Mandy Geyer 8/5/23 Mandy Geyer 8/5/23

Fiber and Healthcare Costs, Part 1: What’s the Problem?

The following series of posts are from Mandy’s Capstone project for her MPH program, focused on how fiber intake could reduce the number of Americans with chronic conditions and reduce healthcare spending for all.

Introduction

Health care costs in the United States reached 18.3% of the gross domestic product in 2021 at $12,941 per person, or $4.3 trillion (1). This is significantly higher than other developed countries, and the Centers for Medicare and Medicaid Services (CMS) projects health care costs will continue to increase beyond inflation at an average increase of 5.1% per year, meaning healthcare costs could reach nearly 20% of the gross domestic product by 2030 (2). This growth in healthcare costs is unsustainable, and for many people in the U.S., unaffordable. The Kaiser Family Foundation found that 40% of Americans have forgone medical care in the last year due to cost, a statistic that is even higher for low-income Americans, as well as Black and Hispanic Americans (3). These cost challenges have led to a variety of proposals to make healthcare in the US more affordable, ranging from a universal health care system to value-based care to digital healthcare solutions.

According to Crunchbase, hundreds of billions of dollars have been invested into thousands of healthcare start-up companies in recent years, many of which promise to solve the problem of affordability of care in the US, though healthcare costs are continuing to increase at rates higher than inflation (4). If we look at the major driver of cost in the US healthcare system, spending on chronic health conditions make up the majority of spending. 60% of American adults have at least one chronic condition, with 12% having five or more chronic conditions (5). People with chronic conditions account for 90% of health care spending in the US, and those with five or more chronic conditions account for 41% of spend5. There are a variety of risk factors for different chronic conditions, but diet and nutrition is a common and significant modifiable risk factor for most (6). An analysis by McCollough and Willet using data from the Nurses Health Study and Health Professionals Follow-up Study examined the impact of diet on the risk of chronic disease, using the Alternate Health Eating Index (AHEI) scoring system (7). They found that diet quality was linked to risk of chronic disease, with an 11% to 20% reduction in risk of chronic disease for those with the highest AHEI scores versus lowest, with even greater reductions in risk found for cardiovascular disease (7).

Fiber has been studied extensively with regards to its impact on chronic disease risk and has been found to decrease risk of many chronic diseases, including diabetes, heart disease, and certain cancers, among others8. In the McCollough and Willet analysis, the amount of cereal fiber consumed in a day was a component of the AHEI score, as were other sources of fiber including fruit, vegetable, and non-meat protein consumption, making fiber intake a significant portion of the total AHEI score (7). This paper summarizes several studies further examining the link between fiber intake and chronic disease risk and discusses the benefits of addressing gaps in fiber intake in adults in the US as a means of reducing chronic disease prevalence, and thus reducing healthcare costs, with a focus on diabetes, heart disease, and colorectal cancer.

Problem

Poor diets are a leading cause of chronic disease in the US, with very few Americans meeting basic dietary guidelines (9). A simple search of dietary interventions for chronic disease turns up a variety of results, including research recommending a vegan diet, low-fat diet, low-carbohydrate diet, no-sugar diet, ketogenic diet, high protein diet, among others. Nutrition research is complex, and in some cases, contradictory. Additionally, significant diet changes are difficult for people to adhere to, evidenced by the fact that research shows people who lose a significant amount of weight tend to regain most, if not all, within 5 years (10). Rather than suggesting people overhaul their diets, a simpler and more sustainable method would be to focus on adding to the diet, rather than taking away or modifying. Adding fiber through increased consumption of fruits, vegetables, whole grains, nuts, and pulses is a dietary change that is easy to communicate and implement, can be low cost, and given the nature of fiber, will increase satiety, leaving less room for other foods that increase risk of chronic disease, such as ultra-processed foods (9).

In the 1960s, Denis Burkitt was studying middle-aged adults in Uganda and noticed a significantly lower incidence of chronic disease when compared with adults of the same age in England (11). He published a theory, which later became known as Burkitt’s hypothesis, that the difference in chronic disease incidence could be attributed to fiber intake, as the adults in Uganda he studied were consuming at least 100g of fiber a day, compared with 15g per day for adults of similar age in England (11). He advocated for daily consumption of at least 50g of fiber per day in order to prevent chronic diseases like diabetes, heart disease, and colon cancer (11). Burkitt’s hypothesis has been supported and verified by the work of many others since his initial paper was published, some of which will be discussed later in this paper (11).

However, despite the fact that Burkitt’s hypothesis was published in the 1960s and has been supported by many epidemiological studies in the years since as detailed by O’Keefe in his 2019 viewpoint in The Lancet (11), only 5% of Americans consume the daily recommended amount of fiber, which is 25g to 38g per day, depending on age and gender, according to the Institute of Medicine (12). In fact, the average fiber intake for adults in the US is around 16g per day, below daily recommendations and well below Burkitt’s recommendation of 50g per day and has been labeled as a “nutrient of concern” by the United States Department of Agriculture (USDA) due to the gap between actual intake and recommended intake (12, 13).

There are two types of fiber that make up total fiber, dietary fiber and functional fiber (8). Dietary fiber is non-digestible carbohydrates found naturally in plants, like whole grains, fruits, vegetables, legumes, nuts, and seeds, while functional fiber is typically fiber that is added to foods from isolated non-digestible carbohydrates and is still beneficial for human health (8).

Functional fiber includes substances such as psyllium husk which can be added to foods low in fiber, like yogurt, in order to improve the nutritional profile (14). Dietary fiber will be the focus of these posts, since it is found naturally in foods and is the focus of USDA dietary guidelines for Americans (13). In looking at an average day, an adult male could meet the USDA daily recommended fiber intake of 38g by eating:

a cup of raspberries with breakfast (8g fiber),
a grain bowl for lunch that includes a cup of cooked black beans (15g fiber) and a cup of brown rice (3.5g fiber),
a snack including 3 cups popcorn (3.5g fiber) and an apple (4.5g fiber), and adding
a cup of broccoli to dinner (5g fiber),

all of which adds up to 39.5g of fiber for the day, not including other foods that would be included to complete the meals (15). Increasing fiber intake is a proven, relatively low cost, accessible, and simple way to address chronic disease risk, which in turn could help lower health care costs for adults in the US.

References

(1) Historical | CMS. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.

(2) CMS. “Major Findings for National Health Expenditure Projection: 2021-2030.” www.cms.gov, https://www.cms.gov/files/document/nhe-projections-forecast-summary.pdf

(3) “Americans’ Challenges With Health Care Costs.” KFF, 14 July 2022, www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs.

(4) “List of Top Health Care Startups (Top 10K) - Crunchbase Hub Profile.” Crunchbase, www.crunchbase.com/hub/health-care-startups.

(5) Buttorff, Christine, et al. Multiple Chronic Conditions in the United States. RAND Corporation, 2017. https://www.rand.org/content/dam/rand/pubs/tools/TL200/TL221/RAND_TL221.pdf

(6) Ojo, Omorogieva. “Nutrition and Chronic Conditions.” Nutrients, vol. 11, no. 2, MDPI AG, Feb. 2019, p. 459. https://doi.org/10.3390/nu11020459.

(7) McCullough, Marjorie L, and Walter C Willett. “Evaluating Adherence to Recommended Diets in Adults: the Alternate Healthy Eating Index.” Public Health Nutrition, vol. 9, no. 1a, 2006, pp. 152–157., doi:10.1079/PHN2005938.25

(8) Dahl, Wendy J., and Maria L. Stewart. “Position of the Academy of Nutrition and Dietetics: Health Implications of Dietary Fiber.” Journal of the Academy of Nutrition and Dietetics, vol. 115, no. 11, Elsevier BV, Nov. 2015, pp. 1861–70. https://doi.org/10.1016/j.jand.2015.09.003.

(9) Poor Nutrition | CDC. www.cdc.gov/chronicdisease/resources/publications/factsheets/nutrition.htm.

(10) Hall, Kevin D., and Scott Kahan. “Maintenance of Lost Weight and Long-Term Management of Obesity.” Medical Clinics of North America, vol. 102, no. 1, Elsevier BV, Jan. 2018, pp. 183–97. https://doi.org/10.1016/j.mcna.2017.08.012.

(11) O’Keefe, Stephen J. “The Association Between Dietary Fibre Deficiency and High-income Lifestyle-associated Diseases: Burkitt’s Hypothesis Revisited.” The Lancet Gastroenterology&Amp; Hepatology, vol. 4, no. 12, Elsevier BV, Dec. 2019, pp. 984–96. https://doi.org/10.1016/s2468-1253(19)30257-2.

(12) Quagliani, Diane, and Patricia Felt-Gunderson. “Closing America’s Fiber Intake Gap.” American Journal of Lifestyle Medicine, vol. 11, no. 1, SAGE Publications, July 2016, pp. 80–85. https://doi.org/10.1177/1559827615588079.

(13) U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.

(14) Belorio M, Gómez M. Psyllium: a useful functional ingredient in food systems. Crit Rev Food Sci Nutr. 2022;62(2):527-538. doi: 10.1080/10408398.2020.1822276. Epub 2020 Sep 21. PMID: 32951436.

(15) “How Much Fiber Is Found in Common Foods?” Mayo Clinic, Mayo Foundation for Medical Education and Research, 5 Jan. 2021, https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/high-fiber-foods/art-20050948.