Vascular Disease in an Expanding World: Seeking Answers Inside and Outside of the Box

In today's world there is a constant bombardment of new gadgets and innovations attempting to change societal behaviors and capabilities. Each requires new skills, adaptation, and incorporation into our lives to enhance our work and play. Technologic advances are eagerly anticipated. The public, and perhaps some health care professionals, perceive and depend on medical advancements, whether the next miracle drug or life‐sustaining device, to trump and solve our medical ills. It is time to take a fresh look inside our box of medical therapeutics and seek the necessary change, cooperation, and integration outside of the box to significantly improve the health of Americans.

As the body mass index of the world's population escalates, so does the soaring number of individuals developing the metabolic syndrome, characterized by hyperinsulinemia, abdominal obesity, dyslipidemia, and hypertension. The increasing epidemic of children developing type II diabetes mellitus with associated hypertension and proteinuria is an alarming marker of obesity and a grim forecast for future cardiovascular disease. ¹ , ² While the cost of health care is now higher than ever, the forecast for future health care expenditures is expanding as rapidly as the world's waistline. ³ For most hypertensives, strict adherence to prescribed medications and normalization of weight to their “ideal” can result in treatment success in the vast majority of patients—particularly in patients willing to exercise and modify their sodium intake. In practice, however, this is achieved in a minority of patients. To address this reality, novel solutions are needed to counter the cost of these growing health concerns. Effective solutions are more likely to come from creative thinking on the part of health care practitioners than from additional drug discoveries or the bland encouragement of therapeutic lifestyle changes.

In December 2006, New York City enacted a law that prohibits the city's 20,000 restaurants from serving food containing more than 500 mg of trans fatty acids (trans fats per serving). The Big Apple is the first large US city to place a dietary restriction of this type on its restaurants on behalf of the well‐being of its residents and visitors. Sustained storage and stability with deep‐frying makes these unsaturated oils a valuable product for the food industry; however, their adverse effects on blood lipids and endothelial function wreak havoc throughout the vascular tree. ⁴ Prospective studies have shown a strong correlation between trans fat ingestion and coronary heart disease. ⁵ A typical American currently ingests a diet containing 5.8 g of trans fat per day. Elimination or significant reduction in trans fat exposure is projected to result in a 19% reduction in cardiovascular events per year. ⁴ While vendors may argue that the cost of a wholesale change to saturated or cis unsaturated oils will be cost prohibitive, a transition from trans fats to healthier cooking oils in Europe has had little financial impact. ⁶ It is unsettling to some, however, that the government should become so involved in mandating what can be served in private establishments. Will there soon be regulations limiting the amount of sour cream that can be put on a baked potato or limiting the calories that a single donut may contain? Perhaps not, but the public discussion of these issues is educational and may motivate some people to adopt a healthier lifestyle—beyond trans fats—at a younger age.

National policy directed at encouraging restriction of trans fats could have an enormous impact on public health. This may occur either with a mandate upheld by law or simply as a massive nutritional education program. Particular attention should be focused on calorie‐dense snack foods, baked goods, and commercially prepared fried foods to maximize the impact. Governmental tax credits and other fiscal incentives may help facilitate transition and offset any initial increased vendor costs associated with food processing, packaging, or equipment purchases needed to implement the change. Widespread adoption of this culinary change has the potential to produce a greater health impact on more people than the release of any one or multiple cardioprotective drugs.

The National School Lunch Program provides billions of dollars each year to fund the nation's largest mass feeding, with more than 27 million schoolchildren receiving meals. Under the program, the federal government also subsidizes agribusiness through the “Commodities Program,” which purchases and distributes millions of dollars worth of meat and dairy products, often laden with saturated fats. While legislation in 2004 attempted to modify this, implementation and enforcement are sorrowfully lacking. ⁷

Food selections and portion sizes are as critical as the deletion of trans fats in school meals. When a 600‐calorie portion of fries (with a total of 30 g of fat and 8 g of trans fat) is added to an already fat‐ and calorie‐laden lunch (approaching 60 total grams of fat and 1000 calories), the true problem lies more in the high‐calorie intake than in the trans fat alone.

Portion control and limiting sodium‐rich, processed, and high‐fat foods would improve the health of our children. Dietary Approaches to Stop Hypertension (DASH)‐guided menus rich in fruits, vegetables, and low‐fat dairy products should be mandated in publicly supported schools. ⁸ These institutions need to set the standard for promoting physical activity and model a diet that youth will adopt as lifelong eating habits. As alternative, non‐subsidized foods and beverages offered by schools allow students to make less than ideal choices, the food industry and schools need the motivation to create and market healthy foods. Public health initiatives may combine directives, incentives, and education to affect change.

As is exemplified by the above simple yet cost‐effective dietary interventions to reduce hypertension and cardiovascular disease, other solutions “outside the box” need to be sought. Older, less expensive, pharmacologic therapies may now have new applications for our “supersized” world. As such, we need to reexamine the forgotten inner contents of that box to find potential answers to these problems, especially in the setting of relatively shrinking health care dollars.

The medical community should embrace generic medication as a means to keep the burgeoning cost of health care down, recognizing that “me too” drugs offer marginal, if any, benefit to overall blood pressure or other cardiovascular risk factor control compared with generics. Analysis of the cost‐savings associated with use of generic drugs was determined in a study published in 2005. ⁹ Overall spending would be reduced by $5.9 billion, an average of $46 per person. For people older than 65 who take more medications, the average savings is $78 per year. Examples of comparative average costs per month between brand name and generic drugs included the following: converting enzyme inhibitors at $55.84 vs $27.75; β‐blockers at $41.39 vs $18.84; and calcium channel blockers $66.06 vs $47.40. ¹⁰ The cost analysis will be even more favorable in the near future as many of these drugs are available for only a $4 monthly copay at many pharmacies. Older, forgotten drugs like chlorthalidone and spironolactone may have new application for hypertensive patients. Chlorthalidone has been demonstrated to be a superior diuretic to hydrochlorothiazide, with equal milligram doses of the former achieving significantly greater reduction in blood pressure compared with hydrochlorothiazide. ¹¹ The use of chlorthalidone was significantly reduced and nearly eliminated in favor of hydrochlorothiazide more than 20 years ago because of more profound hypokalemia and cramping, side effects consistent with its longer‐acting effect, and the high doses that were given. In this era of converting enzyme inhibition and angiotensin receptor blockade, however, diuretic‐induced hypokalemia and its attendant side effects can be offset with the potassium‐elevating effects of the former agents. Use of chlorthalidone can thus provide inexpensive and more effective therapy. Given the magnitude of effect, this diuretic substitution may preclude the need for a third, more expensive antihypertensive agent.

Likewise, spironolactone, an agent that saw little use except in heart failure over the past 20 years, may be used more frequently in treatment of obesity‐related hypertension. Visceral obesity has been associated with increased aldosterone levels, the metabolic syndrome, and associated hypertension. ¹² , ¹³ Indeed, an excess in aldosterone may contribute to resistant hypertension in many patients to an extent greater than indicated by measurement of either plasma or urinary aldosterone levels. ¹⁴ The effectiveness of aldosterone antagonism in obese animals has been demonstrated in recent studies, ¹⁵ and its use in patients with diastolic heart failure is presently under clinical trial.

Efforts by major pharmaceutical firms to develop new drugs to address the ravages of the metabolic syndrome should be applauded. It may be wiser and more effective, however, to invest our resources in developing new strategies to prevent the metabolic syndrome or treat it nonpharmacologically. The recent termination of any further investigation on torcetrapib, a drug touted to increase high‐density lipoprotein while lowering low‐density lipoprotein cholesterol, represented an $800 million loss of investment and serves as an exclamation mark for this point. The drug was shown to demonstrate an “imbalance of mortality and cardiovascular events.”

All elements of society need to identify and participate in finding pathways that will not only have a positive effect on the world's expanding bottoms, but its financial bottom line. Cooperative partnerships between governmental agencies, the insurance industry, medical professionals, and business need to be forged to achieve this end. Most overweight and sedentary patients have been struggling with their weight and ability to exercise their whole lives. Repetitive citation of these problems by a physician is neither an epiphany nor particularly helpful to these individuals. Rather, we must seek to identify what motivates people to adopt healthier lifestyles and follow medical guidance. Then, we must provide them the tools to achieve these goals—but further research is needed to identify effective tools.

The entertainment industry is not exempt in this effort. The new Nintendo Wii is a good example of some new challenges and opportunities. The video game provides players with a workout of more than just their thumbs. The Wii requires players to emulate the physical motions of a given sport. A wireless remote device attached to the competitor's wrist provides an interactive response with the video games of tennis, golf, boxing, or baseball. Many users, however, are apparently playing the games with much more enthusiasm than Nintendo anticipated. Tales of broken TVs and windows, of damaged ceilings and walls, and even of physical injuries to fellow players and innocent bystanders have become commonplace as remotes are launched with unabated velocity by their users. Former “couch potatoes” are getting a workout while playing a computer game, unable to restrain their excitement in participation. While reinforced straps for the remote are now available, a lesson is to be learned here. It's a start. We need to find lost solutions not only within the box, but also outside of it.

Acknowledgment: The authors extend their appreciation to Mary Ann Liebman, MS, BSN, for her editorial assistance.