Everyone knows prevention is better than remediation. That's true of removing snow and ice from roadways, preventing mineral deposits on hot water appliances or avoiding personal accident or injury.

In health, that translates to preventing disease or treating the afflicted. In our national healthcare debate, everyone's for prevention as much as everyone is for "reform." With trillions of dollars at stake, we should be asking ourselves whether it's true that "an ounce of prevention is worth a pound of cure." Is prevention cost-beneficial and, if so, is all prevention justified or should our prevention efforts be targetted where they'll deliver the biggest bang for our bucks? Time magazine made prevention its cover story this week, summarizing the issue:

As the cost of health care continues to climb (60% of U.S. bankruptcies in 2007 were due to medical costs), the health of our nation is not getting any better. Heart disease remains the No. 1 killer of Americans (as it has been for all but a few years since 1900), our collective waistline continues to bulge, diabetes rates march ever higher, and after steadily declining in recent decades, the smoking rate among high schoolers is leveling off. The U.S. boasts the best cutting-edge medicine in the world, yet 75% of our health-care costs are attributable to chronic, preventable diseases. In all, about 40% of premature deaths in the U.S. are caused by lifestyle choices — smoking, poor eating and inactivity.

But while prevention — intervening in patients' lives before they get sick — has long been part of the medical lexicon, programs to educate and encourage patients to adopt healthy behaviors have never truly been embraced. Ours is a system that rewards pills and procedures and nurtures a clinical culture in which the goal is primarily to fix what goes wrong. "I never saw a well patient in my life," says Cosgrove of the years he spent as a heart surgeon. "They were all sick. We are in the sickness business. We need to get into the health business." This idea is at the heart of how President Obama wants to reform health care in America; he argued that the U.S. medical system is designed to provide disease care rather than health care. In a letter to Senators drafting health-care-reform legislation, Obama cited the [Cleveland Clinic] as a model: "We should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country," he wrote.

...

Will prevention work? And will our health system finally embrace the strategy over prescriptions and procedures? We don't have many other options. Prevention is a timeless idea, one our species has always practiced: pioneers preserved food to prevent starvation in the winter; modern workers invest in 401(k)s to prevent destitution when they're older. Applying the same ethos to medical care ought not be that hard — especially since the country's health, economic and otherwise, may depend on it.

In fact, the President is personally modeling as well as cheerleading the prevention effort. Capitol Hill newspaper Politico carried a story earlier this month by Carrie Budoff Brown entitled "Coach Obama: Shape up now." Brown points out that the prevention push is controversial ideologically ("To some, it smacks of a 'nanny state on steroids'"), noting that Obama has imported into the senior ranks of his Administration "officials who, in their previous jobs, outlawed trans fats, banned public smoking or required restaurants to proivde a calorie count with that slice of banana cream pie." She warns: "Obama needs to (avoid) coming across as a public scold or killjoy." She quotes a frustrated David Harsanyi, a Denver Post columnist and author of the book Nanny State: How Food Fascists, Teetotaling Do-Gooders, Priggish Moralists and Other Boneheaded Bureaucrats Are Turning America Into a Nation of Children, saying: “If you care about the sorts of things I do, then you are going to be losing big-time for the next four to eight years,”

Obama's effort is more than ideology, however, Brown continues. The major argument is that prevention will save money.

The public health community has worked intensively in recent years to build a body of evidence in support of the very initiatives Obama and lawmakers are now embracing. They frame the issue as one of money: Chronic diseases account for 75 percent of the nation’s $2 trillion in medical costs, according to the Centers for Disease Control and Prevention. And if the government encourages healthful lifestyles, it could slow the rising cost of health care, though the exact savings are debatable.

Yes, prevention IS debatable. Earlier this year, Rutgers economics professor Louise B. Russell addressed the subject in an article in Health Affairs, "Preventing Chronic Disease: An Important Investment, But Don’t Count On Cost Savings." Dr. Russell explained:

Over the four decades since cost-effectiveness analysis was first applied to health and medicine, hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them. Medications for hypertension and elevated cholesterol, diet and exercise to prevent diabetes, and screening and early treatment for cancer all add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving.

Russell's been quoted a lot recently as the healthcare debate heats up. She told Janet Adamy of the Wall Street Journal that many previous government prevention efforts aimed at costly chronic diseases have had little success in reducing illness or costs: "It is not going to cut costs. We already do a lot more prevention than other countries. We are not healthier." Adamy's report continues:

[Russell's] findings don't question the benefits of a healthy lifestyle, and many preventive measures are effective. The problem is that when testing becomes too widespread, or heavy investments are made in monitoring people with chronic diseases, the rewards often fail to match the costs.

...

The Congressional Budget Office, in a December report, concluded that greater use of preventive care would at best generate modest reductions in costs over 10 years, and might even result in increases.

One reason cost savings are hard to achieve, according to Prof. Russell, is that much of the money spent on disease prevention goes for people who aren't going to get sick anyway. Also, people have trouble making difficult lifestyle changes, such as taking up regular exercise or eating healthier food.

A report published in the New England Journal of Medicine last year examined 279 spending ratios in published studies of health-oriented prevention measures, and another 1,221 on treatments for people who were already sick. Some measures clearly saved money, like screening men in their early 60s for colorectal cancer.

But the report concluded that most preventive measures reviewed didn't save money. For instance, screening all 65-year-olds for diabetes would cost $590,000 for every healthy year of life it adds over just screening people that age with high blood pressure.

Medicare has conducted seven pilot programs in the past decade testing the theory on some of the most costly chronic diseases. Each showed little if any cost savings or measurable improvement in patients' health.

So prevention isn't the magic pill that "everyone" believes it to be. But what I'd call "smart prevention" certainly should play a central role in addressing our national health needs. Smart prevention has two principles: 1) it's evidence-based, not playing to the crowd and, 2) it's selective, focused on interventions and individuals or tightly-defined groups who will benefit. [By that standard, of course, universal salt reduction would be abandoned as a policy].

Dr. Russell would seem to endorse this approach. Her Health Affairs article avers:

Prevention can be a cost-effective, sometimes cost-saving, component of managing established chronic conditions. For example, at $16 per person (1995 dollars), or about $25 today, vaccination against pneumococcal pneumonia reduces medical spending for adults ages 50-64 with congestive heart failure, chronic lung disease, and diabetes, and other chronic conditions...

But, she concludes:

Over the past four decades, hundreds of sutides have shown that prevention usually adds to medical spending. ... 80 percent add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving."

Thanks for the reminder that a bit more humility and a lot less hyperbole are needed concerning prevention.

It's now clear: I lack the patience to await the full four parts of a powerful new series of posts on Junk Food Science before sharing it with Salt Sensibilty readers. They're too good to wait. They examine the subject: “Paradoxes – Compel us to think.” So far, two posts: Part One and Part Two . Sandy Szwarc introduces the quest to “separate science from ideology” (phrase from JAMA ) as follows:

We may know, intellectually, that correlations can never show causation, but when a correlation seems to confirm a reason we believe, it’s very easy to find ourselves falling for the fallacy, anyway, and to not even consider other explanations. We may call our belief “common sense” or what “everyone knows,” without realizing that we’ve come to believe it simply because it’s all we ever hear. It may never even occur to us to question an axiom — especially if we never hear about the evidence which contradicts or disproves it.

Her primary focus remains obesity as we may remember since I've often blogged on her relevant posts. Nevertheless, many of the observations pertain equally to the salt and health controversy. She notes that “The obesity paradox wouldn’t be a paradox at all, for example, if the public had been hearing objective reports of medical research all along.” How true for salt. I've just been participating in an online discussion at Toronto's Globe and Mail that well illustrates the pervasive retreat to unexamined acceptance of asserted medical “truths.”

Understanding the limitations of the scientific method employed is crucial. She observes:

(E)pidemiology has become a vehicle to find associations between every aspect of our everyday lives or our physical features and risks for some feared disease. And it’s being misused to convince us that our diets and lifestyles or appearances are the cause of ill-health. Blame, guilt and fear are the bread and butter of health marketing. That’s why carefully controlled epidemiological studies that find no link — those null studies that rarely get reported — are especially valuable. If there’s not even a strong link between two variables, then a variable can’t possibly have a causal role. Null studies tell credible scientists, and should tell us, to move on and stop worrying about that.

Among the reasons all this matters, she offers as an example the question of exercise. “Everyone” knows exercise is good for us. I feel better when I'm in shape and when I exercise. Of course. Common sense. But there are always unintended consequences. In this case, she provides data from the Centers for Disease Control and Prevention (CDC) that, next to the common cold, sports and exercise injuries are the leading cause of doctor's visits. That doesn't mean: don't exercise. It means, weigh the evidence ( and, probably, engage moderately). Federal data confirm that 488 million work days are impaired by sports injuries and that baby boomer sports injuries cost $18.7 billion in 1998.

Bottom line, she concludes in Part One:

Scientists understand the importance of testing hypotheses about causes and effects — and balancing overall benefits over risks — using carefully designed randomized, controlled clinical trials and measuring hard clinical outcomes. Yet, every randomized, controlled clinical trial of “healthy lifestyles,” as popularly defined, has failed to significantly reduce premature deaths from all causes or to prevent chronic diseases of old age.

Part Two continues to bust obesity-related myths, in this case: that obese individuals have worse health outcomes. “Everyone” believes that, too. Common sense. She offers the Helsinki Businessmen Study as a confounding input. The conclusion:

The only statistically significant inverse correlations to the men’s BMIs were with diabetes and hypertension — but they didn’t affect the men’s mortality rates, perhaps because, as we’ve seen, heavier people with both conditions have lower health complications compared to slender people with those conditions. Other popular myths weren’t supported in this study, which also won’t surprise regular readers who’ve followed the research. The men who gained weight as they aged and those who lost weight to achieve a normal weight had identical rates of developing diabetes, and the same cholesterol levels and blood pressures , as they aged.

Once again, the conclusions track closely with how the salt and health debate was sidetracked into the blind alley of a solitary focus on blood pressure. See the parallel:

Time and again in randomized clinical trials of pharmaceuticals and other medical interventions, we’ve seen the importance of examining confirmed clinical endpoints — with all-cause mortality the most important — rather than surrogate endpoints. Not understanding risk factors and believing that these surrogate health indices are measures of health and future disease has been the greatest way the public been led to believe that weight loss is beneficial, even when it’s not supported in well controlled studies looking at actual clinical outcomes and mortality.

The only difference here is that there have not been repeated RCTs on salt reduction – only a dozen or so observational studies, though they have suggested our uncritical acceptance of the salt hypothesis has been erroneous. It matters not only because we waste time, effort and expense pursuing the wrong remedy, but because the fallacious intervention can actually create health risks. Take the obesity case again:

German epidemiologists, examining 13,362 middle-aged adult men and women in the European Prospective Investigation into Cancer and Nutrition-Potsdam Study, for example, found that fat people who had normal blood pressures prior to weight loss had a nearly 7-fold increased risk of developing essential hypertension during the following two years after weight loss, and those whose weight yo-yoed had a 4.29-fold increase in hypertension.

And, referencing Dr. Thorkild Sorensen at the Institute of Preventive Medicine in Copenhagen from an article in the International Journal of Obesity:

It’s been argued, he summarized, that weight loss does not equal improvement in health and longevity, that staying fat is safer than weight fluctuations, and dieting has negative psychological effects. “In summary, we still do not have conclusive evidence that weight loss has overall beneficial effects.”

She wraps up Part Two with a warning:

The possible healthfulness of natural weight gain with aging, however, is a paradoxical idea in popular media. People may never think to question their beliefs about the deadliness of fat and benefits of weight loss when they never hear anything different.

The importance of research finding seeming paradoxes is that it make us think, question and not be afraid to learn where the evidence might really take us.

Echoes of the salt and health debate. We need to change our paradigm and become evidence-based.