Author’s reply: Impact on health and healthcare costs if monounsaturated fatty acids were substituted for conventional dietary oils in the United States

In his letter,1 Dr. Temple asserts that the cost savings potentially generated in the short run by a reduced incidence of coronary heart disease (CHD) and type 2 diabetes (T2D) following a recommended intake of monounsaturated fatty acids (MUFAs) will likely be cancelled out in the long run by costs generated when people live longer. The argument is that when mortality due to CHD and T2D is reduced, individuals will live longer, thereby developing other diseases common in the elderly and receiving social security payments for more years, which will be costly. While we appreciate the logic and the evidence, although still limited, behind this view into the complex relationship between early prevention of fatal disease and longer-term healthcare spending, it should be noted that our published work2 was concerned with the potential savings in healthcare and societal costs that are directly related to CHD and T2D, in particular, and not to all disorders within the healthcare system. Such cost savings would still be expected to apply to the two diseases of interest in our analysis in later years of life, regardless of incidences of other health conditions and their accompanying costs. In fact, given that CHD and T2D are among the top morbidities and causes of mortality, especially among the elderly, in the United States, it is reasonable to claim that prevention or better management of these chronic diseases early on would result in higher healthcare cost savings of relevance in the long run. As such, the potential dollar value forecasted by avoiding CHD and T2D risks through the substitution of dietary oils rich in MUFAs for oils rich in saturated and trans fatty acids, as an example, and as part of public health strategies that advocate improved adherence to healthy nutritional behaviors, would still be considered real savings. Of course, we agree that a portion of these savings may be used in treating diseases that are common in the elderly, as listed by Temple.1 Perhaps more importantly, however, the available funds could also be used, sooner or later, in the following ways: (1) allocated to public health and community-based programs that would address prevention or early management of other diseases, including those related to aging, thus leading to lower disease rates (and thus costs) in later years; (2) utilized to appropriately improve the construct of, or effectively reform, the healthcare system; and (3) assigned to other nationwide priority domains such as education and infrastructure. That being said, we should also emphasize the need for comparative studies aimed at understanding the health, and possible economic, effects of MUFA consumption alone vs within the context of certain eating patterns. Realizing the benefits of improved consumption of oils rich in healthy fatty acid profiles on health outcomes, professional societies including the Academy of Nutrition and Dietetics, the American Heart Association, the Institute of Medicine, the Food and Agriculture Organization of the United Nations, and the US Department of Health and Human Services (through the Dietary Guidelines for Americans) have established population-wide dietary fatty acid recommendations for optimal health or better management of chronic disease. Without such efforts, it is evident that costs to healthcare and society as a direct consequence of chronic disease would be even more substantial. Similarly, realizing the health benefit and cost-effectiveness of such healthy dietary approaches, the World Health Organization and other health authorities in many countries have already implemented government-supported policy strategies and programs to advocate nutritional behavior change that would result in lower incidence of disease. Examples include salt (sodium) reduction efforts and trans-fat bans. Therefore, caution must be exercised in supporting the idea that healthy individuals who normally live longer are likely to be more expensive for the healthcare sector in the long run than unhealthy persons, or that public health interventions aimed at preventing fatal disease have no benefits. It should be noted that, apart from the healthcare expenditure, costs to society related to CHD and T2D are also high because of workday absences due to illness, reduced performance at work, and premature mortality. Savings related to such “indirect costs” of disease following healthy dietary or any other lifestyle approaches are unlikely to be completely offset by healthcare costs that are linked to a longer lifespan. Increased productivity can translate into a longer presence within the workforce, as well as to contributions to human and financial capital flows to the healthcare system. Unlike our analysis, which took this aspect into consideration, such indirect costs have not been captured in previous analyses that questioned the longer-term economic benefits of smoking cessation and obesity prevention. It should be noted that an increased quality of life is also an important factor related to undertaking strategies that reduce risk for disease. Deficits in health are linked to reductions in quality of life outcomes and serve as another driver for developing population-level strategies that promote healthier longevity and prevent premature mortality. We do not disagree that adjustments for additional healthcare costs that may arise in later years of life as a result of avoiding chronic diseases, such as CHD and T2D, represent an important aspect of any economic analyses. In order to gain a better understanding of the short- and long-term impacts on both the healthcare sector and society as a whole, as well as the implications for clinical or public health practices, further research on the relationship between disease prevention and healthcare spending is warranted. We thank Dr. Temple for his effort to enhance understanding of these issues.

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