1. A presentation at NAVS
Summerfest 06/28/12
Stephan Esser MD
www.esserhealth.com

2. Dollars and Salad: The Economics of
Personal Choice
Stephan Esser MD
www.esserhealth.com

4. Goals
• Plant Seeds
• Stimulate Dialogue
• Harvest Ideas
• Identify a Problem
• Evaluate the Evidence
• Unravel a Solution

5. 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

6. 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?

7. A Paradigm Shift

8. “A global response to a
global 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 non-
communicable diseases, most of them strongly
associated with diet. 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 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.

9. Mortality Statistics

10. Leading Causes of Death in US

11. Top Ten Causes of Death for Men in the United States

12. Actual Causes of Death in US

13. 2 of 3

15. 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
DIABETES
– 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

16. Overweight ↑ risk of DM2 by 3 fold
Obesity ↑ risk by 9 fold

20. How did this Happen?

24. 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

25. Michelangelo’s David:
12 month 20 city tour of the US

26. “A global response to a
global problem: the epidemic
of overnutrition.” WHO
It 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 towards
refined 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.

27. The Problem
1:9 adults

28. The Problem
• High Blood Pressure:
– 1 in 3 adults
1:3 adults

29. 1:6 adults

30. Waist Circumference > 40” M > 35” W
> 29%
34%
Triglycerides > 150 HDL < 40 M or < 50 W
of Americans
BP ≥ 130/85 Fasting Glucose of ≥ 100

32. What we Know
• Americans
– Eat More
– Exercise Less
• 2012:
– Obesity
– Diabetes
– Metabolic Syndrome
– CV Disease

33. The Graying of America

34. The Graying of America

39. 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

40. Spending

41. HealthCare Spending = $2.7 trillion = 17.7% GDP

45. 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

47. Top 35 leading diagnosis groups at ambulatory care clinics
1: Essential Hypertension
7: Diabetes Mellitus
15/17: Heart Disease

48. Number and rate of discharges from short stay hospitals 2009
2: Heart Disease
8: Strokes
11: Diabetes Mellitus
17: Essential Hypertension

49. Admission Diagnosis to Nursing Homes 2009
1: Disease of Circulatory System

50. What we know
• Rising Tide:
– Obesity
– Lifestyle Related Disease
– Population > 65 y/o
• Healthcare Spending
– All time High
– Primarily on Chronic Disease

51. “A global response to a
global 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 the
diseases, 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, education
and trade mechanisms, is necessary to address these matters.

52. =
+

53. The Evidence/Inpatient/Outpatient/Clinical
Models

54. 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

55. 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.

56. Common Ground
• Health Assessments
• Risk Stratification
• “High Touch”
• High Tech and Low Tech
• Family/Spouse Participation
• Incentivization

57. How does “Plant-Based Nutrition” fit in to cost
savings and our “not-so-fabulous 4”?

59. Dietary habits and mortality in 11 000 vegetarians
and 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)).

60. 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.

61. HTN/Heart Disease

62. BLOOD-PRESSURE-LOWERING EFFECT OF A
VEGETARIAN DIET: CONTROLLED TRIAL IN
NORMOTENSIVE SUBJECTS
The Lancet, Volume 321, Issue 8314, Pages 5-10I.Rouse
59 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

63. • 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.

64. Cholesterol
• The Effect of Vegetarian Diets on Plasma
Lipid and Platelet Levels Arch Intern Med. 1986;146(6):1193-1197

65. Rapid reduction of serum cholesterol and
blood 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 blood
pressure of 6% (p < 0.001) and a weight loss of 2.5 kg
for men and 1 kg for women.

67. 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 free
coronary 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

68. 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

69. Diabetes

70. 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

71. 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

72. 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-1596S
Weight 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.

73. 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).

74. Duke Rice Diet Program

77. 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

78. 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 and
diastolic blood pressure ( 4.9% and 5.3%, respectively), total
cholesterol ( 11.0%), low-density lipoprotein
cholesterol( 13.0%), triglycerides ( 7.7%), and fasting plasma
glucose ( 6.1%) p<0/001.
2011 Elsevier Inc. All rights reserved. Am J Cardiol 2011

79. CHIP
Intervention:
28 video classes conducted
in worksite, medical and
community settings
Subjects: 763 middle-aged
adults, ages 30–79 years
Follow-Up: Four to 8 weeks
after baseline

80. 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?

81. 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

82. What we know
• We need more cost data to alter care

83. Opportunity
Knowledge = Responsibility
• Eat more plants
• Impact your circles
• Support the research
• Lobby for change

84. Thank you!

86. Thank You!
Stephan Esser MD
www.esserhealth.com

87. 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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