Earlier this month, the American Heart Association in its official journal, Circulation, published its forecast of "The Future of Cardiovascular Disease in the United States." For anyone who takes the time to look it over, it makes for depressing reading. According to the forecast, one in three Americans has been diagnosed with some form of heart disease. We're talking about high blood pressure, coronary heart disease, heart failure and stroke, among others. By 2030, the cost to treat heart disease in the United States (in real 2008 dollars) will triple, rising from $273 billion to $818 billion. In addition, it is also estimated that the costs resulting from lost productivity due to cardiovascular disease (CVD) will climb by 61% in that same time period from $172 billion to $276 billion.
That means that the costs of heart disease alone in the United States will climb to over $1 trillion dollars a year. Forget cancer. Forget diabetes. Forget Alzheimer's. Forget hospital errors. Heart disease alone will cost over $1 trillion dollars a year in the US. Needless to say, the AHA report concluded by saying, "Effective prevention strategies are needed if we are to limit the growing burden of CVD."
As the study went on to explain, currently, CVD is the leading cause of death in the United States and constitutes 17% of overall national health expenditures. Even more significant, though, was the study's statement that US medical expenditures are the highest in the world and rose from 10% of the Gross Domestic Product in 1985 to 15% of the Gross Domestic Product in 2008. And in just the last decade, the medical costs of CVD have grown at an average annual rate of 6% and have accounted for 15% of the increase in medical spending. (This is something to think about as Republicans in the House of Representatives promise to return us to the "best healthcare system in the world." As I've said before, the current healthcare bill is terrible, but it's far better than the status quo. Keeping the current system in place is guaranteed bankruptcy. Obamacare needs to be drastically overhauled, not repealed.)
According to the study, the prevalence of cardiovascular disease will increase, based on the status quo, by 10% over the next 20 years assuming there is no change in current policy or lifestyle across the general public, whereas the direct costs will increase almost 3-fold. By 2030, the study estimates, 40% of US adults, or 116 million people, will have one or more forms of CVD.
The report speculated that the largest increases will be in the rate of stroke and heart failure, which will climb to 24.9 percent and 25 percent, respectively. The aging of the population (the elderly are more susceptible to heart disease) combined with the growth in per capita medical spending are the primary drivers of increased CVD costs, which are expected to grow the fastest for ages 65 and over. "These increases translate to an additional 27 million people with hypertension [we'll talk more about that later], eight million with CHD [coronary heart disease], four million with stroke, and three million with heart failure in 2030 relative to 2010."
The costs related to hypertension alone are set to increase $130.4 billion (in 2008 dollars), with a total projected annual cost of $200.3 billion by 2030. If the costs of hypertension are expanded to include how much the presence of hypertension adds to the treatment of other diseases and conditions triggered by hypertension, the increase in annual spending from 2010 to 2030 is $258.3 billion, with a projected annual total cost of $389.0 billion by 2030. All in all, the researchers note, the real medical costs of CHD and heart failure are estimated to increase by 200 percent over the next 20 years with stroke having the highest cost increase in real annual medical costs of 238 percent.
Commenting on the study, Paul Heidenreich, MD, the chair of the AHA expert panel that conducted the study, said, "Despite the successes in reducing and treating heart disease over the last half century, even if we just maintain our current rates, we will have an enormous financial burden on top of the disease itself."
The study's recommendations
So how did the study suggest we cope with this financial tsunami? Its authors, not surprisingly, recommended throwing even more money into the mix. They said that what was needed were more personalized, medically-based approaches to prevention that include assessments of genetic variants, biomarkers, and imaging modalities that could help tailor prevention methods and recommendations to specific individuals. On the other hand, the researchers qualified their recommendation and said, "Despite the great enthusiasm for personalized medicine, further studies are needed to determine whether these personalized approaches are superior (or complementary) to population-based approaches to cardiovascular disease prevention."
The authors also suggested that population-based strategies such as decreasing smoking rates, reducing dietary fat intakes, and improving lipid levels, among others, have in the past, and can continue in the future, help treat high-risk individuals and help prevent their risk for cardiovascular disease. Expanding on this idea, they stated, "Although these projections are sobering, they need not become reality, because CVD is largely preventable. Several studies have demonstrated that individuals with favorable levels of major atherosclerotic risks have a marked reduction in the onset of CHD and heart failure. Similarly, people who follow a healthy lifestyle experience a comparably reduced risk of CHD and stroke. Therefore, a greater focus on prevention may alter these CVD projections in the future."
Why is it that whenever I hear the medical community talk about diet and lifestyle, I'm always reminded of the cholesterol ads that conclude with, "When diet and exercise aren't enough, adding Vytorin can help." In other words, there's always an undertone from the medical community that diet and lifestyle are okay choices if you don't have a serious problem, but drugs and surgery are the only "serious" options when life and death are on the line. As if!
In conclusion, the report stated, "In the public health arena, more evidence-based effective policy, combined with systems and environmental approaches should be applied in the prevention, early detection, and management of cardiovascular disease risk factors…Through a combination of improved prevention of risk factors, and treatment of established risk factors, the dire projection of the health and economic impact of cardiovascular disease can be diminished."
Questioning the study's assumptions
First, let me explain that I have no complaints with the study's primary assumptions:
- That the costs of heart disease are increasing dramatically over the next several decades. (Heck, I've been saying the same thing for the past several decades.)
- There are steps that can be taken that can lower these costs. (No argument here. The whole purpose of the Baseline of Health Foundation is to report on those steps.)
So which assumptions do I have a problem with?
- The study's basic, underlying assumption is that medical care has already dramatically impacted the incidence and mortality rates associated with heart disease (as in Dr. Heidenreich's statement regarding the medical community's "successes in reducing and treating heart disease over the last half century").
- Thus the study also projects that improvements in medical care can further improve patient outcomes and bring costs down…As long as we continue to head down that road, but at an accelerated rate??!
Unfortunately, the simple truth is that the facts on the ground do not support these two assumptions.
On a quick reading, the study might seem to downplay the role of drugs and medical intervention in lowering cholesterol VS the benefits of dietary changes. For example, the study says, "Modest improvements in risk factors earlier in life can have a greater impact than more substantial reductions later in life." Reading further would seem to support the assumption, "If everyone received the 11 recommended prevention activities, myocardial infarctions and strokes would be reduced by 63% and 31%, respectively, in the next 30 years. At more feasible levels of performance, myocardial infarctions and strokes would be reduced by 36% and 20%. Unfortunately, the current use of these prevention activities is suboptimal."
Now you might think these prevention activities refer to diet and lifestyle, but you would be mistaken. A good hint lies in the use of the word "received."
So what, one might ask, are these magical 11 prevention activities? Are they the diet and lifestyle associations we might first have surmised the study seemed to be alluding to or are they medical interventions as I am suggesting? Interestingly, one has to go to another study, also published in Circulation some two years earlier, entitled The Impact of Prevention on Reducing the Burden of Cardiovascular Disease, to find the answer. And what we learn from this study is, "Of the specific prevention activities, the greatest benefits to the US population come from providing aspirin to high-risk individuals, controlling pre-diabetes [two activities that involve controlling blood sugar with medication], weight reduction in obese individuals, lowering blood pressure in people with diabetes [two separate pharmaceutical activities], and lowering LDL cholesterol [four pharmaceutical activities] in people with existing coronary artery disease (CAD)." Not surprisingly, with its heavy emphasis on doctor visits, testing, and lifelong medication, the study also concluded, "As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years." How expensive are we talking about? We'll touch on that a bit later.
The bottom line is that the facts on the ground don't support the study's conclusions. No, I'm not saying that high blood pressure isn't a problem -- just that drug "prevention activities" may not be the best way to lower it. And no, I'm not saying that thick, clotty blood is not a problem -- just that aspirin may not be the best way to alleviate it. And likewise for diabetes and cholesterol. Let's examine.
High blood pressure
According to the Future of Cardiovascular Disease study, "Overall, hypertension has the greatest projected medical cost. The increased prevalence of hypertension is in part attributable to the aging of the population." The study also states that, "Increasing body mass index contributed to 50% of the increase in hypertension. Reversing the obesity epidemic will play a pivotal role in favorably impacting the projected hypertension trends."
That said, the primary recommendation for dealing with high blood pressure (based on the 11 prevention activities), other than weight-loss, is the use of pharmaceuticals -- notably:
- Diuretics, which reduce blood pressure by making you eliminate water from your body. Reduce the volume of fluid in the blood, and you reduce the pressure. Unfortunately, side effects can include dizziness, weakness, and impotence. (Not to worry, there are more medications to alleviate these side effects.) It's also probably worth mentioning that a recent analysis of hypertension drugs found that hydrochlorothiazide, the diuretic of choice for most physicians, actually doesn't even work that well. Now, that's an effective strategy!
- Calcium channel blockers, which work to relax and widen the arteries, thus reducing blood pressure. Unfortunately, studies consistently show an increased risk of heart attacks associated with all types of calcium channel blockers, including short, intermediate, and long acting. Another effective strategy!
- Beta blockers, which work by weakening the heart so it won't pump as strongly, thereby reducing blood pressure. What genius thought this one up? Several major problems associated with beta blockers, in addition to the fact that they don't work that well, is the increased risk of diabetes, sudden and profound weight gain, and increased risk of heart attack during the first two-three months of use. Nevertheless, despite these risks, leading doctors have recommended putting every single heart attack survivor on beta blockers. Brilliant!
- ACE inhibitors (the new drug of choice), which like calcium channel blockers also work to relax and widen the arteries, but with fewer side effects (just "minor" things such as kidney impairment, upper respiratory problems, headache, dizziness, and congenital "anomalies").
Keep in mind that, in addition to all of the side effects that these drugs cause, which require further medication, there is a fundamental flaw in these pharmaceutical treatments. All that these drugs do is treat the "manifest" symptom -- high blood pressure -- but do nothing to deal with the underlying cause -- clogged or hardened arteries. So, eventually, as your arteries continue to clog and harden to the point where even the medication no longer helps, you start getting the inevitable chest pains. Your doctor then chases the next set of symptoms and performs a coronary bypass or angioplasty to relieve those symptoms -- until the next, even more radical, intervention.
As a side note, a study published in 2007 found that angioplasties did not save lives or prevent heart attacks in non-emergency patients. In fact, the study showed angioplasties only give slight and temporary relief from chest pain, and by five years, there was no significant difference in symptoms. Oh yes, we spend $48 billion a year on angioplasties in the U.S. alone.
Then again, in addition to all of the side effects, complications, and dangers of surgery, we are once more presented with yet another fundamental flaw in your doctor's treatment. If all your doctor does is bypass or clear the arteries supplying blood to your heart, doesn't that mean that all of the other arteries in your body are still clogged, including the arteries that supply blood to your brain? You bet it does. Isn't that going to be a problem? Since the arteries are narrowed, won't it be more likely that a small blood clot will get lodged in your brain and cause a stroke? Absolutely! But that's a different "symptom." At this point, your doctor once again prescribes another drug or more dangerous surgery to deal with this problem. . .
I've covered the issue of cholesterol in detail in my newsletter, The Cholesterol Myth. To better understand the entire issue, check it out. But for now, the following should suffice.
In January of 2008, I wrote about the results from a study sponsored by Merck and Schering-Plough that found that after several years on two types of cholesterol-lowering medications, patients reduced their cholesterol level, but they reaped no significant health benefit at all unless they already had heart disease. (Note: Merck delayed releasing the results for two years, and only when finally pressed to do so.)
But that's not the worst of it. Just a few months later in October 2008, I reported on the results of a study that found that Vytorin may increase the risk of cancer by 50 percent. In fact, this study found that Vytorin increased the risk of cancer in all major areas of the body. In addition, it found that among those who developed cancer, those taking Vytorin had a much higher rate of death than those taking a placebo.
And the bad news on statins just keeps rolling in like the tide in the Bay of Fundy. In July 2009, I talked about a study published in the Canadian Medical Association Journal that confirmed that statin drugs cause structural damage to muscles. Even worse, the study found that muscle damage can continue to progress even after patients stop taking the drugs.
And how much do we pay for these dazzling results? In the US alone, sales of statin drugs generated approximately $19.7 billion in 2005, or about $120 billion when averaged out over a decade.
Even aspirin, the most innocuous of all medications recommended for the prevention of heart attacks, kills. According to the New England Journal of Medicine, "anti-inflammatory drugs (prescription and over-the-counter, which include Advil®, Motrin®, Aleve®, Ordus®, aspirin, and over 20 others) alone cause over 16,500 deaths and over 103,000 hospitalizations per year in the U.S." The simple fact is that even the smallest amount of aspirin, a child's dose, causes at least some degree of intestinal bleeding. In fact, nearly 70% of those taking aspirin daily show a blood loss of ½ to 1½ teaspoons per day, and 10% lose as much as 2 teaspoons per day.
And why would you use aspirin anyway? Proteolytic enzymes such as nattokinase, Endonase, and Seaprose-S are far more effective and far safer. And they do so much more than aspirin, which merely improves the ability of blood to flow. A good proteolytic enzyme formula will:
- Improve the ability of blood to flow.
- Dissolve plaque in the arterial walls by breaking down the protein based fibrin that holds the plaque together.
- Reduce systemic inflammation in the body and in the circulatory system, thus eliminating the prime cause of plaque build-up in the first place.
- And help break down scar tissue in the arterial walls.
And while you're at it, why not significantly reduce consumption of Omega-6 vegetable oils, which includes virtually all of the vegetable oils (corn, safflower, etc.) you buy in the supermarket other than olive oil. If not balanced by sufficient Omega-3 oils in the diet, Omega-6's cause a build-up of non-esterified fatty acids, also known as NEFAs, a significant independent risk factor for sudden death from heart attacks. Switching to more balanced oils costs about the same, not to mention the fact that they actually taste better. It's not like being forced to eat health-food cookies. In fact, the only advantage to using highly processed polyunsaturated cooking oils is that they never go rancid. You can keep them in your cabinet for as long as you live, and they will never go bad. But when you think about it, how comfortable should you feel about eating a food that can "never die?" Does it even qualify as a food anymore?
Controlling blood sugar levels makes all the sense in the world. Drugs such as metformin are both reasonably effective and reasonably benign. Insulin injections, not so much. But natural sugar metabolic enhancement formulas are at least as effective, and even more benign, than either medical approach.
But even more important, suppressing high blood sugar numbers addresses neither the cause of the disease nor the other issues associated with it, including insulin resistance, damage from excess insulin, destruction of beta cells, and damage to organs. These are all part of diabetes' "echo effect," and must be addressed if you ultimately want to reverse the disease. In effect, any viable alternative needs to stop all of the echoes -- all of them without exception -- so that nothing bounces back to retrigger problems. Drugs do not do that, which is why diabetes tends to progress over the years, even if you use drugs. Yes, the drugs slow down the progression of the disease, but it still progresses -- unless you actually reverse the cause of the disease itself.
Amusingly, the cost savings presumed if the medical community gets its way and can implement the 11 prevention activities recommended in both studies with complete success over the next 30 years, would not only not save money -- it would bankrupt us. As the The Impact of Prevention on Reducing the Burden of Cardiovascular Disease study says, "The cost of caring for CVD, diabetes, and CHD over the coming 30 years will be in the order of $9.5 trillion. If all the recommended prevention activities were applied with 100% success, those costs would be reduced by ∼$904 billion, or almost 10%. However, assuming the costs shown in Table 2, the prevention activities themselves would cost ∼$8.5 trillion, offsetting the savings by a factor of almost 10 and increasing total medical costs by ∼$7.6 trillion (162%).
Now that's a brilliant plan!
And no, I'm not talking about Angelina Jolie's latest movie.
The Forecasting study says, "A reduction in sodium intake is a promising goal for prevention and treatment of hypertension. A recent analysis using the Coronary Heart Disease Policy Model estimated that reducing dietary salt by 3 g per day per person would reduce the annual number of new cases of CHD by 60,000 to 120,000, stroke by 32,000 to 66,000, and myocardial infarction by 54,000 to 99,000 and reduce the annual number of deaths from any cause by 44,000 to 92,000."
At first glance, that statement might seem pretty innocuous and downright commonsensical, but reread it. It talks about reducing dietary salt intake by 3 grams, or 3,000 mg! The United States recommendation for the daily maximum intake of salt is 2,400 mg. Most health experts recommend only 1,500-1,800 mg a day. So what are they talking about? How much salt is actually making its way into people's diets for a recommendation that people reduce consumption by 100-200% of the maximum daily allowance?
Check out this quote from the European Public Health Alliance:
"The current public health recommendations suggest that salt intake should be reduced from 9-12 to 5-6 grams per day for adults. Clinical trials demonstrate a clear link between salt reduction and the fall in blood pressure. A conservative estimate indicates that a reduction of 3 grams per day would reduce strokes by 13% and ischemic heart disease by 10%. The effects would be almost doubled with a 6-gram reduction and tripled with a 9-gram one."
Holy salted beef, Batman! It seems that large numbers of people have become walking salt licks.
All kidding aside, anyone consuming 9-12 g of sodium a day has a problem and is pretty much a walking coronary. But that said, an equally important factor is what type of salt are you consuming? As I've discussed previously, there is a huge difference in how your body handles refined salt and how it handles unrefined, natural sea or Himalayan salt. And be careful, many, many companies are now jumping on the bandwagon and promoting their use of sea salt -- but in many cases, they are using refined sea salt, which is sea salt in name only. Once refined, it is no different from any other commercial salt you can buy...and equally harmful to your body. Make sure that you (or any products you buy) use only unrefined sea or Himalayan salt.
All in all, the report from the American Heart Association on the future of heart disease in the United States (and by extrapolation, anywhere else in the world) is not a bad one. It contains more truth than nonsense -- and when's the last time you heard me say that about a medical study? Unfortunately, it ultimately succumbs to the weight of its medical bias -- the bias that says you can control disease by managing and/or suppressing symptoms. In truth, cardiovascular disease will never truly be controlled (and within any affordable budget for future health care) until medical doctors think more like holistic physicians and deal with the causes of disease rather than just the symptoms.
For more on exactly how the cardiovascular system works, what causes heart disease, and how to reverse it, click here to start reading my series of newsletters on the anatomy and physiology of the cardiovascular system. Also check out our Heart Health page for other related newsletters and blogs.