Assignment

Connecting patients' nutrition, exercise, and other "lifestyle"-related characteristics to health risk assessment and then to care management, could be next in efforts among population health pioneers

Is now the time for the leaders of patient care organizations who are leading population health management initiatives to think broadly about some of the non-clinical aspects of health status, including food and nutrition, exercise, and other so-called "lifestyle choice" elements of health, in the context of care management efforts? Recent articles in The New England Journal of Medicine and Health Affairs certainly seem to point to that possibility. What's more, a small number of patient care organizations are beginning to look at the sociodemographic and socioeconomic aspects of health status among their covered populations. Let's look at what's going on.

To begin with, I was fascinated to read a "Perspective" article that appeared online in The New England Journal of Medicine, entitled "U.S. Nutrition Assistance, 2018-Modifying SNAP to Promote Population Health." The thought-piece, written by Sara N. Bleich, Ph.D., Eric B. Rimm, Sc.D., and Kelly D. Brownell, Ph.D., examines some of the policy foundations of one of the key federal anti-hunger programs in the United States, in the context of current population health management initiatives among U.S. healthcare providers and plans.

"The Supplemental Nutrition Assistance Program (SNAP)," the authors write, "is the cornerstone of the nutrition safety net in the United States, helping 45 million low-income Americans - nearly half of them children - pay for food each month. SNAP is authorized by Congress through the Farm Bill, which also covers agricultural programs such as crop insurance and land-conservation measures. With an annual cost of $74 billion, the program accounts for roughly 80 percent of the spending authorized by the bill. As an entitlement program, SNAP is responsive to economic fluctuations - enrollment can expand rapidly when the economy weakens and shrink when it improves. SNAP is scheduled to be reauthorized in the 2018 Farm Bill, which will set U.S. food policy for the next 5 years and beyond. As Congress deliberates, it's important to consider what changes to the program are feasible and also have the potential to improve population health. Above all," they state, "we believe SNAP should be protected - and, ideally, expanded, since its current benefits don't allow most families to purchase adequate food to maintain a healthy diet."

The researchers note that, while SNAP was never initially designed to focus on nutrition, but rather, was intended primarily to reduce hunger. Originally known as the Food Stamp Program, it was initiated in 1961 but didn't become a permanent, nationwide program until 1974. SNAP has improved food security for millions of Americans. In 2014, SNAP lifted 4.7 million people, including 2.1 million children, out of poverty." As the authors note, the challenge for many low-income families today "is less about obtaining enough food and more about finding dependable access to affordable healthy food. Currently, SNAP benefits can be used to purchase virtually any type of food or nonalcoholic beverage from eligible retailers."

The authors reference a study that made use of point-of-sale transaction data from a leading grocery retailer that found that SNAP-recipient families "allotted a higher proportion of their grocery bills to soft drinks than to any other item (about 5 cents out of every dollar, as compared with 4 cents among non-SNAP households). It also found that both SNAP and non-SNAP households spent roughly 20 cents per dollar on sweetened beverages, desserts, salty snacks, candy, and sugar. Past studies involving nationally representative dietary-intake data have suggested that SNAP participants have poorer-quality diets than nonparticipants with similar incomes."

Meanwhile, an article in the March issue of Health Affairs broadens out the subject. In "Impact Of The YMCA Of The USA Diabetes Prevention Program on Medicare Spending and Utilization," authors Maria L. Alva, Thomas J. Hoerger, Ravikumar Jeyaraman, Peter Amico, and Lucia Rojas-Smith describe an innovative program devised by the YMCA of the USA, with support from a Health Care Innovation Award from the Centers for Medicare and Medicaid Services, that has been providing diabetes prevention education and coaching to Medicare beneficiaries with prediabetes, in 17 regional networks.

As the researchers note, "The YMCAs [participating in the program] use an evidence-based curriculum based on the Y's adaptation of the National Diabetes Prevention Program of the Centers for Disease Control and Prevention (CDC). The goal of the Y model is to get participants to lose 5 percent or more of their body weight and gradually increase their physical activity to 150 minutes per week."

The authors note that "The curriculum comprises 16 core sessions that cover the following topics: healthy eating strategies, understanding fat and calories, and elearning about foods that are high in nutritional value; strategies for increasing physical exercise, including incorporating exercise as part of one's lifestyle and setting and achieving exercise goals; and strategies for changing one's environment to help facilitate weight loss, using positive thinking, managing stress, and improving motivation. During the core sessions, lifestyle coaches facilitate group discussions of behavior changes, challenges, and solutions."