Institute For The Future

Dr. Fran Kaufman - Pediatric Endocrinology Children's Hospital LA - March 20 2009

Pediatric Endocrinology, Head of Center of Endocrinology and Metabolism at Children’s Hospital in Los Angeles

Distinguished Professor Pediatrics and Communications at USC

Moving to Medtronic Diabetes in May 2009 as Chief Medical Officer – working on closing the loop, artificial pancreas, maintaining political advocacy issues, with the state and local community in her other advocacy work. Will continue to hold hospital and university positions.

1. Her Work

Focused on diabetes and understanding how the individual operates amidst the lifestyle environmental factors, schools, workplace, the community in which they live, understanding what are the promoters and detractors of health. What leads to risk factors of diabetes, diabetes for children and their families. Working in Watts and East LA areas regarding community participation to understand the metrics. Geo mapping the communities to understand the high prevalent rates of obesity and diabetes for children. Worked for labeling calories inside restaurants, eliminating trans fats, worked on issues in schools. Worked very hard in LA unified in 2003 for the soda ban, and then the healthy vending policy for LA unified which went statewide and is now going broader.

Big NIH grant, 7000 children in 7 cities, 42 middle schools, to determine impact of intervention in school, food services, physical activity, PR programs, social marketing campaign outreach to families, curriculum around targeting behavior change, teaching children. Grant almost completed, followed these kids from 6,7,8th grade, these kids are now in 8th grade and at end of data collection and will know soon if, comprehensive change in the schools have made a difference in hard outcomes, blood test, BMI.

Lots of policy work. Last year chaired a task force with the governor on what a diabetes prevention and treatment strategy would look like for CA if there were comprehensive health care reform. Involved in a group called Shaping America’s Health, off shoot of ADA, looking at community and overall prevention strategies, vs. treatment of diabetes which has been the traditional approach the ADA has taken.

Try to apply the internet for health strategies and develop the program (with son who is a computer engineer and husband who is in the public health arena) – University of Pittsburg – taking the evidence based prevention program value of coaching, prevention, reduce risk, high risk cohort of adults – made it internet based. Working with Department of Defense, IPAs – a couple of large groups are using it. The program results show that a 26 week on-line curriculum is almost as effective as face to face coaching. The program closes the loop with the provider so that the provider knows what is going on with the individual patient. Diabetes prevention protocol – 54 million people in the country have pre-diabetes – never have enough coaches for this amount of people, now people can get the training they need. One coach can coach 300 people with the on-line program and maybe some people don’t need a coach at all.

Answering Pat Crawford’s question: Is Type 2 diabetes the fastest growing disease for children? In mid 90s Type 2 diabetes was showing up in children – really concerned this would be a massive epidemic. Incidence has not changed much since that time, approx. 4,000 new kids with Type 2 diabetes were diagnosed in 2001. Have done screening and not seeing a large problem of Type 2 in children. Not seeing a cohort of children undiagnosed. Once kids get Type 2 diabetes the impact of disease surfaces rapidly and they become diagnosed quickly. Not overtaking the Type 1 in kids. Still a disease of older adults, but it is creeping down in age. Impacting the workforce of Americans and the people raising the next generation of Americans. What we are seeing is a cohort of children with complications of obesity – cholesterol, fatty liver, depression, feeding into the younger adult getting diabetes. We need to address the childhood obesity epidemic. Now the rate is flat, for the last 2 NHANES has been flat, flat for the last 3 years in LA, maybe we are going in the right direction, changing the environment, changing how the provider interacts, changing the programs.

Trends/Challenges

2. How optimistic about the future of health/healthcare in 2020?

Optimistic

Optimistic that we will have some kind of major health care reform – time of great opportunity and equal peril – don’t know what will be offered. A lot of emphasis on prevention, we can’t prevent everything, can we be aggressive with both pharmacotherapy, and also in supporting healthy lifestyles. We need both disease management and prevention.

3-4. Biggest tends or challenges & responses

• Move towards health IT – sounds great and wonderful, hard to adopt, not easy to deal with health IT as a clinician. Takes longer to do everything. It will make a big difference with quality and understanding disease processes and understanding longer term outcomes, and enable focus on prevention, link through the provider health IT tracking. Very important.

• Other trend, looking at a lot more prevention and primary care. Personally, would like to see all primary care and Medicare a benefit for everyone. People would then buy other insurance for catastrophic events and chronic disease.

• Another trend, medical home – primary care provider, but people also need a specialist if they have a specific need. How do we meld a primary care and chronic care model?

• Another trend, comparative effectiveness – important to figure out.

Forces shaping these trends:

Environment – disease – Obesity and Diabetes, genetic basis for the disease and environmental triggers have a huge effect. Would like to see the healthy choice is the easy choice to get, incentivized because it is part of social norm, some benefit from employer or payer for adopting a healthy lifestyle. Be careful not to penalize people who have a predisposition to disease. Incentives on the individual and provider side - prevention and care. We need food policy, workplace policy – healthy building, zoning, overlapping circles of food industry, advertising, give people tools to access.

For women, the obesity rate is perhaps at biologic saturation as the rates are flat. Look at this outside of the traditional model of randomized clinical trial. There are other innovative strategies to look at evidence outside of the traditional medical model. Really need to incentivize schools, industry, communities to improve the environment for people. Policy is critical. Need to examine what the overall environment looks like inside organizations.

Change in the food industry?

Pepsico hired people to work on changing things. Need to understand how we incentivize people to want the healthy choices. Develop policies to sell healthy choices or would be taxed. Similar to cigarettes, and taking them out of the hospital. Government needs to be the lead in this. E.g. can’t sell candy in organizations. Need to clean up the environments, people get used to it, people change their behaviors. Then the food industry will bring us healthy food as that is where the profits will be.

3.3b. Yes, we are at the tipping point

4. Responses to challenges

• Most promising – incentives, positive and negative incentives inside the health care system, inside the employee system, involving providers, legislation going on, have a strategic plan and focus, people are willing to let legislation, local, state and even federal to come around

• Can figure out how many calories you are eating. Starbucks will eventually fold under these conditions.

• Focus on minority populations, those living at the poverty level – greatest risk and least access to health care.

• Lots of positive things going on and incredible innovation, video game industry is becoming interesting – kids more active; internet as a resource as therapy; community groups, community coaches, community health workers to promote healthy living, YMCA; industry is now interested in can we make money on promoting health and the answer is sure.

Very exciting that this is on everyone’s front page in terms of direction for the future, legislative hotbed, inside the schools, worry about the economic downturn, may not be as much grant money, worry people may turn to cheaper foods which are not as healthy. There is policy and a big focus inside the public health community – there is a coming together around these issues. Need a better laying out of the plan. We need to be more effective in how we gain evidence in how we are doing.

5. Have these trends surfaced before?

In her book Diabesity, Fran describes the food supply system back to cave man – this is a collective effort through the millenia to secure the food supply – we were calorically deprived. Even at the time of WWII about 35% of soldiers in the US were underweight and turned back. World was put in motion industry, human endeavor, domestication of animals, agriculture, industrial revolution. Securing the food supply – very much considered human progress. The science of chemistry was originally about food. Now we have secured it, we have enough calories although not well distributed globally. We have to redefine what progress is. Nutrients need to be in balance. Industry is now taking the step to get back into energy balance. Combination of what is available environmentally, and personal choice. Huge build up to get us to this point, will take time to turn this around. How do we get moderation in what we eat, and more physical activity.

6. Challenges and responses not on radar now?

Likelihood that there will be a lot of new policy – don’t know the consequences to these new policies. We are talking about prevention, worry about the attention paid to chronic disease and chronic disease management. Worry about the balance between prevention and chronic disease management. As we re-orient the health care system, worry about issues in the FDA – regulatory is going to get tough, may stifle discovery that might have a role in prevention and chronic disease management. Worry about the depths of the economic downturn of where this will lead us.

FUTURE SCENARIOS

7. Most preferable scenario

– Everyone has primary care and prevention care as a Medicare benefit.

– Everyone must buy chronic disease and catastrophic care policies.

– Management in community, workplace, school for chronic disease management. Put incentives in place to manage disease.

– Chronic disease policy, public health workers, help people with diabetes do better, interconnectedness, remote monitoring blood pressure, internet disease management, health management program.

– Accessible tools and affordable.

Indicators of preferable scenario

Watching what is coming out of the Obama administration. Think there are some important metrics. NHANES – looking at diabetes outcome measures. Got better and then went flat for diabetes metrics. There is peril in economic downturn in what might be happening with health indicators. It is not enough to make policy, must mandate the policy for change to occur.

Disruptive events - Huge economic world crisis – hasten government involvement to step-up and do something

Winners and losers in preferable scenario – worry that government will come in with primary care vs. disease management

8. Most plausible scenario

Done this now in all administrations, states are completely bankrupt – can’t implement this, California would have done something now there is no money at all, now up to the Federal government. However, moving Federal Policy is very tough, very slow and incremental. The Federal government will push health IT. Inability to cover everyone with universal insurance.

9. Most negative scenario

Do worse than we are doing now, more and more people not covered. Come in sicker with the disease process, no preventive services. As it is today, the system is ready to implode now. Providers can’t afford to provide care. Despite the stimulus package, we must see an improvement in the economy. We are not going to be able to get anything done without the economy improving.

Wrap-up

The U.S. stands alone in the developed world without a universal health care policy. Unfortunate, international colleagues do a lot better. Regress to the mean in the countries that have universal care. Hope that we can still practice state-of-the-art medicine if we have universal coverage. If we are going to get universal coverage, people will buy insurance. Dual system, multiple payers for catastrophic and chronic care, let the government pay for primary care.

Need to emphasize the importance of lifecycle – look at the life cycle, pre-pregnancy, pregnancy, huge hit to mother and child by being exposed to diabetic pregnancy, how is infant fed, preschool – kids to learn how to self regulate and activity level, schools, different targets for behaviors, elderly stage – what is necessary, does it make sense to keep them on statins. Working on the NIH plan - unique issues during the lifecycle. Also looking at strategies around cross-culture needs: food, diet, exercise and genetic differences.

Scientific medical innovation – e.g. bariatric surgery – we need to not give up those avenues of research. No matter what, with all the interventions with the obesity crisis, there has to be an impact of how people live their lives, you can do bariatric surgery, but must still enable people to live healthier lifestyles to have a good outcome with bariatric surgery. We are never going to get back to the starving state in the earlier times of human existence. Need for interventions, can’t erase the impact of lifestyle.

Other people to speak with:

Marlene Kantor – LA unified school district – the role of the school

Alex Pedilla – State Senator in Sacramento – brought forth restaurant labeling

Books/articles to read: Task force to governor – model of chronic care – Fran sent the “Recommendations For The Diabetes Initiative”

Documentary: Fran Kaufman the Discovery Health Channel – Diabetes A Global Epidemic: www.mefeedia.com/entry/diabetes-a-global-epidemic/4385822