-- Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al
Approx. 1,300,000 new cases per year www.cdc.gov/.../mmwrhtml/ figures/m846qsf.gif www.ncbi.nlm.nih.gov/ bookshelf/picrender.fcgi.. http://www.ctahr.hawaii.edu/CS/blogs/sustainable_agriculture/cdc_logo(2).jpg
Modifiable behavioral risk factors are leading causes of mortality in the United States. (JAMA, 2000 Mokdad et al. CDC) www.cdc.gov/cancer/ breast/statistics/ http://www.cdc.gov/cancer/Prostate/publications/decisionguide/
http://www.gallup.com/poll/147317/chronic-illness-rates-swell-middle-age-taper-off.aspx These findings are based on 24 months of Gallup-Healthways Well-Being Index daily tracking data from 2009 through 2010, encompassing surveys with more than 650,000 U.S. adults, aged 18 and older. The resulting sample sizes for every age from 18 through 90 -- ranging from roughly 1,500 to 18,000 cases -- allow for age-specific analysis of the data.
-- Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al
In 2005-2008 11% of adults 20 years of age or older had diabetes. In 2005-2008 the percentage of adults with dm increased with age from 4% of persons 20-44 to 27% of adults 65 years of age or older http://meps.ahrq.gov/mepsweb/ Medical Expenditure Panel survey
http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf The prevalence of hypertension (defined as high blood pressure or taking antihypertensive medication) increases with age. In 2005–2008, 33%–34% of men and women 45–54 years of age had hypertension, compared with 67% of men and 80% of women 75 years of age and over (Table 67).
http://care.diabetesjournals.org/content/early/2010/09/30/dc10-0879.full.pdf+html 2010 --AHA 2004 --States if you have 2 of characteristics =‘s 2 times risk of death from coronary heart dz, if you have 4 of these =‘s you have 3.5 times the risk? http://www.reuters.com/article/2010/10/15/us-metabolic-syndrome-idUSTRE69E5FL20101015
http://sas-origin.onstreammedia.com/origin/gallupinc/GallupSpaces/Production/Cms/POLL/yxirhsg6pe-ttjvtlo_uuq.gif These findings are based on 24 months of Gallup-Healthways Well-Being Index daily tracking data from 2009 through 2010, encompassing surveys with more than 650,000 U.S. adults, aged 18 and older. The resulting sample sizes for every age from 18 through 90 -- ranging from roughly 1,500 to 18,000 cases -- allow for age-specific analysis of the data.
-- Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al
http://diabetescure101.com/graphics/couch-potato.jpg http://www.firsttracksmarketing.com/wp-content/uploads/2011/06/hospital460.jpg http://0.tqn.com/d/fengshui/1/0/w/9/-/-/fruit-basket-cynthia-berridge.jpg If A + B increase the risk of C then will fixing A or preventing B reduce the risk or expense of C
--Fraser et al. Archives of IM: 2001:161;1645-1652
http://www.pmri.org/publications/newsweek/Yes_Prevention_is_Cheaper_than_Treatment_Dean_Ornish.pdf http://www.ncbi.nlm.nih.gov/pubmed/9860380?ordinalpos=33&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Attrition rate of 10-12.7 %
A presentation at NAVSSummerfest 06/28/12 Stephan Esser MD www.esserhealth.com
Dollars and Salad: The Economics of Personal Choice Stephan Esser MD www.esserhealth.com
Goals• Plant Seeds• Stimulate Dialogue• Harvest Ideas• Identify a Problem• Evaluate the Evidence• Unravel a Solution
Goals• Review the state of lifestyle-related disease in America• Understand the widening and graying of America• Unravel the related epidemic of chronic disease• Review the cost associated with management• Review the literature and identify life and cost benefits of plant-based nutrition
Foundational Questions• What are the most common chronic diseases?• How many people have them?• How much do they add to care costs?• Where is the most money spent?• Can plant-based nutrition improve health and save money?
“A global response to aglobal problem: the epidemic of overnutrition.” WHOIt is estimated that by 2020 2/3 rds of the global burden of disease will be attributable to chronic non- communicable diseases, most of them strongly associated with diet. The nutrition transition towardsrefined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other non-communicable conditions.Sedentary lifestyles and the use of tobacco are also significant risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and trade mechanisms, is necessary to address these matters.
Perspective• We eat more – Sugar, Salt, Fat, Meat, Dairy – 1970-2006: • ↑ 24.5 % C/day ≈ 617K/day• We get less then ideal Physical Activity – 18.8% of adults achieved CDC reccs on Exercise – 10% of adults >65 y/o
Michelangelo’s David:12 month 20 city tour of the US
“A global response to aglobal problem: the epidemic of overnutrition.” WHOIt is estimated that by 2020 2/3 rds of the global burden Diabetes diseases, most of Disease Heart of disease will be attributable to chronic non- communicable them strongly associated with diet. The nutrition transition towardsrefined foods, foods of animal origin, and increased High Blood Pressure fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other non-communicable conditions.Sedentary lifestyles and the use of tobacco are also significant High Cholesterol risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and trade mechanisms, is necessary to address these matters.
What we Know• Americans are: – Increasing in Width – Increasing in Age• The Result – Increasing Metabolic Syndrome – Increasing Diabetes – Increased Prevalence of “Heart Disease” – Increased Medication Use – Increased use of the Health Care System
HealthCare Spending = $2.7 trillion = 17.7% GDP
Associated Pathology• CVD: • Obstetrics: – Hypertension – Gestational DM – Congestive Heart Failure – Macrosomia – PVD – Inc. C Section rate – Impotence – Inc. Perinatal Morbidity – Inc. Pre/Eclampsia – Claudication • Cancer:• Endocrine: – Prostate – Diabetes – Colon – PCOS – Breast – Hypothyroidism – Endometrial – Infertility – Renal Cell – Gallbladder• Orthopedics: – Esophageal Adeno. – Osteoarthritis • Other: – AVN • Hyperuricemia, Pancreatitis,• Hepatic: Gallstones, Sleep Apnea, Alzheimer’s, – #1 cause of liver dz in US Dyslipidemia, Metabolic Syndrome
Top 35 leading diagnosis groups at ambulatory care clinics 1: Essential Hypertension 7: Diabetes Mellitus 15/17: Heart Disease
Number and rate of discharges from short stay hospitals 2009 2: Heart Disease 8: Strokes 11: Diabetes Mellitus 17: Essential Hypertension
Admission Diagnosis to Nursing Homes 2009 1: Disease of Circulatory System
What we know• Rising Tide: – Obesity – Lifestyle Related Disease – Population > 65 y/o• Healthcare Spending – All time High – Primarily on Chronic Disease
“A global response to aglobal problem: the epidemic of overnutrition.” WHO It is estimated that by 2020 2/3 rds of the global burden of disease will be attributable to chronic noncommunicable ……if…….Lifestyle is thediseases, most of them strongly associated with diet. Problem The nutrition transition towards refined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other noncommunicable conditions. Sedentary lifestyles and the use of What is risk factors. …….. A concerted tobacco are also significant the answer……..?multi-sectoral approach, involving the use of policy, educationand trade mechanisms, is necessary to address these matters.
The Evidence/Inpatient/Outpatient/Clinical Models
Motorola• Cost ≈ $6 mil/yr on wellness and work/life programs• Offerings: Health Screenings, Education, gym access etc• Cost-effectiveness: – $1 invested in wellness benefits, $3.93 saved – 2.4% increase in annual health care costs for participating employees vs 18% increase for non- participants – $6.5 million annual savings in medical expenses for lifestyle-related diagnoses (e.g., obesity, hypertension, stress) compared with non-participants
Northeast Utilities• 17% healthcare costs = LR• WellAware program: financial incentives for participation, employees and spouses eligible, a health risk assessment, secondary coronary artery disease management program, phone contact and Internet site allows access at work and home, and a toll free hotline for materials and questions.• 1st 2 years: 1.6 return on investment, including a $1,400,000 reduction in lifestyle and behavioral claims and flat per capita costs for health care.• Participants demonstrated: 31% decrease in smoking, a 29% decrease in lack of exercise, a 16% decrease in mental health risk, a 11% decrease in cholesterol risk, an 10% improvement in eating habits, and a 5% decrease in stress.
Common Ground• Health Assessments• Risk Stratification• “High Touch”• High Tech and Low Tech• Family/Spouse Participation• Incentivization
How does “Plant-Based Nutrition” fit in to cost savings and our “not-so-fabulous 4”?
Dietary habits and mortality in 11 000 vegetariansand health conscious people: results of a 17 year follow up BMJ 1996; 313 : 775 (Published 28 September 1996) Results: 2064 (19%) subjects smoked, 4627 (43%) were vegetarian, 6699 (62%) ate wholemeal bread daily, 2948 (27%) ate bran cereals daily, 4091 (38%) ate nuts or dried fruit daily, 8304 (77%) ate fresh fruit daily, and 4105 (38%) ate raw salad daily. After a mean of 16.8 years follow up there were 1343 deaths before age 80. Overall the cohort had a mortality about half that of the general population. Within the cohort, daily consumption of fresh fruit was associated with significantly reduced mortality from ischaemic heart disease (rate ratio adjusted for smoking 0.76 (95% confidence interval 0.60 to 0.97)), cerebrovascular disease (0.68 (0.47 to 0.98)), and for all causes combined (0.79 (0.70 to 0.90)).
Vegetarian diets: what do we know of their effects on common chronic diseases? Am J Clin Nutr May 2009 vol. 89 no. 5 1607S-1612S There is convincing evidence that vegetarians have lower rates of coronary heart disease, largely explained by low LDL cholesterol, probable lower rates of hypertension and diabetes mellitus, and lower prevalence of obesity. Overall, their cancer rates appear to be moderately lower than others living in the same communities, and life expectancy appears to be greater.
BLOOD-PRESSURE-LOWERING EFFECT OF A VEGETARIAN DIET: CONTROLLED TRIAL IN NORMOTENSIVE SUBJECTS The Lancet, Volume 321, Issue 8314, Pages 5-10I.Rouse59 healthy, omnivorous subjects aged 25-63 years were randomly allocated to a control group, which ate an omnivorous diet for 14 weeks, or to one of two experimental groups, whose members ate an omnivorous diet for the first 2 weeks and a lacto-ovo-vegetarian diet for one of two 6-week experimental periods. Mean systolic and diastolic blood pressures did not change in the control group but fell significantly in both experimental groups during the vegetarian diet and rose significantly in the experimental group which reverted to the omnivorous diet. Adjustment of the blood-pressure changes for age, obesity, heart rate, weight change, and blood pressure before dietary change indicated a diet-related fall of some 5-6 mm Hg systolic and 2-3 mm Hg diastolic. Although the nutrient(s) causing these blood-pressure changes are unknown, the effects were apparently not mediated by changes in sodium or potassium intake
• BLOOD PRESSURE IN VEGETARIANS – Am. J. Epidemiol. (1974) 100 (5): 390-398.• Vegetarian diet in mild hypertension: a randomised controlled trial. – 58 subjects aged 30-64 with mild untreated hypertension were allocated either to a control group eating a typical omnivorous diet or to one of two groups eating an ovolactovegetarian diet for one of two six week periods. A fall in systolic blood pressure of the order of 5 mm Hg occurred during the vegetarian diet periods, with a corresponding rise on resuming a meat diet.
Cholesterol• The Effect of Vegetarian Diets on Plasma Lipid and Platelet Levels Arch Intern Med. 1986;146(6):1193-1197
Rapid reduction of serum cholesterol andblood pressure by a twelve-day, very low fat, strictly vegetarian diet. J Am Coll Nutr. 1995 Oct;14(5):491-6. During this short time period, cardiac risk factors improved: there was an average reduction of total serum cholesterol of 11% (p < 0.001), of bloodpressure of 6% (p < 0.001) and a weight loss of 2.5 kg for men and 1 kg for women.
Dean Ornish MD “Can Lifestyle Changes Reverse Coronary Heart Disease?”Lancet 1990 Regression of Atherosclerotic plaques $30,000 per patient in the first year “Intensive Lifestyle Changes for Reversal of Coronary Heart Disease” JAMA 1998 5 yr f/u showed continued atherosclerotic regression and ½ the rate of cardiac events “Angina Pectoris and Atherosclerotic Risk Factors in the Multisite Cardiac Lifestyle Intervention Program” AM J Card 2008 Reduced total health-care costs in those with By 12 weeks 74% were angina freecoronary heart disease by 50 percent after only one year “The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites” Am J Health Promotion 2010 Significant reductions in BMI/SBP/DBP/A1C/Tchol/LDL/Trig
Dean Ornish MD• High Mark BCBS : 2 years f/u post 1 year intervention• MI’s: 87 % in Ornish group, 48% for the control group.• Angioplasty: 84% in OG• Bypass Surgery: 80% in OG• Catheterizations: 64% in OG
Diabetes• Does a vegetarian diet reduce the occurrence of diabetes? American Journal of Public Health, Vol. 75, Issue 5 507-512 – 25,698 adult White Seventh-day Adventists identified in 1960 followed for 21 years – vegetarians had a substantially lower risk than non-vegetarians of diabetes as an underlying or contributing cause of death• Fruit and Vegetable Consumption and Diabetes Mellitus Incidence among U.S. Adults Preventive Medicine Vol 32 Iss 1 January 2001. Pages 33-39 – Appr. 10, 000 participants, highest fruit and vegetable consumption = lowest risk of T2D• Dietary Patterns and the Incidence of Type 2 Diabetes Am. J. Epidemiol. (2005) 161 (3): 219-227. – 4,000 Finnish men and women, followed 23 years – Highest consumption of fruits/vegetables in prudent diet resulted in decreased risk
A Low-Fat Vegan Diet Improves Glycemic Control and Cardiovascular Risk Factors in a Randomized Clinical Trial in Individuals With Type 2 Diabetes Diabetes Care August 2006 vol. 29 no. 8 1777-1783 – 100 people randomized vegan vs ADA diet 22 weeks – 43% VG 26% ADA reduced diabetes medications. – HbA1c (A1C) 0.96 points VG 0.56 points in the ADA group – Excluding those who changed medications, A1C fell 1.23 points in the vegan group compared with 0.38 points in the ADA group – Body weight 6.5 kg VG and 3.1 kg ADA – LDL cholesterol 21.2% in the vegan group and 10.7% in the ADA group (P = 0.02). – urinary albumin reductions 15.9 mg/24h VG than in the ADA group 10.9 mg/24 h
A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial Clin Nutr May 2009 vol. 89 no. 5 1588S-1596SWeight loss was significant within each diet group but not significantly different between groups (−4.4 kg in the vegan group and −3.0 kg in the conventional diet group, P = 0.25) and related significantly to Hb A1c changes (r = 0.50, P = 0.001). Hb A1c changes from baseline to 74 wk or last available values were −0.34 and −0.14 for vegan and conventional diets, respectively (P = 0.43). Hb A1c changes from baseline to last available value or last value before any medication adjustment were −0.40 and 0.01 for vegan and conventional diets, respectively (P = 0.03). In analyses before alterations in lipid-lowering medications, total cholesterol decreased by 20.4 and 6.8 mg/dL in the vegan and conventional diet groups, respectively (P = 0.01); LDL cholesterol decreased by 13.5 and 3.4 mg/dL in the vegan and conventional groups, respectively (P = 0.03).Conclusions: Both diets were associated with sustained reductions in weight and plasma lipid concentrations. In an analysis controlling for medication changes, a low-fat vegan diet appeared to improve glycemia and plasma lipids more than did conventional diabetes diet recommendations. Whether the observed differences provide clinical benefit for the macro- or microvascular complications of diabetes remains to be established.
Toward Improved Management of NIDDM: A Randomized, Controlled, Pilot Intervention Using a Low-fat, Vegetarian Diet Preventive Medicine, Volume 29, Number 2, August 1999 , pp. 87-91(5)28% mean reduction in fasting serum glucose of the experimental group, from 10.7 to 7.75 mmol/L (195 to 141 mg/dl), was significantly greater than the 12% decrease, from 9.86 to 8.64 mmol/L (179 to 157 mg/dl), for the control group (P < 0.05). The mean weight loss was 7.2 kg in the experimental group, compared to 3.8 kg for the control group (P < 0.005).
Precedent• Pritikin et al. Effects of a high-complex-carbohydrate, low-fat, low- cholesterol diet on levels of serum lipids and estradiol AJM 1985 – 26 day inpatient stay 15-20% in TC• Pritikin et al Long-Term Use of a High-Complex-Carbohydrate, High-Fiber, Low-Fat Diet and Exercise in the Treatment of NIDDM Patients Diabetes Care 1983 – 26 day inpatient stay, 77% off Oral Hypoglycemics, 25% in TC• Effect of Short-Term Pritikin Diet Therapy on the Metabolic Syndrome Journal of Cardio-Metabolic Disease 2006 – 12-15 day stays, BMI 3%, SBP, SG, LDL 10-15% – 37% no longer met criteria for Metabolic Syndrome
30-day lifestyle modification program delivered by volunteers in a community setting. -5,070 participants (January 2006 to October 2009) -Outcomes: Reduction in body mass ( 3.2%), systolic anddiastolic blood pressure ( 4.9% and 5.3%, respectively), total cholesterol ( 11.0%), low-density lipoproteincholesterol( 13.0%), triglycerides ( 7.7%), and fasting plasma glucose ( 6.1%) p<0/001. 2011 Elsevier Inc. All rights reserved. Am J Cardiol 2011
CHIPIntervention: 28 video classes conducted in worksite, medical and community settingsSubjects: 763 middle-aged adults, ages 30–79 yearsFollow-Up: Four to 8 weeks after baseline
What we know• What are the most common chronic diseases?• How many people have them?• How much do they add to care costs?• Where is the most money spent?
What we know• Plant-Based Nutrition can prevent, reverse or improve management of the “not-so fabulous 4”• Plant-Based Nutrition appears likely to be able to reduce health care spending at all levels
What we know• We need more cost data to alter care
Opportunity Knowledge = Responsibility• Eat more plants• Impact your circles• Support the research• Lobby for change
Thank You! Stephan Esser MD www.esserhealth.com
References• http://aspe.hhs.gov/health/prevention• Prevention of Type 2 Diabetes Mellitus by Changes of Lifestyle Among Subjects with Impaired Glucose Tolerance. N Engl J Med 2001;344:1343-50.• Knowler, WC. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. NEJM 2002 Feb 7;346(6):393-403• Herman et al. The Cost-Effectiveness of Lifestyle Modification or Metformin in Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance. Ann Intern Med. 2005 Mar 1;142(5):323-32.• Crandall. J et al. The influence of age on the effects of lifestyle Modification and Metforming in Prevention of Diabetes. J Gerontol A Biol Sci Med Sci. 2006 Oct;61(10):1075-81.• Chopra M et al Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23.• www.cdc.gov/.../mmwrhtml/ figures/m846qsf.gif• www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf• Fox, Caroline. Et al. Trends in the Incidence of Type 2 Diabetes Mellitus: Circulation 2006:113;2914-2918.• http://meps.ahrq.gov/mepsweb/• http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf• http://care.diabetesjournals.org/content/early/2010/09/30/dc10-0879.full.pdf+html• http://www.ncbi.nlm.nih.gov/books/NBK91989/• http://meps.ahrq.gov/mepsweb/data_files/publications/cb11/cb11.shtml• http://www.cdc.gov/nchs/data/series/sr_13/sr13_169.pdfh• ttp://www.cdc.gov/nchs/data/nhds/2average/2009ave2_firstlist.pdfRankin, Am J Cardiol. 2012 Jan 1;109(1):82-6. Aldana et al., A video-based Lifestyle Intervention and changes in coronary risk. Health Education Research. 2008; 23:115-124.• Ali et al. How Effective Were Lifestyle Interventions In Real-World Settings That Were Modeled On The Diabetes Prevention Program? Health Aff January 2012 vol. 31 no. 1 67-75• Verhaeghe et al Effectiveness and cost-effectiveness of lifestyle interventions on physical activity and eating habits in persons with severe mental disorders : a systematic review Int Jrnl of Beh Nutr and PA 2011••
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