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Sunday, May 8, 2016

Nutrition and health—Why payors should get involved

An apple a day keeps the doctor away. From infancy to adolescence and adulthood, a healthy diet plays a key role in the prevention of chronic diseases and the promotion of a higher quality of life. Infants with iron deficiency display negative performance with regards to psychomotor and cognitive development [1], and adolescents with insufficient intake of calcium and vitamin D have an increased risk of fractures due to osteopenia or osteoporosis [1].

Nutrition has the ability to improve health standards. A healthy diet is important even before birth: During embryonic stages, our mother's diet affects our health. Mothers with folic acid deficiencies during the onset of pregnancy are at higher risk of fetal neural tube defects due to epigenetic alterations in gene expression. Conversely, long-chain omega-3 fatty acids are associated with improved embryo morphology [1]. The combination of certain risk factors, such as smoking during pregnancy and excessive gestational weight gain, can result in an increased risk of childhood obesity.

Why should this be of any interest to payors? Health insurance companies and policy makers need to consider reimbursement given a potentially interesting return on investment. Studies have reported that in the United States, a 1% decline in excess body fat alone could save $84.9 billion in obesity-related medical costs by 2030 [2]. The burden of chronic disease is escalating and the potential of healthier lifestyles to curb health care costs cannot be understated.

A less obvious nutrition-associated health hazard is malnutrition. Nutritional Risk Screening (NRS 2002) has revealed that the prevalence of malnutrition in European hospitals varies from 20% to a perturbing 50%. If malnutrition is such a severe issue and health promotion could restrain health expenditure in the long-run, then the question should be: why are payors not getting involved?

Although the overall benefits of a healthy diet are undisputed, they are often based on empirical evidence. For this reason, evidence-based medicine is hard to apply to nutrition. Establishing evidence for pharmaceuticals using randomized clinical trials can be more easily controlled and achieved in a shorter time frame. Claims on nutritional labels are often inaccurate, unfounded, and can mislead consumers. Providers might not be willing to offer a patient nutritional advice for health on the grounds of their own personal liability [3].

Beside concerns about the authenticity of nutrition claims, a second reason for payors' reluctance to involve themselves is the difficulty of assessing the economic impact of nutrition recommendations. In light of limited health care budgets, the cost-effectiveness of certain changes in nutritional behavior has become increasingly critical to payors [3]. Although the field of nutrition economics has long been a research gap, studies have recently emerged showing that cost-effectiveness analyses can be applicable to nutrition and not just health care technology—pharmaceuticals, for example. One recent study assessed the cost-effectiveness of probiotics for the primary prevention of atopic dermatitis, finding that probiotics cause a reduction in atopic dermatitis and also lead to positive economic outcomes [4]. Admittedly, nutrition economics is in an embryonic stage. Nevertheless, this field of research carries the potential to reform the way we approach health care. The diseases that cause a constant drain on health care budgets can be prevented by nutrition. If payors decide to bear the costs for nutrition, whether it be nutraceuticals or dietary supplements or probiotics, as they do for evidence-based medicine, the combination of evidence-based medicine and nutrition economics could have favorable effects on health expenditure and, perforce, the sustainability of health care systems. But the power to prevent diseases and the cost-effectiveness of nutrition are not the only reasons for payors to become involved with nutrition.

We have all experienced the personalization of market offerings over the past few years. Whether it is iTunes recommending music or Amazon.com giving us advice on what books to purchase next, personalized advice is trending. Due to recent developments in nutrigenomics, payors can follow this trend with personalized nutrition advice. Studies have shown that nutrition advice tailored to the individual needs of a person is much more valuable than generic advice [5]. If the consumers are willing to provide personal information (i.e. anything ranging from dietary patterns to phenotypic details to information about genetic composition), this information could serve as a basis for developing personalized advice. It is then left to consumers to integrate these recommendations into their dietary behavior. Personalized nutrition advice is a way to generate added value for payors that want to set themselves apart from their competition and can reduce both confusion and the costs of working through large amounts of nutrition information [5]. Also, personalized nutrition advice requires continuous relationships with patients. Much like therapy, nutrition recommendations are more than a one-off interaction. This is advantageous because constantly finding new customers is not cost-efficient [5]

Evidence shows that an apple a day does not keep the doctor away [6]. However, authors have found that apple eaters are less likely to smoke and use prescribed drugs [6]. Whether through the nutritional aspects of the apple or the apple eaters' awareness and general health literacy, a greater emphasis on nutrition might save patients from soaring medical bills and our health care systems from staggering health care spending in the future. Thus, payors should definitely get involved.

For health insurance companies to reimburse nutritional services and health-enhancing nutritional products, researchers need to be encouraged to further examine the positive effects and cost-effectiveness of nutrition. To give an example: research has shown great progress within personalized nutrition using new technologies for dietary assessment and advice and examining new clusters by using phenotypic and genotypic information [7] and [8]. However, all agree that more research needs to be done to assess effectiveness of personalized nutrition, preferably randomized controlled trials as they are most convincing to policy makers.

However, reimbursement alone might not result in a healthier population and a leaner health care system. When the day for nutrition reimbursement comes, countries may need to provide patients with proper settings in which nutrition and health literacy can unfold. Health ministries might be forced to consider alternatives to the overloaded and expensive doctor's office.

Furthermore, to reduce the mortality of non-communicable diseases, reimbursement alone will not be able to make a difference if not supported by other policies. In contrast to pharmaceutical products distributed in pharmacies and physician offices, nutrition and its suppliers are everywhere. Governments will need to address multiple stakeholders across all sectors and further promote awareness [9].


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