Want to drop that nasty habit of smoking? New research shows that eating healthy can have a positive impact on smoking cessation.

Fruits and Veggies May Help Patients Quit Smoking

Fran Lowry

 

June 19, 2012 — Cigarette smokers who eat more fruits and vegetables are more likely to quit smoking and stay off cigarettes over the long term, new research shows.

Investigators from the University of Buffalo in New York found that smokers who ate fruits and vegetables an average of 4 or more times per day were 3 times more likely to be abstinent from all tobacco products, including cigarettes, at 14-month follow-up.

According to lead author Jeffrey P. Haibach, MPH, the study is the first to longitudinally evaluate the relationship between fruit and vegetable consumption and cigarette smoking cessation.

The study was published online May 21 in Nicotine and Tobacco Research.

According to Haibach, research on the diets of current smokers, former smokers, and persons who have never smoked (never-smokers) indicates that dietary practices of current smokers are the least optimal and that the diets of former smokers begin to resemble those of never-smokers with increasing duration of abstinence.

Intrigued, lead author Gary A. Giovino, PhD, began to wonder about the direction of the relationship and added questions on fruit and vegetable intake to the questionnaire of a national cohort study he was conducting on adult smokers.

"As I examined the scientific literature, I was surprised by the lack of longitudinal research on the topic, given such an expanse of cross-sectional research findings," Haibach said. "I became aware of multiple ways in which diet might influence smoking and quitting."

The researchers randomly surveyed 1000 cigarette smokers aged 25 years and older from around the United States, using random-digit dialing telephone interviews. They then contacted the participants again 14 months later, asking whether they had abstained from smoking and other tobacco use for at least the previous month.

More Health Conscious? 
 
They found that the cigarette smokers who ate fruits and vegetables an average of 4 or more times per day were 3 times more likely to be abstinent from all tobacco products, including cigarettes, 14 months later, compared with those who ate fruits and vegetables fewer than 2 times per day (P < .01).

This held true even after controlling for age, sex, race and ethnicity, education, household income, and behavioral indicators of general health orientation.

Those who ate more fruits and vegetables also exhibited fewer measures of dependence. They were less likely to smoke 20 or more cigarettes per day (P < .001), to smoke within 30 minutes of waking (P < .05), or to have a Nicotine Dependence Syndrome Scale (NDSS) score of at least 9 (P < .01) at baseline than those who consumed the least amount of fruits and vegetables.

"People who eat more fruits and vegetables may be more health conscious to begin with and therefore be more amenable to smoking cessation," Haibach said.

"Multiple surveys indicate that people who smoke cigarettes are more likely to binge drink, use illicit drugs, and exercise less, and we controlled for this using exercise, heavy drinking, and street drug use as markers of general health orientation," he added.

However, residual confounding may still exist, and the researchers recommend further research, including studies that incorporate all dietary factors and experimental studies.

For now, doctors should continue to ask all of their patients about tobacco use.

"For their patients who use tobacco, they should ask about tobacco use at each visit, advise of consequences of tobacco use, assess willingness to quit, assist the patient with a cessation plan, and arrange follow-up, including behavioral and pharmaceutical strategies they feel are appropriate for the patient," he said.

Doctors can also suggest that patients who are experiencing a cigarette craving eat a piece of fruit, a vegetable, or drink a glass of water "to help them avoid giving in to the urge to smoke," he added.

Noteworthy Study
 
Scott McIntosh, PhD, associate professor in the Department of Community and Preventive Medicine at the University of Rochester, in New York, said the study was "noteworthy" for finding an important relationship between fruit and vegetable consumption and a smoker's current level of addiction, as well as their future success with being abstinent from smoking.

"This tells us that future research might not only confirm these relationships but will lead to interventions with smokers to incorporate changes in their diet to increase their chances of being successful with their quit attempts," Dr. McIntosh told Medscape Medical News.

"This study and related future studies can give us improved evidence-based strategies for patient education of proper diet, not only during a quit attempt but as a long-term strategy to successfully remain smoke-free for good," he said.

The authors and Dr. McIntosh have disclosed no relevant financial relationships.

A recent Swedish study found that lowering blood sugar reduced cardiovascular risk. Lowering blood sugar, weight, and blood pressure indeed provides a tremendous health benefit. A low glycemic index diet may well be the most effective way to do so.

Glycemic index diet: What's behind the claims

By Mayo Clinic staff
 

Definition

Glycemic index diet is a general term for weight-loss diets that are based on your blood sugar level. Many popular commercial diets, diet books and diet websites revolve around the glycemic index, including Nutrisystem, the Zone diet and Sugar Busters.

A glycemic index diet uses the glycemic index to guide your eating plan. The glycemic index was originally developed to help improve blood sugar control in diabetes. The glycemic index classifies carbohydrate-containing foods according to their potential to raise your blood sugar level.

The glycemic index diet is not a true low-carbohydrate diet because you don't have to count carbohydrates (carbs). Nor is it a low-fat diet. It also doesn't require you to reduce portion sizes or count calories. But the glycemic index diet does steer you toward certain types of carbs.

Purpose

Diets based on the glycemic index suggest that you eat foods and beverages with low glycemic index rankings to help you keep your blood sugar balanced. Proponents say this will help you lose weight and reduce risk factors for certain chronic diseases.

Why you might follow the glycemic index diet

You might choose to follow the glycemic index diet because you:

• Want to change blood sugar imbalances related to your current diet
• Want to change your overall eating habits
• Don't want to count calories or go low-carb
• Want a diet that you can stick to for the long term

Check with your doctor or health care provider before starting any weight-loss diet, especially if you have any health conditions, including diabetes.

Diet details

Proponents of the glycemic index diet, sometimes called a low GI diet, say that high blood sugar levels are linked to a variety of health problems, including diabetes, obesity and heart disease. They say that following a diet based on the glycemic index can help you choose foods that will result in weight loss and prevention of chronic diseases. But scientific evidence supporting the role of the glycemic index diet in weight loss remains mixed. And you might be able to achieve the same health benefits by eating a healthy diet, maintaining a healthy weight and getting enough exercise.

Blood sugar basics

Sugar (glucose) is a main source of energy for the cells that make up your muscles and other tissues. Glucose comes from two major sources: carbohydrates in food and extra stores in your liver.

Carbohydrates come in the form of sugar, starch and fiber. After you eat or drink something with carbs, your body breaks down each type of carbohydrate in essentially the same way, converting it into sugar. The exception is fiber, which passes through your body undigested. The sugar then enters your bloodstream. From there, it enters individual cells throughout your body to provide energy. Extra sugar is stored in your liver and muscles in a form called glycogen.

Two hormones from your pancreas help regulate the level of blood sugar. The hormone insulin moves sugar from your blood into your cells when your blood sugar level is high. The hormone glucagon helps release the sugar stored in your liver when your blood sugar level is low. This process helps keep your body fueled and ensures a natural balance in blood sugar.

Blood sugar imbalance

Some food is thought to disrupt this natural balance by creating large spikes in your blood sugar level. When your blood sugar and insulin levels stay high, or cycle up and down rapidly, your body has trouble responding and over time this could contribute to insulin resistance. Insulin resistance is associated with a host of health problems, including:

• Type 2 diabetes
• Obesity
• High blood pressure
• Stroke
• Heart disease

Glycemic index ranking

The glycemic index ranks foods and beverages based on how they affect your blood sugar level. Foods are scored on a scale of 0 to 100. Only foods and beverages that contain carbs are ranked, since they have the biggest effect on blood sugar. You can find extensive lists online and in books of GI rankings, but many foods and beverages remain unranked. Manufacturers can pay to have their brand-name products ranked by Sydney University Glycemic Index Research Services in Sydney, Australia, which maintains a comprehensive database of glycemic index values for carbohydrate-containing foods.

Foods ranked by the glycemic index are given scores: 

• High: 70 and up. Examples include instant white rice, brown rice, plain white bread, white skinless baked potato, boiled red potatoes with skin and watermelon.
• Medium: 56 to 69. Examples include sweet corn, bananas, raw pineapple, raisins and certain types of ice cream.
• Low: 55 and under. Examples include raw carrots, peanuts, raw apple, grapefruit, peas, skim milk, kidney beans and lentils.

With the glycemic index diet, a high glycemic index is undesirable. Proponents say that foods and beverages with high glycemic index scores are rapidly digested by your body. This causes a spike in your blood sugar, which may then be followed by a rapid decline in blood sugar, creating wide fluctuations in your blood sugar level. In contrast, items with low glycemic index rankings are digested more slowly, raising blood sugar in a more regulated and gradual way.

Because low glycemic index foods are absorbed more slowly, they stay in your digestive tract longer. This is why these foods are sometimes called slow carbs. These foods may help control appetite and delay hunger cues, which can help with weight management. Balanced blood sugar also can help reduce the risk of insulin resistance.

Typical menu for a glycemic index diet

Many commercial diets are based on the glycemic index. What you can eat depends on the specific commercial diet you follow. Sydney University's glycemic index website doesn't promote specific commercial weight-loss plans or label carbs as good or bad. Rather, it recommends that you use the glycemic index to help you choose what foods to eat and suggests that you:

• Focus on breakfast cereals based on oats, barley and bran
• Choose breads with whole grains, stone-ground flour or sourdough
• Eat fewer potatoes
• Eat plenty of fruits and vegetables
• Avoid oversized portions of rice, pasta and noodles

Results

Weight loss

Commercial diets that are based on the glycemic index say that you'll lose weight without having to count carbs or calories. Foods that have a low glycemic index ranking are said to make you feel full longer and to balance your blood sugar.

Results from research studies are mixed, and some studies have been of poor quality. Some studies show that calorie for calorie, there's little difference in hunger after eating a high GI food or a low GI food. Other studies, though, conclude that you're more likely to lose weight and reduce your body mass index (BMI) with a glycemic index diet than with a traditional diet, even if you're obese and need to lose a significant amount of weight. That may be, at least in part, because it's easier to stick to the glycemic index diet for the long term since it's not considered an extreme diet.

One study showed that participants following the Zone diet maintained a weight loss of about 7 pounds (3.2 kilograms) after one year — about the same amount of weight lost as in the three other diets in the study.

There have been few studies about the impact of the glycemic index diet on weight loss after a year or more. But some evidence suggests that a diet higher in protein and lower on the glycemic index may lead to sustained weight loss. Some evidence also suggests that you may lose weight on a glycemic index diet simply because you choose more fiber and protein, which helps you reduce portion sizes and eat less.

Still other studies suggest that there's little if any evidence that having an elevated blood sugar level leads to weight gain if you're healthy. These studies note that insulin is vital to good health, and that insulin becomes a problem only when insulin resistance develops. Insulin resistance doesn't develop from eating certain carbs or proteins but from being overweight. Weight loss from any type of diet improves blood sugar control.

The bottom line is that to lose weight, you must reduce the calories you take in and increase the calories you burn. Traditional recommendations for weight loss advise losing 1 to 2 pounds (0.45 to 0.9 kilograms) a week by reducing calories and fat and emphasizing complex carbohydrates. Losing a large amount of weight rapidly could indicate that you're losing water weight or lean tissue, rather than fat.

Health benefits

Proponents of the glycemic index diet say that you can improve or reduce the risk of serious diseases, including diabetes and cardiovascular disease.

Almost any diet can reduce or even reverse risks factors for diabetes and cardiovascular disease — if it helps you shed excess weight. And most weight-loss diets can improve blood cholesterol or blood sugar levels, at least temporarily.

On the other hand, the glycemic index doesn't rank foods according to how healthy they actually are. Indeed, some foods with the preferred lower GI ranking may, in fact, be less healthy because they contain large amounts of calories, sugar or saturated fat, especially packaged and processed foods. Both potato chips and ice cream, for instance, have a lower glycemic index ranking than do baked potatoes, even though baked potatoes are generally considered healthier. So while lower GI items may help blood sugar balance, choosing them indiscriminately could lead to other health problems.

Other concerns

One major concern with the glycemic index is that it ranks foods in isolation. But in reality, how your body absorbs and handles carbs depends on many factors, including how much you eat; how the food is ripened, processed or prepared; the time of day it's eaten; other foods you eat it with; and health conditions you may have, such as diabetes. So the glycemic index may not give an accurate picture of how one particular food affects your blood sugar. Glycemic load is a related concept that scores a food product based on both carb content and portion size. But the larger the portion size, the greater the calories consumed whether the glycemic index is high or low.

It also can be difficult to follow a glycemic index diet on your own. For one thing, most foods aren't ranked by glycemic index. Packaged foods don't generally list their GI rank on the label, and it can be hard to estimate what it might be. And for some types of food, the glycemic index database has multiple entries — you may not be sure which entry is accurate.

On the other hand, many generally healthy foods are naturally low on the glycemic index, such as whole grains, legumes, vegetables, fruits and dairy products. If you eat a healthy diet, based on fresh foods that aren't highly processed, you may get the same benefits of the glycemic index diet. But if you need extra guidance toward healthier choices, the glycemic index may help.

Risks

Studies of the glycemic index diet haven't revealed any specific health risks to following the diet. However, it's possible that if you choose lots of low GI foods that are high in calories, sugar and saturated fats, you could develop some of the same health problems the diet hopes to prevent.

For those who exercise and feel muscle pain afterwards, a new study finds that taking NSAIDS for muscle pain is ineffective and may interfere with the healing process. Maybe Vanilla Ice & Earthquake were right - "Ice, ice, Baby."

Sore Muscles May Not Benefit from Regular NSAIDs

By John Gever, Senior Editor, MedPage TodayPublished: June 11, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

BERLIN -- Muscle pain after heavy exercise is natural and even healthy, and taking anti-inflammatory drugs for normal soreness may be a bad idea, researchers suggested here.

 

Studies in healthy volunteers who exercised hard enough to cause muscle soreness indicated that the potent nonsteroidal anti-inflammatory drug (NSAID) ketoprofen inhibited the recovery process, according to Matthias Rother, MD, PhD, of International Medical Research in Graefelfing, Germany, and colleagues.

The total amount of pain, as quantified by the area under the curve (AUC) for pain severity over a one-week period after the exercise, was increased in participants who took ketoprofen at first onset of muscle soreness.

Celecoxib (Celebrex) treatment diminished total pain slightly, Rother and colleagues reported at the annual meeting of the European League Against Rheumatism.

But precisely because the reduction was small, and in light of the clear lack of benefit from ketoprofen, the researchers concluded that there is no value in NSAID treatment for muscle soreness.

Although NSAIDs are effective against a wide range of painful and inflammatory states, their benefit in exercise-induced muscle soreness has been controversial.

For example, a previous study found elevated cytokine levels in ultra-marathon runners who took ibuprofen relative to those who went untreated (Brain Behav Immun 2005; 9: 398-403). Another study by a different group indicated that ketoprofen extended the time with pain after tonsillectomy compared with celecoxib (Otolaryngol Head Neck Surg 2005; 132: 287-294).

In the current studies, Rother and colleagues had a total of 64 healthy volunteers walk down stairs for a total of 300 to 400 vertical meters, similar to walking all the way down from the top of a 100-story building.

Forty of the participants were randomized to take 200 mg of oral celecoxib or placebo twice daily for a week afterward, starting 12 to 26 hours after completing the stair test.

The other 24 completed an identical protocol except the NSAID was oral ketoprofen at 100 mg twice daily.

Participants in the latter study simply reported overall leg muscle pain, whereas those in the celecoxib study were asked to rate pain separately for the calf and thigh during contraction. All pain assessments were performed at pre-exercise baseline and at numerous intervals over the week after exercise.

At no point during the ketoprofen study did participants taking the active drug report less pain than those in the placebo group, Rother and colleagues found.

The AUC for pain scores was 462 (standard deviation 160) for ketoprofen versus 376 (SD 159) for placebo (P=0.02).

Most importantly, pain ended at hour 122 in the ketoprofen group versus hour 105 in the placebo group (P=0.005). Rother and colleagues said this was "the most negative effect" of ketoprofen.

In the celecoxib study, the drug was most effective in reducing calf pain on contraction. For thigh contraction, scores at each time point were virtually identical between participants taking the active drug versus placebo.

The sum of calf plus thigh pain was reduced 12% to 13% over the full study period, according to Rother and colleagues.

The peak reduction was measured 3 days after exercise (mean 2.7 for celecoxib compared with 2.0 for placebo, P-value not reported).

Overall, the findings imply "that the inflammatory reaction following muscle injury is essential for recovery," Rother and colleagues indicated in their poster presentation.

"Since the effect of celecoxib ... was only modest, usage of NSAIDs for the treatment of exercise induced muscle soreness cannot be supported," they concluded.

The trial had no commercial funding.
Rother is a shareholder and former employee of IDEA AG, which is developing a topical NSAID product. Other investigators declared they had no relevant financial interests.

Primary source: European League Against Rheumatism
Source reference:
Rother M, et al "Is the inflammatory reaction an essential part of recovery after muscle injury?" EULAR 2012; Abstract FRI0457.

The Capitol takes actions on healthcare including rating your hospital's safety (be sure to click on the hospital safety score hyperlink).

D.C. Week: Hospitals Now Get Graded

By Emily P. Walker, Washington Correspondent, MedPage TodayPublished: June 09, 2012

WASHINGTON -- Hospitals will now be ranked by letter grade for how well they perform on safety measures; internists flocked to Washington this week to lobby for reimbursement reform; and pharmacy groups protested a possible reclassification of drugs containing hydrocodone.

New Rankings for Hospitals

For the first time, hospitals across the nation have been given letter grades indicating how well, or poorly, they perform on measures of patient safety, and the American Hospital Association isn't happy about it.

The Leapfrog Group, a nonprofit quality-improvement organization, has ranked more than 2,600 hospitals and given them scores based on an "A, B,C, D, or F" scale for hospital safety on its free site Hospitalsafetyscore.org.

Of the 2,652 hospitals issued a safety score by Leapfrog, 729 earned an A, 679 earned a B, and 1,243 earned a C or below. The American Hospital Association (AHA) disputed Leapfrog's ratings, arguing that many of the measures used to determine the grades are flawed.

Internists Lobby Congress

Several hundred internists and medical students were on Capitol Hill Thursday, meeting with their members of Congress to advocate for issues facing internal medicine.

Chief among them, not surprisingly, is a fix for the sustainable growth rate (SGR), the Medicare formula that, year after year, calls for steep cuts in Medicare reimbursement rates for physicians. Doctors' groups -- including the American College of Physicians (ACP), which represents internists -- as well as several lawmakers, have been pushing for bills to totally revamp the formula, which both Democrats and Republicans agree is flawed.

Fred Ralston, MD, an internist in Fayetteville, Tenn., and former president of the ACP, told MedPage Today that he doesn't expect a permanent SGR fix to happen this year, but that doesn't mean physicians should stop pressing the issue. Sen. Max Baucus (D-Mont.), said in an interview that he's been "a little disappointed over the years that we haven't found a better formula to reimburse physicians."

Pharmacy Groups Oppose Reclassification of Hyrdocodone

Pharmacy groups voiced their opposition to an amendment in the Senate's FDA user fee reauthorization bill that would reclassify all medications containing hydrocodone as Schedule II drugs.

The Senate provision, drafted by Sen. Joe Manchin (D-W.Va.), would reclassify hydrocodone-containing combination products as Schedule II controlled substances, a category reserved for drugs with medical uses that have a high potential for abuse and may lead to severe psychological or physical dependence.

Hydrocodone in pure form and any formulations of hydrocodone combination products containing more than 15 mg hydrocodone per dose are already classified as Schedule II drugs, for which prescriptions cannot be phoned in and a new prescription is needed for each refill.

Manchin's amendment would add products in which hydrocodone in smaller doses is combined with other drugs, such as acetominophen (Vicodin). Those combination products are currently classified as Schedule III drugs, which are defined as drugs that have a lesser potential for abuse, and also carry a lower risk of addiction.

"While we share your concerns regarding the abuse and diversion of these prescription drugs, and we appreciate your leadership on this unfortunate situation, these concerns must be balanced with the impact on patients who legitimately need access to these products," wrote the American Pharmacists Association, the Food Marketing Institute, the International Academy of Compounding Pharmacists, the National Association of Chain Drug Stores, and the National Community Pharmacists Association in a May 30 letter sent to Manchin and congressional leaders.

CEOs Write Checklist for Better Care

Eleven health systems have joined with the Institute of Medicine to develop a checklist to help provide better quality care with lower cost.

The list, developed by leaders of healthcare organizations including the Cleveland Clinic and Geisinger Health System, includes 10 strategies that have been "proven effective and essential to improving quality and reducing costs." They deal with foundational, infrastructure, care delivery, and feedback components of a healthcare system.

"As demand for high-value healthcare builds, care delivery leaders face the near-term imperative to transform the way their organizations operate," the authors of the checklist wrote. "We know the potential for improvement exists."

Next Week

The House is in recess next week.
 
On Wednesday, the FDA's Circulatory System Devices Panel will make recommendations on the Edwards Sapien Transcatheter Heart Valve for use in patients with symptomatic severe aortic stenosis who have high operative risk. Sapien is already approved for use in high-risk patients who were considered inoperable or unable to undergo open heart surgery.


On Thursday, a Senate Homeland Security and Governmental Affairs subcommittee will hold a hearing on efforts to saving taxpayer dollars by curbing waste and fraud in Medicaid. The same day, the Senate Finance Committee will hold a hearing on "Medicare Physician Payment Policy: Lessons from the Private Sector."

With the Supreme Court possibly ruling this month on the constitutionality of ObamaCare, here are a few scenarios of possible outcomes.

Supreme Court: Decision Nears on 'Obamacare'

By Emily P. Walker, Washington Correspondent, MedPage TodayPublished: June 05, 2012

WASHINGTON -- The Supreme Court is expected to announce its ruling on the Affordable Care Act (ACA) this month, and with the countdown started speculation about the impact of that decision is heating up on both sides of the "Obamacare" debate.

And both sides predict disaster for doctors -- massive disruption if the law is struck down -- or if it is upheld.
If the court decides to go with something in between, confusion is likely to be the short-term result.

Health policy experts generally list five possible scenarios for how the Supreme Court might rule:

Individual Mandate is Struck Down, but Rest of Law Remains

Under this scenario, the law's most controversial provision -- the mandate that everyone must have health insurance or else pay a penalty -- would be ruled unconstitutional, but everything else in the law -- including the insurance market reforms, health insurance exchanges, and subsidies for those who can't afford insurance -- would remain.

The states that are suing the government want the Supreme Court to strike down the entire law if the individual mandate is found to be unconstitutional.

The Obama administration counters with a "half a loaf" argument: if the mandate is found to be unconstitutional, the law should be able to stand, with the exception of two provisions -- the guaranteed-issue provision, which bans insurers from refusing to offer coverage due to a preexisting medical condition, and the community rating provision, which bars insurers from charging higher premiums based on a person's medical history.

Most agree that the guaranteed issue and community rating provisions would be difficult to enforce absent the requirement that everyone have health insurance.

During oral arguments on the issue -- known as the mandate's "severability" -- the Supreme Court justices enunciated these differing positions.

Justice Elena Kagan asked, "Isn't a half of loaf [of bread] better than no loaf?"

No, said Paul Clement, the lawyer for the 26 states that are suing the federal government over the law. Sometimes no loaf is indeed better than half a loaf, he said. In the case of the ACA, the mandate is too integral to the overall survival of the whole law.

"If you don't have the individual mandate to force people into the market, premiums will skyrocket," Clement said during oral arguments in March.

Clement and the Obama administration agree that without forcing young and healthy people into the insurance market, many would not buy insurance. That would mean the insurance pool would largely be comprised of less-healthy people, which would cause insurance to be more expensive for everyone.

A brief about the different decision scenarios issued by consulting firm Deloitte said the mandate being struck down but other parts remaining is a "distinct possibility."

Leonardo Cuello, an attorney and director of health reform for the National Health Law Program, which advocates for low-income individuals, gave it 50/50 odds.

The Entire Law Is Struck Down

If the mandate is found to violate the Constitution and the justices also decide it's too enmeshed in the larger law to be separated, they could overturn the entire law.

This outcome would be the most disruptive to doctors, said Ron Pollack, executive director of Families USA, a liberal consumer group that supports the ACA. That's because they've already been working to prepare for the law -- for example, by taking steps to form accountable care organizations encouraged under the law.

Hospitals, meanwhile, may be bearing the brunt in preparing for major changes under the ACA. Hospitals are already cutting costs to absorb the $155 billion the industry agreed to give up to fund the expansion of health insurance under the ACA, the Deloitte brief said.

Aside from affecting doctors directly, it's U.S. citizens as a whole who have benefited from provisions of the law that have already been implemented, according to the Deloitte consultants. Some 27.8 million people have already been impacted, including seniors who have received doughnut hole rebates and young adults under 26 who are now covered by their parents' insurance plan.

Consultants at Deloitte predicted the entire law would likely not be overturned.

The Entire Law Remains As Is

"If you want chaos, this is a good way to do it," Joe Antos of the American Enterprise Institute, a right-leaning think tank, said of this option. He added that he thinks the court will go this route and either uphold the law, or else rule the mandate unconstitutional -- but it won't repeal the whole thing.

"If everything is allowed to continue, there's a lot of uncertainly about how the law will actually be implemented," Antos said.

Grace Marie Turner, president of the Galen Institute, a free-market think tank, predicted that even if the law remains as is, many provisions will have to be tweaked once they are deemed unworkable.

For instance, many states are not ready to start health insurance exchanges in 2014, so that provision may have to be substantially delayed. She also predicted that states may not have the capacity to treat new patients that would be brought into the system by the ACA's expansion of Medicaid in 2014, so the start date on that could very well be pushed back as well.

Pollack disagrees with Antos and Turner and said if the law remained as is, it would be the least disruptive for doctors and for patients.

Medicaid Expansion is Removed from Law 

Another option -- striking down the ACA's Medicaid expansion, is thought to be an unlikely outcome of the Supreme Court challenge.

Starting in 2014, the ACA expands Medicaid to cover nearly all people under age 65 with household incomes at or below 133% of the federal poverty level.

Currently, most states' Medicaid programs only cover pregnant women and children who are very poor, as well as certain low-income, disabled adults. Congress has never required mandatory coverage criteria for childless adults who are not within the covered categories, but it has expanded the Medicaid program a number of times.

The 26 states that are suing the federal government over the law argue that the Medicaid expansion is a violation of the Spending Clause of the Constitution largely because it's coercive -- it conditions receipt of all federal Medicaid funds on the states' expanding Medicaid.

"How can they claim that this is coercive?" asked Antos. "It doesn't seem reasonable to me. "

Cuello also said he'd be surprised if the court ruled the Medicaid expansion unconstitutional.

The Anti-Injunction Act Is Ruled Applicable and the Court Defers its Decision

Finally, the court must decide whether an 1867 federal law called the Anti-Injunction Act, which prohibits a lawsuit from being brought over a particular tax until that tax actually takes effect, applies in the case of the ACA.

Under the ACA, everyone is required to have health insurance starting in 2014, or else pay a penalty in 2015. If the court were to decide the Anti-Injunction Act bars the issue from being heard now because 2015 is still several years away, the Supreme Court could postpone a decision on the controversial healthcare law until after 2015 -- the year in which the penalty would first be collected.

Both sides -- the Obama administration and the 26 states suing the federal government -- agree that the old tax law doesn't apply to the ACA and shouldn't stand in the way of a court ruling on the case.

Based on oral arguments, and the fact that no side is pushing for the tax law to apply, it is unlikely the court would defer a decision based on the Anti-Injunction Act, experts agree.

The Supreme Court decision on the ACA is expected by June 28.

A British Medical Journal report - loved by Hershey's, Dove, Lindner, Nestles, and millions of others - finds eating dark chocolate daily is a healthy and cost effective approach to stemming some heart disease. But, the 30 lbs you'll gain from the calories of a diet of chocolate may pose other concerns.

Dark Chocolate: Sweet Prevention for CV Events

By Kristina Fiore, Staff Writer, MedPage TodayPublished: May 31, 2012
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

Action Points

• A "best case scenario" analysis based on a Markov model concluded that daily consumption of dark chocolate could reduce the risk of cardiovascular events over a 10-year period in patients with metabolic syndrome.
• Note that the model also predicted that this prevention approach was cost-effective assuming 100% compliance.

Dark chocolate may be an inexpensive way to help prevent cardiovascular events in patients at risk for heart disease, researchers found.

A modeling study predicts that patients with metabolic syndrome who eat dark chocolate every day could have 85 fewer events per 10,000 population over 10 years, Chris Reid, PhD, of Monash University in Melbourne, and colleagues reported online in BMJ.

At a cost of only $42 per year, treatment with dark chocolate falls into an acceptable category of cost-effectiveness, at an incremental cost-effectiveness ratio (ICER) of $50,000 per years of life saved.

"Chocolate benefits from being by and large a pleasant, and hence sustainable, treatment option," they wrote. "Evidence to date suggests that the chocolate would need to be dark and of at least 60% to 70% cocoa, or formulated to be enriched with polyphenols."

Several recent studies have suggested that eating dark chocolate has blood-pressure and lipid-lowering effects. To assess whether it could be an effective and cost-effective treatment option in patients potentially at risk for cardiovascular events, the researchers looked at data from patients in the Australian Diabetes, Obesity, and Lifestyle study.

They used a Markov model to assess health effects and associated costs of daily consumption of plain dark chocolate compared with no chocolate in a population with metabolic syndrome but without diabetes or cardiovascular disease.

The investigators also used risk-prediction algorithms and population life tables to determine the probability of patients developing or dying from heart disease or other noncardiovascular causes each year.

Data on the blood-pressure-lowering effects of dark chocolate were taken from a meta-analysis of 13 randomized controlled trials, and lipid-lowering effects from a meta-analysis of eight short-term trials.

Costs were taken from a review of the costs of cardiovascular complications in a healthy population, and included the direct costs of myocardial infarction and stroke.

They calculated the number of deaths prevented by determining the difference in the number of deaths between those consuming and not consuming dark chocolate.

The final model included a total of 2,013 patients with metabolic syndrome, mean age 53.6, mean systolic blood pressure 141.1 mmHg, mean total cholesterol 6.1 mmol/L, mean HbA1c 34.4 mmol/mol, and mean waist circumference 100.4 cm.

Reid and colleagues found that daily consumption of dark chocolate -- a polyphenol content equivalent to 100 grams of dark chocolate -- can reduce cardiovascular events by 85 per 10,000 population over 10 years.

Specifically, with 100% compliance, treatment would prevent 70 non-fatal and 15 fatal cardiovascular events per 10,000 population over that time. The authors noted that this was a "best case scenario" analysis.

When compliance was reduced to 90%, the number of preventable non-fatal and fatal events fell to 60 and 10, respectively, and at a compliance of 80%, was reduced to 55 and 10, respectively. Even at these levels, however, daily dark chocolate was still considered an effective and cost-effective intervention strategy, they wrote.

At a cost of $42 per person per year, dark chocolate prevention strategies came to an estimated ICER of $50,000 per years of life saved -- a figure well within typical cost-effectiveness thresholds, the researchers said.

That $42 could be spent on advertising, educational campaigns, or subsidization of dark chocolate in higher-risk populations, they wrote.

Reid and colleagues noted that the study was limited by its reliance on the Framingham algorithm, which may underestimate risk in a high-risk population, and by assumptions about the risk of death following a cardiovascular event.

The study was also limited by the assumption that the benefits of dark chocolate, which have only been observed in short-term trials, extend to 10 years. Still, they concluded that the findings suggest dark chocolate may be an effective and cost-effective strategy for preventing heart disease in patients with metabolic syndrome.

The study was supported by an Australian Research Council linkage grant with Sanofi-Aventis Australia.
The researchers reported no conflicts of interest.

 

Primary source: BMJ
Source reference:
Zomer E, et al "The effectiveness and cost effectiveness of dark chocolate consumption as prevention therapy in people at high risk of cardiovascular disease: best case scenario analysis using a Markov model" BMJ 2012; DOI: 10.1136/bmj.e3657.