Normally we have a testimonial on Mondays, but I have something to share with you that is important enough to break tradition a little. If you’ve listened to the podcasts you might have heard me mention a risk assessment program sponsored by the City of Reno. I did a radio show talking about this program, a little about it’s history and where we need to steer our collective boat if we are to avoid the looming economic catastrophe that is type 2 diabetes and obesity. You can listen to that show here, just click on the link for the April 14th show.
That’s a good overview of what we are up to, how this program came to be, but I’d like to go more into the history of the program and really explore the implications if programs like this are broadly embraced. I try not to hype things too much but folks, this could be world changing.
Cops Were Dying
About 10 years ago 3 officers from the UNLV police force (30 officers total on the force) nearly died due to cardiac events.
In the span of about a month.
If a police officer, fire fighter or similar city worker has some kind of major medical event while on duty, the state of Nevada considers that a workman’s comp issue. Dealing with the initial medical expenses can run upwards of $1 million while the medical claims to retire that same individual average $1.2 million. That is a serious chunk-o-change out of the city coffers to say nothing of the trauma experienced by the person who suffered this event, their families, co-workers etc. These events were not unique to UNLV. Anyone in the police/fire scene was well aware of the health of our service personnel and knew something should be done to help these people. I want to get this story on video and include the key players to describe their part in this story, so I’m just going to supply a 30,000 ft over flight for now. But here are the nuts and bolts:
Key players in the local police, fire and medical scene got together to try to figure out how to save lives, and money. A risk assessment program monitored by Specialty Health was born. In the early years a high carb, low-fat diet was the recommended nutritional protocol. Framingham scores were the risk assessment benchmarks. An exercise program was implemented. Early on, the program did not work that well. True disease risk was flying under the radar. People who appeared to be at low risk of problems were getting sick, the program as it was being implemented was not really modifying CVD risk factors. The folks involved did not give up, did not stay entrenched in the standard ADA/AMA fantasies, and continued to learn and evolve the program. Eventually a low carb paradigm worked it’s way into the program, connections with the National Lipid Association were forged. Risk profiling and dietary recommendations changed and not surprisingly, the results improved dramatically. Let me share a little bit of how they used to assess risk (which is largely standard of care at present) and how that changed over time.
Specialty Health looked at 2 public safety agencies with a combined population of ~750 Police and Fire. Routine testing found the following:
Total Cholesterol: 9% high (% of the total group)
Blood pressure: 11% high
BMI: 26% high
LDL: 29% high
Glucose: 1% high
Tobacco use: 11% high
Framingham Score 1% Classified as “high risk for CVD”
ATPIII Score 2% classified as “high risk”
This represents Standard of Care in most programs. Individuals at “high risk” were told to lose weight (standard high carb, low fat protocol) might be put on statins, were told to exercise. Folks with blood glucose over 100 but lower than the overt “diabetic range” (160+) were (and still are in most situations) overlooked for what they are: pre-diabetic time bombs.
A theme you will see that emerges from this program can be boiled down to the following: Standard of care will kill you.
When Specialty Health included testing for parameters such as metabolic syndrome and insulin resistance a much different picture emerged:
19% were at high risk for metabolic syndrome
22% were INSULIN RESISTANT.
26% were at high risk due to 3 ore more risk factors: BMI, BP, tobacco, Cholesterol, LDL, HDL Blood glucose. Yes, I know and they know BMI is to be taken with a grain of salt. Stay with me.
In the Standard of Care model 1-2% of these folks trip the system and are considered “high risk.” Most however are considered “normal.”The “high risk” folks are given a dietary protocol that consistently fails to improve CVD parameters and are provided little in the way of education, support or encouragement. Additionally, Standard of Care misses the point that “normal” (what we see day in, day out) is in fact, not healthy. Using the insulin resistance and metabolic syndrome categorizations we now have close to ¼ of the population properly categorized as sick and at risk.
I’ll talk later about what exactly we are doing with the current program but I want to share some more stats, in this case a group of 196 officers were not only assessed by the methods described above, but were also screened for LDL-P, and LDL particle size. With these additional screens it was determined that 92% (180 officers) were actually at high risk of CVD. Standard of Care does not look at these simple to track biomarkers, nor does it recognize the connection between insulin resistance, systemic inflammation and the development of undesirable LDL-P nor LDL particle size.
Something worth mentioning is that Specialty Health has a risk assessment database of ~1.5 million people, so they can precisely forecast risk based on these metabolic parameters and blood work. These are not numbers pulled from neither regions, but statistically robust findings. The projected savings of properly managing this group of 196 officers is $215 million. Program cost: $324,000. In a small pilot study 35 officers were found to be at high risk of CVD. These folks were put on the integrated program (which I’ll get to in a minute) and given the changes in risk markers, this three year pilot study is estimated to have saved the City of Reno ~$25 million. Given the program costs this is about a 6000 to 1 return on investment. Those are the best odds you can get anywhere in Reno!
What the current program consists of
At present the program consists of a risk assessment as I’ve described above. Folks who are at risk are put through a comprehensive program of paleo/low carb nutrition*, exercise (mandatory strength & conditioning) , help with managing sleep issues and continued monitoring. Police and Fire are not simply told “go lose weight” they are actually guided through an effective program.
Why this program works
There are some critical pieces to this program that if any one element were missing, it would not exist, lives and money would not be saved. Here are the players:
Chiefs of Police and Fire-Critical to this piece, the LEADERSHIP (Police and Fire Chief’s) are 100% behind this program. There is NOT resistance from leadership, this is NOT a grassroots phenomena. The LEADERSHIP understands this is saving the lives of their people.
Prominent City Council members-Several members of the City Council have gone through the program and benefited from the risk assessment. they saw the value of “An ounce of Prevention” and have saved the city millions of dollars.
A well established risk assessment program (Medical community)
This program was born of a need to save lives and money. Screening was initiated, interventions recommended, (high carb low fat at first, low-carb paleo became the dominant paradigm) outcomes were tracked and that provided feedback to further modify the program. No one needed “faith” for this program to work, they just needed to have their priorities straight (save lives) and to keep tinkering with inputs and outputs. So long as people were not dogmatic about what the program “should” be the program was allowed to grow and learn and ultimately find the “right” or at least better answer.
*One of the largest hurdles the program has faced would be funny if it did not indicate what a battle we have ahead of us: By and large, the Registered Dietitians employed by the program have refused to follow the MD prescribed low-carb diet. Even when the medical directors showed these individuals the lab changes wrought by a paleo/low-carb, the RD’s were often discharged as they were unwilling to educate the officers how to eat a low-carb, paleo type diet. Let me say this more directly: these RD’s refused to believe the data before their eyes. Not all, but most and it’s been a hell of a problem as the MD’s say one thing to the officers, the RD’s say ‘high carb, low fat.” The program will (I suspect) have even better numbers as we get the right RD’s on the bus.
Where the program is going
Since I’ve become a part of the group the paleo/anti-inflammatory/gut health message has been ramping up. As good as the results have been with the current intervention it was clear when I started looking at lab work that many of these folks were still suffering from autoimmune/systemic inflammatory issues. Tightening the message about grains, getting vit-d levels up and tackling the sleep/shift work issues in a more aggressive way has already produced impressive (but not surprising) results. I’ll share that info as it is made available. Our Chief of Police is presenting at a huge law enforcement conference later in the month and he will be sharing this information to several hundred key personnel. People who are in the position to make policy and affect change. Keep your fingers crossed.
Get In the Ring
It’s tough to describe how excited I am about this program and I think it’s almost impossible to overstate the importance. We have a risk assessment program with “a lot” of people in the database (over a million people) that we can use to track the efficacy of this or other programs. The Standard of Care has failed like building a rocket out of Balsa wood. It has cost lives and is contributing to an impending economic situation that if you really look at the implications should absolutely terrify you. As with most things, the economics have finally caught up with this health-care problem. Bad food, bad meds and a lack of accountability have run their course. We now have a large and ever growing data set indicating a much better way of doing things. This also creates the opportunity for market based competition. If a Berkeley based risk assessment program wants to run a Dean Ornish vegan intervention, go for it. In a matter of a few years we will see which program works better, which saves more lives, which costs less money. Perhaps several viable options will emerge. Let the numbers speak, not some goofy notion of “consensus”, which I’ll be talking about in a future piece.
In an epidemic scientists try to find “patient zero”, the first person to introduce a contagion to a population. I suspect this program, the City of Reno and Specialty Health will effectively be “Patient Zero.” This is where a city with leaders in the Police, Fire and Medical community united to make a change. They did not know where the program would go, they just knew they had to do something and they were not afraid to try protocols outside the Medical Orthodoxy. That is nothing short of amazing.
I’ll leave you with a few videos from Specialty Health. The first is a documentary presented to the National Fire Fighters association. The others are a few of yours truly.