When it comes to metabolic disease, including diabetes, new interventions such as precision nutrition are redefining outcomes and replacing low-value programs.
00:10 hello
00:11 welcome my name is alisa weider and i’m
00:13 your host from day two welcome to day
00:16 two’s webinar on increasing quality care
00:18 from diabetes and metabolic disease
00:22 we’re thrilled that you’re joining us
00:23 for what promises to be a lively
00:24 discussion
00:26 right now as employers and payers are
00:28 finding that reducing costs
00:30 and increasing roi from their wellness
00:32 and benefits programs
00:33 has come to a crunch with the covid19
00:36 pandemic focusing mindshare on how to
00:39 get more value from existing programs
00:41 and putting pace on the search to find
00:43 and implement
00:44 more effective programs that can tackle
00:47 the underlying causes of the disease
00:50 i’m joined today by our esteemed
00:52 panelists first
00:53 i’d like to welcome dr alan spiro dr
00:56 spero
00:57 was most recently chief medical officer
00:59 for blue health intelligence
01:01 and his experience covers over 30 years
01:03 as a health care leader
01:04 with blue cross blue shield accolade
01:07 anthem and willis towers watson
01:11 dr jan berger is a multi-published
01:13 author on the topic of health care
01:14 reform
01:15 and a seasoned tri-secretary executive
01:18 with
01:19 cvs health and midwest business group on
01:21 health
01:23 melinda marinuck is an award-winning
01:25 diabetes educator
01:27 with over 35 years of experience at the
01:29 jocelyn diabetes center
01:31 she currently holds the position of
01:33 director of care programs
01:34 for the jocelyn innovations division
01:37 welcome everyone so to get us started i
01:41 would like to really ground our
01:42 discussion with a question
01:44 first to you dr berger how should we
01:47 define
01:48 low value care for diabetes and
01:49 metabolic disease
01:52 well that’s a great question and it’s a
01:54 great question because if we’re not
01:56 all speaking the same language the next
01:59 hour
02:00 may not make sense for many people in a
02:03 number of ways
02:04 um the definition today
02:08 of our conversation is about increasing
02:10 quality care
02:12 and quality has been tied very
02:16 tightly to a component of value
02:19 value in healthcare really started to
02:22 take hold in conversations about 10
02:24 years ago
02:25 and people like dr mark fendrick
02:29 who’s the director of the center for
02:30 value-based insurance design at
02:32 university of michigan
02:35 mike chernow who is at harvard
02:38 and dr will shrank who’s presently the
02:40 chief medical officer of humana
02:43 have been very very active in describing
02:46 high value and low value care this has
02:49 become
02:50 very important to employers and to
02:53 health plans payers because of the fact
02:57 that as you said we have to make sure
03:00 that we’re getting
03:01 what we want and desire and expect
03:05 of our health care dollars and so it’s
03:07 really
03:08 important that value and care
03:11 is the outcomes achieved per dollar but
03:14 there are two things in value of care
03:16 that we have to think about one what is
03:18 the outcome we’re looking for
03:20 is it a clinical outcome is it a
03:22 financial outcome
03:23 is it a humanistic outcome or is it some
03:26 mix of all three the second is
03:30 value to whom we have a health care
03:33 system
03:34 where a large portion of the care is
03:37 paid for
03:39 by the employer by government or by a
03:42 health plan
03:43 increasingly the patient is
03:46 also having to take on greater financial
03:49 responsibility
03:51 so the challenge is how do we get value
03:55 to all four of the sectors who may be
03:58 payers and impacted by the care that is
04:02 given
04:04 so i would say as we think about today
04:07 and the three of us have a conversation
04:10 is do we look at is there no
04:14 or low benefit to a patient or
04:17 is it a driver of inefficiency or is
04:20 there
04:20 untapped opportunity because of new
04:23 science or personalization
04:26 of what we do that really means is it a
04:29 mismatch of service or intervention
04:32 to time or person and that’s really i
04:34 think
04:35 what we have to look at because that’s
04:37 where the world is
04:38 changing that’s great thank you dr
04:41 burger
04:42 i love that concept of mismatching i
04:44 think that’s really critical
04:46 and one thing i’ve noticed in the
04:47 industry is that we’re really hearing a
04:48 lot about personalization
04:50 um particularly we’re kind of moving
04:52 from population health to
04:55 more personalized health so is it
04:57 possible to practice both
04:59 absolutely um and i’m going to start but
05:02 i know
05:03 that both of my colleagues here have
05:07 strong thoughts and experience in this
05:11 really one is a top-down model that’s
05:14 population health we’re thinking of the
05:16 whole group
05:18 versus the individual where
05:20 personalization is an n of one
05:23 it’s not looking at the average patient
05:26 it’s looking at
05:27 you or i as an individual and a number
05:30 of variables have come into play here
05:32 and are very important especially in
05:34 metabolic disease
05:36 at things such as heterogeneity of
05:40 preferences
05:42 of culture of capabilities of
05:46 more and more the conversation of social
05:47 determinants of health
05:49 historically we’re not taken into
05:52 consideration
05:53 in population health lee hood
05:56 is the founder for systems biology in
05:58 seattle
05:59 he really is the leader that said
06:03 that population health is actually based
06:08 on individual personalized care
06:11 the question we hear often is isn’t that
06:14 hard and expensive at looking at the
06:16 individual level
06:17 and i would argue a no
06:20 with new technologies and new analytics
06:23 tools
06:24 we really can get to the individual
06:27 and build up to a population it also
06:30 allows us
06:31 better value when we talk about low
06:34 value or high value care
06:37 alan what do you think about what i said
06:39 true false different what do you think
06:42 i agree with you it’s really interesting
06:44 when you think
06:45 about value and the question of
06:49 population
06:50 versus personal care personalized care
06:54 there’s often a mismatch
06:58 you know on a population basis
07:01 from a pure resource consumption point
07:04 of view it might be better
07:06 to focus on
07:09 what i’ll call the vast majority of
07:12 pregnancies
07:13 as opposed to advanced cancer
07:16 surgery because overall the population
07:19 benefit is going to be greater if you’re
07:21 the person with cancer
07:23 you may not agree with that priority um
07:27 you know there there’s always been that
07:29 tension
07:30 and it’s almost an ethical tension is
07:32 out it’s often how i see it
07:35 between population health and
07:37 personalized health
07:38 but now biology is entered in because
07:41 when you
07:42 look at personalized health especially
07:44 in the range
07:45 of something like diabetes you see very
07:49 uh different and smaller sub sub
07:52 segments so to speak
07:54 getting down to that n of one based on
07:57 certainly the biology
07:59 and the biology includes the person’s
08:03 unique genetic makeup it also includes
08:06 the
08:07 genetics of their friendly visitors
08:10 mainly the microbiome the trillion
08:12 bugs that live in each one of us that
08:14 are very different
08:15 and have a dramatic effect on the
08:18 individuality of each person
08:20 biologically you then have all those
08:22 non-biological
08:24 components which include what’s
08:27 called the social determinants but it
08:29 includes things like economics
08:31 it includes uh culture it includes
08:34 uh the the entire life context
08:38 of what people live with do they have
08:41 competing priorities sick children or
08:44 sick parents
08:45 do they have multiple jobs do there’s
08:48 just a whole
08:49 range it’s what makes the
08:51 personalization to me so
08:53 fascinating and so compelling
08:57 when you’re talking about diabetes in
08:58 particular
09:00 diabetes is and whenever you’re talking
09:02 about any chronic disease but diabetes
09:04 is a poster child
09:06 because um you can say on a population
09:09 basis that everyone should get their
09:10 glycosylated hemoglobin level
09:13 once every quarter and that becomes a
09:16 metric and it’s an important metric but
09:20 what about the fact that we know
09:23 that diabetes impacts different social
09:26 strata
09:26 and different um other types of groups
09:30 disproportionately how does it
09:33 go ahead i’m sorry go ahead i wanted to
09:36 jump into
09:37 something you mentioned there uh you
09:39 touched on metrics but before we go into
09:41 that i’d really love to dig into
09:44 um the the the biology of of of the host
09:47 of the patient
09:48 um and just bring in the topic of food
09:50 because i know that is such a big focus
09:52 for the shift in care
09:54 um from for diabetes and particularly
09:56 metabolic disease as well
09:58 so i’d love to bring in melinda and just
10:00 hear her thoughts at this stage
10:02 um so melinda can you tell us what is
10:04 the value of
10:05 food and diabetes sorry food and diet in
10:08 diabetes
10:09 ah sure and you know it’s interesting
10:12 alice
10:13 um that in so many arenas food is being
10:16 now talked about as this sort of
10:19 new and important treatment that we
10:21 should be paying more attention to
10:23 but uh i might call your attention to
10:25 the fact that this year
10:27 we celebrate the 100th anniversary of
10:30 the discovery of
10:31 insulin and prior to the discovery of
10:34 insulin in 1921
10:37 food was the only way to
10:40 treat and manage people with diabetes
10:43 now certainly with the
10:45 advent of insulin and after that many
10:47 other medicines
10:48 food has sort of taken a back seat with
10:51 this which is
10:52 really unfortunate because it’s
10:55 extremely effective
10:56 i think if you look at the literature it
10:59 talks about
11:00 the triad of treatments for diabetes
11:03 food exercise and medications but
11:08 speaking about value i think that we
11:10 would all agree that
11:12 food and appropriate food treatments are
11:15 very
11:16 high value care especially for people
11:19 with
11:20 type 2 diabetes and for many people it
11:22 really
11:23 could go back to being the only
11:25 treatment
11:26 it may be that medications are
11:28 absolutely not necessary
11:30 so that that’s a great point that you
11:32 make melinda thank you i appreciate you
11:34 really grounding us in the power of food
11:36 in this uh care program
11:38 so and something we know extremely well
11:40 at day two of course
11:41 um so i did want to just follow up on
11:43 that and ask you about um
11:44 sort of the role of dietary counselling
11:46 but before i do
11:47 i think we’re struggling a little bit on
11:49 your sound and i wonder if you could
11:50 come slightly closer to the microphone
11:52 when you answer this question
11:53 okay thank you so much so
11:56 tell us do you think wellness and
11:57 benefits programs are recognizing
11:59 dietary
12:00 counseling as bringing value well
12:03 i would say i don’t know exactly for all
12:06 benefits programs but i would say
12:08 nationwide we’re doing a terrible job
12:10 taking advantage of the benefits that
12:13 people
12:14 uh usually have so we have data from
12:18 medicare beneficiaries that only about
12:20 five percent
12:22 of individuals take advantage of
12:24 benefits related to either diabetes
12:26 education
12:27 or medical nutrition therapy um and
12:30 that’s
12:31 really low uh in terms of those with
12:33 private insurance
12:34 it’s a little bit higher but only about
12:37 seven percent
12:38 so it’s an extremely underutilized
12:40 research
12:41 source in terms of either accessing a
12:43 registered dietitian nutritionist
12:45 or for people with diabetes accessing a
12:48 recognized
12:49 or accredited diabetes education program
12:52 so
12:53 i think absolutely uh it is very under
12:56 utilized um a couple of other comments i
12:59 wanted to
13:00 make related to that is that we
13:03 definitely
13:04 know the benefits of medical nutrition
13:06 therapy it’s been well documented
13:08 and i’ll just speak right now about
13:09 people with type 2 diabetes that
13:12 when done well it really
13:16 can reduce a1c we have evidence that
13:19 up to 2 drop in a1c is realized
13:22 just with medical nutrition therapy
13:26 we know that there are a couple of
13:27 things that make it
13:29 more likely to go well and that is
13:33 that it be done by an experienced
13:35 dietitian
13:36 who has um experience in
13:40 diabetes and metabolic conditions uh
13:43 an extra bonus is if that individual is
13:46 certified as a diabetes
13:48 care and education specialist the second
13:50 item is
13:51 if there are multiple touch points
13:54 multiple visits
13:56 we know that just by giving a list of
13:59 recommendations
14:00 whether it’s very personalized or not
14:03 but only having one or two contacts will
14:06 also
14:07 not do it so just sending somebody to a
14:10 dietician once
14:11 i mean it’s sort of like sending them to
14:13 a doctor once and not having any
14:15 follow-up
14:16 with adjusting medications it’s not
14:18 going to work so
14:19 um ongoing care and ongoing support is
14:22 really important
14:23 and the third thing that we’re learning
14:26 is the more
14:27 tailored and customized and personalized
14:30 that information is those
14:32 recommendations are the better they are
14:34 and i can speak a little bit more later
14:36 if you want about
14:38 what i see as the difference between
14:42 population nutrition individualized
14:45 nutrition
14:46 and personalized nutrition that is great
14:49 thank you so much we will definitely be
14:51 circling back to personalization and
14:54 what that truly means
14:55 shortly thank you i really appreciate
14:57 that uh i
14:58 would love to just uh pass back to dr
15:01 spiro but before i do that
15:03 i wanted to remind the audience because
15:05 i know we do have a lot of
15:07 uh executives in the benefits and
15:09 wellness space here today
15:10 um to just remind them to post any
15:12 questions that you might have in the q a
15:15 box so that we can circle back and uh
15:17 make sure we cover those for you towards
15:19 the end
15:20 so uh dr spiro please tell us um
15:23 can personalization and individualized
15:26 care
15:27 contribute to existing sorry increasing
15:30 quality care
15:32 absolutely um it’s really
15:36 interesting because um
15:39 we’re we’re unfortunately we got into
15:42 and i’m going to go back to something
15:43 jan was talking about earlier
15:45 we we got into a cycle where we were so
15:48 concerned with the population health
15:50 that i think that
15:52 we lost a lot of the personalized health
15:56 that is necessary and and i’m
15:59 even talking and this alludes a little
16:01 bit to what i think melinda is going to
16:03 um talk about this whole issue of
16:07 how care always used to be
16:10 individualized
16:11 it used to be very much you would go to
16:14 your local
16:15 physician your local health professional
16:18 who would know you
16:20 who would know your culture and your
16:22 social setting and
16:23 would know all about you and your family
16:26 and would treat you in that life context
16:30 and as we moved more towards
16:32 population-based
16:33 care we lost some of that and
16:36 good reason we there are other quality
16:40 things but for example
16:41 the move to having a hospitalist instead
16:43 of your doctor taking care of you
16:45 in the hospital there are clearly some
16:49 improvements in responsiveness
16:52 and in the quality of hospital-based
16:54 care
16:56 but there’s also a loss there’s a loss
16:58 in the holistic care
17:00 that comes about because of that which
17:02 results in poorer quality on that regard
17:06 um there’s also the issue of how you
17:08 define quality
17:10 um from whose point of view which jan
17:12 brought up earlier
17:14 there is what i’ll call quality of
17:17 the pure biologic care
17:21 following care-based algorithms
17:23 following best practice
17:24 but there’s also quality from a person’s
17:27 point of view
17:29 the person receiving the care and that
17:32 includes the quality of what i’ll call
17:34 caring does someone care about me
17:38 the quality of the interaction
17:42 the quality of the entire experience
17:46 when you get stressed and confused by
17:50 trying to access care that’s not good
17:53 quality
17:55 and that’s the norm for much of our
17:57 population
17:58 today so we’ve got to define quality
18:01 correctly
18:02 thank you that i think that’s super
18:04 important to point out and i actually
18:06 wanted to just build on something you
18:08 said there
18:08 can you tell us about the ethics of
18:11 population health
18:12 so for example is it ethical
18:16 well is ethical population health and
18:17 oxymoron do you do you see it that way
18:20 you know in some ways um this is a topic
18:23 that’s interested me for years
18:26 because um in many ways um again
18:29 alluding something jan said earlier um
18:32 i’ve been part of the problem
18:33 i’ve been leading in population health
18:36 and um for many many years
18:39 and i’ve always struggled with this
18:41 point that
18:42 when you’re dealing with a population
18:44 decision
18:46 that’s not the same as dealing with an
18:48 individual decision
18:51 in some ways i i now as a patient
18:55 at my age you’re always a patient as a
18:58 patient i go to
18:59 young physicians who
19:02 have learned population health almost
19:05 too well
19:06 because i almost feel that they’re not
19:08 being an advocate for me
19:10 from a statistical point of view which
19:12 is the
19:13 data science part of it is something i
19:15 know very well
19:17 when you’re dealing with a bell curve a
19:20 normal distribution
19:22 on the population health way you’re
19:24 going to deal with the center of the
19:25 bell curve
19:26 but there’s always those individuals on
19:29 either end of the bell curve
19:31 and as a treating physician as a
19:33 treating
19:34 clinician you have to treat each
19:38 person and not assume they’re going to
19:39 be in the middle of the bell curve
19:42 and that’s what quality is you will
19:45 always have to be looking for those low
19:47 probability
19:48 high consequence events because if
19:50 you’re not looking for them you’re
19:52 not being a good health professional and
19:54 that’s the antithesis
19:56 of population health in some ways
19:59 you you have to make sure that when
20:02 you’re
20:02 a clinician the ethics are treating
20:06 every person as the individual they are
20:09 and when you’re doing population health
20:11 you have to talk about
20:13 putting resources where they’re needed
20:15 most and the two are
20:18 can be in conflict another area that
20:20 we’ve ignored
20:21 certainly during my training as a
20:23 gastroenterologist
20:25 as a nutritionist the fact that we have
20:28 all these lovely little critters living
20:30 inside our
20:31 intestines that are actually live with
20:34 us very nicely are
20:35 in many ways good for us and we’re
20:38 learning
20:39 the dramatic impact they have
20:42 on our well-being and and on
20:46 all aspects of our biology
20:49 so you know the research that eran
20:52 siegel and iran elena
20:54 first published in 2014
20:59 that found that totally dependent on
21:03 the specifics of your microbiome
21:06 the whole genome sequencing the
21:08 metabolic byproducts that you find
21:10 in a really in-depth analysis of your
21:12 stool
21:14 that you can predict blood sugars
21:18 and it turns out you can individualize
21:22 a diet on that basis which for me
21:25 as someone who’s steeped in gi and
21:27 nutrition is
21:29 fascinating and it’s wonderful so that
21:32 you can give to a patient or
21:34 even better to a certified diabetes
21:39 care and education specialist this kind
21:41 of fact and say you know what for that
21:43 person
21:44 who for whom rice is such a
21:47 huge cultural aspect we can test and it
21:50 might be that rice combined with some
21:51 other food
21:52 it actually does not have a glycemic
21:54 response doesn’t raise glucose
21:57 yep bring melinda in here and just hear
22:00 a little bit about
22:01 what she’s seen with individual uh
22:03 patients in her
22:04 in her world well uh you’re giving just
22:07 a great example
22:08 and you know just building off on the
22:10 rice and you can fill it in with so many
22:12 other food combinations a particular
22:14 food that classically
22:16 might be one that raises blood sugar too
22:19 high
22:19 like rice combining it with some
22:23 chicken with some pork with some egg and
22:26 a
22:26 stir-fry can dramatically change that
22:30 and for that individual you find the
22:32 best combination of
22:34 and this is important foods that they
22:36 like
22:37 because too often population based
22:40 recommendations especially very popular
22:42 diets and things that we’re
22:44 hearing a lot about lately it’s sort of
22:46 like the same recommendations for
22:47 everybody
22:48 everybody has to go very low carb or
22:51 everybody has to go
22:53 whatever the diet of the of the week is
22:56 but
22:56 the great thing about some of this um
23:00 uh discoveries that we have is that we
23:03 can
23:03 tailor those recommendations to bring
23:06 a food such as rice that classically
23:10 will spike someone’s blood sugar with
23:12 the food
23:13 that that individual likes and enjoys
23:16 that will
23:17 bring that response lower so that they
23:20 overall have a really
23:22 good impact on their on their glucose so
23:24 a very minimal impact on their food
23:26 that’s great thank you melinda and i
23:27 know this is extremely uh popular topics
23:30 i just wanted to remind the audience if
23:31 you do have any specific questions
23:33 on uh you know the food program aspect
23:36 of it
23:36 um i would love to hear those and and
23:39 give them to our panelists
23:40 so dr espiro i would love you to just
23:43 tell us uh
23:44 something about the yo-yo syndrome what
23:46 is that
23:47 and how does it play into quality care
23:50 yeah it’s really i’m very again it gets
23:53 to how we define
23:54 value and quality um
23:57 like uh melinda although not as
24:00 intensively as melinda i’ve been
24:01 treating people
24:02 with nutrition since i studied nutrition
24:07 as a nutrition fellow and
24:11 it’s we always talk about in a sense
24:15 weight loss whenever you’re talking
24:16 about nutrition you’re talking about
24:17 healthy eating
24:18 you can get someone to eat healthy and
24:21 lose weight
24:25 in a short time period
24:28 getting them to stay at it forever is
24:31 really the challenge
24:33 you know when you speak to people who
24:34 want to lose weight they will often tell
24:36 you that they’ve lost a thousand pounds
24:37 in their lifetime
24:40 just keep gaining it back each time
24:42 that’s the classic story
24:44 it’s it’s very hard
24:47 to change the way you do something
24:51 and make it permanent it’s often can be
24:55 a chronic
24:56 struggle and the yoyo syndrome is that
24:59 syndrome of going up
25:00 and down now it turns out like in so
25:02 many things
25:03 that’s more dangerous for your health
25:05 than just staying heavy
25:08 and there’s an analogous situation here
25:11 with blood sugars
25:13 we’re finding now that it’s not some
25:16 it is high blood sugars that aren’t
25:17 healthy but even worse than that
25:20 is blood sugar variability
25:23 the going up and down which is
25:25 associated with inflammatory response in
25:27 the body
25:28 with catecholamine release so it’s those
25:31 continued spikes and troughs and spikes
25:33 and troughs
25:34 which are the most dangerous piece and
25:36 that’s the analogous situation from a
25:38 blood sugar
25:39 point of view there’s almost a concept
25:42 of
25:42 being in this kind of steady state um
25:46 biologically that really fosters
25:49 health and that having dramatic swings
25:53 in many ways is
25:55 is like that yo-yo is more dangerous
25:58 than anything else and i see melinda
26:00 wants to jump in and i would just love
26:02 to hear her thoughts also
26:04 no i’m i’m just really nodding my head
26:07 in agreement
26:08 it can be so frustrating for individuals
26:11 who spend a lifetime
26:12 with that yo-yo effect and um
26:16 yeah it also does a number not only on
26:19 them
26:20 biologically with increased inflammation
26:23 but also
26:24 on their mental health because they just
26:26 begin to feel
26:27 i’m no good i can’t do this and so the
26:30 negative self-talk
26:31 just makes their health even worse so um
26:34 i agree
26:35 that’s that’s great thank you for uh
26:37 raising the topic of mental health as
26:39 well i know that it’s such a priority
26:41 this year for so many employers
26:43 as they’re thinking through how to
26:45 develop their care programs
26:47 can i bring can i bring it back to
26:48 microbiome for a minute
26:50 in terms of mental health because the
26:53 microbiome has a tremendous
26:54 impact on depression and mental health
26:57 as well you wouldn’t think so but
26:58 there’s something called
27:00 the brain gut microbiome
27:03 axis and the microbiome
27:07 affects the biology of the gut which
27:10 affects the autonomic nervous system
27:13 which affects endocrine release in the
27:15 brain and the hypothalamic
27:17 adrenal access so
27:20 changes in the microbiome can make you
27:22 depressed
27:24 and also change depression can cause
27:26 changes in the microbiome in the gut
27:29 so all of this also fits together
27:32 and makes it a when you do a microbiome
27:36 analysis and a predictive algorithm
27:38 for might say glycemic response you also
27:40 end up
27:41 affecting people’s mental health
27:44 so that’s great thank you for grounding
27:47 us in that and
27:48 you mentioned you know risks i think
27:50 that is kind of the overall
27:51 theme uh that we’re cut that’s coming
27:54 through here and i think a huge elephant
27:55 in the room that we haven’t really
27:57 spoken about yet
27:58 is the risk of medications and and the
28:01 the value equation that lives there
28:03 and so dr berger i would love to bring
28:05 you in and ask you
28:07 um you know there are many diabetes
28:09 medications available as we know some
28:10 for pre-diabetes and many more for type
28:12 2 diabetes
28:14 how do medications play into this value
28:16 equation
28:17 i think if you go back to melinda’s
28:20 comment
28:20 that we should be throwing a big
28:22 birthday party for insulin
28:24 it is true um it is a very valuable
28:28 medication it has changed people’s lives
28:31 that being said and i’ve spent for those
28:34 of you who are listening who know me
28:36 i’ve spent a lot of years in the arena
28:39 of medication management and medication
28:42 safety um you know i sit on the board of
28:45 a medication safety
28:47 uh company but the issue
28:50 is finding again the personalization
28:53 uh and the value statements are two
28:56 things you have to think about with
28:58 um medication all right
29:01 when we do medi when when
29:05 medication companies
29:08 manufacturers do their studies for the
29:12 fda
29:13 they are done population based again
29:16 they are not
29:17 personalized and so what we have found
29:20 is in some cases
29:21 it’s a matching dilemma just like
29:25 in other treatments the other
29:28 issue is medications are high value
29:32 if they’re used for the right person at
29:35 the right time
29:38 if there are other things that are
29:42 equally effective or safer
29:46 or that are less costly
29:50 then when you look at quality and cost
29:53 as part of value
29:54 you have to say is this the right time
29:59 alan and melinda both talked about the
30:01 impact
30:02 as of food as medicine
30:06 in impacting blood sugar
30:10 and food can be much safer
30:13 in some cases and higher value because
30:17 of cost
30:18 in some cases in many cases
30:22 than going to medication
30:26 or in partnership with medication but we
30:29 have to start to seriously take in
30:32 the theory of food as medicine
30:36 evidence-based science
30:39 generally leads and has in some cases up
30:43 to 17 years
30:45 lag to how people
30:49 practice medicine um
30:52 physicians and other providers we’re
30:54 very smart people but sometimes we’re
30:56 slow to change
30:58 and the truth is food as medicine
31:01 and the very very important
31:04 differentiated role
31:06 the papers that alan was talking about
31:09 finally
31:10 are becoming more
31:14 um real world activated
31:17 so we’re seeing in um for example
31:20 nih is now talking about food as
31:23 medicine
31:24 and is talking about precision nutrition
31:28 this is five six years after the papers
31:31 first came out we’re seeing at the
31:34 american diabetes association
31:36 them starting to recognize food as
31:38 medicine
31:40 i think we all have to get on board that
31:43 when you talk about value food has a
31:46 very very high value in many cases
31:50 over medication as a first or second
31:53 line
31:54 again please nobody i am not saying
31:56 medication
31:57 is not good but i am saying
32:00 timing and the personality
32:04 of the being getting it and all those
32:07 other attributes and personalized
32:08 medicine
32:10 food as medicine is one of the highest
32:12 value
32:13 activities you can do for
32:17 um diabetes that’s great thank you
32:20 melinda please jump in and then i’d love
32:21 to hear what dr spiro has to say on this
32:23 topic too
32:24 yeah no i just thought you reminded me
32:27 dr berger of an article
32:28 that uh in our diabetes world we just
32:32 love it was
32:33 a copy of the presidential address from
32:35 the american diabetes association in
32:37 2016
32:39 and it was called if diabetes education
32:41 and nutrition therapy
32:42 were a pill would you prescribe it
32:45 and it sort of postulated that you know
32:48 as
32:49 physicians are so good at prescribing
32:52 um you know insulin pills and all this
32:54 stuff but we’re not
32:56 as the data that i gave you before of
32:58 writing a prescription to see a
33:00 dietitian
33:01 and the author compared head to head
33:04 what nutrition therapy
33:06 was like in terms of efficacy the risk
33:09 of low blood sugar
33:10 weight loss side effects cost all the
33:12 other benefits compared to metformin
33:14 probably the most popular first line
33:16 medication treatment
33:18 and found out when compared head to head
33:20 nutrition comes ahead
33:22 so why don’t we use it more who are the
33:25 cheerleaders in the marketing teams
33:27 promoting
33:28 food as medicine so uh you reminded me
33:31 of that article in that mantra
33:33 that’s great thank you for sharing it um
33:36 and so dr spero tell us uh
33:38 we’d love to hear your view on the the
33:40 value of medications
33:42 um i’m sure you share many of the same
33:44 opinions as dr berger has
33:46 um but i know that you also have a lot
33:48 of experience of taking patients off
33:50 medications and so tell us a little bit
33:51 about how that goes
33:52 yeah you know it it again very
33:55 interesting that
33:56 people get stuck on medications and
33:59 there’s a tremendous what i’ll call fear
34:01 factor
34:02 that is not just true for um themselves
34:06 but for their doctors you know doctors
34:08 often treat their own anxiety
34:10 um in many ways they they uh
34:13 and someone’s doing well on something so
34:15 you get nervous about taking them
34:17 off that pill taking them off that
34:19 medication
34:21 when often you do need to reassess and
34:24 take people off medications very often
34:27 to keep them in the best of health
34:31 and it’s just something to be aware of
34:35 we know that if you
34:38 have the right nutritional therapy
34:42 that is based on the right parameters
34:45 microbiome being um an example of one
34:49 and um just baseline other types of
34:52 tests
34:53 lab tests being another example what’s
34:55 your cholesterol etc
34:57 um that you can really get to a very
35:00 good result well
35:04 i won’t say eliminating but minimizing
35:06 the need for medication
35:08 yeah and we also know that there’s
35:10 always a risk
35:12 with any therapy you know
35:15 anything it has a risk and it might be a
35:18 minor risk
35:19 but it has a risk um and you have to
35:23 be always thinking not just of therapy
35:26 if you’re a clinician but how
35:28 do you continuously mitigate risk how do
35:31 you decrease the risk
35:33 and the fact is that um
35:36 if you’re able to do things without
35:37 medication
35:39 you minimize the risk because everything
35:41 has a risk
35:43 so that’s great so so if the you know if
35:45 we’re really talking about increasing
35:47 the quality of care
35:48 through reducing the risk um i would
35:51 love to
35:51 to know are we focused on the right
35:54 metrics
35:57 okay great question so
36:00 we have to think in terms of whenever
36:03 you think about metrics
36:05 you know there’s a classic series of
36:08 errors that
36:08 you make when you’re measuring things
36:12 um it was the old joke about the person
36:16 who
36:16 is in a very dark black night
36:20 under a street lamp on his hands and
36:22 knees and someone else comes along
36:25 and says what are you doing and he says
36:26 you know i’m looking for my car keys
36:29 and the person says well it’s a good
36:30 thing you lost them under that street
36:32 lamp because otherwise
36:33 you have a horrible time trying to find
36:34 them they said oh i didn’t i lost them a
36:36 block away but this is where the light
36:38 is
36:40 so you often find that people aren’t
36:43 measuring the right things in terms of
36:46 metrics
36:48 um but that’s where the light is they’re
36:50 using the data they have
36:51 rather than looking at what you need we
36:54 see this certainly
36:55 in the fact that we’re just starting to
36:58 pay attention to social
37:00 and non-biological factors
37:03 because we’re starting to think about
37:04 how do we measure them
37:07 um we’re um now first measuring
37:11 these uh detailed microbiome analyses
37:15 which we never did before so we we
37:17 thought for a while that you know we
37:19 keep getting arrogant if i can put it
37:21 that way
37:22 about what we know because we’re so
37:24 quantitative and we
37:26 look at all these things um but
37:28 sometimes
37:29 we’re just not looking at the right
37:30 things sometimes we’re
37:32 looking under that street lamp when the
37:34 answer answer’s a block away
37:37 and and it’s really important that we
37:40 start to
37:41 understand that there are a lot of
37:44 variables if i can put it in
37:45 almost um quantitative terms out there
37:49 that we’re not yet measuring and it’s
37:52 not that they’re not important
37:53 they are important we’re just not
37:55 measuring them we have to
37:58 you know it’s interesting let me i want
38:00 to jump in
38:01 um early on in our conversation today
38:05 melinda talked about five percent seven
38:08 percent
38:09 of people utilizing the um
38:12 education and the dietary support
38:16 we measure like alan said a lot of
38:19 things
38:20 including by the way medication
38:24 adherence but we don’t
38:27 measure dietary
38:30 visit adherence which actually
38:34 is as high a value if not
38:37 in some cases higher value so
38:40 i would challenge because i love to do
38:42 this for anybody who is
38:44 listening to this um and you are an
38:48 employer and you are looking to see do
38:50 are you getting value for the benefits
38:52 you’re offering
38:54 your employees
38:58 i would ask you and challenge you to
39:00 look at
39:01 what is the adherence level
39:05 of this very very high value
39:11 set of services that most of you offer
39:13 and if you don’t offer it that’s the
39:15 other question is
39:16 it’s a as high a value as medication and
39:19 much less expensive
39:21 why aren’t you offering it
39:24 and then why aren’t you measuring it so
39:26 to your comment
39:28 about metrics the metrics have to keep
39:31 up
39:32 with the science and i would argue right
39:35 now
39:36 there is a mismatch that’s great thank
39:39 you
39:39 and so uh either dr berg or dr spiro
39:43 tellers
39:44 what are what are the metrics that you
39:45 think are most valuable to measure
39:49 alan talk about time and range because
39:51 you talked about it before come back to
39:53 measuring that either in addition to a1c
39:57 or soon to be maybe even instead of
40:00 yeah so i i time and range which is the
40:03 amount of time that you’re in control
40:05 is a critical measure it’s more
40:07 associated with
40:08 end organ damage from diabetes then
40:12 is glycosylated hemoglobin which is an
40:14 average it’s an average
40:16 over um you know a longer period
40:20 even more important i think which we’re
40:22 starting to see some data and i’d
40:23 love to hear what melinda has to say
40:25 about that is variability
40:27 when i talked about those peaks and
40:29 troughs when i talked about the yoyo
40:31 effect
40:32 you can now measure variability in blood
40:36 sugar either by
40:38 measuring directly through a cgm
40:42 or through a bgm even with multiple uh
40:45 testing or we can predict it honestly on
40:49 the basis of the microbiome analysis and
40:51 other parameters that we used
40:53 in the uh algorithm that we
40:56 that has been developed by the brilliant
40:59 people behind day two
41:01 um there’s that variability is so
41:04 dangerous that time and range the need
41:06 for it to be
41:07 over a long time is so compelling
41:10 a measure but then you’ve got other
41:13 measures as well
41:14 you’ve got other metrics that are
41:16 socially
41:18 related um just from a whole different
41:21 thing
41:21 you know we like to think about things
41:23 like readmissions to the hospital
41:25 what’s the number one reason that people
41:27 over 65 are readmitted to the hospital
41:29 is it a disease
41:30 no it’s living alone that’s why
41:34 and unless you’re measuring people on
41:36 the basis of are they living alone or
41:38 not
41:39 you don’t focus on it you have to create
41:42 focus around it
41:44 but back to time and range and
41:45 variability
41:47 um melinda do you want to comment to
41:48 that as well
41:50 um nothing really to add other than you
41:52 know i think for
41:53 many of the people listening they may
41:55 never have heard of this
41:56 it’s even new in the diabetes community
41:59 but
42:00 growing rapidly you know i think we
42:04 are not looking at this necessarily as a
42:06 measure that we
42:07 need to get on every individual with
42:09 diabetes
42:10 but it’s uh such important data
42:14 that can really guide us in making
42:16 treatment decisions
42:17 and uh reducing risks of complications
42:20 um it’s a very exciting metric that
42:24 we’re seeing more and more
42:25 of so uh that’s all i’ll add
42:29 that’s great thank you well we actually
42:31 have a question on this from
42:33 from uh those who are joining today
42:35 specifically from christina that i’d
42:37 love to read out
42:38 um and just see if you know we can offer
42:41 some
42:41 advice here so the question is to what
42:44 extent do you think
42:45 cgm manufacturers are thinking about
42:48 nutrition and lifestyle
42:50 and so she works in healthcare
42:52 consulting
42:53 and worked on the exact area of cgns in
42:56 time in range for abbott diabetes
42:59 and found that it was unfortunately not
43:00 a focus area at all
43:02 uh and this was really quite
43:03 disappointing from a dietitian
43:05 perspective
43:06 awesome i i think that’s very
43:09 interesting i’m surprised that
43:11 we didn’t see more of a focus i think
43:14 that
43:15 i was actually intrigued with an article
43:18 that appeared
43:19 in the new york times the other day
43:22 she’s probably familiar with it that was
43:24 looking at the utilization of
43:27 cgm in more i’ll call it normal healthy
43:30 population populations without diabetes
43:33 and how
43:34 that as a technology can actually be
43:37 suggesting guiding influencing food
43:40 choices so
43:42 this is not an area i know a lot about
43:44 in terms of
43:45 cgm and food choice in the non-diabetes
43:49 population but i was surprised to see
43:51 how
43:51 rapidly that’s growing so um
43:55 alan or dan you have anything to add to
43:57 that
43:59 um interestingly um elite athletes
44:03 were the first to look at that because
44:05 they then know
44:07 these are a group of people who probably
44:09 know their bodies more than anybody else
44:12 um the issue though becomes and again
44:15 it’s
44:15 um something that i would suggest
44:18 whether it’s a consultant or
44:21 a an employer looking at benefit design
44:25 is the role of cgm
44:28 in nutrition in food is medicine
44:33 and whether it’s healthy lifestyle or
44:35 being as healthy
44:36 as you can be in a chronic lifestyle
44:40 issue we know in oncology inflammation
44:44 and blood sugar have big roles so i
44:47 think that the pharmaceutical
44:50 manufacturers and this young lady who
44:52 was at abbott which does have a cgm
44:55 have been very focused on the value of
44:58 cgm where it has been covered and where
45:01 it has been
45:01 fda approved and again it goes to the
45:04 light
45:05 in alan’s story um i am going to
45:07 remember that story i like that
45:09 um um so the answer actually alan is to
45:13 drop your keys only where the light is
45:16 correct um i think that the reason is
45:19 the tie-in to the two
45:21 although and you know abbott is also a
45:24 nutrition company
45:25 so um you would think that that would be
45:28 more tightly tied
45:30 there’s a lot of concern that people are
45:32 not covering
45:33 cgms except for a very small area
45:37 and i do think we have to look at the
45:39 role if we believe blood sugar for both
45:41 healthy people
45:43 and people who have are challenged by
45:45 chronic conditions
45:46 we really do have to it’s probably in
45:49 many cases
45:50 a higher value
45:53 um and quality metric
45:57 that we have to start looking at much
45:59 more seriously
46:00 but i will say and the truth of the
46:03 matter is
46:04 as we get to the mic more and more about
46:06 the microbiome
46:09 if you have a.i artificial intelligence
46:12 and you have these metrics like
46:14 microbiome
46:16 actually they work even better
46:20 in many ways than cgms because it’s a
46:23 proactive piece of knowledge if i know
46:25 i’m going to eat something and my micro
46:28 and my cgm would jump up
46:32 what if i knew that before i ate it
46:35 and saw the cgm and was reactive and
46:38 proactive
46:40 so i think the use of microbiome
46:43 um and good artificial intelligence
46:46 in many cases can replace the cgf
46:50 yeah and i agree a hundred percent i was
46:53 uh
46:54 going to make the same point um
46:57 we have the opportunity to take this
47:01 what i’ll call transitional technology
47:05 of a cgm and i truly do consider it a
47:07 transitional technology for a whole
47:08 bunch of reasons
47:11 and become much more proactive
47:15 using the right data sources with the
47:17 right
47:18 algorithms that are developed and you
47:21 know i
47:22 part of what i do is play with
47:23 algorithms and um
47:26 which i know sounds strange but you know
47:28 but
47:29 you can do that and actually
47:33 just get rid of the need for cgms in
47:36 terms of the pharmaceutical companies
47:39 they also there’s almost something
47:44 transitional about current day
47:46 medication
47:47 because they are not necessarily
47:49 personalized
47:51 they are more fitted for a population
47:55 rather than an
47:56 individual and um
48:00 you know that’s actually an opportunity
48:02 for the pharmaceutical industry if they
48:04 would think in a more individualized way
48:07 in
48:08 both of uh therapies being part of
48:11 what i’ll call an ecosystem of therapies
48:14 including nutrition
48:16 including activity including social
48:19 factors you get a whole different
48:22 approach
48:23 um from a benefit design point of view
48:26 should we be thinking
48:27 of grocery prescriptions
48:31 that are and making them specific based
48:33 on the microbiome
48:35 anyway i’d love to get into that topic
48:37 i’m glad you mentioned transitions i
48:39 have one last question that i would love
48:40 to hear a brief opinion from all of you
48:42 on
48:42 um are there changes in coverage and
48:45 medical policies that need to be made in
48:47 order to increase
48:48 value in diabetes care so whether that
48:50 is food programs
48:52 um or anything else that comes to mind
48:55 absolutely um and i i’ve already
48:58 challenged
48:59 my colleagues who are
49:03 creating plan designs or advising on
49:05 plan designs
49:06 that looking at things in addition to
49:10 medication
49:12 um i think looking at things that are
49:14 personalized
49:15 today our plan designs are population
49:18 based
49:19 they also don’t look at high value
49:22 activities
49:23 such as dietary support
49:27 and education in some cases it’s it’s
49:30 very similar to
49:31 mental health for many years it was
49:33 looked at that you got
49:35 12 visits so you got 10 visits physical
49:38 therapy as well
49:39 and now we’re saying you know people
49:41 don’t overuse
49:42 these things it was it was an un
49:46 it was an untrue perception
49:49 we need to make what’s of high value
49:52 easy and that is things such as
49:56 um uh dietary support
50:00 um more more use of cgms for
50:03 as an alternative programs
50:07 that personalize and aren’t barriered
50:11 to low engagement
50:15 and really start to look at
50:17 personalization or precision
50:20 instead of population based because
50:23 otherwise
50:23 you’re losing a lot of the value you
50:26 think you’re having you’re paying for
50:27 things
50:28 that aren’t at at highest value and as
50:30 dr fendrick said
50:32 reward and make easy that which is of
50:35 high value
50:37 nice thank you dr spero thoughts on
50:40 um reform in coverage and policies
50:44 yes we need it so but but
50:47 um to to just build upon what jan was
50:51 saying
50:51 the insurance industry in some ways has
50:53 been based for years and years and years
50:56 on the actuarial slash economic
51:01 basis that moral hazard can
51:04 drive up cost moral hazard being that
51:07 people use what you give them
51:10 if there’s no cost to it in 2012 there
51:14 was a
51:15 wonderful article in the journal of
51:16 economics on behavioral hazard
51:20 which gets to the point that jan was
51:21 making it turns out that people don’t
51:24 want to overuse health care
51:25 my god do you like going to the doctor i
51:28 don’t
51:29 i mean it’s not really um the moral
51:33 hazard piece has been overblown
51:36 and we have to understand and i’m not
51:40 advocating for an open checkbook as old
51:43 indemnity insurance days did which was a
51:45 problem
51:46 what i am advocating for is to think
51:48 smartly about this
51:50 not be weighted down and
51:54 panicked by this issue of moral hazard
51:56 and
51:57 pay for the right nutrition and pay for
51:59 the dietitians
52:01 to really counsel people over time and
52:04 pay for
52:04 telehealth which is now being paid for
52:06 for the first time
52:08 and um understand there are certain
52:11 things you can pay for
52:12 safely without worrying about moral
52:14 hazard that’s great thank you melinda
52:17 30 seconds from yeah i will just agree
52:20 and i would say definitely decrease the
52:22 limits on visits to a dietitian and an
52:25 educator
52:26 because they’re way too low and it won’t
52:27 be overutilized and secondly
52:30 increasing technology for those who need
52:31 it whether it’s cgm or as simple as one
52:34 with those strips
52:34 not enough people even get those so
52:38 that’s great advice thank you so much
52:39 we’re going to have to leave it there
52:41 because we are out of time so i’m sorry
52:42 to cut you off
52:43 but thank you for sharing all of your
52:45 opinions i really appreciate it i’m sure
52:47 um everyone joining us today does too
52:49 i just wanted to signal that we are
52:50 leaving some details
52:52 in the chat if you do want to reach out
52:54 today too uh or to any of our panelists
52:57 who we would be lovely you know we’d be
52:58 delighted to connect you with
53:00 so thank you with that you’ll say have a
53:03 great day
00:11 welcome my name is alisa weider and i’m
00:13 your host from day two welcome to day
00:16 two’s webinar on increasing quality care
00:18 from diabetes and metabolic disease
00:22 we’re thrilled that you’re joining us
00:23 for what promises to be a lively
00:24 discussion
00:26 right now as employers and payers are
00:28 finding that reducing costs
00:30 and increasing roi from their wellness
00:32 and benefits programs
00:33 has come to a crunch with the covid19
00:36 pandemic focusing mindshare on how to
00:39 get more value from existing programs
00:41 and putting pace on the search to find
00:43 and implement
00:44 more effective programs that can tackle
00:47 the underlying causes of the disease
00:50 i’m joined today by our esteemed
00:52 panelists first
00:53 i’d like to welcome dr alan spiro dr
00:56 spero
00:57 was most recently chief medical officer
00:59 for blue health intelligence
01:01 and his experience covers over 30 years
01:03 as a health care leader
01:04 with blue cross blue shield accolade
01:07 anthem and willis towers watson
01:11 dr jan berger is a multi-published
01:13 author on the topic of health care
01:14 reform
01:15 and a seasoned tri-secretary executive
01:18 with
01:19 cvs health and midwest business group on
01:21 health
01:23 melinda marinuck is an award-winning
01:25 diabetes educator
01:27 with over 35 years of experience at the
01:29 jocelyn diabetes center
01:31 she currently holds the position of
01:33 director of care programs
01:34 for the jocelyn innovations division
01:37 welcome everyone so to get us started i
01:41 would like to really ground our
01:42 discussion with a question
01:44 first to you dr berger how should we
01:47 define
01:48 low value care for diabetes and
01:49 metabolic disease
01:52 well that’s a great question and it’s a
01:54 great question because if we’re not
01:56 all speaking the same language the next
01:59 hour
02:00 may not make sense for many people in a
02:03 number of ways
02:04 um the definition today
02:08 of our conversation is about increasing
02:10 quality care
02:12 and quality has been tied very
02:16 tightly to a component of value
02:19 value in healthcare really started to
02:22 take hold in conversations about 10
02:24 years ago
02:25 and people like dr mark fendrick
02:29 who’s the director of the center for
02:30 value-based insurance design at
02:32 university of michigan
02:35 mike chernow who is at harvard
02:38 and dr will shrank who’s presently the
02:40 chief medical officer of humana
02:43 have been very very active in describing
02:46 high value and low value care this has
02:49 become
02:50 very important to employers and to
02:53 health plans payers because of the fact
02:57 that as you said we have to make sure
03:00 that we’re getting
03:01 what we want and desire and expect
03:05 of our health care dollars and so it’s
03:07 really
03:08 important that value and care
03:11 is the outcomes achieved per dollar but
03:14 there are two things in value of care
03:16 that we have to think about one what is
03:18 the outcome we’re looking for
03:20 is it a clinical outcome is it a
03:22 financial outcome
03:23 is it a humanistic outcome or is it some
03:26 mix of all three the second is
03:30 value to whom we have a health care
03:33 system
03:34 where a large portion of the care is
03:37 paid for
03:39 by the employer by government or by a
03:42 health plan
03:43 increasingly the patient is
03:46 also having to take on greater financial
03:49 responsibility
03:51 so the challenge is how do we get value
03:55 to all four of the sectors who may be
03:58 payers and impacted by the care that is
04:02 given
04:04 so i would say as we think about today
04:07 and the three of us have a conversation
04:10 is do we look at is there no
04:14 or low benefit to a patient or
04:17 is it a driver of inefficiency or is
04:20 there
04:20 untapped opportunity because of new
04:23 science or personalization
04:26 of what we do that really means is it a
04:29 mismatch of service or intervention
04:32 to time or person and that’s really i
04:34 think
04:35 what we have to look at because that’s
04:37 where the world is
04:38 changing that’s great thank you dr
04:41 burger
04:42 i love that concept of mismatching i
04:44 think that’s really critical
04:46 and one thing i’ve noticed in the
04:47 industry is that we’re really hearing a
04:48 lot about personalization
04:50 um particularly we’re kind of moving
04:52 from population health to
04:55 more personalized health so is it
04:57 possible to practice both
04:59 absolutely um and i’m going to start but
05:02 i know
05:03 that both of my colleagues here have
05:07 strong thoughts and experience in this
05:11 really one is a top-down model that’s
05:14 population health we’re thinking of the
05:16 whole group
05:18 versus the individual where
05:20 personalization is an n of one
05:23 it’s not looking at the average patient
05:26 it’s looking at
05:27 you or i as an individual and a number
05:30 of variables have come into play here
05:32 and are very important especially in
05:34 metabolic disease
05:36 at things such as heterogeneity of
05:40 preferences
05:42 of culture of capabilities of
05:46 more and more the conversation of social
05:47 determinants of health
05:49 historically we’re not taken into
05:52 consideration
05:53 in population health lee hood
05:56 is the founder for systems biology in
05:58 seattle
05:59 he really is the leader that said
06:03 that population health is actually based
06:08 on individual personalized care
06:11 the question we hear often is isn’t that
06:14 hard and expensive at looking at the
06:16 individual level
06:17 and i would argue a no
06:20 with new technologies and new analytics
06:23 tools
06:24 we really can get to the individual
06:27 and build up to a population it also
06:30 allows us
06:31 better value when we talk about low
06:34 value or high value care
06:37 alan what do you think about what i said
06:39 true false different what do you think
06:42 i agree with you it’s really interesting
06:44 when you think
06:45 about value and the question of
06:49 population
06:50 versus personal care personalized care
06:54 there’s often a mismatch
06:58 you know on a population basis
07:01 from a pure resource consumption point
07:04 of view it might be better
07:06 to focus on
07:09 what i’ll call the vast majority of
07:12 pregnancies
07:13 as opposed to advanced cancer
07:16 surgery because overall the population
07:19 benefit is going to be greater if you’re
07:21 the person with cancer
07:23 you may not agree with that priority um
07:27 you know there there’s always been that
07:29 tension
07:30 and it’s almost an ethical tension is
07:32 out it’s often how i see it
07:35 between population health and
07:37 personalized health
07:38 but now biology is entered in because
07:41 when you
07:42 look at personalized health especially
07:44 in the range
07:45 of something like diabetes you see very
07:49 uh different and smaller sub sub
07:52 segments so to speak
07:54 getting down to that n of one based on
07:57 certainly the biology
07:59 and the biology includes the person’s
08:03 unique genetic makeup it also includes
08:06 the
08:07 genetics of their friendly visitors
08:10 mainly the microbiome the trillion
08:12 bugs that live in each one of us that
08:14 are very different
08:15 and have a dramatic effect on the
08:18 individuality of each person
08:20 biologically you then have all those
08:22 non-biological
08:24 components which include what’s
08:27 called the social determinants but it
08:29 includes things like economics
08:31 it includes uh culture it includes
08:34 uh the the entire life context
08:38 of what people live with do they have
08:41 competing priorities sick children or
08:44 sick parents
08:45 do they have multiple jobs do there’s
08:48 just a whole
08:49 range it’s what makes the
08:51 personalization to me so
08:53 fascinating and so compelling
08:57 when you’re talking about diabetes in
08:58 particular
09:00 diabetes is and whenever you’re talking
09:02 about any chronic disease but diabetes
09:04 is a poster child
09:06 because um you can say on a population
09:09 basis that everyone should get their
09:10 glycosylated hemoglobin level
09:13 once every quarter and that becomes a
09:16 metric and it’s an important metric but
09:20 what about the fact that we know
09:23 that diabetes impacts different social
09:26 strata
09:26 and different um other types of groups
09:30 disproportionately how does it
09:33 go ahead i’m sorry go ahead i wanted to
09:36 jump into
09:37 something you mentioned there uh you
09:39 touched on metrics but before we go into
09:41 that i’d really love to dig into
09:44 um the the the biology of of of the host
09:47 of the patient
09:48 um and just bring in the topic of food
09:50 because i know that is such a big focus
09:52 for the shift in care
09:54 um from for diabetes and particularly
09:56 metabolic disease as well
09:58 so i’d love to bring in melinda and just
10:00 hear her thoughts at this stage
10:02 um so melinda can you tell us what is
10:04 the value of
10:05 food and diabetes sorry food and diet in
10:08 diabetes
10:09 ah sure and you know it’s interesting
10:12 alice
10:13 um that in so many arenas food is being
10:16 now talked about as this sort of
10:19 new and important treatment that we
10:21 should be paying more attention to
10:23 but uh i might call your attention to
10:25 the fact that this year
10:27 we celebrate the 100th anniversary of
10:30 the discovery of
10:31 insulin and prior to the discovery of
10:34 insulin in 1921
10:37 food was the only way to
10:40 treat and manage people with diabetes
10:43 now certainly with the
10:45 advent of insulin and after that many
10:47 other medicines
10:48 food has sort of taken a back seat with
10:51 this which is
10:52 really unfortunate because it’s
10:55 extremely effective
10:56 i think if you look at the literature it
10:59 talks about
11:00 the triad of treatments for diabetes
11:03 food exercise and medications but
11:08 speaking about value i think that we
11:10 would all agree that
11:12 food and appropriate food treatments are
11:15 very
11:16 high value care especially for people
11:19 with
11:20 type 2 diabetes and for many people it
11:22 really
11:23 could go back to being the only
11:25 treatment
11:26 it may be that medications are
11:28 absolutely not necessary
11:30 so that that’s a great point that you
11:32 make melinda thank you i appreciate you
11:34 really grounding us in the power of food
11:36 in this uh care program
11:38 so and something we know extremely well
11:40 at day two of course
11:41 um so i did want to just follow up on
11:43 that and ask you about um
11:44 sort of the role of dietary counselling
11:46 but before i do
11:47 i think we’re struggling a little bit on
11:49 your sound and i wonder if you could
11:50 come slightly closer to the microphone
11:52 when you answer this question
11:53 okay thank you so much so
11:56 tell us do you think wellness and
11:57 benefits programs are recognizing
11:59 dietary
12:00 counseling as bringing value well
12:03 i would say i don’t know exactly for all
12:06 benefits programs but i would say
12:08 nationwide we’re doing a terrible job
12:10 taking advantage of the benefits that
12:13 people
12:14 uh usually have so we have data from
12:18 medicare beneficiaries that only about
12:20 five percent
12:22 of individuals take advantage of
12:24 benefits related to either diabetes
12:26 education
12:27 or medical nutrition therapy um and
12:30 that’s
12:31 really low uh in terms of those with
12:33 private insurance
12:34 it’s a little bit higher but only about
12:37 seven percent
12:38 so it’s an extremely underutilized
12:40 research
12:41 source in terms of either accessing a
12:43 registered dietitian nutritionist
12:45 or for people with diabetes accessing a
12:48 recognized
12:49 or accredited diabetes education program
12:52 so
12:53 i think absolutely uh it is very under
12:56 utilized um a couple of other comments i
12:59 wanted to
13:00 make related to that is that we
13:03 definitely
13:04 know the benefits of medical nutrition
13:06 therapy it’s been well documented
13:08 and i’ll just speak right now about
13:09 people with type 2 diabetes that
13:12 when done well it really
13:16 can reduce a1c we have evidence that
13:19 up to 2 drop in a1c is realized
13:22 just with medical nutrition therapy
13:26 we know that there are a couple of
13:27 things that make it
13:29 more likely to go well and that is
13:33 that it be done by an experienced
13:35 dietitian
13:36 who has um experience in
13:40 diabetes and metabolic conditions uh
13:43 an extra bonus is if that individual is
13:46 certified as a diabetes
13:48 care and education specialist the second
13:50 item is
13:51 if there are multiple touch points
13:54 multiple visits
13:56 we know that just by giving a list of
13:59 recommendations
14:00 whether it’s very personalized or not
14:03 but only having one or two contacts will
14:06 also
14:07 not do it so just sending somebody to a
14:10 dietician once
14:11 i mean it’s sort of like sending them to
14:13 a doctor once and not having any
14:15 follow-up
14:16 with adjusting medications it’s not
14:18 going to work so
14:19 um ongoing care and ongoing support is
14:22 really important
14:23 and the third thing that we’re learning
14:26 is the more
14:27 tailored and customized and personalized
14:30 that information is those
14:32 recommendations are the better they are
14:34 and i can speak a little bit more later
14:36 if you want about
14:38 what i see as the difference between
14:42 population nutrition individualized
14:45 nutrition
14:46 and personalized nutrition that is great
14:49 thank you so much we will definitely be
14:51 circling back to personalization and
14:54 what that truly means
14:55 shortly thank you i really appreciate
14:57 that uh i
14:58 would love to just uh pass back to dr
15:01 spiro but before i do that
15:03 i wanted to remind the audience because
15:05 i know we do have a lot of
15:07 uh executives in the benefits and
15:09 wellness space here today
15:10 um to just remind them to post any
15:12 questions that you might have in the q a
15:15 box so that we can circle back and uh
15:17 make sure we cover those for you towards
15:19 the end
15:20 so uh dr spiro please tell us um
15:23 can personalization and individualized
15:26 care
15:27 contribute to existing sorry increasing
15:30 quality care
15:32 absolutely um it’s really
15:36 interesting because um
15:39 we’re we’re unfortunately we got into
15:42 and i’m going to go back to something
15:43 jan was talking about earlier
15:45 we we got into a cycle where we were so
15:48 concerned with the population health
15:50 that i think that
15:52 we lost a lot of the personalized health
15:56 that is necessary and and i’m
15:59 even talking and this alludes a little
16:01 bit to what i think melinda is going to
16:03 um talk about this whole issue of
16:07 how care always used to be
16:10 individualized
16:11 it used to be very much you would go to
16:14 your local
16:15 physician your local health professional
16:18 who would know you
16:20 who would know your culture and your
16:22 social setting and
16:23 would know all about you and your family
16:26 and would treat you in that life context
16:30 and as we moved more towards
16:32 population-based
16:33 care we lost some of that and
16:36 good reason we there are other quality
16:40 things but for example
16:41 the move to having a hospitalist instead
16:43 of your doctor taking care of you
16:45 in the hospital there are clearly some
16:49 improvements in responsiveness
16:52 and in the quality of hospital-based
16:54 care
16:56 but there’s also a loss there’s a loss
16:58 in the holistic care
17:00 that comes about because of that which
17:02 results in poorer quality on that regard
17:06 um there’s also the issue of how you
17:08 define quality
17:10 um from whose point of view which jan
17:12 brought up earlier
17:14 there is what i’ll call quality of
17:17 the pure biologic care
17:21 following care-based algorithms
17:23 following best practice
17:24 but there’s also quality from a person’s
17:27 point of view
17:29 the person receiving the care and that
17:32 includes the quality of what i’ll call
17:34 caring does someone care about me
17:38 the quality of the interaction
17:42 the quality of the entire experience
17:46 when you get stressed and confused by
17:50 trying to access care that’s not good
17:53 quality
17:55 and that’s the norm for much of our
17:57 population
17:58 today so we’ve got to define quality
18:01 correctly
18:02 thank you that i think that’s super
18:04 important to point out and i actually
18:06 wanted to just build on something you
18:08 said there
18:08 can you tell us about the ethics of
18:11 population health
18:12 so for example is it ethical
18:16 well is ethical population health and
18:17 oxymoron do you do you see it that way
18:20 you know in some ways um this is a topic
18:23 that’s interested me for years
18:26 because um in many ways um again
18:29 alluding something jan said earlier um
18:32 i’ve been part of the problem
18:33 i’ve been leading in population health
18:36 and um for many many years
18:39 and i’ve always struggled with this
18:41 point that
18:42 when you’re dealing with a population
18:44 decision
18:46 that’s not the same as dealing with an
18:48 individual decision
18:51 in some ways i i now as a patient
18:55 at my age you’re always a patient as a
18:58 patient i go to
18:59 young physicians who
19:02 have learned population health almost
19:05 too well
19:06 because i almost feel that they’re not
19:08 being an advocate for me
19:10 from a statistical point of view which
19:12 is the
19:13 data science part of it is something i
19:15 know very well
19:17 when you’re dealing with a bell curve a
19:20 normal distribution
19:22 on the population health way you’re
19:24 going to deal with the center of the
19:25 bell curve
19:26 but there’s always those individuals on
19:29 either end of the bell curve
19:31 and as a treating physician as a
19:33 treating
19:34 clinician you have to treat each
19:38 person and not assume they’re going to
19:39 be in the middle of the bell curve
19:42 and that’s what quality is you will
19:45 always have to be looking for those low
19:47 probability
19:48 high consequence events because if
19:50 you’re not looking for them you’re
19:52 not being a good health professional and
19:54 that’s the antithesis
19:56 of population health in some ways
19:59 you you have to make sure that when
20:02 you’re
20:02 a clinician the ethics are treating
20:06 every person as the individual they are
20:09 and when you’re doing population health
20:11 you have to talk about
20:13 putting resources where they’re needed
20:15 most and the two are
20:18 can be in conflict another area that
20:20 we’ve ignored
20:21 certainly during my training as a
20:23 gastroenterologist
20:25 as a nutritionist the fact that we have
20:28 all these lovely little critters living
20:30 inside our
20:31 intestines that are actually live with
20:34 us very nicely are
20:35 in many ways good for us and we’re
20:38 learning
20:39 the dramatic impact they have
20:42 on our well-being and and on
20:46 all aspects of our biology
20:49 so you know the research that eran
20:52 siegel and iran elena
20:54 first published in 2014
20:59 that found that totally dependent on
21:03 the specifics of your microbiome
21:06 the whole genome sequencing the
21:08 metabolic byproducts that you find
21:10 in a really in-depth analysis of your
21:12 stool
21:14 that you can predict blood sugars
21:18 and it turns out you can individualize
21:22 a diet on that basis which for me
21:25 as someone who’s steeped in gi and
21:27 nutrition is
21:29 fascinating and it’s wonderful so that
21:32 you can give to a patient or
21:34 even better to a certified diabetes
21:39 care and education specialist this kind
21:41 of fact and say you know what for that
21:43 person
21:44 who for whom rice is such a
21:47 huge cultural aspect we can test and it
21:50 might be that rice combined with some
21:51 other food
21:52 it actually does not have a glycemic
21:54 response doesn’t raise glucose
21:57 yep bring melinda in here and just hear
22:00 a little bit about
22:01 what she’s seen with individual uh
22:03 patients in her
22:04 in her world well uh you’re giving just
22:07 a great example
22:08 and you know just building off on the
22:10 rice and you can fill it in with so many
22:12 other food combinations a particular
22:14 food that classically
22:16 might be one that raises blood sugar too
22:19 high
22:19 like rice combining it with some
22:23 chicken with some pork with some egg and
22:26 a
22:26 stir-fry can dramatically change that
22:30 and for that individual you find the
22:32 best combination of
22:34 and this is important foods that they
22:36 like
22:37 because too often population based
22:40 recommendations especially very popular
22:42 diets and things that we’re
22:44 hearing a lot about lately it’s sort of
22:46 like the same recommendations for
22:47 everybody
22:48 everybody has to go very low carb or
22:51 everybody has to go
22:53 whatever the diet of the of the week is
22:56 but
22:56 the great thing about some of this um
23:00 uh discoveries that we have is that we
23:03 can
23:03 tailor those recommendations to bring
23:06 a food such as rice that classically
23:10 will spike someone’s blood sugar with
23:12 the food
23:13 that that individual likes and enjoys
23:16 that will
23:17 bring that response lower so that they
23:20 overall have a really
23:22 good impact on their on their glucose so
23:24 a very minimal impact on their food
23:26 that’s great thank you melinda and i
23:27 know this is extremely uh popular topics
23:30 i just wanted to remind the audience if
23:31 you do have any specific questions
23:33 on uh you know the food program aspect
23:36 of it
23:36 um i would love to hear those and and
23:39 give them to our panelists
23:40 so dr espiro i would love you to just
23:43 tell us uh
23:44 something about the yo-yo syndrome what
23:46 is that
23:47 and how does it play into quality care
23:50 yeah it’s really i’m very again it gets
23:53 to how we define
23:54 value and quality um
23:57 like uh melinda although not as
24:00 intensively as melinda i’ve been
24:01 treating people
24:02 with nutrition since i studied nutrition
24:07 as a nutrition fellow and
24:11 it’s we always talk about in a sense
24:15 weight loss whenever you’re talking
24:16 about nutrition you’re talking about
24:17 healthy eating
24:18 you can get someone to eat healthy and
24:21 lose weight
24:25 in a short time period
24:28 getting them to stay at it forever is
24:31 really the challenge
24:33 you know when you speak to people who
24:34 want to lose weight they will often tell
24:36 you that they’ve lost a thousand pounds
24:37 in their lifetime
24:40 just keep gaining it back each time
24:42 that’s the classic story
24:44 it’s it’s very hard
24:47 to change the way you do something
24:51 and make it permanent it’s often can be
24:55 a chronic
24:56 struggle and the yoyo syndrome is that
24:59 syndrome of going up
25:00 and down now it turns out like in so
25:02 many things
25:03 that’s more dangerous for your health
25:05 than just staying heavy
25:08 and there’s an analogous situation here
25:11 with blood sugars
25:13 we’re finding now that it’s not some
25:16 it is high blood sugars that aren’t
25:17 healthy but even worse than that
25:20 is blood sugar variability
25:23 the going up and down which is
25:25 associated with inflammatory response in
25:27 the body
25:28 with catecholamine release so it’s those
25:31 continued spikes and troughs and spikes
25:33 and troughs
25:34 which are the most dangerous piece and
25:36 that’s the analogous situation from a
25:38 blood sugar
25:39 point of view there’s almost a concept
25:42 of
25:42 being in this kind of steady state um
25:46 biologically that really fosters
25:49 health and that having dramatic swings
25:53 in many ways is
25:55 is like that yo-yo is more dangerous
25:58 than anything else and i see melinda
26:00 wants to jump in and i would just love
26:02 to hear her thoughts also
26:04 no i’m i’m just really nodding my head
26:07 in agreement
26:08 it can be so frustrating for individuals
26:11 who spend a lifetime
26:12 with that yo-yo effect and um
26:16 yeah it also does a number not only on
26:19 them
26:20 biologically with increased inflammation
26:23 but also
26:24 on their mental health because they just
26:26 begin to feel
26:27 i’m no good i can’t do this and so the
26:30 negative self-talk
26:31 just makes their health even worse so um
26:34 i agree
26:35 that’s that’s great thank you for uh
26:37 raising the topic of mental health as
26:39 well i know that it’s such a priority
26:41 this year for so many employers
26:43 as they’re thinking through how to
26:45 develop their care programs
26:47 can i bring can i bring it back to
26:48 microbiome for a minute
26:50 in terms of mental health because the
26:53 microbiome has a tremendous
26:54 impact on depression and mental health
26:57 as well you wouldn’t think so but
26:58 there’s something called
27:00 the brain gut microbiome
27:03 axis and the microbiome
27:07 affects the biology of the gut which
27:10 affects the autonomic nervous system
27:13 which affects endocrine release in the
27:15 brain and the hypothalamic
27:17 adrenal access so
27:20 changes in the microbiome can make you
27:22 depressed
27:24 and also change depression can cause
27:26 changes in the microbiome in the gut
27:29 so all of this also fits together
27:32 and makes it a when you do a microbiome
27:36 analysis and a predictive algorithm
27:38 for might say glycemic response you also
27:40 end up
27:41 affecting people’s mental health
27:44 so that’s great thank you for grounding
27:47 us in that and
27:48 you mentioned you know risks i think
27:50 that is kind of the overall
27:51 theme uh that we’re cut that’s coming
27:54 through here and i think a huge elephant
27:55 in the room that we haven’t really
27:57 spoken about yet
27:58 is the risk of medications and and the
28:01 the value equation that lives there
28:03 and so dr berger i would love to bring
28:05 you in and ask you
28:07 um you know there are many diabetes
28:09 medications available as we know some
28:10 for pre-diabetes and many more for type
28:12 2 diabetes
28:14 how do medications play into this value
28:16 equation
28:17 i think if you go back to melinda’s
28:20 comment
28:20 that we should be throwing a big
28:22 birthday party for insulin
28:24 it is true um it is a very valuable
28:28 medication it has changed people’s lives
28:31 that being said and i’ve spent for those
28:34 of you who are listening who know me
28:36 i’ve spent a lot of years in the arena
28:39 of medication management and medication
28:42 safety um you know i sit on the board of
28:45 a medication safety
28:47 uh company but the issue
28:50 is finding again the personalization
28:53 uh and the value statements are two
28:56 things you have to think about with
28:58 um medication all right
29:01 when we do medi when when
29:05 medication companies
29:08 manufacturers do their studies for the
29:12 fda
29:13 they are done population based again
29:16 they are not
29:17 personalized and so what we have found
29:20 is in some cases
29:21 it’s a matching dilemma just like
29:25 in other treatments the other
29:28 issue is medications are high value
29:32 if they’re used for the right person at
29:35 the right time
29:38 if there are other things that are
29:42 equally effective or safer
29:46 or that are less costly
29:50 then when you look at quality and cost
29:53 as part of value
29:54 you have to say is this the right time
29:59 alan and melinda both talked about the
30:01 impact
30:02 as of food as medicine
30:06 in impacting blood sugar
30:10 and food can be much safer
30:13 in some cases and higher value because
30:17 of cost
30:18 in some cases in many cases
30:22 than going to medication
30:26 or in partnership with medication but we
30:29 have to start to seriously take in
30:32 the theory of food as medicine
30:36 evidence-based science
30:39 generally leads and has in some cases up
30:43 to 17 years
30:45 lag to how people
30:49 practice medicine um
30:52 physicians and other providers we’re
30:54 very smart people but sometimes we’re
30:56 slow to change
30:58 and the truth is food as medicine
31:01 and the very very important
31:04 differentiated role
31:06 the papers that alan was talking about
31:09 finally
31:10 are becoming more
31:14 um real world activated
31:17 so we’re seeing in um for example
31:20 nih is now talking about food as
31:23 medicine
31:24 and is talking about precision nutrition
31:28 this is five six years after the papers
31:31 first came out we’re seeing at the
31:34 american diabetes association
31:36 them starting to recognize food as
31:38 medicine
31:40 i think we all have to get on board that
31:43 when you talk about value food has a
31:46 very very high value in many cases
31:50 over medication as a first or second
31:53 line
31:54 again please nobody i am not saying
31:56 medication
31:57 is not good but i am saying
32:00 timing and the personality
32:04 of the being getting it and all those
32:07 other attributes and personalized
32:08 medicine
32:10 food as medicine is one of the highest
32:12 value
32:13 activities you can do for
32:17 um diabetes that’s great thank you
32:20 melinda please jump in and then i’d love
32:21 to hear what dr spiro has to say on this
32:23 topic too
32:24 yeah no i just thought you reminded me
32:27 dr berger of an article
32:28 that uh in our diabetes world we just
32:32 love it was
32:33 a copy of the presidential address from
32:35 the american diabetes association in
32:37 2016
32:39 and it was called if diabetes education
32:41 and nutrition therapy
32:42 were a pill would you prescribe it
32:45 and it sort of postulated that you know
32:48 as
32:49 physicians are so good at prescribing
32:52 um you know insulin pills and all this
32:54 stuff but we’re not
32:56 as the data that i gave you before of
32:58 writing a prescription to see a
33:00 dietitian
33:01 and the author compared head to head
33:04 what nutrition therapy
33:06 was like in terms of efficacy the risk
33:09 of low blood sugar
33:10 weight loss side effects cost all the
33:12 other benefits compared to metformin
33:14 probably the most popular first line
33:16 medication treatment
33:18 and found out when compared head to head
33:20 nutrition comes ahead
33:22 so why don’t we use it more who are the
33:25 cheerleaders in the marketing teams
33:27 promoting
33:28 food as medicine so uh you reminded me
33:31 of that article in that mantra
33:33 that’s great thank you for sharing it um
33:36 and so dr spero tell us uh
33:38 we’d love to hear your view on the the
33:40 value of medications
33:42 um i’m sure you share many of the same
33:44 opinions as dr berger has
33:46 um but i know that you also have a lot
33:48 of experience of taking patients off
33:50 medications and so tell us a little bit
33:51 about how that goes
33:52 yeah you know it it again very
33:55 interesting that
33:56 people get stuck on medications and
33:59 there’s a tremendous what i’ll call fear
34:01 factor
34:02 that is not just true for um themselves
34:06 but for their doctors you know doctors
34:08 often treat their own anxiety
34:10 um in many ways they they uh
34:13 and someone’s doing well on something so
34:15 you get nervous about taking them
34:17 off that pill taking them off that
34:19 medication
34:21 when often you do need to reassess and
34:24 take people off medications very often
34:27 to keep them in the best of health
34:31 and it’s just something to be aware of
34:35 we know that if you
34:38 have the right nutritional therapy
34:42 that is based on the right parameters
34:45 microbiome being um an example of one
34:49 and um just baseline other types of
34:52 tests
34:53 lab tests being another example what’s
34:55 your cholesterol etc
34:57 um that you can really get to a very
35:00 good result well
35:04 i won’t say eliminating but minimizing
35:06 the need for medication
35:08 yeah and we also know that there’s
35:10 always a risk
35:12 with any therapy you know
35:15 anything it has a risk and it might be a
35:18 minor risk
35:19 but it has a risk um and you have to
35:23 be always thinking not just of therapy
35:26 if you’re a clinician but how
35:28 do you continuously mitigate risk how do
35:31 you decrease the risk
35:33 and the fact is that um
35:36 if you’re able to do things without
35:37 medication
35:39 you minimize the risk because everything
35:41 has a risk
35:43 so that’s great so so if the you know if
35:45 we’re really talking about increasing
35:47 the quality of care
35:48 through reducing the risk um i would
35:51 love to
35:51 to know are we focused on the right
35:54 metrics
35:57 okay great question so
36:00 we have to think in terms of whenever
36:03 you think about metrics
36:05 you know there’s a classic series of
36:08 errors that
36:08 you make when you’re measuring things
36:12 um it was the old joke about the person
36:16 who
36:16 is in a very dark black night
36:20 under a street lamp on his hands and
36:22 knees and someone else comes along
36:25 and says what are you doing and he says
36:26 you know i’m looking for my car keys
36:29 and the person says well it’s a good
36:30 thing you lost them under that street
36:32 lamp because otherwise
36:33 you have a horrible time trying to find
36:34 them they said oh i didn’t i lost them a
36:36 block away but this is where the light
36:38 is
36:40 so you often find that people aren’t
36:43 measuring the right things in terms of
36:46 metrics
36:48 um but that’s where the light is they’re
36:50 using the data they have
36:51 rather than looking at what you need we
36:54 see this certainly
36:55 in the fact that we’re just starting to
36:58 pay attention to social
37:00 and non-biological factors
37:03 because we’re starting to think about
37:04 how do we measure them
37:07 um we’re um now first measuring
37:11 these uh detailed microbiome analyses
37:15 which we never did before so we we
37:17 thought for a while that you know we
37:19 keep getting arrogant if i can put it
37:21 that way
37:22 about what we know because we’re so
37:24 quantitative and we
37:26 look at all these things um but
37:28 sometimes
37:29 we’re just not looking at the right
37:30 things sometimes we’re
37:32 looking under that street lamp when the
37:34 answer answer’s a block away
37:37 and and it’s really important that we
37:40 start to
37:41 understand that there are a lot of
37:44 variables if i can put it in
37:45 almost um quantitative terms out there
37:49 that we’re not yet measuring and it’s
37:52 not that they’re not important
37:53 they are important we’re just not
37:55 measuring them we have to
37:58 you know it’s interesting let me i want
38:00 to jump in
38:01 um early on in our conversation today
38:05 melinda talked about five percent seven
38:08 percent
38:09 of people utilizing the um
38:12 education and the dietary support
38:16 we measure like alan said a lot of
38:19 things
38:20 including by the way medication
38:24 adherence but we don’t
38:27 measure dietary
38:30 visit adherence which actually
38:34 is as high a value if not
38:37 in some cases higher value so
38:40 i would challenge because i love to do
38:42 this for anybody who is
38:44 listening to this um and you are an
38:48 employer and you are looking to see do
38:50 are you getting value for the benefits
38:52 you’re offering
38:54 your employees
38:58 i would ask you and challenge you to
39:00 look at
39:01 what is the adherence level
39:05 of this very very high value
39:11 set of services that most of you offer
39:13 and if you don’t offer it that’s the
39:15 other question is
39:16 it’s a as high a value as medication and
39:19 much less expensive
39:21 why aren’t you offering it
39:24 and then why aren’t you measuring it so
39:26 to your comment
39:28 about metrics the metrics have to keep
39:31 up
39:32 with the science and i would argue right
39:35 now
39:36 there is a mismatch that’s great thank
39:39 you
39:39 and so uh either dr berg or dr spiro
39:43 tellers
39:44 what are what are the metrics that you
39:45 think are most valuable to measure
39:49 alan talk about time and range because
39:51 you talked about it before come back to
39:53 measuring that either in addition to a1c
39:57 or soon to be maybe even instead of
40:00 yeah so i i time and range which is the
40:03 amount of time that you’re in control
40:05 is a critical measure it’s more
40:07 associated with
40:08 end organ damage from diabetes then
40:12 is glycosylated hemoglobin which is an
40:14 average it’s an average
40:16 over um you know a longer period
40:20 even more important i think which we’re
40:22 starting to see some data and i’d
40:23 love to hear what melinda has to say
40:25 about that is variability
40:27 when i talked about those peaks and
40:29 troughs when i talked about the yoyo
40:31 effect
40:32 you can now measure variability in blood
40:36 sugar either by
40:38 measuring directly through a cgm
40:42 or through a bgm even with multiple uh
40:45 testing or we can predict it honestly on
40:49 the basis of the microbiome analysis and
40:51 other parameters that we used
40:53 in the uh algorithm that we
40:56 that has been developed by the brilliant
40:59 people behind day two
41:01 um there’s that variability is so
41:04 dangerous that time and range the need
41:06 for it to be
41:07 over a long time is so compelling
41:10 a measure but then you’ve got other
41:13 measures as well
41:14 you’ve got other metrics that are
41:16 socially
41:18 related um just from a whole different
41:21 thing
41:21 you know we like to think about things
41:23 like readmissions to the hospital
41:25 what’s the number one reason that people
41:27 over 65 are readmitted to the hospital
41:29 is it a disease
41:30 no it’s living alone that’s why
41:34 and unless you’re measuring people on
41:36 the basis of are they living alone or
41:38 not
41:39 you don’t focus on it you have to create
41:42 focus around it
41:44 but back to time and range and
41:45 variability
41:47 um melinda do you want to comment to
41:48 that as well
41:50 um nothing really to add other than you
41:52 know i think for
41:53 many of the people listening they may
41:55 never have heard of this
41:56 it’s even new in the diabetes community
41:59 but
42:00 growing rapidly you know i think we
42:04 are not looking at this necessarily as a
42:06 measure that we
42:07 need to get on every individual with
42:09 diabetes
42:10 but it’s uh such important data
42:14 that can really guide us in making
42:16 treatment decisions
42:17 and uh reducing risks of complications
42:20 um it’s a very exciting metric that
42:24 we’re seeing more and more
42:25 of so uh that’s all i’ll add
42:29 that’s great thank you well we actually
42:31 have a question on this from
42:33 from uh those who are joining today
42:35 specifically from christina that i’d
42:37 love to read out
42:38 um and just see if you know we can offer
42:41 some
42:41 advice here so the question is to what
42:44 extent do you think
42:45 cgm manufacturers are thinking about
42:48 nutrition and lifestyle
42:50 and so she works in healthcare
42:52 consulting
42:53 and worked on the exact area of cgns in
42:56 time in range for abbott diabetes
42:59 and found that it was unfortunately not
43:00 a focus area at all
43:02 uh and this was really quite
43:03 disappointing from a dietitian
43:05 perspective
43:06 awesome i i think that’s very
43:09 interesting i’m surprised that
43:11 we didn’t see more of a focus i think
43:14 that
43:15 i was actually intrigued with an article
43:18 that appeared
43:19 in the new york times the other day
43:22 she’s probably familiar with it that was
43:24 looking at the utilization of
43:27 cgm in more i’ll call it normal healthy
43:30 population populations without diabetes
43:33 and how
43:34 that as a technology can actually be
43:37 suggesting guiding influencing food
43:40 choices so
43:42 this is not an area i know a lot about
43:44 in terms of
43:45 cgm and food choice in the non-diabetes
43:49 population but i was surprised to see
43:51 how
43:51 rapidly that’s growing so um
43:55 alan or dan you have anything to add to
43:57 that
43:59 um interestingly um elite athletes
44:03 were the first to look at that because
44:05 they then know
44:07 these are a group of people who probably
44:09 know their bodies more than anybody else
44:12 um the issue though becomes and again
44:15 it’s
44:15 um something that i would suggest
44:18 whether it’s a consultant or
44:21 a an employer looking at benefit design
44:25 is the role of cgm
44:28 in nutrition in food is medicine
44:33 and whether it’s healthy lifestyle or
44:35 being as healthy
44:36 as you can be in a chronic lifestyle
44:40 issue we know in oncology inflammation
44:44 and blood sugar have big roles so i
44:47 think that the pharmaceutical
44:50 manufacturers and this young lady who
44:52 was at abbott which does have a cgm
44:55 have been very focused on the value of
44:58 cgm where it has been covered and where
45:01 it has been
45:01 fda approved and again it goes to the
45:04 light
45:05 in alan’s story um i am going to
45:07 remember that story i like that
45:09 um um so the answer actually alan is to
45:13 drop your keys only where the light is
45:16 correct um i think that the reason is
45:19 the tie-in to the two
45:21 although and you know abbott is also a
45:24 nutrition company
45:25 so um you would think that that would be
45:28 more tightly tied
45:30 there’s a lot of concern that people are
45:32 not covering
45:33 cgms except for a very small area
45:37 and i do think we have to look at the
45:39 role if we believe blood sugar for both
45:41 healthy people
45:43 and people who have are challenged by
45:45 chronic conditions
45:46 we really do have to it’s probably in
45:49 many cases
45:50 a higher value
45:53 um and quality metric
45:57 that we have to start looking at much
45:59 more seriously
46:00 but i will say and the truth of the
46:03 matter is
46:04 as we get to the mic more and more about
46:06 the microbiome
46:09 if you have a.i artificial intelligence
46:12 and you have these metrics like
46:14 microbiome
46:16 actually they work even better
46:20 in many ways than cgms because it’s a
46:23 proactive piece of knowledge if i know
46:25 i’m going to eat something and my micro
46:28 and my cgm would jump up
46:32 what if i knew that before i ate it
46:35 and saw the cgm and was reactive and
46:38 proactive
46:40 so i think the use of microbiome
46:43 um and good artificial intelligence
46:46 in many cases can replace the cgf
46:50 yeah and i agree a hundred percent i was
46:53 uh
46:54 going to make the same point um
46:57 we have the opportunity to take this
47:01 what i’ll call transitional technology
47:05 of a cgm and i truly do consider it a
47:07 transitional technology for a whole
47:08 bunch of reasons
47:11 and become much more proactive
47:15 using the right data sources with the
47:17 right
47:18 algorithms that are developed and you
47:21 know i
47:22 part of what i do is play with
47:23 algorithms and um
47:26 which i know sounds strange but you know
47:28 but
47:29 you can do that and actually
47:33 just get rid of the need for cgms in
47:36 terms of the pharmaceutical companies
47:39 they also there’s almost something
47:44 transitional about current day
47:46 medication
47:47 because they are not necessarily
47:49 personalized
47:51 they are more fitted for a population
47:55 rather than an
47:56 individual and um
48:00 you know that’s actually an opportunity
48:02 for the pharmaceutical industry if they
48:04 would think in a more individualized way
48:07 in
48:08 both of uh therapies being part of
48:11 what i’ll call an ecosystem of therapies
48:14 including nutrition
48:16 including activity including social
48:19 factors you get a whole different
48:22 approach
48:23 um from a benefit design point of view
48:26 should we be thinking
48:27 of grocery prescriptions
48:31 that are and making them specific based
48:33 on the microbiome
48:35 anyway i’d love to get into that topic
48:37 i’m glad you mentioned transitions i
48:39 have one last question that i would love
48:40 to hear a brief opinion from all of you
48:42 on
48:42 um are there changes in coverage and
48:45 medical policies that need to be made in
48:47 order to increase
48:48 value in diabetes care so whether that
48:50 is food programs
48:52 um or anything else that comes to mind
48:55 absolutely um and i i’ve already
48:58 challenged
48:59 my colleagues who are
49:03 creating plan designs or advising on
49:05 plan designs
49:06 that looking at things in addition to
49:10 medication
49:12 um i think looking at things that are
49:14 personalized
49:15 today our plan designs are population
49:18 based
49:19 they also don’t look at high value
49:22 activities
49:23 such as dietary support
49:27 and education in some cases it’s it’s
49:30 very similar to
49:31 mental health for many years it was
49:33 looked at that you got
49:35 12 visits so you got 10 visits physical
49:38 therapy as well
49:39 and now we’re saying you know people
49:41 don’t overuse
49:42 these things it was it was an un
49:46 it was an untrue perception
49:49 we need to make what’s of high value
49:52 easy and that is things such as
49:56 um uh dietary support
50:00 um more more use of cgms for
50:03 as an alternative programs
50:07 that personalize and aren’t barriered
50:11 to low engagement
50:15 and really start to look at
50:17 personalization or precision
50:20 instead of population based because
50:23 otherwise
50:23 you’re losing a lot of the value you
50:26 think you’re having you’re paying for
50:27 things
50:28 that aren’t at at highest value and as
50:30 dr fendrick said
50:32 reward and make easy that which is of
50:35 high value
50:37 nice thank you dr spero thoughts on
50:40 um reform in coverage and policies
50:44 yes we need it so but but
50:47 um to to just build upon what jan was
50:51 saying
50:51 the insurance industry in some ways has
50:53 been based for years and years and years
50:56 on the actuarial slash economic
51:01 basis that moral hazard can
51:04 drive up cost moral hazard being that
51:07 people use what you give them
51:10 if there’s no cost to it in 2012 there
51:14 was a
51:15 wonderful article in the journal of
51:16 economics on behavioral hazard
51:20 which gets to the point that jan was
51:21 making it turns out that people don’t
51:24 want to overuse health care
51:25 my god do you like going to the doctor i
51:28 don’t
51:29 i mean it’s not really um the moral
51:33 hazard piece has been overblown
51:36 and we have to understand and i’m not
51:40 advocating for an open checkbook as old
51:43 indemnity insurance days did which was a
51:45 problem
51:46 what i am advocating for is to think
51:48 smartly about this
51:50 not be weighted down and
51:54 panicked by this issue of moral hazard
51:56 and
51:57 pay for the right nutrition and pay for
51:59 the dietitians
52:01 to really counsel people over time and
52:04 pay for
52:04 telehealth which is now being paid for
52:06 for the first time
52:08 and um understand there are certain
52:11 things you can pay for
52:12 safely without worrying about moral
52:14 hazard that’s great thank you melinda
52:17 30 seconds from yeah i will just agree
52:20 and i would say definitely decrease the
52:22 limits on visits to a dietitian and an
52:25 educator
52:26 because they’re way too low and it won’t
52:27 be overutilized and secondly
52:30 increasing technology for those who need
52:31 it whether it’s cgm or as simple as one
52:34 with those strips
52:34 not enough people even get those so
52:38 that’s great advice thank you so much
52:39 we’re going to have to leave it there
52:41 because we are out of time so i’m sorry
52:42 to cut you off
52:43 but thank you for sharing all of your
52:45 opinions i really appreciate it i’m sure
52:47 um everyone joining us today does too
52:49 i just wanted to signal that we are
52:50 leaving some details
52:52 in the chat if you do want to reach out
52:54 today too uh or to any of our panelists
52:57 who we would be lovely you know we’d be
52:58 delighted to connect you with
53:00 so thank you with that you’ll say have a
53:03 great day
