THE POWER OF

NUTRITION

Table of ConTenTs

Acknowledgements .......................................................................................................................................................................... 2

PrefAce ................................................................................................................................................................................................... 3

executive summAry ........................................................................................................................................................................... 4

BAckground ......................................................................................................................................................................................... 5

methodology ...................................................................................................................................................................................... 8

diABetes mellitus ............................................................................................................................................................................. 10

hiv/Aids ................................................................................................................................................................................................. 19

sAving money through nutrition ............................................................................................................................................. 25

conclusions ....................................................................................................................................................................................... 28

ACKNOWLEDGEMENTS

On behalf of everyone at ANSA, we would like to express our gratitude to those individuals who contributed their time, energy and insights to this project. Their generosity with this project and their on-going support of ANSA are deeply appreciated. Kristin Anderson - The Congressional Hunger Center Shawn Daniels - Food & Friends Deane Edelman, MBA, DTR - Whitman-Walker Clinic Marcy Fenton, MS, RD Los Angeles County AIDS Programs and Policies Howard Grossman, MD - American Academy of HIV Medicine Celia Hayes, MPH, RD - Health Resources and Services Association, HIV/AIDS Bureau

ANSA would also like to send thanks to the following organizations that voluntarily completed surveys detailing expenditures and scope of services. Their willingness to participate in this project is proof of the extensive and unifying commitment among those in this eld to serving others above all else. A Loving Spoonful, BC Chicken Soup Brigade, WA Community Servings, MA EAC, Inc., NY Food & Friends, DC Food Outreach, MO Meals on Wheels of Northern Virginia, VA Moveable Feast, MD Open Arms of Minnesota, MN Positive Directions, KS Project Angel Food, CA Project Angel Heart, CO Project Open Hand, CA Project Open Hand Columbus, OH Senior Meals Food Pantry, MI Special Delivery San Diego, CA
Design: Project Design Company

Charlotte Hayes, MMSC, MS, RD, CDE - Project Open Hand Atlanta Charnay Henderson - Food & Friends Janelle LHeureux, MS, RD - AIDS Project Los Angeles Joya Parenteau, RD American Dietetic Association, Dietetic Practice Group Julie Poole, RD, CNSD, LD - Food & Friends Mary Reed - Food & Friends Mike Saag, MD - University of Alabama @ Birmingham Paul Sax, MD - Harvard University Mary Lee Watts, MPH, RD - American Dietetic Association

Gods Love We Deliver, NY LIACC, NY Los Angeles Jewish AIDS Services, CA MANNA, PA

Special thanks go to the Congressional Hunger Center for their support of the Bill Emerson National Fellowship Program and their alliance with ANSA on the campaign for Food as Medicine funded by The UPS Foundation.

PrefaCe

in health care costs for individuals, local communities, states and our nation as a whole. leaders in the anti-hunger field reached this conclusion at the hunger forum convened by the congressional hunger center in 2004. in 2005, at the 12th annual conference of the Association of nutrition services Agencies (AnsA), leaders in the field of nutrition services from across the country also agreed that maintaining a medically appropriate diet during illness is crucial to improving health and reducing health care costs. inspired by these conclusions, AnsA helped form the national nutrition collaborative in september of 2005 and established a research working group dedicated to elucidating the specific effects of nutrition on health and health care during times of critical illness. of particular interest are the drastic economic implications of the current lack of food and nutrition for the critically ill and the potential for intervention through nutrition services programs. this report seeks to estimate the cost of inadequate nutrition during serious illness. in doing so, it compares the expense of treating potentially preventable disease complications to the cost of support through nutrition services that can reduce such consequences. no comprehensive study of this type has yet been conducted. this paper fuses scientific information demonstrating the value of nutrition during serious illness with hospital cost data and evaluations from the country's leading nutrition services agencies to predict areas of potential cost saving and identify areas for further research. frank Abdale executive director AnsA it is the hope of everyone involved that this project will lead to a comprehensive study of the Power of nutrition to save money and to save lives.

he concept for this white paper evolved from a growing consensus that secure access to food, nutrition interventions, and quality health care are all fundamentally and inextricably related. together they contribute to positive health outcomes and significant savings

this project, completed by emerson fellow Brigit Adamus in collaboration with AnsA, its member agencies, and its partners across America marks the emerging collaboration of AnsA and the chc on their food as medicine campaign funded by the uPs foundation. the emerson fellowship, a project of the congressional hunger center, is a unique leadership development opportunity for individuals seeking to make a difference in the struggle to eliminate hunger and poverty. each year, participants spend six months with rural and urban community-based organizations across the country involved in fighting hunger at the local level. they then move to washington, dc, to complete the year with six months of work at national organizations involved in the anti-hunger and poverty movement, including national advocacy organizations, think tanks, and federal agencies.

exeCuTive summary

poverty and bad health that impairs the well-being and productivity of millions of Americans. the resulting disease complications also place a significant and potentially preventable burden on the u.s. health care system. for the past 20 years, providers of nutrition services have reported that participation improves nutrition, health, and compliance with medical treatments. As a result of fewer complications of disease, nutrition providers observe decreases in health care costs. this paper analyzes the science supporting these anecdotal reports and the potential national cost-savings generated for those with diabetes and hiv/Aids.

xperts in nutrition and medicine agree that food access and proper nutrition are absolutely critical for those suffering from chronic and life-threatening illnesses. Poor food access, from inadequate resources and physical complications to disease, creates a vicious cycle of

Diabetes
managing diabetes requires careful attention to diet and often strict medication regiments in order to control blood sugar and blood pressure. most complications to diabetes are associated with poor control to one or both of these factors. this paper examines the role of nutrition in preventing five common complications to diabetes: hyperglycemic crises, nephropathy, ophthalmic conditions, neuropathy, and circulatory conditions. the cost of hospital stays related to diabetes was nearly $10 billion25 for over 480,000 hospitalizations in 2003 and the estimated economic impact was over $40 billion.18 nutrition services agencies have great potential to avoid a significant portion of these costs.

HIV/AIDS
People living with hiv/Aids face many nutritional difficulties, including: metabolic changes, decreased appetite, and digestive difficulties from medication side-effects. Proper nutrition is needed to increase absorption of medication, reduce sideeffects, and maintain body weight. nutrition services reduce costs of care for hiv/Aids by improving cd4+ t-cell count ($4,000-$13,000 per person per year), improving adherence to medications ($5,100 per person per year), and reducing income based inequalities in health care ($41,000 per person per year).

Conclusions
Based on current research and widely supported anecdotal evidence, nutrition services agencies appear reduce health care costs by improving food access and nutrition for those living with chronic and/or lifethreatening illnesses. for those living with diabetes and hiv/Aids improved food access and nutrition could reduce cost on the magnitude of billions. more research is needed to quantify the extent of medical and economic effects and enable a more evidence-based approach to evaluating services. the evident positive health effects and promising cost-effectiveness of nutrition services prove the value of these programs to individuals and to society at large while also demonstrating an urgent need for increased support through policy.

BACKGROUND

Mounting evidence for Food as Medicine

Each year, the U.S. government spends billions of dollars treating latestage disease through Medicaid, Medicare, and specialized programs such as the AIDS Drug Assistance Program. Growing evidence indicates, however, that some medical treatments are ineffective without adequate nutritional support, while others could be avoided or minimized through proper nutrition. Furthermore, food security alone predicts the likelihood that one will receive timely and consistent medical care, a factor that reduces health care expenditures through early disease management. Even so, basic nutritional care is not covered by most forms of health insurance. Recently, Medicare took a signicant stride forward by expanding coverage to include medical nutrition therapy for those with diabetes and/or renal disease. Medical nutrition therapy consists of an in-depth nutrition assessment of a patients nutrition status, followed by nutritional diagnosis and appropriate therapy and counseling provided by a registered dietitian, usually on referral from a patients physician.1 Evidence-based research indicates that not only is medical nutrition therapy effective at improving health for a variety of conditions, but it also reduces the cost of care for patients by reducing the need for surgeries, hospitalizations, and long-term care.2 The effectiveness of medical nutrition therapy hinges on the assumption that when a registered dietitian provides information,

support, and an appropriately prescribed diet, people are able to make changes that positively inuence their health. Research indicates that this is indeed true for many people with secure access to food and the economic capacity to participate in their own care. There is, however, a very large group for whom making these changes is impossible because they lack the required resources and/or social supports. The people who have trouble accessing the benets of medical nutrition therapy are typically those who are already the most medically and nutritionally vulnerable. They are the 30-50% of people living with HIV/AIDS that are homeless or are at risk of homelessness.3 They are the nearly 30% of people living below the poverty level that suffer from obesity and are at high risk of developing type II diabetes.4 These are the same people who experience the worst outcomes from their encounters with the medical system an inequality that frequently goes unaddressed in the realm of health care. For years, nutrition services agencies have identied this great disparity in health care and have realized that access to reliable and adequate nutrition can play a large role in reversing discrepancies. Poor nutrition,

FIGURE 1: THE VICIOUS CYCLE OF POOR NUTRITION & HEALTH

Disease/Disease Complications (disease complications,nutricion-related disease, poor access to health care, poor medical compliane) hunger frequently lead to Poor Nutrition (obesity, nutrient deciencies, medically inappropriate nutrition) Poverty (loss of job, reduced income, loss of health insurance) inadequate or medically inappropriate diets that cripple the bodys immune system and its ability to sustain daily functions while battling Poor Food Access (lack of nancial resources, inability to prepare food, lack of nutrition knowledge) existing illness. Social Security Disability Income, which falls just above the unlike other factors that inuence health and experience with health care, is selfperpetuating as it relates to disease. As demonstrated in Figure 1, poor nutrition can be both a cause and a consequence of poor health and poverty. Because of the vicious nature of this cycle, health and nutrition will only decline further until an intervention occurs that takes one or more factors out of the equation. By removing poor food access from the cycle, nutrition services agencies address problems associated with both poverty and disease. Nutrition services programs are successful because they address two primary features of this cycle that contribute to its downward spiral. First, access to food alone addresses the poverty-related issues with food access that contribute to income-based inequalities in health outcomes. Food insecurity and poverty line, and Supplemental Security Income, which falls well below the poverty level, are inadequate to purchase a medically appropriate diet, especially when large portions of a persons budget are allocated to health care expenses. Due to the stringent qualications for Social Security, many individuals experiencing signicant effects of illness may receive little or no government benet and may be without access to health insurance.5, 6 When income becomes so restricted, food becomes a malleable budget item that can be reduced to allow for other necessities such as housing and medication. As the effects of poor nutrition and food insecurity ensue, the vicious cycle continues. When nutrition services agencies are able to eliminate problems of food access, individuals suffering from disease-related poverty are able to In addition to breaking through the vicious cycle of poor nutrition and disease, nutrition services during critical illness can optimize nutrition through consumption of foods that actually enhance the medical treatment of disease. For some conditions, consumpEven for those not experiencing diseaserelated poverty, disabling illness complicates every step of the nutrition process from earning income, to shopping for food, to preparing and consuming it. Serious disease can make a medically appropriate diet nearly impossible to attain by interfering with even one of these steps. With restricted food access, health worsens and long-term care may become necessary to satisfy the most basic nutritional needs. By providing medically appropriate meals that require no additional preparation, providers of nutrition services facilitate independence and improve health. attain a level of nutrition that further serves to maintain or improve their health as well as their independence. They also have more expendable income to put towards medication and consistent medical care that helps maintain and improve health while avoiding costly emergency medical situations.

ANSA member organizations serve more than 250,000 people and more than 25% of all people living with HIV/AIDS in the United States.

tion of an ideal diet to meet disease-specic nutrition needs may transcend the effects of medical nutrition therapy alone by resolving issues of non-compliance and misunderstanding of directions. This may be particularly appropriate when cognitive function is impaired, or when additional social supports are needed to encourage a specic diet. In this way, nutrition services agencies enhance the effects of medical nutrition therapy and other medical treatments.

in the United States. They provide access to food pantries and meal sites, and they deliver meals and groceries to the most vulnerable and isolated. Many organizations have staff nutritionists who design medically appropriate meals to be delivered to people with specic illnesses. Some also offer nutrition education classes and medical nutrition therapy in combination with meal services. The abundance of anecdotal evidence supporting the broad success of nutrition services for the seriously ill has created a need for new, more detailed and persuasive ways to measure success. Previously, success has been measured in meals per person and pounds of food delivered similar to the tools used to evaluate food banks and groups targeting the food-insecure population in general. This, however, overlooks the greatest success witnessed by nutrition services agencies which is the positive effect of nutrition on managing disease and improving health. Reported broadly from the beginning, this type of success calls for more quantitative evaluation tools that demonstrate the enormous value of these programs to people living with critical illness, to communities, and to the health care system. This white paper considers quantitative evidence-based

mechanisms such as disease markers and cost-effectiveness to measure the progress and success of nutrition services.

Nutrition PolicyAn Urgent Need

ANSAs leadership role in the eld of nutrition for those with chronic and/or lifethreatening illness is increasingly important. Many nutrition programs that receive federal funding through the Ryan White CARE Act face crippling budget cuts. Furthermore, increasing strains on Medicare and Medicaid programs due to an aging population have initiated discussions of more stringent qualications and reduced benets. Economically, the government is experiencing an increasingly tight budget and increasing demand on every system of health care. Because of the implications of nutrition on health and health care, it is critical that ANSA utilize its unique vantage point to demonstrate not only the medical effectiveness of nutrition programs, but also the cost-effectiveness in comparison to likely health and health care outcomes without the service. This white paper begins the discussion of cost-effectiveness of services provided by ANSA members and seeks to engage others in more comprehensive analysis and research to come.

ANSA The Association of Nutrition Services Agencies

For the last 20 years, nutrition services agencies have witnessed the success of providing nutrition to the critically ill. Many began serving only those with HIV/AIDS, but over time expanded their missions to serve people suffering from any form of serious illness. ANSA, previously known as the AIDS Nutrition Services Alliance, responded to the changing membership by similarly expanding its mission to serving the needs of people living with HIV/AIDS and other life-threatening illnesses. With the expanded target audience, success has also broadened. Today, over 120 ANSA member organizations serve more than 250,000 people and more than 25% of all people living with HIV/AIDS

METHODOLOGY

ith this white paper, ANSA aims to demonstrate the cost-effectiveness of nutrition services programs for those living with critical illness, and to

limited research, this white paper excludes these other conditions from in-depth review. For both diabetes and HIV/AIDS, positive health effects of nutrition were dened as delay of disease progression and/or the minimization of complications of disease. Figures for potential cost-savings were calculated by totaling the costs of identied complications (or accelerated disease progression). The reported cost savings must be qualied to allow for several imprecisions. While these considerations may moderately impact the calculated numbers, they do not impair the objectives of the study nor invalidate the conclusions. First, most nutrition services agencies have stringent guidelines for service qualication that may eliminate many of those suffering from disease complications from participating in a home-delivered meal program and thus experiencing the benecial effects. Limitations to who may participate are currently necessary to distribute benets equitably in a situation of scarce nancial resources. Although this limits the current potential of the system, this factor could be easily overcome with additional nancial support. Second, use of the total cost as a projected savings implies that improved nutrition improves health and

introduce new ways to quantitatively measure the successes of these programs. The examination for cost-effectiveness began by selecting a number of ANSA member organizations to participate in a survey of costs and services. A sample survey can be found in the appendix (page 32). 105 ANSA members in the United States were contacted via email and asked to participate in the survey. 84 responses were received. To focus the analysis on organizations with the maximum nutritional effects, surveys were only included if the responding organization provided freshly prepared, home-delivered meal services and if all meals were designed by a registered dietitian with disease-specic needs in mind. Thirteen organizations were included in the nal sample after 64 were eliminated due to lack of a freshly prepared home-delivered meals, and seven were eliminated due to meals designed by someone other than a registered dietitian. By using this small group of nutrition providers with the highest standards of service, ANSA was able to examine the health benets of disease-specic nutrition in addition to the effects of food security alone. Two disease conditions were selected for in-depth review to determine the proven health effects of nutrition. Diabetes mellitus and Acquired Immune Deciency Syndrome (HIV/AIDS) were selected for analysis because of their well-documented connections between improved nutrition and improved health outcome. Other conditions such as cardiovascular disease, renal disease, and cancer also show promise for nutrition intervention, but due to the limited time frame of this project and comparatively

staves off disease complications 100% of the time. This has not been proven. From a statistical perspective, a change that reduces negative outcomes by even 30% is considered large. Indeed, large public health benets would result from a 30% decline in accelerated disease progression and disease complications. Because the exact level of nutritions inuence was unknown for most disease complications considered, an effectiveness of 100% was assumed. Since this greatly enhances the reported cost-savings, the reported gures should be considered potential savings. In other respects, however, the cost-analysis may have understated the economic impact of nutrition. First, the economic analysis excludes consideration of earned income, receipt of social security income, and the cost of long-term care through nursing homes and assisted living. These categories likely account for some of the largest overall economic effects of home-delivered meal services. Though time restraints kept these factors beyond the scope of this project, they warrant consideration in the future. Second, the fact that home-delivered meal programs are already in place (although they have not nearly reached the capacity of their demand)

may dilute the overall economic impact by decreasing the level of current health care expenditures. For example, if a diabetes patient is hospitalized with disease-related complications, that patient may be able to go home earlier because of the availability of home-delivered nutrition services that will help stabilize the condition outside the hospital. Patients such as this are included in the current reported annual cost of diabetes complications. Because there is no true control group that excludes the current effect of nutrition services, the gures for cost-savings represent potential savings in addition to any existing savings. Perhaps the greatest limitation of this project was that no new data was collected. The 6month project time frame precluded the possibility of following a cohort of participants, but this type of research will be most valuable in predicting the precise economic value of nutrition services during critical disease. Conclusions regarding the precise economic value of nutrition services cannot be made without such a study. When time, resources, and public awareness exist to undertake this thorough, long-term research project, ANSAs white paper will contribute necessary background and perspective to design and carry

it out. In the meantime, this paper identies key features of cost-effectiveness in nutrition services, the potential mechanisms through which they act, and suggests new ways to quantify the effects of nutrition services organizations. The paper is organized by disease condition. Each section includes an overview of the disease and its typical effects. It then analyzes the numerous ways that nutrition impacts people with the condition and attributes an expense to each and potential cost-savings to each nutritional effect. Finally, the white paper reports the cost of providing nutrition to the critically ill as reported by the providers of the most comprehensive services, and compares these costs to those of current complications related to poor nutrition. Although the paper does not seek to determine the specic economic impact of current programs, it demonstrates potential for such an analysis and considers additional areas for further research.

DIABETES MELLITUS

Disease Background
Diabetes mellitus is an endocrine disease that leads to the inability to properly regulate blood glucose. It occurs when beta cells of the pancreas cease insulin production or when body tissues become desensitized to insulin. The condition results in hyperglycemia and impaired metabolism of nutrients especially carbohydrates and often leads to a multitude of physical complications including heart disease, stroke, renal failure, blindness, amputations, and death. However, with proper control through diet and/or medications, people with diabetes can live full lives and enjoy good health.7, 8 Type 1 diabetes mellitus In type 1 diabetes, the beta cells of the pancreas stop producing insulina hormone that supports tissue glucose uptake, fat and protein storage, and glycogen synthesis. Insulin also inhibits gluconeogenesis. The condition is sometimes also referred to as juvenile-onset diabetes or insulindependent diabetes because of these historically dening characteristics. Development of type 1 diabetes is often linked to viral infection or autoimmune disorder, although genetic factors also create a strong predisposition. Treatment of type 1 diabetes mellitus requires life-long administration of synthetic insulin. For some, this means multiple daily injection insulin in combination with a controlled meal plan. Others use insulin pumps to deliver doses of insulin that match their eating patterns. Both treatment

methods require careful attention to diet and consistent healthful eating patterns. With vigilant control, blood glucose levels can be maintained within a narrow range and diabetes complications can be minimized.9, 10 Type 2 diabetes mellitus Type 2 diabetes occurs when tissue receptors become resistant to the effects of insulin and consequently, blood glucose cannot be maintained within a normal range. Though this type of diabetes typically occurs in adulthood, an increasing number of children are being diagnosed with type 2 diabetes a situation that is linked to poor diet and physical inactivity. The future health of children with type 2 diabetes is a considerable concern. While the specic cause of type 2 diabetes is unknown, there is a strong correlation between obesity and disease with risk increasing directly with weight. In its early stages, the condition can often be controlled by diet and physical activity alone. Many patients also use medications that increase the sensitivity of insulin receptors, increase insulin production or both. In later stages, the beta cells may become exhausted from over-producing insulin and will cease production. In this case, treatment shifts to replace the missing insulin as in type 1

11

diabetes.11, 12 the key to managing type 2 diabetes is maintaining blood glucose levels, blood lipids and blood pressure within an acceptable range through a variety of lifestyle changes and medical treatments., 13, 14

supports, such as prepared meal services, can be essential to maintaining health and avoiding exorbitant health care costs.

billion from disability and work loss resulting for premature death and disability and $92 billion from direct medical costs.18

The State of Diabetes in the united States

Approximately 14.6 million people are currently diagnosed with diabetes in the u.s. the centers for disease control and Prevention estimates that another 6.2 million people in the united states live with diabetes but have not been diagnosed. in total, the 20.8 million people living with diabetes represents about % of the total u.s. population. from 199when current diagnostic standards were implementedto 2004, the portion of the population with diagnosed diabetes has grown by over 6%. type 2 diabetes accounts for 90-95% of cases and is the primary source of overall growth in diabetes prevalence. currently, diabetes ranks sixth as a leading cause of death due to its indication on 3,249 death certificates in 2002.21 it is estimated that in 2002, an additional 150,843 deaths were also caused by diabetes, potentially ranking the disease as high as the third most common cause of death in the united states.22 the total economic impact of diabetes in 2005 was estimated to be $132 billion, including $40

Costs and Interventions

As the ability to treat diabetes has improved with advances in medical technology and understanding of the disease, the condition itself has become manageable. with adequate control through medical care and diabetes self-management training, people with diabetes frequently live full and healthy lives. still, the disease puts people at risk for a number of medical complications that result from diabetes. in total, complications from diabetes resulted in over 480,000 hospital visits in 2003, which led to approximately $10 billion in hospital costs and represented about 1.3% of all hospitalizations. overall, 51% of these hospitalizations related to diabetes complications were covered by medicare and 23% were covered by medicaid. Another 4.2% of the costs were incurred by patients with no health insurance.23 Below is an examination of each major type of complication, its contribution to health care costs and a consideration of techniques for prevention through nutrition. the discussion of costs focuses primarily on the

Diet and Nutrition in Diabetes

the crucial role of nutrition in diabetes management is exemplified by the comprehensive nutrition recommendations for diabetes issued by the American diabetes Association. the united states government also acknowledged the importance of nutrition in diabetes by providing reimbursement for medical nutrition therapy for people with diabetes covered under medicare Part B.15 medical nutrition therapy aims to maintain optimal blood glucose, lipid, and lipoprotein levels as well as satisfactory blood pressure through educating patients about healthy food choices.16 By changing behavior, medical nutrition therapy has been shown to significantly reduce both complications from diabetes and health care costs.1, 18, 19, 20 some are unable to access the benefits provided by medical nutrition therapy because they face barriers to making the necessary dietary modifications. for these people, external nutritional

With adequate control through medical care and diabetes self-management training,

metabolism produces ketoacids (acetoacetic acid and B-hydroxybutiric acid) in the blood, cost of hospital stays as to avoid inclusion of necessary care aimed at disease control and prevention of complications. Costs not included due to lack of reliable research include costs of outpatient services, diagnostics, and surgeries, cost of long-term care, and cost of premature death and disability. Because the goal of this paper is to elucidate the economic effects of preventive nutrition through home-delivered meal program participation, the discussion of prevention is focused on the role of diet in improving glycemic control. This is one of many strategies to prevent and manage diabetes complications. Hyperglycemic Crises Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are two of the most serious complications of diabetes, because they present an immediate and often life-threatening emergency. Ketoacidosis is caused by inadequate insulin supply, which prevents glucose from being metabolized for energy. As a result, the body relies heavily on the metabolism of fats to sustain body functions. Normal fatty acid which can reach abnormally high levels when the body relies heavily on fat metabolism for energy. This problem is exacerbated by the fact that conversion of the ketoacids into energy requires oxaloacetate, a product of carbohydrate metabolism, which is halted due to lack of glucose absorption. Dehydration from glucosurea and proteinuria further contribute the high concentration of blood ketoacids.4 A high concentration of acid in the blood causes clinical acidosis which can lead to coma and death if untreated. Approximately 5% of patients admitted for DKA at well-trained hospitals do not survive.
24, 25

Immediate advanced treatment is essential for both DKA and HHS. Usually, this treatment consists of intravenous hydration and administration of electrolytes, insulin, and glucose. Minor hyperglycemic incidents can be treated with outpatient services such as oral rehydration, and phone support from clinical staff or diabetes educators, but this more basic care is not included in the cost of hospital stays. Many patients, though, require advanced support with in-patient hospitalization due to coma and/or complex imbalances of electrolytes. If these conditions are not corrected quickly, permanent life-support or care may be needed. The cost of long-term care and rehabilitation are also excluded from the hospital cost data. In 2003, nearly 180,000 people in the United States with diabetes were admitted to hospitals for hyperglycemic crises (either DKA or HHS) resulting from poorly controlled diabetes.28 Their stays averaged just under 4 days and resulted in hospital charges of approximately $13,100 per discharge. Together, the hospital changes from ketoacidosis and hyperosmolar hyperglycemic state were approximately $2.4 billion.25 Based on the payer ratio for treat-

Hyperosmolar hyperglycemia also results from very high levels of blood glucose and low levels of insulin, but presents without elevated levels of ketones. The reason has not been determined conclusively, but the condition ultimately results in a hyperosmolar state that impairs body functions.26, 27 The condition frequently results in coma and approximately 15% of admitted patients do not survive.21, 22

13

people with diabetes frequently live full and healthy lives.

ment of diabetes complications overall, the annual cost of hyperglycemic events to Medicare was approximately $1.2 billion and the cost to Medicaid was $552 million. Another $100 million in charges were incurred by patients with no health insurance.20 Control of blood glucose is fundamental to preventing hyperglycemic events. Because extreme hyperglycemia results from a lack of insulin, prevention takes two forms. First, control of type 2 diabetes through a consistent and nutritious diet may slow disease progression to beta cell failure. If the body continues to produce insulin on its own, as it does in early stages of type 2 diabetes, severe hyperglycemic events are much less likely to occur. If exogenous insulin required to maintain glycemic control (as with type 1 diabetes or beta cell exhaustion), several common events tend to precede a hyperglycemic event including: illness and infection, alcohol abuse, and stopping insulin treatment for economic or other reasons.29 Dietitians and food providers report that improved nutrition through reliable access to healthy food combined with education and support of lifestyle modications can help to correct and prevent each of these precipitating factors.

Through both prevention of insulin dependence and indirect avoidance of risk factors for acute incidents, nutrition plays a signicant role in reducing the incidence of hyperglycemia and the costs associated with it. While the precise portion of 180,000 annual events and $2.4 billion in hospital costs that could be avoided is uncertain, nutrition presents one viable option for reducing these costs by avoiding this unfortunate complication. Further research examining the relationship between improved nutrition program participation is needed to develop a gure for cost savings attributable to nutrition including outpatient services and long-term care in addition to hospital costs. Nephropathy Kidney disease (nephropathy) is a condition of diminished kidney function that results in a progressive inability to lter the blood. In diabetes, nephropathy is associated with prolonged poor glycemic control and hypertension.30, 31, 32, 33 High blood glucose concentration (which is associated with improper diet and/or medication regimens) tends to increase the ltration rate in the kidneys. Long periods of hyperglycemia are associated with damaged glomeruli that begin to leak

blood proteins into the urine. Increased protein catabolism as a result of controlled diabetes may exacerbate the problem by increasing the quantity of urea byproducts that must be excreted.27 Hypertension, which is frequently associated with diabetes and may be reective of poor glycemic control, also contributes to the development of renal failure by increasing the pressure exerted on the glomerular capillary and thus the strain on the organ.34, 30 For patients demonstrating microalbuminuria (small amounts of protein in the urine), 20-40% proceed to macroalbuminuria (large amounts) within 10 years. Of these, approximately 20% of patients experience Stage 5 Chronic Kidney Disease (CKD) within the same time frame.35 Stage 5 CKD or renal failure occurs when the kidney loses virtually all ltering capacity and can no longer eliminate wastes from the body. At this stage of disease, damage is irreversible and life-long dialysis or kidney transplant is necessary for survival. Diabetes is the number one cause of Stage 5 CKD in the United States.27 In early stages, nephropathy can be slowed by decreasing blood pressure and improving glycemic

control.27, 29 When Stage 5 CKD rst presents (before dialysis), glycemic control is a signicant predictor of both survival time and morbidity. Treatment at this stage
28

steps reduce the risk of contracting Stage 5 CKD and predict longer survival time during renal failure. Consequently, proper nutrition is essential to slow, reverse, and avoid damage from nephropathy. It is possible that with proper nutrition, health care savings could amount to as much as $94,500 per patient per year of avoided nephropathy. Although changes in diet alone are unlikely to eliminate nephropathy entirely, improving glycemic control and blood pressure through nutrition will play a key role in reducing the $1.1 billion in annual hospital costs due to this complication. More research is needed to demonstrate the full extent of potential cost savings through a reduction in the need for hospital stays, outpatient services, and long-term care. Ophthalmic conditions While ophthalmic conditions represent a relatively small portion of complications due to diabetes, these complications remain the number one cause of blindness for adults in the United States. Each year 12,000-24,000 cases of avoidable blindness result from diabetic retinopathy18 and many people suffer vision damage from glaucoma and cataracts.

Retinopathy is a condition of impaired circulation to the eye. As blood vessels become blocked, uid leaks into the macula and causes it to swell. Edema of the macula can blur or destroy vision. If the condition progresses to proliferative retinopathy, the opportunity for medical treatment narrows. New blood vessels form in the retina to compensate for those which have been blocked and these weaker vessels can leak uid, hemorrhage, create scar tissue, and/or pull the retina out of alignment.38 Surgery is used to treat retinopathy and can correct the condition if detected early enough. Procedures include scatter or focal photocoagulation and vitrectomy, both of which are outpatient procedures. Carefully maintaining blood sugar level signicantly reduces the risk of experiencing retinopathy and if the condition does occur the effects are typically less severe in those with tightly regulated blood sugar.35, 39, 40 Glaucoma is a condition of the optic nerve that causes vision decits and in some, blindness. Diabetics are approximately 40% more likely than the general public to contract glaucoma.35 High glaucoma rates in diabetics are strongly correlated to incidence of retinopathy and thus hyperglycemia, but

includes both improving glycemic control and prescribing medication to control hypertension. The majority of
30

nephropathy-related health care costs, however, come from dialysis, transplants, and hospitalizations related to ESRD. Diabetic patients with nephropathy contributed to approximately 30,000 hospital discharges in 2003 with an average length of stay of about 7 days. These stays totaled $1.1 billion in 2003, of which an estimated $554
25

million was covered by Medicare and $250 million was covered by Medicaid. Another $46 million of these costs were incurred by people with no health insurance. Cost
20

analyses estimate that upon instigation of dialysis, the cost of health care for a diabetic patient increase by a factor of eleven.
36

During the rst year of dialysis, health care costs for a person with diabetes are predicted to increase to over $96,000 compared to between $1,500 and $4,000 at baseline without nephropathy.37 Diet plays a major role in improving glycemic control and blood pressure, and these

15

the precise pathology is largely unknown. Because diabetes causes many changes to the vascular system, which are also tied to hyperglycemia, diabetics also have an elevated risk of neovascular glaucoma, a generally less treatable subgroup of glaucoma that comes with high risk of blindness. In early stages, glaucoma is usually treatable with medication to reduce eye pressure and/ or surgery, however any and all vision loss that occurs is permanent. Perhaps due to
41

ment has yet to be discovered, so while the American Diabetes Association recommends controlling blood sugar to decrease risk for glaucoma and retinopathy, this recommendation is absent for preventing cataracts because a causal link has not yet been studied. Together, the above ophthalmic conditions that were diagnosed as complications to diabetes mellitus by physicians accounted for over 1800 hospital stays with health care charges totaling nearly $28 million in 2003.25 This number is relatively small because many procedures to treat ophthalmic conditions are treated outside the hospital on an outpatient basis. Because vision loss that occurs is permanent, costs due to long-term care, loss of ability to work, and collection of social security benets are likely to add signicantly to the gure for hospital care. Due

the American Diabetes Association and the American Optometric Association recommend maintaining stable blood sugar as a key vehicle of prevention.35, 36 Because diet plays an inextricable role in stabilizing blood sugar through consistent, balanced intake and consumption of medically appropriate foods, it too is critical to preventing and reducing ophthalmic complications and the costs that accompany them. While it is not clear exactly what portion of ophthalmic complications might be avoided through improved nutrition, scientic research demonstrates potential for a preventive link that could partially reduce the $28 million dollars in hospital stays each year in addition to reducing need for expensive outpatient services and long-term assistance and disability that result from blindness. Neuropathy Diabetic neuropathy is a disease of the nervous system that is characterized by weakening or degenerating of the peripheral and/or autonomic nerves. Nervous tissue, like the retina and the kidneys, can absorb glucose even in the absence of insulin. This makes neurons particularly vulnerable during chronic hyperglycemia which typies

the link between retinopathy and glaucoma, diabetics with well-controlled blood sugar experience reduced risk of glaucoma. While the percentage of diabetes-related glaucoma is unknown, the total economic effect of glaucoma (including social-security income, health care costs, and lost income tax revenues) was estimated at $1.5 billion in 1998.
42

Cataracts are characterized by clouding of the lens in the eye due to chemical changes. This clouding can result in minor to severe levels of obscured vision. Cataracts are about 60% more prevalent among diabetics than in the normal population although the reason for this is unclear.35, 36 A causal mechanism between diabetes and cataract develop-

to the prolonged nature of these additional costs, they may even compose the majority of the economic loss that results from ophthalmic complications to diabetes, though they have not yet been quantied. To reduce these complications and thus the cost of care that accompanies them,

uncontrolled diabetes. Approximately 60% of people with diabetes about 8.8 million people are diagnosed with some form of neuropathy in their lifetime. Neuropathy
43

neurovascular function, gastroparesis and other digestive problems such as diabetic diarrhea.
4, 44

care system because many of the conditions may be treated through outpatient services or may require long term care such as physical therapy and prosthetics for food amputation, or nursing care after severe cardiac complications. Still, even the hospital costs alone are striking. Approximately 61,000 patients were admitted to the hospital in 2003 with neuropathic complications to diabetes and these costs amounted to over $1.2 billion.25 The annual cost of foot amputations alone is estimated at $2.6 billion, so it is clear that the gure for hospital costs is not representative of the total health care costs of neuropathy. The economic burden of lost work and need for long-term care is anticipated to be larger still. Nutrition plays an enormous role in reducing these costs because the single greatest risk factor for diabetic neuropathy is hyperglycemia.51 While the effects of some results of neuropathy, like foot amputation, are permanent, others can be improved through tighter glycemic control. Consequently, glycemic control is essential to both prevention of neuropathy and to its management and treatment.52 Since a stable and nutritious diet is critical to glycemic control,

For those with diabetic

autonomic neuropathy (DAN), the risk of myocardial ischemia and death are double that of an individual with diabetes without DAN. For those experiencing cardiovascular
45

can be categorized as peripheral or autonomic as described below: Peripheral neuropathy causes loss of sensation in the extremities and often contributes to foot ulceration and infection by decreasing the feeling of pain. As a result, peripheral neuropathy in combination with microvascular disease contributes to the 82,000 foot amputations in people with diabetes each year.18 The Medicare reimbursement for an average foot amputation, including a preoperative exam, diagnostic tests, hospitalization, physical therapy, and a prosthetic is over $32,000 per patient.(NY Times CHANGE) According to the Medicare reimbursement rate, the cost of foot amputations totals over $2.6 billion each year. Autonomic neuropathy is a severe and often life-threatening complication of diabetes characterized by resting tachycardia, exercise intolerance, orthostatic hypoglycemia, sudomotor dysfunction, impaired bladder control, sexual dysfunction, hypoglycemic autonomic failure, disordered

effects of neuropathy, use of ACE inhibitors and beta-blockers can be effective in reducing this risk.46 Prevalence of erectile dysfunction, a condition requiring long-term drug treatment which tends to range from $2$5 per dose, is estimated to be as much as three times higher in men with diabetes than among the male population in general, and risk increases with poor glycemic control.
48, 49, 50 47

Gastroinstestinal complica-

tions often result in hospitalizations and expensive diagnostic tests as well as severe nutritional problems and disability. For gastroparesis, a feeding tube may be necessary. This involves an inpatient hospital stay of at least one day followed by charges of up to $6,000 per week for home health agencies to perform feedings and maintenance. For diabetic neuropathy, hospital costs alone do not accurately represent the total economic burden of disease on the health

17

it is also fundamental to avoiding neuropathy and consequently reducing the economic burden of several billion dollars that it places on the U.S. health care system. Circulatory Conditions For people with diabetes, circulatory conditions particularly heart disease and stroke account for over 65% of deaths. While not all of these cases can be directly linked to diabetes, people with diabetes have increased risk of both heart disease and stroke and the risk of death from heart disease is 2-4 times greater for diabetics with the condition than other who have been diagnosed with heart disease.18 Circulatory complications of diabetes can be classied as microvascular affecting the peripheral vascular system, or macrovascular affecting the heart and brain. Although the etiology of these conditions in diabetes is not certain, most hypotheses point to atherosclerosis and hypertension as underlying causes. Atherosclerosis is a disease of the arteries characterized by the formation of plaques on artery walls. Plaques begin to form when circulating cholesterol becomes imbedded and continues to collect in the muscle tissue of artery walls. As the tissue proliferates,

the cholesterol crystals develop into larger plaques that protrude into the artery and restrict blood ow. A partial blockage of blood ow can lead to angina (chest pains), and increased risk of thrombosis (blood clot). These clots can then travel throughout the body to cause stroke, hemorrhage, and heart attack. Severely restricted blood ow reduces the ability of other organs to function properly due to lack of oxygen a condition known as heart failure. The complete blockage of an artery can lead to myocardial infarction (heart attack) or stroke. In addition to narrowing the artery and reducing blood ow, calcium salts precipitate with the cholesterol in the plaques and cause the artery to become rigid and at high risk of rupture. Hemorrhage of major arteries is frequently fatal. Microvascular disease causes loss of circulation to the extremities, which can contribute to foot amputation by decreasing healing capacity of common ulcerations. It may also worsen the effects of diabetic neuropathy. Diabetes contributes to atherosclerosis and consequently to all of its complications though several avenues. The increased risk of macrovascular disease is partially explained by frequent comorbidity of hypertension and

obesity with diabetes. Dyslipidemia also increases risk and may be caused in part by a lack of insulin due to diabetes. Since atherosclerosis is tied strongly to hypertension and dyslipidemia, treating these complications is more effective at reducing atherosclerosis than tight control of blood sugar alone.53 Consequently, physicians use medications to treat hypertension and high cholesterol in effort to reduce more serious and debilitating complications such as heart attack, stroke, and thrombosis. Even so, there is still a place for prevention. Reducing risk factors through diet, lifestyle, and medication are primary goals of physicians. For microvascular complications, the greatest risk factor is hyperglycemia although the mechanism of this relationship is largely uncertain.54, 37 A 1% reduction in HbA1c (a measure of long-term glycemic control) can result in as much as a 35% reduction in microvascular complications.55 Reducing blood pressure and LDL levels can also reduce the risk of complications, but the primary mediating factor is hyperglycemia. People with diabetes who suffer from macroor microvascular complications accounted for over 50,000 hospitalizations in 2003

TABLE 1
Complication Hyperglycemic Crisis Nephropathy Ophthalmic Conditions Neuropathy Circulatory Conditions Other Manifestations Total Charged to Medicare Charged to Medicaid Accrued by patients without insurance 2003 Total Hospital Costs25 $2,363,969,938 $1,088,687,383 $27,670,557 $1,235,838,400 $2,284,197,217 $2,984,607,310 $9,984,970,805 $5,092,335,111 $2,296,543,285 $419,368,773

reduce blood pressure and cholesterol, and the large economic losses from premature death and disability. Poor glycemic control is responsible for many of these costs due to its causal relationship to microvascular disease. Further research is needed to quantify what portion of health care costs related to circulatory complications of diabetes are attributable to microvascular disease. Because the relationship of glycemic control to macrovascular disease is unclear, the effect of nutrition on reducing costs due to macrovascular conditions such as heart attack and stroke is unknown. Even so, because poor diet is a risk factor for heart attack and stroke outside the context of diabetes, access to proper nutrition independent of good glycemic control may provide a route for prevention.

on these costs is expected to vary, although it has not yet been researched. Hospital costs provide valuable insight to the care received in addition to preventive care and that needed to maintain the diabetes control. Hospital costs also place one of the largest economic burdens on the health care system.58 Consequently, these costs are used below to estimate the overall health care costs of complications to diabetes. It is important to consider that several important features of health care cost are excluded from using hospital costs alone. These include long-term nursing care, diagnostic technology, parenteral nutrition, prosthetics, and rehabilitative care. Disability and death from diabetes cause signicant economic loss in the U.S. estimated at $40 billion annually.18 Although current research does not provide sufcient information to predict the precise amount that could be saved from the national health care bill though improved nutrition in diabetes, the potential savings are clear. This potential calls for more research to accurately quantify the savings and demonstrate likely cost-effectiveness of this intervention.

Overview
Most health care costs associated with with a mean length of stay of nearly 11 days. These stays amounted to hospital charges of approximately $2.3 billion. Additional
14

diabetes come from treatment of its complications and result in part from poor glycemic control.
56, 57

For each complication below,

charges are accrued due to the long-term care needed after stroke and amputation, the need for long-term medication use to

the percent of cost that might be prevented though improved glycemic control varies. Similarly, the effect of nutrition intervention

19

Disease Background
Human Immunodeciency Virus (HIV) is the RNA-containing virus that leads to Acquired Immune Deciency Syndrome (AIDS), the most severe stage of infection. The rst site of infection with HIV is the immune system via the CD4+ T cells. Once the virus enters the cells, it uses reverse transcriptase to replicate DNA. As the cell replicates, the virus proliferates in the body and enters other cells. A recently infected person typically experiences brief viremia soon after infection, followed by a prolonged asymptomatic period typically lasting about 2-10 years during which the virus replicates in the lymph nodes.59 Symptoms appear as the immune system weakens and CD4+ cell count declines. A physician diagnoses AIDS when CD4+ cell count drops below 200 cells/L or upon the appearance of AIDS dening illness as described by the Centers for Disease Control and Prevention.60 Treatment for HIV and AIDS has changed drastically in recent years. Due to highly active anti-retroviral therapy (HAART), people may live for many years following diagnosis with AIDS. The Department of Health and Human Services provides the following guidelines for initiating treatment:61 Initiate treatment in all patients with history of an AIDS-dening illness or severe symptoms of HIV infection regardless of CD4+ T cell count. Initiate treatment in asymptomatic patients with <200 CD4+ T cells//L

Offer treatment to asymptomatic patients with CD4+ T cell counts of 201350 cells/mm3 upon patient desire to begin treatment. Consider treatment in asymptomatic patients with CD4+ T cell of >350 cells//L and plasma HIV RNA >100,000 copies/ml. Defer treatment for patients with CD4+ T cell counts of >350 cells/L and plasma HIV RNA <100,000 copies/mL. HAART treatment is intended to slow the decline in CD4+ T cells and thus prolong the functions of the immune system, leading to fewer opportunistic infections and prolonged life. Because HIV is able to rapidly mutate, strict adherence to medication regiments are essential to the success of therapy. If adherence is sporadic, resistance can develop quickly and treatment can actually advance the severity of the condition. Because of these risks, certain complicating factors such as drug use, depression, food security, living situation, and other social factors that might affect compliance ought to be considered and mediated. 58, 62, 63

HIV/AIDS

Individualized nutrition care plans will be an essential feature of the medical management of persons with HIV infection and AIDS.
American Dietetic Association & Dieticians of Canada85

Diet and Nutrition in HIV/AIDS

Myriad nutritional complications arise from AIDS and call for complex solutions through diet. The nutrition complications are unied by their largely preventable contributions to decreased immunity, cachexia (wasting) and ultimately to increased morbidity and mortality from HIV/AIDS. Nutritional assistance plays a key role in managing these complications, and thus enhancing immunity and decreasing morbidity and mortality. Meeting Increased Energy and Nutrient Needs: Upon infection with HIV, cells of the immune system increase their production of cytokines, which trigger characteristic immune responses including increased metabolism.56 Asymptomatic individuals with HIV are likely to have energy needs 10% higher than that required to maintain weight under illness-free conditions. During symptomatic HIV and/or presence of AIDS, energy requirements are expected to be 20-30% higher.64 Presence of opportunistic infections further increases caloric need by causing fever and respiratory complications which independently increase metabolism. Meeting a higher caloric need requires more nan-

cial resources allocated to food, more time spent grocery shopping and preparing food, and knowledge that nutritional need has increased. If any of these factors are missing, inadequate intake to meet elevated caloric need will contribute to weight loss, muscle wasting, and decreased immunity, all of which contribute signicantly to morbidity and mortality in HIV/AIDS.

when HIV infects the brain (organic brain syndrome). Inadequate access to food because of nancial status or living situation. When the typical stimuli to provoke eating are absent or decreased or when food is unavailable, as often is true for those living with HIV/AIDS, nutritional assistance is needed to encourage and support adequate intake, thus improving immunity, and decreasing risk for morbidity and mortality. Combating Malabsorption Decreased ability to absorb nutrients comes from gastrointestinal infections during HIV/AIDS and side-effects from medications used to treat AIDS and complicating infections and cancers. Protease inhibitors frequently cause gastrointestinal intolerance especially diarrhea, and antibiotics to treat infections can cause diarrhea, constipation, nausea, vomiting, and general malaise.83 Diarrhea and vomiting cause loss of essential nutrients needed to preserve immune function and stave off wasting, which is strongly correlated to increased risk of mortality. Increased intake compensates for malabsorption and combats gastrointestinal

Avoiding Decreased Intake People living with HIV/AIDS eat less for many reasons:
56, 81, 82, 84

Decreased appetite due to effects of cytokines in immune response and medications Nausea, vomiting, and gastrointestinal problems from medications and infection. Dulled sensation and changes in taste perception Oral and esophageal lesions from infections that cause painful eating Respiratory infection that makes eating difcult Decreased interest in food that accompanies depression and dementia

21

effects of some medications. this contributes to maintaining and increasing weight, an effective strategy for decreasing morbidity and mortality for people with hiv/Aids, especially those already experiencing wasting syndrome.
65

important. lack of knowledge of appropriate diet and lack of access to appropriate food often hinder people living with hiv/Aids from maximizing the efficiency of their medications through diet. therefore, nutritional support programs, such as those providing home-delivered meals designed by registered dietitians, pose a viable strategy for maximizing the efficiency of medications. improving adherence to medication regiment & facilitating Positive lifestyle Beginning highly active anti-retroviral therapy (hAArt) and maintaining adherence to arduous medication regiments can be difficult for all people living with hiv/Aids. Proper nutrition can reduce side-effects of medications and thus make them easier to tolerate. this makes patients more likely to
83

secondary priorities such as attending medical appointments and seeking drug rehabilitation if applicable. for people living with hiv/Aids, food security contributes to these healthy lifestyle decisions that in turn contribute to decreased morbidity, mortality, and health care costs. home-delivered meal programs combat physical and socioeconomic food access barriers and their consequences to effectively improve medication adherence, and facilitate healthy lifestyle choices.

improving absorption of medication some medications for hiv/Aids are significantly less effective if they are not taken with food or with specific types of food. other medications are absorbed poorly because they cause severe gastrointestinal side effects when taken in the absence of food. for example, Alovoquone, a drug commonly used to treat opportunistic infections is as much as 3 times more effective when taken with a high fat meal. drugs such as glanciclover and itraconazol, are up to 30% more bioavailable if taken following specific nutritional protocols.66 People living with hiv/Aids frequently take many of these medications and thus require an appropriate nutrition regiment to maximize the effects of their medications. since medications are the single most effective factor in reducing morbidity and mortality from hiv/Aids, ensuring their effectiveness through nutrition is fundamentally

The State of HIV/AIDS in the u.S.

in the united states 462,92 people were known to be living with hiv/Aids in 2004.9 of these, approximately 45,000 cases are recognized as in the Aids stage of infection, meaning that the individual has a cd4+ t cell count at or below 200 cells//l, and/or presence of an Aids-defining illness. the total number of people who are infected with hiv is expected to be much higher than that reflected in the figure above because of pervasive lack of hiv testing. the number is also limited because current reporting to the center for disease control and Prevention is limited to 33 states and 2 territories. People living with hiv/Aids in the remaining 1 states are excluded from the u.s. estimate. more generous estimations suggest

adhere to their medication plans and reduces the need for frequent medication changes due to acquired resistance.
104, 105

Adhering to

medication regiments improves cd4+ t cell counts and reduces morbidity and mortality from hiv/Aids. for those with inadequate access to food, participation in a meal program would provide the added benefit of alleviating daily concerns of hunger. when this primary need is fulfilled, additional time and energy becomes available for fulfilling

FRAMEWORK: NUTRITION AND HIV/AIDS PROGRESSION AN OVERVIEW OF CURRENT RESEARCH89

CLINICAL EFFECTS:
Wasting Syndrome/ Cell Mass Nutrition Intervention Addressing nutritional complications of AIDS
58, 62, 82, 86, 88, 89, 90, 91 65, 71, 72, 73, 75, 77, 78, 79

Nutrition Intervention Serum Zinc Serum B-12 & other B complex

70

Managing and reversing the negative effects of AIDS

64 62, 68, 69, 74, 77, 85

81, 88, 89, 90

Mal-Absorption
81, 86, 88, 89, 90

76, 86, 89, 90

Serum Selenium

66, 67

80 76

HIV Infection Diagnosis & Treatment

Anorexia
81, 84, 86, 88, 89, 90

Serum Vitamin A

65

Energy Imbalance
58, 87, 86

MEDICATION EFFECTS:
89, 92, 93

81, 88, 89, 90

Progress of HIV/AIDS (decrease CD4+ count, increase Morbidity, increase Disability, increase Mortality)

Poor Food Access

Poor Medication Adherence

83, 89, 92

Medication SideEffects

57

Low Medication Absorption

23

that there are between 650.000 and 900,000 people living with HIV/AIDS in the United States. Overall, HIV contributes to 8% of the years of life lost to illness in the U.S.
98

In 1996, the total cost of all HIV care including hospitalizations, medication, and outpatient services was estimated at $6.7 billion.
95

Nutrition interventions, especially in the form of meal support, serve as potentially cost-reducing measures by directly improving health and independence, increasing the likelihood of medication adherence, and addressing health inequalities. First, especially for those already experiencing the negative effects of wasting syndrome, dyslipidemia, and nutrient deciencies, nutrition slows disease progression. While any form of nutrition intervention can potentially have this positive effect by

Only about 20% of patients are hospitalized in a 6-month period, but in 2003 the annual total of just over 70,000 hospital stays resulting from HIV/AIDS resulted in a national bill of approximately $3 billion. On average, each stay lasted approximately 9 days and accrued charges of over $41,000.100 Overwhelmingly, people who were hospitalized for HIV/AIDS-related reasons were recipients of public health insurance (71%) and the majority received Medicaid (53%).101 For overall HIV/AIDS health care, however, recipients of public insurance only compose 48% of the payer population and Medicaid recipients account for only 29%.95 This difference in payer populations indicates that recipients of Medicaid are far more likely to become hospitalized than those with private insurance coverage. Health inequality in HIV/AIDS extends to a nearly doubled risk of death for patients with HIV/AIDS who have accumulated no nancial assets.
102, 103

Costs and Interventions

For those receiving regular care for HIV, the cost of medical treatment averages $20,000 per person per year.95 Annual costs range from just under $14,000 in early stages of infection and increase to nearly $37,000 for those with late stage disease.99 For all stages of infection, hospital care and pharmaceutical treatment make up the majority of these costs 46% and 40% respectively. Chen, et al. found the difference in annual medical cost between those with the least progressed disease (CD4+ T cell counts equal to or greater than 350 cells//L) and those with the most progressed disease (CD4+ T cell counts equal to or less than 50 cells//L) was attributable to an 8-fold increase in expenditures for non-antiretroviral medication and a 6-fold increase in expenditures for hospitalization. Therefore, health care cost-saving
96

PAYER DISTRIBUTION FOR ALL HIV HEALTH CARE

Commercial 32%

Uninsured 20%

Medicare 19% Medicaid 29%

PAYER DISTRIBUTION FOR HIV-RELATED HOSPITAL STAYS

Because of the
Commercial 18% Medicaid 53% Uninsured 11% Medicare 18%

strategies for HIV/AIDS ought to focus on slowing disease progression and taking steps to reduce hospitalizations and need for nonantiretroviral medication as for treatment of opportunistic infections.

greater risk of death and higher incidence of hospitalization among the indigent, costsaving measures should also aim to reduce the level of health inequality between socioeconomic groups.

As an urgent priority, greater political, nancial and technical support should be provided for improving dietary quality and increasing dietary intake to recommended levels. In addition, focused evidence-based nutrition interventions should be part of all national AIDS control and treatment programmes.
- The World Health Organization61

TABLE 2: REDUCED HIV/AIDS EXPENDITURES WITH NUTRITION SERVICES

therapy (HAART). Numerous studies ensure that HAART not only improves health, but also saves health care dollars.
104, 105, 106

meal program is likely to create signicant reduction in the annual cost of health care for an individual. Complicating this fact is the concomitant extension of life, and thus extension of annual costs for each additional year additional year of life. A study by Goldie, et al. demonstrates that improved adherence to HAART can extend life (quality adjusted) for as much as 34.8 months.102 Assuming an annual cost of care of $20,000, the additional cost of extended life could be as much as $58,000. Whether nutrition interventions would reduce the lifetime cost of care enough to offset this amount is unclear. External factors to consider in a broad economic analysis would include ability to work and care for family, receipt of disability income through social security, and overall market consumption. Because such a complex analysis has not yet been conducted, it is necessary to assume a fundamental, moral and ethical value of life and prolonging quality years of independent life. Given this, the economic savings generated through nutrition support and specically through home-delivered meal programs is both signicant and indisputable.

Mechanism CD4+ Cell Count <50 cells/L 1 Increasing CD4+ T cell count96 50-199 cells/L 20 0-349 cells/L >349 cells/L 2 3 Adhering to HAART103 Equalizing income-based disparities in hospitalizations98

Potential Effect Annual Cost $36,532 $23,864 $18,274 $13,885 Inter-quartile savings $0 per person/yr $12,668 per person/yr $5,590 per person/yr $4,389 per person/yr

Adher-

ence to HAART and its consequent healthand cost-effectiveness is largely correlated to the ability to minimize side-effects.
107

Because side-effects are most effectively managed through proper diet and presence of social supports,
108

nutrition programs en-

$5,196 per person/yr $585,213,510 per year ($41,593 per person/yr)

courage adherence to HAART and thus maximize the cost-effectiveness of the medication. Finally, nutrition programs address the troublesome gap in health outcomes based on income and insurance status by addressing underlying inequalities that affect the poor such as food insecurity. This may help reduce the excess number of hospitalizations among recipients of Medicaid by altering one of the primary conditions that contributes to this increased need. Quantifying the precise economic impact of nutrition programs would further demonstrate the numerous ways that these programs reduce the costs of health care. Currently, there are a few simple ways to estimate the potential economic effects. It is clear from each of these measurements that participation in a home-delivered

inuencing behavior changes, homedelivered meals overcomes the uncertainty and inconsistency of independent behavior change by providing food itself. This additional step avoids confusion about nutritional recommendations, access barriers to obtaining proper food, and physical barriers to preparing healthful and appropriate meals. Ultimately, meal program participation may help reduce hospitalizations by improving health and immunity, especially among those with low incomes who are subject to the negative inuence of health disparities. Hospital costs, as well as overall costs will be further reduced by improving adherence to highly active anti-retroviral

25

SAVING LIVES AND SAVING MONEY

of life, and ultimately reducing health care expenditures. For the most vulnerable populations that already experience signicant disparities in health outcomes, nutrition also plays an important role in closing these gaps by addressing one of the most prevalent root disparities, access to nutritious food. ANSA member organizations turn the need for improved nutrition in the critically ill into action by offering a wide range of services. The smallest organizations are volunteer-staffed pantry programs designed especially for the HIV-positive who lack access to food and would suffer more severe consequences of wasting without adequate caloric intake. Large non-prot organizations are staffed with nutritionists who tailor meals to dietary needs based on disease. They mass produce and deliver hot and frozen meals to people in surrounding areas with all forms of critical illness. Most ANSA members monitor their progress with clients through annual or quarterly surveys that track satisfaction with the program along with other indicators of success detailed in Table 3. To begin considering the use cost-effectiveness as another marker of success for these programs, organizations responded to a brief survey regarding the expense involved in providing freshly prepared homedelivered meals to their clients. Only those respondents who reported that all meals were designed by a registered dietitian were included in the results below. The meal cost

s demonstrated in the previous sections, nutrition is critical to managing illness, reducing its complications, extending quality years

includes raw food, kitchen staff salaries, packaging materials and delivery. The total cost includes meal costs and additional costs of administering the program and managing the organization. Costs reported below are listed per person, per year of services received. This value is calculated by dividing the total cost of all services by the number of clients served annually. The complete survey and survey responses can be found in the appendix on page 32. The inter-quartile range of total costs associated with freshly prepared homedelivered meal services is $1,052 - $2,263 with a mean cost of $1,507 per person, per year of services. The large inter-quartile range of costs reects the diverse level of services. The level of administrative infrastructure may contribute to the discrepancy in costs as may the type and quality of food served. More research would be needed for a complete cost-effectiveness analysis of services provided within these agencies.

Comparing costs
The mean cost of one day in the hospital for those with complications to diabetes is approximately $3,839. One average, patients spend 5.4 days for an average cost of $20,730

TABLE 3: CLIENT SURVEY RESULTS (ADMINISTERED BY INDIVIDUAL ORGANIZATIONS)

Food & Friends Clients receive medical nutrition therapy* Most of food is eaten (>50% >75%) Clients receives Food Stamps Clients have mobility problems Overall program satisfaction Perceived improvement in nutrition Perceived improvement in health Weight gain Fewer infections Improved medication adherence/purchasing Participation preserved independence 100% 74% 51% 86% 83% 25% 19% Community Servings 89% 97% 76% 70% 23% MOW-VA 35% 94% 64% 91% 88% 75% Senior Meals Food Pantry 72% 89% 61% 74% Kitchen Angels 77% 49% 83% 74% Gods Love We Deliver-NJ 67% 89% 94% 89% 100% 100% Gods Love We Deliver-NY 79% 76% 76% 65% 82% 71% Food Outreach 73% 53% 81-95% 73% Averages 72% 83% 53% 73% 80% 89% 79% 25% 19% 81% 75%

- indicates a tracking category not measured by the given organization. * all reporting organizatins offer medical nutrition therapy to their clients in addition to using dietitians to design meals based on the special nutritional needs of their clients.

per stay. If participation in a nutrition program could eliminate even one day in the hospital, savings could amount to as much as $2,332 per person. For HIV/AIDS, the daily hospital cost averaged $4,574 in 2003.
109

determine how many hospital stays might be avoided though participation in a homedelivered meal program, but the potential for savings is signicant. When considering quantifying the level of savings, it is also necessary to take into consideration potential cost increases. Lengthened life could actually increase cost

in some cases due to extensive needs for medication and care. While the overwhelming value placed on individual life shadows this argument in a social context, it is important to consider at an economic level, even if it is ultimately not useful in making decisions regarding the value of nutrition. An extensive economic analysis would require following a cohort of individuals and

The elimination of one day in the hospital through nutrition program participation could save as much as $3,067 per person per year. Further research is necessary to

27

TABLE 4: HOME-DELIVERED MEAL COSTS

Organization LIAAC MOW-Virigina Project Open Hand Gods Love We Deliver EAC, Inc. Open Arms of Minnesota Community Servings A Loving Spoonful Senior Meals Food Pantry Food Outreach Kitchen Angels Moveable Feast Food & Friends Project Angel Food Clients Served HIV/AIDS Any Illness Any Illness Any Illness HIV/AIDS HIV/AIDS, breast cancer, MS, ALS Any Illness HIV/AIDS Any Illness HIV/AIDS Any Illness HIV/AIDS Any Illness Any Illness Meals per week 5 7 7 10 10 10 10 11 13 14 17 18 18 21 Clients per year 261 1,500 3,575 3,690 145 380 1,200 196 2,320 87 162 771 2,000 1,800 MEAN: MEDIAN: STANDARD DEVIATION: CONFIDENCE INTERVAL ( =0.05): Meal cost per client/yr $412.22 $583.33 $839.85 $1,357.05 $267.93 $763.16 $1,294.63 $1,608.83 $780.18 $2,224.46 $2,548.15 $1,556.42 $1,063.72 $1,024.07 $1,166 $1,063.72 656.01 +/- 287.05 Total cost per client/yr $1,240.18 $1,800 $994.10 $1,522.36 $537.93 $2,289.47 $2,333.33 $2,677.25 $1,023.05 $2,458.85 $2,732.35 $1,880.67 $1,168.89 $2,271.66 $1,780.72 $1,800 704.68 +/- 308.83

FIGURE 1

Total Annual Cost per Client

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

Annual Cost per Client

monitoring their lifetime health care needs. Such a study would elucidate which types of care can be avoided by improved nutrition and which types of additional care are needed. It would also provide insight into other potential social benets of improved nutrition such as being able to

more effectively care for ones dependents or ones self and responsibilities. The current data indicate strong potential for such research to demonstrate wide-reaching economic benets of improved nutrition during critical illness.

ANSA member organizations turn the need for improved nutrition in the critically ill into action by offering a wide range of services.

n the united states, nearly 800,000 people are diagnosed with hiv infection and 14.6 million suffer from diabetes.110 for many, disease leads to disability, poverty and poor nutrition that only exacerbate their declining health. research clearly indicates that these people

could make significant improvements in their health by receiving nutrition that addresses their medical needs. the nutritional standards for these diseases are outlined clearly by the American dietetic Association, but they remain out of reach for many who are economically or physically unable to obtain an ideal, or sometimes even minimally adequate, diet without assistance. nutrition services agencies bring medically appropriate meals to these individuals and in doing so, bring them improved nutrition status and improved health. many years of

research conducted by both medical experts and nutrition services providers supports this conclusion. Beyond the widely accepted positive impacts on health, three important trends have emerged: Promising cost-effectiveness of care nutrition services, a need for new quantitative evaluation methods and new research, and an increasing need for initiative and support through the policy process.

ConClusions

Cost-effectiveness of Care
in addition to improving health and wellbeing, nutrition services appear to have significant economic impacts. Available data suggest potential for savings in health care expenditure by both slowing disease progression and avoiding costly disease complications. A complex economic analysis that measures lifetime cost of care is needed to quantify specific cost savings. Available hospital cost data, however, indicate potential savings at the magnitude of billions of dollars for diabetes and hiv/Aids alone. Providers of nutrition services report that this is also true of other conditions such as renal disease, cardiovascular disease and cancer. the relatively low cost of these programs makes a strong argument for maximal implementation and utilization of nutrition services.

New Measurements and New research

to optimize the health and economic benefits of nutrition services in the future two major steps must be taken. first, scientific research is needed to validate the promising connections between receipt of nutrition services, improved health, and decreased health care costs. research should seek to determine the specific features of health that are affected by nutrition program participation and to what degree nutrition is responsible for the observed changes. future studies should track both clinical markers of disease such as cd4+ t-cell count for hiv/ Aids and A1c for diabetes, and economic effects such as health care costs, ability to work, and receipt of disability. these longterm cohort studies would allow stronger conclusions as to the broad and complex effects of nutrition programs on the

economy of health care in the united states. second, nutrition services agencies must adopt new, scientific measurement tools to demonstrate their far reaching successes in health and health care. in a culture of evidence-based decision making, quantitative measurements using factors such as health markers and economic impact are crucial to ensuring a programs long-term viability. Quantifying these effects will enable nutrition providers to more effectively provide services. it will also enable policy-makers to make more educated decisions in the best interest of people who most need their support and for the greater tax-paying society.

29

Funding and Policy

Health care policy is an increasingly debated topic at the national, state and local levels. As the population ages and health follows a natural decline, the nations health care systems Medicare and Medicaid will experience a burden of increased utilization. The increased nancial strain, especially from treatment of late-stage disease complications, has caused a more apparent need to maximize the efciency of healthcare spending. Private care providers such as Kaiser Permanente have shifted focus to proactive health management from traditional reactive treatment of disease. New research demonstrating cost savings and new evidence-based evaluation tools will prove nutrition services to be a key player in the movement toward more cost-effective medical care. Recognizing the primary role of nutrition services in the ght for cost-effective medical care is especially important in the current political climate of funding cuts to initiatives like the Ryan White CARE Act.

Realizing the great potential for cost-effectiveness and the already apparent need for improved health, ANSA calls for new research that quanties the precise economic impact of nutrition services and develops quantitative evaluation methods for nutrition service agencies. This new information will facilitate needed changes in policy that lend nancial support to nutrition services agencies and thus to the cost-effectiveness of medical care. Ultimately these steps will allow our nation to provide improved nutrition, improved health, and improved participation in society to people who are sick, disenfranchised, and looking for change.

ANSA/emerson Hunger Fellow Survey 1. what is the total "meal cost" each year including:
raw food food Preparation (cook staff salary, equipment, etc) Packaging materials delivery (mileage, driving staff, vehicle and maintenance) (Add the above costs for an entire year) = $

7. most common reason(s) that clients stop receiving

services (if known):

8. which (if any) additional nutrition services does your organization

provide to clients? (Please check any that apply) __nutrition/diet Assessment __menu designed by a dietitian __nutrition counseling/mnt __special diet options (please list)

2. total nutrition program costs per year: (cost from #1 + total

administrative costs for the nutrition program) = $

__other (please describe)

9. if your organization uses a client survey, please attach the most

recent years data. (this will not be used to evaluate your organization in any way. it allows us to make positive references to successes such as improved nutrition status, health, satisfaction, medication regiment, and others that your clients experience)

aPPendix

3. total number of home-delivered, freshly prepared

meals served per year =

4. number of clients served home-delivered freshly

prepared meals per year =

5. Average length of time each client

receives services = Additional comments:

6. how many home-delivered, freshly prepared meals per

week do most clients receive? number hot meals= number frozen meals= other meals= (please describe)

endnoTes

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