that pass through the muscles, where it could be burned. Instead, it was captured by the adipose tissue, a type of connective tissue where globules of fat are stored. That tissue is found around organs such as the kidneys, so it's not really where you want to see the fat end up.

The researchers also took a close look at a fat-splitting enzyme, called lipase, that is critical to the body's ability to break down fat.

After the animals remained seated for several hours, "the enzyme was suppressed down to 10 percent of normal," Hamilton said. "It's just virtually shut off."

The results from the animal studies were very convincing, he said, and human experiments were just as compelling. The researchers injected a small needle into the muscles of the human volunteers and extracted a small sample for biopsy. Once again, the enzyme was suppressed while the humans remained seated. That resulted in retention of fat, and it also resulted in lower HDL, the "good cholesterol," and an overall reduction in the metabolic rate.
You Need to Move Those Legs

The implications, Hamilton said, are clear. While much thought has been given to the good effects of regular exercise, scientists have not paid enough attention to what happens during the rest of the time when we may be fairly active but are probably sitting too much. That could help explain the rising tide of obesity, because people tend to sit more these days than they did a half century ago. Not to mention eating too much and getting precious little exercise.

Some might argue that playing video games, or even working at the computer, involves movement of the upper body, especially the hands and arms, so that's not really inactive. But Hamilton counters that arms don't weigh very much, and the big muscles in the human body which are so critical to burning fat are located in our legs and back.

"When we think about the postural muscles that are mostly in the legs and back, these are big, powerful muscles," he said. "We're talking probably 20 pounds of muscle in each leg. That's a lot of muscle that can be engaged in routine activities," including burning fat. But they can't do that without the enzyme that is suppressed while seated.

Much is still not known, including such fundamental issues as how long the effect lasts from getting up and moving around for a while, but Hamilton expects the answers to come fairly soon.

"There is going to be a flood of research on this in the next couple of years, and not just by us," he said. "This has raised the attention of a lot of great scientists around the world who have begun doing their own studies."

In the meantime, he suggests, we do the obvious. Take the time to get up and "putter" for a while. If his research turns out to be on the mark, it could save your life.

Lee Dye is a former science writer for the Los Angeles Times. He now lives in Juneau, Alaska.

Copyright © 2007 ABC News Internet Ventures