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mso-paper-source:0;}div.Section3 {page:Section3; mso-endnote-numbering-style:arabic;}-->/style>!--if gte mso 10>style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:Table Normal; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:Times New Roman; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;}/style>!endif-->!--if gte mso 9>xml> o:shapedefaults v:extedit spidmax6146/>/xml>!endif-->!--if gte mso 9>xml> o:shapelayout v:extedit> o:idmap v:extedit data1/> /o:shapelayout>/xml>!endif-->/head>body langEN-US linkblue vlinkpurple styletab-interval:.5in>div classSection1>p classMsoNormal aligncenter styletext-align:center;line-height:200%;tab-stops:.25in 261.0pt>a nameOLE_LINK2>/a>a nameOLE_LINK1>spanstylemso-bookmark:OLE_LINK2>/span>/a>ahrefhttp://www.cuthealthcarecosts.org/ChallengetotheInsuranceIndustry.pdf titleClick for printer friendly PDF of A Solution to Significantly Reduce Health Care Costs>spanstylemso-bookmark:OLE_LINK1>span stylemso-bookmark:OLE_LINK2>bstylemso-bidi-font-weight:normal>Challenge to the Insurance Industry: A Solutionto Significantly Reduce Health Care Costs/b>/span>/span>spanstylemso-bookmark:OLE_LINK1>span stylemso-bookmark:OLE_LINK2>/span>/span>/a>spanstylemso-bookmark:OLE_LINK2>/span>span stylemso-bookmark:OLE_LINK1>/span>bstylemso-bidi-font-weight:normal>o:p>/o:p>/b>/p>p classMsoNormal aligncenter styletext-align:center;line-height:200%;tab-stops:.25in 261.0pt>by Ken Beckman, ASA, ACAS, MAAA, CFA/p>p classMsoNormal styletext-align:justify;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal styletext-align:justify;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>/div>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>br clearall stylepage-break-before:auto;mso-break-type:section-break>/span>div classSection2>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylefont-size:10.0pt>span stylemso-tab-count:1> /span>/span>Acynical point of view would say the insurance industry benefits from highhealth care costs because these rising costs are simply passed on to both individualsand employers in terms of higher premiums and insurers take a fixed percentageof these premiums as increasing profits. As such, insurers have not done asmuch as they could to help reduce heath care costs because lower costs wouldhurt their bottom line. While this author does not share that cynical view, thefact remains that after many sincere (past and ongoing) efforts on the part ofinsurers (both private companies and government entities) health care costshave continued to rise at a rate much greater than that of overall inflation. /p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>But is there a solution that theinsurance industry can help implement that will realistically solve thisapparently intractable problem? What if there was a medication that couldsuccessfully treat and even u>reverse/u> heart disease, type 2 diabetes, highblood pressure and many other chronic conditions without any negative sideeffects and offered the promise of dramatically reduced health care costs.Imagine all the advertising there would be promoting this medication and thelarge price tag likely to go along with it. Then what if you were told thismedication exists today, is available to everyone in unlimited quantities at alow cost, but the vast majority of the American public has never heard aboutit. Confused?/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Before exploring this topic further,a brief review of st1:place w:ston>st1:country-region w:ston>U.S./st1:country-region>/st1:place>health care costs is in order. Total expenditures exceed $2.5 trillion and havegrown from 5% of GDP in 1960 to about 18% of GDP today.a stylemso-endnote-id:edn1 href#_edn1 name_ednref1 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>1/span>!endif>/span>/a>Heart disease remains the most common and costly condition, with over 1,000,000bypass surgeries or angioplasties annually.a stylemso-endnote-id:edn2href#_edn2 name_ednref2 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>2/span>!endif>/span>/a> Nearly half ofindividuals 65 and over are taking prescription drugs for high cholesterol andthe total direct cost of treatments for cardiovascular disease (includinghigh-blood pressure) is approximately $200 billion.a stylemso-endnote-id:edn3 href#_edn3 name_ednref3 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>3/span>!endif>/span>/a>About 45% of the st1:place w:ston>st1:country-region w:ston>U.S./st1:country-region>/st1:place>population was overweight in the early 1960s compared to 75% today, with theproportion of obese individuals up nearly 200% over the same time period.astylemso-endnote-id:edn4 href#_edn4 name_ednref4 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>4/span>!endif>/span>/a> This has contributedto an increase in the incidence of diagnosed diabetes from less than 1% in 1960to nearly 7% in 2010 resulting in annual direct costs of over $175 billion.astylemso-endnote-id:edn5 href#_edn5 name_ednref5 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>5/span>!endif>/span>/a> In total, about 85% ofhealth care spending is for individuals having one or more chronic conditions.astylemso-endnote-id:edn6 href#_edn6 name_ednref6 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>6/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Although the answer to this healthcare cost crisis is not found in any one single medication there is a solutionthat has been proven to rapidly eliminate symptoms, stop the progression, andin many cases even reverse numerous chronic and other conditions. The solutionis to use food as medical treatment. Specifically, the right types of foodwithout calorie limits or complicated diet plans. Studies are released on aregular basis concluding that one food or another is either good or bad forhealth, but rather than relying on a handful of academic studies this approachis based on the many years of both research and real world experiences ofmillions in the U.S. and around the world that demonstrate the benefits ofconsuming a whole food plant-based diet. What does that mean? It simply meanseating foods made from plants with a minimal amount of processing. Someexamples are rice, beans and other legumes, whole-grain products includingpasta and bread, potatoes, fruits, and vegetables. Excluded from the diet areanimal products such as meat, dairy and eggs as well as foods containingartificial ingredients or extracted plant components, such as vegetable oils./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Over the past several decades, therehas been a constant stream of various fad diets so the question arises, how isthis any different? Most importantly, this approach should not be thought of asa diet at all, where short-term changes are made to achieve certain weightgoals, but rather a permanent lifestyle change to optimize health outcomes.While "permanent lifestyle change" may sound drastic, for someoneliving with a chronic health condition who has already experienced a negativeimpact to their lifestyle, a whole food plant-based diet provides a positiveopportunity do much more than just lose a few pounds.spanstylemso-spacerun:yes> /span>It allows the patient to take control overtheir health, which today is often dictated by a battery of pills, many withharmful side effects. A whole food plant-based diet has (1) no limits on caloriesor number of meals per day, (2) no proprietary packaged food, drinks, orformulas to buy, and (3) no specialized exercise equipment or rigorous fitnessregimes. While diets requiring participants to eat less or limit calories leadto food cravings and are unsustainable long-term, a plant-based approachencourages consumption of as much whole plant-based foods as desired, withouttargeting any exact proportion of carbohydrates, fat or protein. In fact,nutrition science researcher and biochemist T. Colin Campbell argues againstprecision, writing "virtually nothing in biology is as precise as we tryto make it seem" and that eating in this way "eliminates the need toworry about the details. Just eat lots of different plant foods; your body willdo the math for you!"a stylemso-endnote-id:edn7 href#_edn7name_ednref7 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>7/span>!endif>/span>/a> While there may be aperception that a plant-based diet consists mainly of salads or vegetables,nothing could be further from the truth. Fruits and vegetables are certainly animportant component of the diet, but these alone do not satisfy most appetites.astylemso-endnote-id:edn8 href#_edn8 name_ednref8 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>8/span>!endif>/span>/a> Many favoritetraditional dishes such as burgers, pizza, sloppy joes, mashed potatoes,lasagna, and burritos can be prepared consistent with and can be at the centerof a whole food plant-based diet./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 1.5in>span stylemso-tab-count:1> /span>Thereare now a small, but growing number of physicians who use a whole foodplant-based diet as a primary form of treatment in their daily practice. Whilethe diet can easily be adopted by anyone without formal guidance fromphysicians or nutritionists, it is helpful to review a few examples from someof the established physician-supervised programs that help individuals withchronic disease understand and implement such a change in diet and lifestyle.Arguably the most prominent of such programs was developed by Dr. Dean Ornish,who for nearly 40 years has treated patients with what has become known as"lifestyle medicine" rather than drugs and surgery. His program iscurrently available at a number of hospitals across the country and consists of18 four hour sessions, where patients are provided instruction on the benefitsand practical implementation of a plant-based diet, along with stress reductiontechniques, moderate exercise, and social support.a stylemso-endnote-id:edn9 href#_edn9 name_ednref9 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>9/span>!endif>/span>/a>Although this may seem like a large commitment, an analysis of nearly 4,000patients enrolled in the program found that the adherence rates exceeded 85%after one year.a stylemso-endnote-id:edn10 href#_edn10 name_ednref10title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>10/span>!endif>/span>/a> Evidence from acontrolled trial showed 99% of patients assigned to the Ornish program hadeither stopped the progression or u>reversed their existing heart disease/u>after five-years and had 2.5 times fewer cardiac events than the control group.astylemso-endnote-id:edn11 href#_edn11 name_ednref11 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>11/span>!endif>/span>/a> A different study ofthose who were eligible for either bypass surgery or angioplasty showedparticipation in the Ornish program saved nearly $30,000 per patient over athree-year period compared to the control group.a stylemso-endnote-id:edn12href#_edn12 name_ednref12 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>12/span>!endif>/span>/a>After review of this and other evidence, the Centers for Medicare and MedicaidServices (CMS) concluded the Ornish program was effective as it spanstylecolor:black>showed "significant regression" or reversal ofcoronary atherosclerosis, reduced the need for bypass or angioplasty and led tosignificant reduction in all of the following cardiac risk factors: (1) LDLcholesterol, (2) triglycerides, (3) Body Mass Index (4) blood pressure, and (5)required medications./span>a stylemso-endnote-id:edn13 href#_edn13name_ednref13 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>13/span>!endif>/span>/a> While the Ornishprogram has been covered by some private insurers for about 20 years, thisdetermination in 2010 made the program eligible for reimbursement for Medicarebeneficiaries with heart conditions meeting certain criteria.astylemso-endnote-id:edn14 href#_edn14 name_ednref14 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>14/span>!endif>/span>/a>b stylemso-bidi-font-weight:normal>o:p>/o:p>/b>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in;mso-layout-grid-align:none;text-autospace:none>span stylemso-tab-count:1> /span>Another program, developed independently of Ornish, foundsimilar results. Dr. Caldwell Esselstyn, a successful surgeon, who by themid-1980s felt the medical professions traditional focus on drugs and surgerywas doing little to prevent disease, began his work with high-risk heartpatients who had been told by their doctors there was little else that could bedone for them. Esselstyn, like Ornish, prescribed a whole food plant-baseddiet, but did not include the other elements such as stress reduction andexercise. Esselstyn has used a single five hour seminar providing instructionon why a plant-based diet is effective, practical implementation advice,recipes, and an actual meal. After the seminar, participants were provided withadditional assistance by phone or email. A study that followed his patients overan average of nearly four years showed that 89% adhered to the program and ofthose 94% showed improvement in symptoms with 22% demonstrating actual reversalof their existing heart condition. Less than 1% of the patients had asubsequent cardiac event after starting the program. Esselstyn observed,"the present cardiovascular medicine approach...can neither cure thedisease nor end the epidemic and is financially unsustainable. The safety,diminished expense, and prompt, powerful, and persistent results in treatingthe cause of vascular disease by whole-food plant-based nutrition offer aparadigm shift from existing practice."a stylemso-endnote-id:edn15href#_edn15 name_ednref15 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>15/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>An additional program was developedby Dr. John McDougall, who began a traditional medical practice in st1:Statew:ston>st1:place w:ston>Hawaii/st1:place>/st1:State>. He treated multiplegenerations of families and noticed many of the older generation who wereoriginally from Asian countries accustomed to a plant-based diet, had very fewof the medical problems that afflicted their children and especially theirgrandchildren who were raised on the standard American diet. Based on thisexperience, he has used a plant-based diet as the primary means of treatmentand has had numerous patients with not only heart disease, but many otherconditions including diabetes, obesity, rheumatoid arthritis, and cancer whoreversed or dramatically improved their condition.a stylemso-endnote-id:edn16 href#_edn16 name_ednref16 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>16/span>!endif>/span>/a>McDougall, among other methods, uses a 10-day program hosted at a hotel whereparticipants receive daily instruction on diet and meal preparation and areprovided unlimited plant-based meals. Opportunities for moderate exercise areavailable, but not required. Of the approximately 1,600 patients participatingin this program from 2002-2011, cholesterol was reduced by 29%, blood pressureby 18%, and triglycerides by 48% in only seven days. About 86% of those takingblood pressure medications and 90% of those taking diabetes medications wereable to reduce or stop them in this short time frame.a stylemso-endnote-id:edn17 href#_edn17 name_ednref17 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>17/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>The intent of highlighting the threeprograms presented here is not to endorse these or any other specific programs,but to illustrate there are various methods that have been successful inreducing health care costs using a whole food plant-based diet. An additionalpurpose is to demonstrate the basic research has been done with clear outcomes andto offer the suggestion it is not productive to spend additional time waitingfor the results of every last study, trial or investigation. As an analogy, thefirst federal government report linking smoking and disease was issued in 1964and even after countless subsequent studies and research, tobacco executivestestified before Congress thirty years later that evidence showing smokingcauses lung cancer and other health conditions was inconclusive.astylemso-endnote-id:edn18 href#_edn18 name_ednref18 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>18/span>!endif>/span>/a> There will always bethose who say more study or evidence is needed, but in this case the goal isnot to prove with clinical certainty which specific foods u>cause/u> certaindiseases, but rather to determine the best way to reduce health care costs andsave individuals and governments from financial ruin. For example, in auto andhomeowners insurance as there is strong correlation between credit scores andloss experience, the scores are widely used in rate classification even thoughno one suggests that adverse loss experience is u>caused/u> by poor creditscores. In this same way, while there is legitimate debate about which foods orother factors may cause disease, there is now overwhelming evidence of a strongcorrelation between a whole food plant-based diet and improved health anddecreased costs, especially among those with chronic disease. As such, it isonly logical to see that all patients with or at risk for a chronic healthcondition are educated about a plant-based diet as a realistic treatment optionas soon as possible. However, in order for such an effort to be successful on alarge scale, it is first necessary to understand, address and solve some of theexisting obstacles to implementation./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>One of the main barriers is simplythe current widespread belief that once someone has a chronic condition, such asheart disease or type 2 diabetes, there is very little that can be done toactually reverse the disease and the best outcome possible is to maintain thecondition so that it does not get any worse. The fact that a whole foodplant-based approach provides a safe, effective, low-cost alternative toeliminate symptoms and potentially reverse the underlying condition withoutdrugs or surgery is unknown to a vast majority of Americans. In contrast to thepharmaceutical industry that spends large sums to market new drugs, the salesof which rightfully compensate investors who provided R&D funding, thereare not big profits in promoting a plant-based diet. Grocery stores will earnessentially the same margin regardless of the type of food consumers buy andnone of the research in this area was funded by investors demanding returns.But even though there are not vast financial resources available for mass mediaadvertising, the inherent advantage of a plant-based diet is it can beeffectively implemented using a one-on-one physician to patient approach thatdoes not require large capital investment, sophisticated technology, andlengthy training. It simply requires physicians to accept the concept, provideit as an option to their patients, and support those patients who are willingto make these changes./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 1.5in>span stylemso-tab-count:1> /span>However,many physicians and other health care providers, even those who may be familiarwith the benefits of whole food plant-based diet, feel that since it differssignificantly from the average American diet it is too extreme or would be aradical change for patients to accept. Esselstyn, who often faced thiscriticism in the course of his practice using a plant-based diet responded,/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in .5in 261.0pt>istylemso-bidi-font-style:normal>But as far as the words “extreme” or “radical,”I would say that change is significant. But the truth is, the nutrition that isextreme or radical is the one that results in 1.2 million coronary stents beingdone per year in this country; 500,000 bypass operations where your entirechest is divided in half, veins are taken off your leg and put in your heart.And they may last several years and at the end of that, you will have to haveanother procedure. Or, maybe it’s a little bit more extreme or radical when youspend $25 billion in statin drugs, $5 billion on stents, an epidemic ofobesity, an epidemic of diabetes, an epidemic of heart disease. This is thediet that’s radical and extreme./i>a stylemso-endnote-id:edn19href#_edn19 name_ednref19 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>19/span>!endif>/span>/a>istylemso-bidi-font-style:normal>o:p>/o:p>/i>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>In terms of receptiveness ofpatients to these changes, the evidence from the programs previously describedsuggest they are more easily accepted than commonly believed, especially aspatients begin to quickly experience improvement in their personal health. Assuch, health care providers and others involved in coordinating and supportingchronic care delivery can be confident in recommending the diet, but must beclear in the way it is presented and the language used. Often, insurers andhealth care providers give their patients non-specific dietary advice such as"eat healthier", "eat more fruits and vegetables" or"consume less fat." This vague language does little to motivatepatients, especially in an environment of confusion caused by numerous studiesthat often seem to provide contradictory information on the benefits of eatinghealthy. An illustrative example is the Women’s Health Initiative (WHI) trialthat involved 48,000 women over an average eight year period. One goal was todetermine the impact on cardiovascular disease as a result of intensivecounseling that advised increasing consumption of fruits and vegetables andreducing the amount of fat in the diet to 20% of calories from the groupscurrent 38% level. In comparison, roughly 10% of calories from fat resultsnaturally for those following a varied whole food plant-based diet. The WHI trialshowed the group receiving dietary counseling increased their intake of fruitsand vegetables and reduced their level of fat to about 29% of calories, butwere significantly short of the 20% goal of the study. The study found therewere no significant differences in the incidence of cardiovascular diseasebetween the group that received dietary counseling and the control group thatdid not, leading to headlines declaring there are no benefits from eatinghealthy.a stylemso-endnote-id:edn20 href#_edn20 name_ednref20 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>20/span>!endif>/span>/a> This is just one ofmany studies that confuses the public and offers little motivation to changeexisting dietary patterns, demonstrating it is not sufficient to advise eating"more fruits and vegetables" to facilitate disease prevention andreversal. It requires clear direction from physicians and other health careproviders that the goal is not really to "eat healthier" but to offera specific, achievable, comprehensive solution that allows patients to feelbetter, have more energy, reduce or eliminate medications and ultimately regaincontrol over their health.span stylemso-tab-count:1> /span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Health care providers can best dothis by providing examples of actual patients who reversed their chronic healthconditions or were able to reduce or eliminate their use of prescription drugs.Sharing real life examples and explaining in simple terms why these lifestylechanges achieved such remarkable results is a powerful message to patients,many of whom have been told they must be on multiple medications for the restof their lives. One significant step in this direction was a 2013 article byphysicians from Kaiser Permanente that reviewed the evidence and concluded"physicians should consider recommending a plant-based diet to all theirpatients, especially those with high blood pressure, diabetes, cardiovasculardisease, or obesity."a stylemso-endnote-id:edn21 href#_edn21name_ednref21 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>21/span>!endif>/span>/a> Kaiser has followedup with user friendly guides (freely available online) for both physicians andpatients explaining the benefits and practical aspects of implementing aplant-based diet.a stylemso-endnote-id:edn22 href#_edn22 name_ednref22title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>22/span>!endif>/span>/a> Ideally, each patientfacing a bypass surgery, new medications, or a lifetime of insulin shots wouldbe presented with the benefits and risks of both traditional methods and theplant-based diet treatment approach. Even if only a minority of patients wouldselect the plant-based approach, a significant reduction in health care costscould be realized just by offering it as a legitimate option. While there willalways be those who just want to take a handful of pills rather than makelifestyle changes, st1:City w:ston>st1:place w:ston>Campbell/st1:place>/st1:City>advises we: /p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>istylemso-bidi-font-style:normal>should not be ignoring ideas just because weperceive that the public does not want to hear them. Consumers have theultimate choice of whether to integrate our findings into their lifestyles, butwe owe it to them to give them the best information possible with which to makethat decision and not decide for them./i> a stylemso-endnote-id:edn23href#_edn23 name_ednref23 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>23/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Although Kaisers integrated careand payment model is not entirely applicable to more traditional insurers andproviders, it does highlight the fact that the issue of provider payment is thefinal and arguably most important hurdle that must be addressed in making sureevery patient has an opportunity for treatment using the plant-based approach.Ornish observed in his work that there was no "shortage of motivatedpatients" that were receptive to lifestyle changes as an alternative todrugs or surgery but rather "the primary limiting factor has been the lackof widespread insurance coverage."a stylemso-endnote-id:edn24href#_edn24 name_ednref24 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>24/span>!endif>/span>/a>He concluded, "no matter how good a program is clinically, if its notreimbursable, its not sustainable."a stylemso-endnote-id:edn25href#_edn25 name_ednref25 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>25/span>!endif>/span>/a>While physicians such as Ornish have identified this important barrier tomaking lifestyle medicine a more common practice over more traditionalapproaches, even comic strip writers have observed the sometimes painful truthabout the current system. (See i stylemso-bidi-font-style:normal>ahrefhttp://ornishspectrum.com/wp-content/uploads/wizard-of-id.jpg>http://ornishspectrum.com/wp-content/uploads/wizard-of-id.jpg/a>/i>and i stylemso-bidi-font-style:normal>ahrefhttp://www.gocomics.com/nonsequitur/2014/11/19>http://www.gocomics.com/nonsequitur/2014/11/19/a>/i>)/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>istylemso-bidi-font-style:normal>o:p> /o:p>/i>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>While Medicare and some private insurersreimburse the Ornish and another similar program, it often is limited to heartpatients meeting strict criteria. There are still no direct financialincentives for physicians to educate the millions of patients not eligible forthese programs about the benefits of a plant-based diet.spanstylemso-spacerun:yes> /span>However, in recent years there has been amovement toward the use of incentives in value-based provider payment models,including efforts by CMS and private insurers to develop innovative payment andservice models, such as Accountable Care Organizations (ACOs). While these areworthwhile programs and should be continued, often their stated goal, as withACOs is "span langEN stylemso-ansi-language:EN>to help slow thegrowth of health care costs."/span>a stylemso-endnote-id:edn26href#_edn26 name_ednref26 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>26/span>!endif>/span>/a>spanlangEN stylemso-ansi-language:EN> However, even if these /span>effortscould reduce the growth in health spending to the level of overall economicgrowth, it still leaves an unacceptably high 18% of GDP consumed by health carecosts. As such, incentives should primarily be focused on methods that willactually u>reduce/u> total health care costs instead of just slowing growth. spanlangEN stylemso-ansi-language:EN>Since/span> 85% of health care spendingis due to chronic conditions, many of which are attributable to poor foodchoices, even the most optimized payment and service models are unlikely toreduce health care costs unless a specific and effective dietary component isemployed. With the proper financial incentives, a plant-based treatmentapproach can be widely incorporated into both traditional fee for service aswell as value-based payment models./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>There are numerous ways to structureprovider incentives, but two key principles for any large scale implementationof a plant-based diet to treat chronic and other conditions are (1) incentivesthat work with existing provider payment structures and (2) opportunities foradditional income for physicians, without requiring capital expenditures ontheir part. One possible implementation, consistent with these principles, isfor insurers, both public and private, to first provide educational materialabout the benefits of a whole food plant-based diet directly to their insuredmembers. Much in the same way prescription drugs are advertised today as"Ask your doctor if drug XYZ is right for you" insureds would beprompted to ask their physician about the ability of plant-based diet to reduceor eliminate prescription drug use and reverse disease. Of course thesematerials would also have to list all side effects such as increased energy,lower blood pressure, and improved digestion, all while eating unlimitedquantities of satisfying food. Physicians would receive a per capita fee fromthe insurer for each patient that is "prescribed" a plant-based diettreatment approach. In addition, physicians could be eligible for additionalcompensation based on certain health outcomes of the patients that choose thisoption.span stylemso-spacerun:yes> /span>Both of these financialincentives for physicians would not replace their existing fee for service orvalue-based payment contracts, but would be above and beyond those amounts. Theplant-based "prescription" would be "filled" by the patientattending an educational seminar such as the Esselstyn model previouslydescribed. While this is only one possible approach, it shows that without alarge capital investment, an intensive one-day seminar, focused solely on dietand providing participants a clear, practical and motivating demonstration canbe highly effective. While these seminars would be the financial responsibilityof the insurer, rather than the physician or patient, they could likely bedeveloped more quickly and cost effectively by independent third-partiesserving all insurers. To encourage highly effective seminars, insurers couldalso compensate seminar providers using incentive payments based on patienthealth outcomes./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>While the political fires of theAffordable Care Act are still smoldering, its cornerstone in providing accessto insurance regardless of pre-existing conditions will almost certainlyremain. Even though the access problem has been solved the challenge ofaffordability persists and with the wave of baby boomers entering the primeyears for complications from heart disease, diabetes, obesity, high bloodpressure and many other chronic conditions a financial tsunami is approaching.The time is near where even with employer or government subsidies, the cost ofhealth insurance will be out of reach for middle-income Americans, which islikely to cause the entire insurance system to collapse. When insurerscalculate premium rates that accurately reflect existing health care costs itserves an important need, but is insufficient to guarantee the long-termviability of the insurance system. Insurers--whether that be private commercialcarriers or public entities like Medicare or Medicaid--have an obligation tosociety to develop financially stable insurance systems for the long-term. Infact, actuaries, who are responsible for the calculation of health insurancepremium rates are bound by a Professional Code of Conduct that requires them to"act...in a manner to fulfill the profession’s responsibility to thepublic" and places that responsibility ahead of any they may have to anemployer or industry.a stylemso-endnote-id:edn27 href#_edn27name_ednref27 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>27/span>!endif>/span>/a> /p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Often professionals, whether it beactuaries, economists, physicians, or any number of others that are working toreduce the growth of health care costs feel that sophisticated mathematical andfinancial models or the latest medical technology and drugs are the only way tosolve large problems such as this. However, in this instance, it can be moreuseful and effective to take a simpler approach even if traditional educationand training may suggest a more complex intervention. The evidence isoverwhelming that a whole food plant-based diet provides the best opportunityto not only reduce the growth in spending, but actually decrease total healthcare costs more than any drug, medical procedure, insurance reform, or providerpayment model could hope to. The insurance industry faces a tremendouschallenge and responsibility in helping society solve this ever mountingproblem, but the solution is clear and delaying implementation should beavoided. By developing financially sound incentives that support and motivate acritical mass of health care providers to integrate this proven approach intotheir daily practice as a routine treatment option made available to allpatients and especially those with chronic conditions, the health care costcrisis can be solved./p>/div>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>br clearall stylepage-break-before:auto;mso-break-type:section-break>/span>div classSection3>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>________________________________________________________________________________________________________________________________________________________o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>i stylemso-bidi-font-style:normal>spanstylefont-size:10.0pt>Ken Beckman, ACAS, ASA, MAAA, CFA is an actuary withmore than 20 years of experience in the insurance industry. The informationpresented in this paper is neither a statement of actuarial opinion nor anactuarial communication and tem>span stylecolor:black;mso-bidi-font-weight:bold>he opinions expressed are the authors own and do not reflect the viewsof his employer/span>/em>/span>/i>em>span stylefont-size:10.0pt;color:black;mso-bidi-font-weight:bold;font-style:normal;mso-bidi-font-style:italic>. /span>/em>i stylemso-bidi-font-style:normal>spanstylefont-size:10.0pt>It is provided for the consideration of the insuranceand other industries involved in health care costs and should not be reliedupon as providing medical, nutritional, financial, actuarial or otherprofessional services or guidance.o:p>/o:p>/span>/i>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>Forcomments send an email to: a hrefmailto:contact@cuthealthcarecosts.org>contact@cuthealthcarecosts.org/a>o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>b stylemso-bidi-font-weight:normal>ahrefhttp://www.cuthealthcarecosts.org/ChallengetotheInsuranceIndustry.pdf titleClick for PDF of A Solution to Significantly Reduce Health Care Costs>Click here for a PDF of this paper./a>/b>span stylefont-size:10.0pt>o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal styletext-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-left:1.0in;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-left:1.0in;text-align:justify;mso-pagination:none;tab-stops:1.0in>span stylefont-size:10.0pt>Referenceso:p>/o:p>/span>/p>/div>div stylemso-element:endnote-list>!if !supportEndnotes>br clearall>hr alignleft size1 width33%>!endif>div stylemso-element:endnote idedn1>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn1 href#_ednref1 name_edn1 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>1/span>/span>!endif>/span>/span>/a> st1:PlaceNamew:ston>span stylecolor:black>National/span>/st1:PlaceName>spanstylecolor:black> st1:PlaceType w:ston>Center/st1:PlaceType> for HealthStatistics, st1:place w:ston>st1:City w:ston>i stylemso-bidi-font-style: normal>Health/i>/st1:City>i stylemso-bidi-font-style:normal>, st1:country-region w:ston>United States/st1:country-region>/i>/st1:place>istylemso-bidi-font-style:normal>, 2015/i>. 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(st1:place w:ston>st1:City w:ston>Hyattsville/st1:City>, st1:State w:ston>MD./st1:State>/st1:place>:GPO, 2016),/span> 275./p>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>span stylefont-size:10.0pt>spanstylemso-spacerun:yes> /span>Dariush Mozaffarian et. al., "Heartdisease and Stroke Statistics—2015 Update: A Report From the American Heart Association,"i>Circulation /i>span stylemso-bidi-font-style:italic>131 (/span>2015):espan stylemso-bidi-font-weight:bold>283. /span>o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn4>p classDefault stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>a stylemso-endnote-id:edn4 href#_ednref4 name_edn4 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;color:black;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>4/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> span stylemso-bidi-font-style:italic>Cheryl D.Fryar, Margaret D. 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Ogden, /span>i stylemso-bidi-font-style:normal>Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults:United States, 1960–1962 Through 2011–2012/i>, st1:place w:ston>st1:PlaceName w:ston>National/st1:PlaceName> st1:PlaceType w:ston>Center/st1:PlaceType>/st1:place>for Health Statistics, (September 2014)./span>/p>/div>div stylemso-element:endnote idedn5>p classDefault stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>a stylemso-endnote-id:edn5 href#_ednref5 name_edn5 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;color:black;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>5/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> Centers for Disease Control Division of DiabetesTranslation, i stylemso-bidi-font-style:normal>span stylemso-bidi-font-weight:bold>Long-Term Trends in Diagnosed Diabetes,/span>/i>span stylemso-bidi-font-weight:bold> /span>span stylemso-spacerun:yes> /span>(October 2011).o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>span stylefont-size:10.0pt>Wenya Yang, et. al," Economic Costs of Diabetes in the st1:place w:ston>st1:country-region w:ston>U.S./st1:country-region>/st1:place> in 2012," istylemso-bidi-font-style:normal>Diabetes Care /i>(2013). o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn6>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn6 href#_ednref6 name_edn6 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>6/span>/span>!endif>/span>/span>/a>"Chronic Disease Overview," Centers for Disease Control, accessedJuly 2, 2016, span stylecolor:black>ahrefhttp://www.cdc.gov/chronicdisease/overview/index.htm>http://www.cdc.gov/chronicdisease/overview/index.htm/a>./span>/p>/div>div stylemso-element:endnote idedn7>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn7 href#_ednref7 name_edn7 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>7/span>/span>!endif>/span>/span>/a> T.Colin Campbell, span classa-size-large1>i stylemso-bidi-font-style:normal>spanstylefont-family:Times New Roman;color:#111111>Whole: Rethinking theScience of Nutrition/span>/i>/span>, (st1:place w:ston>st1:City w:ston>Dallas/st1:City>/st1:place>:BenBella Books, Inc., 2013), 11./p>/div>div stylemso-element:endnote idedn8>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn8 href#_ednref8 name_edn8 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>8/span>/span>!endif>/span>/span>/a>John A. 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McDougall uses the term starches to describe the whole grains, legumes,and starchy vegetables (e.g. potatoes) that provide a feeling of fullness alongwith the necessary energy, while pointing out that a diet overly focused onfruits or non-starchy vegetables, while very healthy, does not providesufficient calories and may lead to filling up on unhealthy foods tocompensate./p>/div>div stylemso-element:endnote idedn9>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn9href#_ednref9 name_edn9 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>9/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> "Dr. Dean Ornish Program for Reversing HeartDisease," Ornish Lifestyle Medicine, accessed July 2, 2016, ahrefhttps://www.ornish.com/wp-content/uploads/FAQ_Ornish_Program_8.19.14.pdf>https://www.ornish.com/wp-content/uploads/FAQ_Ornish_Program_8.19.14.pdf/a>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn10>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn10 href#_ednref10 name_edn10 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>10/span>/span>!endif>/span>/span>/a>"Evidence Based Medicine Redefining the Standard of Care in Coronary HeartDisease," The Dr. Dean Ornish Program for Reversing Heart Diseasesup>TM/sup>,accessed July 2, 2016,a nameOLE_LINK8>/a>a nameOLE_LINK9>/a>anameOLE_LINK10>span stylemso-bookmark:OLE_LINK9>span stylemso-bookmark:OLE_LINK8> /span>/span>/a>ahrefhttp://rehab.ucla.edu/workfiles/Dean%20Ornish/Ornish/ScienceBehindProgram.pdf>spanstylemso-bookmark:OLE_LINK10>span stylemso-bookmark:OLE_LINK9>spanstylemso-bookmark:OLE_LINK8>http://rehab.ucla.edu/workfiles/Dean%20Ornish/Ornish/ScienceBehindProgram.pdf/span>/span>/span>spanstylemso-bookmark:OLE_LINK10>span stylemso-bookmark:OLE_LINK9>spanstylemso-bookmark:OLE_LINK8>/span>/span>/span>/a>span stylemso-bookmark:OLE_LINK10>span stylemso-bookmark:OLE_LINK9>span stylemso-bookmark:OLE_LINK8>./span>/span>/span>/p>/div>div stylemso-element:endnote idedn11>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn11 href#_ednref11 name_edn11 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>11/span>/span>!endif>/span>/span>/a>K. Lance Gould, Dean Ornish et al., "Changes in Myocardial PerfusionAbnormalities by Positron Emission Tomography After Long-term, Intense RiskFactor Modification,"i stylemso-bidi-font-style:normal> JAMA/i>274 (September 20, 1995): 894-901span classreftext>span stylecolor:#333333>./span>/span>istylemso-bidi-font-style:normal>o:p>/o:p>/i>/p>/div>div stylemso-element:endnote idedn12>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn12 href#_ednref12 name_edn12 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>12/span>/span>!endif>/span>/span>/a>Dean Ornish, "Avoiding Revascularization with Lifestyle Changes: TheMulticenter Lifestyle Demonstration Project", i stylemso-bidi-font-style:normal>American Journal of Cardiology/i> 82 (1998):72T-76T./p>/div>div stylemso-element:endnote idedn13>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn13 href#_ednref13name_edn13 title>span classMsoEndnoteReference>span stylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>13/span>/span>!endif>/span>/span>/span>/a>"span stylefont-size:10.0pt>Decision Memo for Intensive CardiacRehabilitation (ICR) Program - Dr. Ornishs Program for Reversing Heart Disease(CAG-00419N)," August 12, 2010, Centers for Medicare & MedicaidServices, accessed July 2, 2016, a hrefhttp://www.cms.gov/>http://www.cms.gov//a>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn14>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn14 href#_ednref14 name_edn14 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>14/span>/span>!endif>/span>/span>/a>Amy Lynn Sorrel, "Medicares new approach to familiar diseases," istylemso-bidi-font-style:normal>American Medical News/i>, (May 14, 2012), ahrefhttp://www.amednews.com/article/20120514/government/305149956/4/>http://www.amednews.com/article/20120514/government/305149956/4//a>./p>/div>div stylemso-element:endnote idedn15>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn15 href#_ednref15 name_edn15 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>15/span>/span>!endif>/span>/span>/a>Caldwell B. Esselstyn Jr. et al., "A way to reverse CAD?" istylemso-bidi-font-style:normal>The Journal of Family Practice/i> 63 (July2014)./p>/div>div stylemso-element:endnote idedn16>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn16href#_ednref16 name_edn16 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>16/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt>"Success Stories," Dr. McDougalls st1:placew:ston>st1:PlaceName w:ston>Health & Medical/st1:PlaceName> st1:PlaceType w:ston>Center/st1:PlaceType>/st1:place>, accessed July 2, 2016, ahrefhttps://www.drmcdougall.com/health/education/health-science/stars/>https://www.drmcdougall.com/health/education/health-science/stars//a>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn17>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn17 href#_ednref17name_edn17 title>span classMsoEndnoteReference>span stylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>17/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> John McDougall et al., "Effects of 7 days on anad libitum low-fat vegan diet: the McDougall Program cohort," istylemso-bidi-font-style:normal>Nutrition Journal/i> 13 (2014).o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn18>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn18 href#_ednref18 name_edn18 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>18/span>/span>!endif>/span>/span>/a>Philip J. 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"span langEN stylemso-ansi-language:EN;mso-bidi-font-weight:bold>Tobacco Chiefs Say Cigarettes Arent Addictive," istylemso-bidi-font-style:normal>New York Times/i>, April 15, 1994, accessedJuly 2, 2016,/span>span langEN stylemso-ansi-language:EN> /span>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>a nameOLE_LINK5>/a>anameOLE_LINK6>/a>a nameOLE_LINK7>span stylemso-bookmark:OLE_LINK6>spanstylemso-bookmark:OLE_LINK5>/span>/span>/a>ahrefhttp://www.nytimes.com/1994/04/15/us/tobacco-chiefs-say-cigarettes-aren-t-addictive.html>spanstylemso-bookmark:OLE_LINK7>span stylemso-bookmark:OLE_LINK6>spanstylemso-bookmark:OLE_LINK5>http://www.nytimes.com/1994/04/15/us/tobacco-chiefs-say-cigarettes-aren-t-addictive.html/span>/span>/span>spanstylemso-bookmark:OLE_LINK7>span stylemso-bookmark:OLE_LINK6>spanstylemso-bookmark:OLE_LINK5>/span>/span>/span>/a>span stylemso-bookmark:OLE_LINK5>/span>span stylemso-bookmark:OLE_LINK6>/span>spanstylemso-bookmark:OLE_LINK7>/span>./p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>"Reflectingon 50 Years of Progress," U.S. Department of Health & Human Services,accessed July 2, 2016, ahrefhttp://www.surgeongeneral.gov/priorities/tobacco/>http://www.surgeongeneral.gov/priorities/tobacco//a>./p>/div>div stylemso-element:endnote idedn19>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in>astylemso-endnote-id:edn19 href#_ednref19 name_edn19 title>spanclassMsoEndnoteReference>span stylefont-size:10.0pt>spanstylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>19/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> Mark Huberman, "Best. 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AnInterview with Caldwell Esselstyn, Jr. M.D.," Healthy Girls Kitchen,accessed July 2, 2016, o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in>anameOLE_LINK3>/a>a nameOLE_LINK4>span stylemso-bookmark:OLE_LINK3>/span>/a>ahrefhttp://www.healthygirlskitchen.com/2012/03/best-interview-ever-interview-with.html>spanstylemso-bookmark:OLE_LINK4>span stylemso-bookmark:OLE_LINK3>spanstylefont-size:10.0pt>http://www.healthygirlskitchen.com/2012/03/best-interview-ever-interview-with.html/span>/span>/span>spanstylemso-bookmark:OLE_LINK4>span stylemso-bookmark:OLE_LINK3>/span>/span>/a>spanstylemso-bookmark:OLE_LINK3>/span>span stylemso-bookmark:OLE_LINK4>/span>spanstylefont-size:10.0pt>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn20>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn20 href#_ednref20 name_edn20 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>20/span>/span>!endif>/span>/span>/a>Barbara V. Howard et al., "Low-Fat Dietary Pattern and Risk of CardiovascularDisease: The Womens Health Initiative Randomized Controlled DietaryModification Trial," i stylemso-bidi-font-style:normal>JAMA /i>295(February 8, 2006)./p>/div>div stylemso-element:endnote idedn21>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn21 href#_ednref21 name_edn21 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>21/span>/span>!endif>/span>/span>/a> spanstylemso-bidi-font-weight:bold>Philip J. Tuso et al., "/span>NutritionalUpdate for Physicians: Plant-Based Diets," i stylemso-bidi-font-style:normal>Permanente Journal/i> 17 (Spring 2013): 61-66./p>/div>div stylemso-element:endnote idedn22>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn22 href#_ednref22 name_edn22 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>22/span>/span>!endif>/span>/span>/a>"The Plant-Based Diet: st1:Street w:ston>st1:address w:ston>A Healthier Way/st1:address>/st1:Street> to Eat," Kaiser Permanente,accessed July 2, 2016, ahrefhttps://share.kaiserpermanente.org/wp-content/uploads/2015/10/The-Plant-Based-Diet-booklet.pdf>https://share.kaiserpermanente.org/wp-content/uploads/2015/10/The-Plant-Based-Diet-booklet.pdf/a>./p>/div>div stylemso-element:endnote idedn23>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn23 href#_ednref23 name_edn23 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>23/span>/span>!endif>/span>/span>/a>T. Colin Campbell and Thomas M. Campbell, i stylemso-bidi-font-style:normal>Thest1:country-region w:ston>China/st1:country-region> Study: The MostComprehensive Study of Nutrition Ever Conducted and the Startling Implicationsfor Diet, Weight Loss and Long-term Health/i>, (st1:City w:ston>st1:place w:ston>Dallas/st1:place>/st1:City>: BenBella Books, Inc., 2004), 287./p>/div>div stylemso-element:endnote idedn24>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn24 href#_ednref24 name_edn24 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>24/span>/span>!endif>/span>/span>/a>Dean Ornish, "Avoiding Revascularization with Lifestyle Changes: TheMulticenter Lifestyle Demonstration Project," i stylemso-bidi-font-style:normal>American Journal of Cardiology /i>82 (1998): 75T./p>/div>div stylemso-element:endnote idedn25>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn25 href#_ednref25 name_edn25 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>25/span>/span>!endif>/span>/span>/a>Sorrel, 2012./p>/div>div stylemso-element:endnote idedn26>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn26 href#_ednref26 name_edn26 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>26/span>/span>!endif>/span>/span>/a>Robert Tagalicod, "span langEN stylemso-ansi-language:EN>AccountableCare Organizations: The Future of Coordinated Care,"/span> Centers forMedicare & Medicaid Services, accessed July 2, 2016,/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>span langENstylemso-ansi-language:EN>ahrefhttps://www.cms.gov/eHealth/ListServ_AccoutableCareOrgs.html>htspanlangEN-US stylemso-ansi-language:EN-US>tps://www.cms.gov/eHealth/ListServ_AccoutableCareOrgs.html/span>/a>/span>./p>/div>div stylemso-element:endnote idedn27>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn27 href#_ednref27 name_edn27 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>27/span>/span>!endif>/span>/span>/a>Code of Professional Conduct, Precept 1, st1:place w:ston>st1:PlaceName w:ston>American/st1:PlaceName> st1:PlaceType w:ston>Academy/st1:PlaceType>/st1:place>of Actuaries./p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>Published July2016./p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>bstylemso-bidi-font-weight:normal>span stylefont-size:12.0pt>ahrefhttp://www.cuthealthcarecosts.org/plantbaseddietresources.html>Clickhere for further resources about a whole food plant-based diet and its ability to reverse chronic disease and improve health./a>o:p>/o:p>/span>/b>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>/div>/div>/body>/html>
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mso-paper-source:0;}div.Section3 {page:Section3; mso-endnote-numbering-style:arabic;}-->/style>!--if gte mso 10>style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:Table Normal; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:Times New Roman; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;}/style>!endif-->!--if gte mso 9>xml> o:shapedefaults v:extedit spidmax6146/>/xml>!endif-->!--if gte mso 9>xml> o:shapelayout v:extedit> o:idmap v:extedit data1/> /o:shapelayout>/xml>!endif-->/head>body langEN-US linkblue vlinkpurple styletab-interval:.5in>div classSection1>p classMsoNormal aligncenter styletext-align:center;line-height:200%;tab-stops:.25in 261.0pt>a nameOLE_LINK2>/a>a nameOLE_LINK1>spanstylemso-bookmark:OLE_LINK2>/span>/a>ahrefhttp://www.cuthealthcarecosts.org/ChallengetotheInsuranceIndustry.pdf titleClick for printer friendly PDF of A Solution to Significantly Reduce Health Care Costs>spanstylemso-bookmark:OLE_LINK1>span stylemso-bookmark:OLE_LINK2>bstylemso-bidi-font-weight:normal>Challenge to the Insurance Industry: A Solutionto Significantly Reduce Health Care Costs/b>/span>/span>spanstylemso-bookmark:OLE_LINK1>span stylemso-bookmark:OLE_LINK2>/span>/span>/a>spanstylemso-bookmark:OLE_LINK2>/span>span stylemso-bookmark:OLE_LINK1>/span>bstylemso-bidi-font-weight:normal>o:p>/o:p>/b>/p>p classMsoNormal aligncenter styletext-align:center;line-height:200%;tab-stops:.25in 261.0pt>by Ken Beckman, ASA, ACAS, MAAA, CFA/p>p classMsoNormal styletext-align:justify;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal styletext-align:justify;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>/div>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>br clearall stylepage-break-before:auto;mso-break-type:section-break>/span>div classSection2>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylefont-size:10.0pt>span stylemso-tab-count:1> /span>/span>Acynical point of view would say the insurance industry benefits from highhealth care costs because these rising costs are simply passed on to both individualsand employers in terms of higher premiums and insurers take a fixed percentageof these premiums as increasing profits. As such, insurers have not done asmuch as they could to help reduce heath care costs because lower costs wouldhurt their bottom line. While this author does not share that cynical view, thefact remains that after many sincere (past and ongoing) efforts on the part ofinsurers (both private companies and government entities) health care costshave continued to rise at a rate much greater than that of overall inflation. /p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>But is there a solution that theinsurance industry can help implement that will realistically solve thisapparently intractable problem? What if there was a medication that couldsuccessfully treat and even u>reverse/u> heart disease, type 2 diabetes, highblood pressure and many other chronic conditions without any negative sideeffects and offered the promise of dramatically reduced health care costs.Imagine all the advertising there would be promoting this medication and thelarge price tag likely to go along with it. Then what if you were told thismedication exists today, is available to everyone in unlimited quantities at alow cost, but the vast majority of the American public has never heard aboutit. Confused?/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Before exploring this topic further,a brief review of st1:place w:ston>st1:country-region w:ston>U.S./st1:country-region>/st1:place>health care costs is in order. Total expenditures exceed $2.5 trillion and havegrown from 5% of GDP in 1960 to about 18% of GDP today.a stylemso-endnote-id:edn1 href#_edn1 name_ednref1 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>1/span>!endif>/span>/a>Heart disease remains the most common and costly condition, with over 1,000,000bypass surgeries or angioplasties annually.a stylemso-endnote-id:edn2href#_edn2 name_ednref2 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>2/span>!endif>/span>/a> Nearly half ofindividuals 65 and over are taking prescription drugs for high cholesterol andthe total direct cost of treatments for cardiovascular disease (includinghigh-blood pressure) is approximately $200 billion.a stylemso-endnote-id:edn3 href#_edn3 name_ednref3 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>3/span>!endif>/span>/a>About 45% of the st1:place w:ston>st1:country-region w:ston>U.S./st1:country-region>/st1:place>population was overweight in the early 1960s compared to 75% today, with theproportion of obese individuals up nearly 200% over the same time period.astylemso-endnote-id:edn4 href#_edn4 name_ednref4 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>4/span>!endif>/span>/a> This has contributedto an increase in the incidence of diagnosed diabetes from less than 1% in 1960to nearly 7% in 2010 resulting in annual direct costs of over $175 billion.astylemso-endnote-id:edn5 href#_edn5 name_ednref5 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>5/span>!endif>/span>/a> In total, about 85% ofhealth care spending is for individuals having one or more chronic conditions.astylemso-endnote-id:edn6 href#_edn6 name_ednref6 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>6/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Although the answer to this healthcare cost crisis is not found in any one single medication there is a solutionthat has been proven to rapidly eliminate symptoms, stop the progression, andin many cases even reverse numerous chronic and other conditions. The solutionis to use food as medical treatment. Specifically, the right types of foodwithout calorie limits or complicated diet plans. Studies are released on aregular basis concluding that one food or another is either good or bad forhealth, but rather than relying on a handful of academic studies this approachis based on the many years of both research and real world experiences ofmillions in the U.S. and around the world that demonstrate the benefits ofconsuming a whole food plant-based diet. What does that mean? It simply meanseating foods made from plants with a minimal amount of processing. Someexamples are rice, beans and other legumes, whole-grain products includingpasta and bread, potatoes, fruits, and vegetables. Excluded from the diet areanimal products such as meat, dairy and eggs as well as foods containingartificial ingredients or extracted plant components, such as vegetable oils./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Over the past several decades, therehas been a constant stream of various fad diets so the question arises, how isthis any different? Most importantly, this approach should not be thought of asa diet at all, where short-term changes are made to achieve certain weightgoals, but rather a permanent lifestyle change to optimize health outcomes.While "permanent lifestyle change" may sound drastic, for someoneliving with a chronic health condition who has already experienced a negativeimpact to their lifestyle, a whole food plant-based diet provides a positiveopportunity do much more than just lose a few pounds.spanstylemso-spacerun:yes> /span>It allows the patient to take control overtheir health, which today is often dictated by a battery of pills, many withharmful side effects. A whole food plant-based diet has (1) no limits on caloriesor number of meals per day, (2) no proprietary packaged food, drinks, orformulas to buy, and (3) no specialized exercise equipment or rigorous fitnessregimes. While diets requiring participants to eat less or limit calories leadto food cravings and are unsustainable long-term, a plant-based approachencourages consumption of as much whole plant-based foods as desired, withouttargeting any exact proportion of carbohydrates, fat or protein. In fact,nutrition science researcher and biochemist T. Colin Campbell argues againstprecision, writing "virtually nothing in biology is as precise as we tryto make it seem" and that eating in this way "eliminates the need toworry about the details. Just eat lots of different plant foods; your body willdo the math for you!"a stylemso-endnote-id:edn7 href#_edn7name_ednref7 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>7/span>!endif>/span>/a> While there may be aperception that a plant-based diet consists mainly of salads or vegetables,nothing could be further from the truth. Fruits and vegetables are certainly animportant component of the diet, but these alone do not satisfy most appetites.astylemso-endnote-id:edn8 href#_edn8 name_ednref8 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>8/span>!endif>/span>/a> Many favoritetraditional dishes such as burgers, pizza, sloppy joes, mashed potatoes,lasagna, and burritos can be prepared consistent with and can be at the centerof a whole food plant-based diet./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 1.5in>span stylemso-tab-count:1> /span>Thereare now a small, but growing number of physicians who use a whole foodplant-based diet as a primary form of treatment in their daily practice. Whilethe diet can easily be adopted by anyone without formal guidance fromphysicians or nutritionists, it is helpful to review a few examples from someof the established physician-supervised programs that help individuals withchronic disease understand and implement such a change in diet and lifestyle.Arguably the most prominent of such programs was developed by Dr. Dean Ornish,who for nearly 40 years has treated patients with what has become known as"lifestyle medicine" rather than drugs and surgery. His program iscurrently available at a number of hospitals across the country and consists of18 four hour sessions, where patients are provided instruction on the benefitsand practical implementation of a plant-based diet, along with stress reductiontechniques, moderate exercise, and social support.a stylemso-endnote-id:edn9 href#_edn9 name_ednref9 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>9/span>!endif>/span>/a>Although this may seem like a large commitment, an analysis of nearly 4,000patients enrolled in the program found that the adherence rates exceeded 85%after one year.a stylemso-endnote-id:edn10 href#_edn10 name_ednref10title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>10/span>!endif>/span>/a> Evidence from acontrolled trial showed 99% of patients assigned to the Ornish program hadeither stopped the progression or u>reversed their existing heart disease/u>after five-years and had 2.5 times fewer cardiac events than the control group.astylemso-endnote-id:edn11 href#_edn11 name_ednref11 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>11/span>!endif>/span>/a> A different study ofthose who were eligible for either bypass surgery or angioplasty showedparticipation in the Ornish program saved nearly $30,000 per patient over athree-year period compared to the control group.a stylemso-endnote-id:edn12href#_edn12 name_ednref12 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>12/span>!endif>/span>/a>After review of this and other evidence, the Centers for Medicare and MedicaidServices (CMS) concluded the Ornish program was effective as it spanstylecolor:black>showed "significant regression" or reversal ofcoronary atherosclerosis, reduced the need for bypass or angioplasty and led tosignificant reduction in all of the following cardiac risk factors: (1) LDLcholesterol, (2) triglycerides, (3) Body Mass Index (4) blood pressure, and (5)required medications./span>a stylemso-endnote-id:edn13 href#_edn13name_ednref13 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>13/span>!endif>/span>/a> While the Ornishprogram has been covered by some private insurers for about 20 years, thisdetermination in 2010 made the program eligible for reimbursement for Medicarebeneficiaries with heart conditions meeting certain criteria.astylemso-endnote-id:edn14 href#_edn14 name_ednref14 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>14/span>!endif>/span>/a>b stylemso-bidi-font-weight:normal>o:p>/o:p>/b>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in;mso-layout-grid-align:none;text-autospace:none>span stylemso-tab-count:1> /span>Another program, developed independently of Ornish, foundsimilar results. Dr. Caldwell Esselstyn, a successful surgeon, who by themid-1980s felt the medical professions traditional focus on drugs and surgerywas doing little to prevent disease, began his work with high-risk heartpatients who had been told by their doctors there was little else that could bedone for them. Esselstyn, like Ornish, prescribed a whole food plant-baseddiet, but did not include the other elements such as stress reduction andexercise. Esselstyn has used a single five hour seminar providing instructionon why a plant-based diet is effective, practical implementation advice,recipes, and an actual meal. After the seminar, participants were provided withadditional assistance by phone or email. A study that followed his patients overan average of nearly four years showed that 89% adhered to the program and ofthose 94% showed improvement in symptoms with 22% demonstrating actual reversalof their existing heart condition. Less than 1% of the patients had asubsequent cardiac event after starting the program. Esselstyn observed,"the present cardiovascular medicine approach...can neither cure thedisease nor end the epidemic and is financially unsustainable. The safety,diminished expense, and prompt, powerful, and persistent results in treatingthe cause of vascular disease by whole-food plant-based nutrition offer aparadigm shift from existing practice."a stylemso-endnote-id:edn15href#_edn15 name_ednref15 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>15/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>An additional program was developedby Dr. John McDougall, who began a traditional medical practice in st1:Statew:ston>st1:place w:ston>Hawaii/st1:place>/st1:State>. He treated multiplegenerations of families and noticed many of the older generation who wereoriginally from Asian countries accustomed to a plant-based diet, had very fewof the medical problems that afflicted their children and especially theirgrandchildren who were raised on the standard American diet. Based on thisexperience, he has used a plant-based diet as the primary means of treatmentand has had numerous patients with not only heart disease, but many otherconditions including diabetes, obesity, rheumatoid arthritis, and cancer whoreversed or dramatically improved their condition.a stylemso-endnote-id:edn16 href#_edn16 name_ednref16 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>16/span>!endif>/span>/a>McDougall, among other methods, uses a 10-day program hosted at a hotel whereparticipants receive daily instruction on diet and meal preparation and areprovided unlimited plant-based meals. Opportunities for moderate exercise areavailable, but not required. Of the approximately 1,600 patients participatingin this program from 2002-2011, cholesterol was reduced by 29%, blood pressureby 18%, and triglycerides by 48% in only seven days. About 86% of those takingblood pressure medications and 90% of those taking diabetes medications wereable to reduce or stop them in this short time frame.a stylemso-endnote-id:edn17 href#_edn17 name_ednref17 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>17/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>The intent of highlighting the threeprograms presented here is not to endorse these or any other specific programs,but to illustrate there are various methods that have been successful inreducing health care costs using a whole food plant-based diet. An additionalpurpose is to demonstrate the basic research has been done with clear outcomes andto offer the suggestion it is not productive to spend additional time waitingfor the results of every last study, trial or investigation. As an analogy, thefirst federal government report linking smoking and disease was issued in 1964and even after countless subsequent studies and research, tobacco executivestestified before Congress thirty years later that evidence showing smokingcauses lung cancer and other health conditions was inconclusive.astylemso-endnote-id:edn18 href#_edn18 name_ednref18 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>18/span>!endif>/span>/a> There will always bethose who say more study or evidence is needed, but in this case the goal isnot to prove with clinical certainty which specific foods u>cause/u> certaindiseases, but rather to determine the best way to reduce health care costs andsave individuals and governments from financial ruin. For example, in auto andhomeowners insurance as there is strong correlation between credit scores andloss experience, the scores are widely used in rate classification even thoughno one suggests that adverse loss experience is u>caused/u> by poor creditscores. In this same way, while there is legitimate debate about which foods orother factors may cause disease, there is now overwhelming evidence of a strongcorrelation between a whole food plant-based diet and improved health anddecreased costs, especially among those with chronic disease. As such, it isonly logical to see that all patients with or at risk for a chronic healthcondition are educated about a plant-based diet as a realistic treatment optionas soon as possible. However, in order for such an effort to be successful on alarge scale, it is first necessary to understand, address and solve some of theexisting obstacles to implementation./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>One of the main barriers is simplythe current widespread belief that once someone has a chronic condition, such asheart disease or type 2 diabetes, there is very little that can be done toactually reverse the disease and the best outcome possible is to maintain thecondition so that it does not get any worse. The fact that a whole foodplant-based approach provides a safe, effective, low-cost alternative toeliminate symptoms and potentially reverse the underlying condition withoutdrugs or surgery is unknown to a vast majority of Americans. In contrast to thepharmaceutical industry that spends large sums to market new drugs, the salesof which rightfully compensate investors who provided R&D funding, thereare not big profits in promoting a plant-based diet. Grocery stores will earnessentially the same margin regardless of the type of food consumers buy andnone of the research in this area was funded by investors demanding returns.But even though there are not vast financial resources available for mass mediaadvertising, the inherent advantage of a plant-based diet is it can beeffectively implemented using a one-on-one physician to patient approach thatdoes not require large capital investment, sophisticated technology, andlengthy training. It simply requires physicians to accept the concept, provideit as an option to their patients, and support those patients who are willingto make these changes./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 1.5in>span stylemso-tab-count:1> /span>However,many physicians and other health care providers, even those who may be familiarwith the benefits of whole food plant-based diet, feel that since it differssignificantly from the average American diet it is too extreme or would be aradical change for patients to accept. Esselstyn, who often faced thiscriticism in the course of his practice using a plant-based diet responded,/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in .5in 261.0pt>istylemso-bidi-font-style:normal>But as far as the words “extreme” or “radical,”I would say that change is significant. But the truth is, the nutrition that isextreme or radical is the one that results in 1.2 million coronary stents beingdone per year in this country; 500,000 bypass operations where your entirechest is divided in half, veins are taken off your leg and put in your heart.And they may last several years and at the end of that, you will have to haveanother procedure. Or, maybe it’s a little bit more extreme or radical when youspend $25 billion in statin drugs, $5 billion on stents, an epidemic ofobesity, an epidemic of diabetes, an epidemic of heart disease. This is thediet that’s radical and extreme./i>a stylemso-endnote-id:edn19href#_edn19 name_ednref19 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>19/span>!endif>/span>/a>istylemso-bidi-font-style:normal>o:p>/o:p>/i>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>In terms of receptiveness ofpatients to these changes, the evidence from the programs previously describedsuggest they are more easily accepted than commonly believed, especially aspatients begin to quickly experience improvement in their personal health. Assuch, health care providers and others involved in coordinating and supportingchronic care delivery can be confident in recommending the diet, but must beclear in the way it is presented and the language used. Often, insurers andhealth care providers give their patients non-specific dietary advice such as"eat healthier", "eat more fruits and vegetables" or"consume less fat." This vague language does little to motivatepatients, especially in an environment of confusion caused by numerous studiesthat often seem to provide contradictory information on the benefits of eatinghealthy. An illustrative example is the Women’s Health Initiative (WHI) trialthat involved 48,000 women over an average eight year period. One goal was todetermine the impact on cardiovascular disease as a result of intensivecounseling that advised increasing consumption of fruits and vegetables andreducing the amount of fat in the diet to 20% of calories from the groupscurrent 38% level. In comparison, roughly 10% of calories from fat resultsnaturally for those following a varied whole food plant-based diet. The WHI trialshowed the group receiving dietary counseling increased their intake of fruitsand vegetables and reduced their level of fat to about 29% of calories, butwere significantly short of the 20% goal of the study. The study found therewere no significant differences in the incidence of cardiovascular diseasebetween the group that received dietary counseling and the control group thatdid not, leading to headlines declaring there are no benefits from eatinghealthy.a stylemso-endnote-id:edn20 href#_edn20 name_ednref20 title>spanstylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>20/span>!endif>/span>/a> This is just one ofmany studies that confuses the public and offers little motivation to changeexisting dietary patterns, demonstrating it is not sufficient to advise eating"more fruits and vegetables" to facilitate disease prevention andreversal. It requires clear direction from physicians and other health careproviders that the goal is not really to "eat healthier" but to offera specific, achievable, comprehensive solution that allows patients to feelbetter, have more energy, reduce or eliminate medications and ultimately regaincontrol over their health.span stylemso-tab-count:1> /span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Health care providers can best dothis by providing examples of actual patients who reversed their chronic healthconditions or were able to reduce or eliminate their use of prescription drugs.Sharing real life examples and explaining in simple terms why these lifestylechanges achieved such remarkable results is a powerful message to patients,many of whom have been told they must be on multiple medications for the restof their lives. One significant step in this direction was a 2013 article byphysicians from Kaiser Permanente that reviewed the evidence and concluded"physicians should consider recommending a plant-based diet to all theirpatients, especially those with high blood pressure, diabetes, cardiovasculardisease, or obesity."a stylemso-endnote-id:edn21 href#_edn21name_ednref21 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>21/span>!endif>/span>/a> Kaiser has followedup with user friendly guides (freely available online) for both physicians andpatients explaining the benefits and practical aspects of implementing aplant-based diet.a stylemso-endnote-id:edn22 href#_edn22 name_ednref22title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>22/span>!endif>/span>/a> Ideally, each patientfacing a bypass surgery, new medications, or a lifetime of insulin shots wouldbe presented with the benefits and risks of both traditional methods and theplant-based diet treatment approach. Even if only a minority of patients wouldselect the plant-based approach, a significant reduction in health care costscould be realized just by offering it as a legitimate option. While there willalways be those who just want to take a handful of pills rather than makelifestyle changes, st1:City w:ston>st1:place w:ston>Campbell/st1:place>/st1:City>advises we: /p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>istylemso-bidi-font-style:normal>should not be ignoring ideas just because weperceive that the public does not want to hear them. Consumers have theultimate choice of whether to integrate our findings into their lifestyles, butwe owe it to them to give them the best information possible with which to makethat decision and not decide for them./i> a stylemso-endnote-id:edn23href#_edn23 name_ednref23 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>23/span>!endif>/span>/a>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Although Kaisers integrated careand payment model is not entirely applicable to more traditional insurers andproviders, it does highlight the fact that the issue of provider payment is thefinal and arguably most important hurdle that must be addressed in making sureevery patient has an opportunity for treatment using the plant-based approach.Ornish observed in his work that there was no "shortage of motivatedpatients" that were receptive to lifestyle changes as an alternative todrugs or surgery but rather "the primary limiting factor has been the lackof widespread insurance coverage."a stylemso-endnote-id:edn24href#_edn24 name_ednref24 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>24/span>!endif>/span>/a>He concluded, "no matter how good a program is clinically, if its notreimbursable, its not sustainable."a stylemso-endnote-id:edn25href#_edn25 name_ednref25 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>25/span>!endif>/span>/a>While physicians such as Ornish have identified this important barrier tomaking lifestyle medicine a more common practice over more traditionalapproaches, even comic strip writers have observed the sometimes painful truthabout the current system. (See i stylemso-bidi-font-style:normal>ahrefhttp://ornishspectrum.com/wp-content/uploads/wizard-of-id.jpg>http://ornishspectrum.com/wp-content/uploads/wizard-of-id.jpg/a>/i>and i stylemso-bidi-font-style:normal>ahrefhttp://www.gocomics.com/nonsequitur/2014/11/19>http://www.gocomics.com/nonsequitur/2014/11/19/a>/i>)/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 261.0pt>istylemso-bidi-font-style:normal>o:p> /o:p>/i>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>While Medicare and some private insurersreimburse the Ornish and another similar program, it often is limited to heartpatients meeting strict criteria. There are still no direct financialincentives for physicians to educate the millions of patients not eligible forthese programs about the benefits of a plant-based diet.spanstylemso-spacerun:yes> /span>However, in recent years there has been amovement toward the use of incentives in value-based provider payment models,including efforts by CMS and private insurers to develop innovative payment andservice models, such as Accountable Care Organizations (ACOs). While these areworthwhile programs and should be continued, often their stated goal, as withACOs is "span langEN stylemso-ansi-language:EN>to help slow thegrowth of health care costs."/span>a stylemso-endnote-id:edn26href#_edn26 name_ednref26 title>span stylemso-special-character:footnote>!if !supportFootnotes>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>26/span>!endif>/span>/a>spanlangEN stylemso-ansi-language:EN> However, even if these /span>effortscould reduce the growth in health spending to the level of overall economicgrowth, it still leaves an unacceptably high 18% of GDP consumed by health carecosts. As such, incentives should primarily be focused on methods that willactually u>reduce/u> total health care costs instead of just slowing growth. spanlangEN stylemso-ansi-language:EN>Since/span> 85% of health care spendingis due to chronic conditions, many of which are attributable to poor foodchoices, even the most optimized payment and service models are unlikely toreduce health care costs unless a specific and effective dietary component isemployed. With the proper financial incentives, a plant-based treatmentapproach can be widely incorporated into both traditional fee for service aswell as value-based payment models./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>There are numerous ways to structureprovider incentives, but two key principles for any large scale implementationof a plant-based diet to treat chronic and other conditions are (1) incentivesthat work with existing provider payment structures and (2) opportunities foradditional income for physicians, without requiring capital expenditures ontheir part. One possible implementation, consistent with these principles, isfor insurers, both public and private, to first provide educational materialabout the benefits of a whole food plant-based diet directly to their insuredmembers. Much in the same way prescription drugs are advertised today as"Ask your doctor if drug XYZ is right for you" insureds would beprompted to ask their physician about the ability of plant-based diet to reduceor eliminate prescription drug use and reverse disease. Of course thesematerials would also have to list all side effects such as increased energy,lower blood pressure, and improved digestion, all while eating unlimitedquantities of satisfying food. Physicians would receive a per capita fee fromthe insurer for each patient that is "prescribed" a plant-based diettreatment approach. In addition, physicians could be eligible for additionalcompensation based on certain health outcomes of the patients that choose thisoption.span stylemso-spacerun:yes> /span>Both of these financialincentives for physicians would not replace their existing fee for service orvalue-based payment contracts, but would be above and beyond those amounts. Theplant-based "prescription" would be "filled" by the patientattending an educational seminar such as the Esselstyn model previouslydescribed. While this is only one possible approach, it shows that without alarge capital investment, an intensive one-day seminar, focused solely on dietand providing participants a clear, practical and motivating demonstration canbe highly effective. While these seminars would be the financial responsibilityof the insurer, rather than the physician or patient, they could likely bedeveloped more quickly and cost effectively by independent third-partiesserving all insurers. To encourage highly effective seminars, insurers couldalso compensate seminar providers using incentive payments based on patienthealth outcomes./p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>While the political fires of theAffordable Care Act are still smoldering, its cornerstone in providing accessto insurance regardless of pre-existing conditions will almost certainlyremain. Even though the access problem has been solved the challenge ofaffordability persists and with the wave of baby boomers entering the primeyears for complications from heart disease, diabetes, obesity, high bloodpressure and many other chronic conditions a financial tsunami is approaching.The time is near where even with employer or government subsidies, the cost ofhealth insurance will be out of reach for middle-income Americans, which islikely to cause the entire insurance system to collapse. When insurerscalculate premium rates that accurately reflect existing health care costs itserves an important need, but is insufficient to guarantee the long-termviability of the insurance system. Insurers--whether that be private commercialcarriers or public entities like Medicare or Medicaid--have an obligation tosociety to develop financially stable insurance systems for the long-term. Infact, actuaries, who are responsible for the calculation of health insurancepremium rates are bound by a Professional Code of Conduct that requires them to"act...in a manner to fulfill the profession’s responsibility to thepublic" and places that responsibility ahead of any they may have to anemployer or industry.a stylemso-endnote-id:edn27 href#_edn27name_ednref27 title>span stylemso-special-character:footnote>!if !supportFootnotes>spanstylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>27/span>!endif>/span>/a> /p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:.25in 1.5in>spanstylemso-tab-count:1> /span>Often professionals, whether it beactuaries, economists, physicians, or any number of others that are working toreduce the growth of health care costs feel that sophisticated mathematical andfinancial models or the latest medical technology and drugs are the only way tosolve large problems such as this. However, in this instance, it can be moreuseful and effective to take a simpler approach even if traditional educationand training may suggest a more complex intervention. The evidence isoverwhelming that a whole food plant-based diet provides the best opportunityto not only reduce the growth in spending, but actually decrease total healthcare costs more than any drug, medical procedure, insurance reform, or providerpayment model could hope to. The insurance industry faces a tremendouschallenge and responsibility in helping society solve this ever mountingproblem, but the solution is clear and delaying implementation should beavoided. By developing financially sound incentives that support and motivate acritical mass of health care providers to integrate this proven approach intotheir daily practice as a routine treatment option made available to allpatients and especially those with chronic conditions, the health care costcrisis can be solved./p>/div>span stylefont-size:12.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>br clearall stylepage-break-before:auto;mso-break-type:section-break>/span>div classSection3>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;tab-stops:.25in 261.0pt>o:p> /o:p>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>________________________________________________________________________________________________________________________________________________________o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>i stylemso-bidi-font-style:normal>spanstylefont-size:10.0pt>Ken Beckman, ACAS, ASA, MAAA, CFA is an actuary withmore than 20 years of experience in the insurance industry. The informationpresented in this paper is neither a statement of actuarial opinion nor anactuarial communication and tem>span stylecolor:black;mso-bidi-font-weight:bold>he opinions expressed are the authors own and do not reflect the viewsof his employer/span>/em>/span>/i>em>span stylefont-size:10.0pt;color:black;mso-bidi-font-weight:bold;font-style:normal;mso-bidi-font-style:italic>. /span>/em>i stylemso-bidi-font-style:normal>spanstylefont-size:10.0pt>It is provided for the consideration of the insuranceand other industries involved in health care costs and should not be reliedupon as providing medical, nutritional, financial, actuarial or otherprofessional services or guidance.o:p>/o:p>/span>/i>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>Forcomments send an email to: a hrefmailto:contact@cuthealthcarecosts.org>contact@cuthealthcarecosts.org/a>o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>b stylemso-bidi-font-weight:normal>ahrefhttp://www.cuthealthcarecosts.org/ChallengetotheInsuranceIndustry.pdf titleClick for PDF of A Solution to Significantly Reduce Health Care Costs>Click here for a PDF of this paper./a>/b>span stylefont-size:10.0pt>o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:1.0in;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;text-indent:.5in;mso-pagination:none;mso-outline-level:1;tab-stops:.25in 261.0pt>spanstylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal styletext-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-left:1.0in;text-align:justify;mso-pagination:none;tab-stops:.25in 261.0pt>span stylefont-size:10.0pt>o:p> /o:p>/span>/p>p classMsoNormal stylemargin-left:1.0in;text-align:justify;mso-pagination:none;tab-stops:1.0in>span stylefont-size:10.0pt>Referenceso:p>/o:p>/span>/p>/div>div stylemso-element:endnote-list>!if !supportEndnotes>br clearall>hr alignleft size1 width33%>!endif>div stylemso-element:endnote idedn1>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn1 href#_ednref1 name_edn1 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>1/span>/span>!endif>/span>/span>/a> st1:PlaceNamew:ston>span stylecolor:black>National/span>/st1:PlaceName>spanstylecolor:black> st1:PlaceType w:ston>Center/st1:PlaceType> for HealthStatistics, st1:place w:ston>st1:City w:ston>i stylemso-bidi-font-style: normal>Health/i>/st1:City>i stylemso-bidi-font-style:normal>, st1:country-region w:ston>United States/st1:country-region>/i>/st1:place>istylemso-bidi-font-style:normal>, 2015/i>. 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(st1:place w:ston>st1:City w:ston>Hyattsville/st1:City>, st1:State w:ston>MD./st1:State>/st1:place>:GPO, 2016),/span> 275./p>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>span stylefont-size:10.0pt>spanstylemso-spacerun:yes> /span>Dariush Mozaffarian et. al., "Heartdisease and Stroke Statistics—2015 Update: A Report From the American Heart Association,"i>Circulation /i>span stylemso-bidi-font-style:italic>131 (/span>2015):espan stylemso-bidi-font-weight:bold>283. /span>o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn4>p classDefault stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>a stylemso-endnote-id:edn4 href#_ednref4 name_edn4 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;color:black;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>4/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> span stylemso-bidi-font-style:italic>Cheryl D.Fryar, Margaret D. Carroll, and Cynthia L. Ogden, /span>i stylemso-bidi-font-style:normal>Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults:United States, 1960–1962 Through 2011–2012/i>, st1:place w:ston>st1:PlaceName w:ston>National/st1:PlaceName> st1:PlaceType w:ston>Center/st1:PlaceType>/st1:place>for Health Statistics, (September 2014)./span>/p>/div>div stylemso-element:endnote idedn5>p classDefault stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>a stylemso-endnote-id:edn5 href#_ednref5 name_edn5 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;color:black;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>5/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> Centers for Disease Control Division of DiabetesTranslation, i stylemso-bidi-font-style:normal>span stylemso-bidi-font-weight:bold>Long-Term Trends in Diagnosed Diabetes,/span>/i>span stylemso-bidi-font-weight:bold> /span>span stylemso-spacerun:yes> /span>(October 2011).o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>span stylefont-size:10.0pt>Wenya Yang, et. al," Economic Costs of Diabetes in the st1:place w:ston>st1:country-region w:ston>U.S./st1:country-region>/st1:place> in 2012," istylemso-bidi-font-style:normal>Diabetes Care /i>(2013). o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn6>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn6 href#_ednref6 name_edn6 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>6/span>/span>!endif>/span>/span>/a>"Chronic Disease Overview," Centers for Disease Control, accessedJuly 2, 2016, span stylecolor:black>ahrefhttp://www.cdc.gov/chronicdisease/overview/index.htm>http://www.cdc.gov/chronicdisease/overview/index.htm/a>./span>/p>/div>div stylemso-element:endnote idedn7>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn7 href#_ednref7 name_edn7 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>7/span>/span>!endif>/span>/span>/a> T.Colin Campbell, span classa-size-large1>i stylemso-bidi-font-style:normal>spanstylefont-family:Times New Roman;color:#111111>Whole: Rethinking theScience of Nutrition/span>/i>/span>, (st1:place w:ston>st1:City w:ston>Dallas/st1:City>/st1:place>:BenBella Books, Inc., 2013), 11./p>/div>div stylemso-element:endnote idedn8>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn8 href#_ednref8 name_edn8 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>8/span>/span>!endif>/span>/span>/a>John A. McDougall, i stylemso-bidi-font-style:normal>The Starch Solution:Eat the Foods You Love, Regain Your Health, and Lose the Weight for Good,/i> (st1:placew:ston>st1:State w:ston>New York/st1:State>/st1:place>: Rodale, Inc.,2012), 5-8. McDougall uses the term starches to describe the whole grains, legumes,and starchy vegetables (e.g. potatoes) that provide a feeling of fullness alongwith the necessary energy, while pointing out that a diet overly focused onfruits or non-starchy vegetables, while very healthy, does not providesufficient calories and may lead to filling up on unhealthy foods tocompensate./p>/div>div stylemso-element:endnote idedn9>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn9href#_ednref9 name_edn9 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>9/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> "Dr. Dean Ornish Program for Reversing HeartDisease," Ornish Lifestyle Medicine, accessed July 2, 2016, ahrefhttps://www.ornish.com/wp-content/uploads/FAQ_Ornish_Program_8.19.14.pdf>https://www.ornish.com/wp-content/uploads/FAQ_Ornish_Program_8.19.14.pdf/a>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn10>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn10 href#_ednref10 name_edn10 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>10/span>/span>!endif>/span>/span>/a>"Evidence Based Medicine Redefining the Standard of Care in Coronary HeartDisease," The Dr. Dean Ornish Program for Reversing Heart Diseasesup>TM/sup>,accessed July 2, 2016,a nameOLE_LINK8>/a>a nameOLE_LINK9>/a>anameOLE_LINK10>span stylemso-bookmark:OLE_LINK9>span stylemso-bookmark:OLE_LINK8> /span>/span>/a>ahrefhttp://rehab.ucla.edu/workfiles/Dean%20Ornish/Ornish/ScienceBehindProgram.pdf>spanstylemso-bookmark:OLE_LINK10>span stylemso-bookmark:OLE_LINK9>spanstylemso-bookmark:OLE_LINK8>http://rehab.ucla.edu/workfiles/Dean%20Ornish/Ornish/ScienceBehindProgram.pdf/span>/span>/span>spanstylemso-bookmark:OLE_LINK10>span stylemso-bookmark:OLE_LINK9>spanstylemso-bookmark:OLE_LINK8>/span>/span>/span>/a>span stylemso-bookmark:OLE_LINK10>span stylemso-bookmark:OLE_LINK9>span stylemso-bookmark:OLE_LINK8>./span>/span>/span>/p>/div>div stylemso-element:endnote idedn11>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn11 href#_ednref11 name_edn11 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>11/span>/span>!endif>/span>/span>/a>K. Lance Gould, Dean Ornish et al., "Changes in Myocardial PerfusionAbnormalities by Positron Emission Tomography After Long-term, Intense RiskFactor Modification,"i stylemso-bidi-font-style:normal> JAMA/i>274 (September 20, 1995): 894-901span classreftext>span stylecolor:#333333>./span>/span>istylemso-bidi-font-style:normal>o:p>/o:p>/i>/p>/div>div stylemso-element:endnote idedn12>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn12 href#_ednref12 name_edn12 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>12/span>/span>!endif>/span>/span>/a>Dean Ornish, "Avoiding Revascularization with Lifestyle Changes: TheMulticenter Lifestyle Demonstration Project", i stylemso-bidi-font-style:normal>American Journal of Cardiology/i> 82 (1998):72T-76T./p>/div>div stylemso-element:endnote idedn13>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn13 href#_ednref13name_edn13 title>span classMsoEndnoteReference>span stylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>13/span>/span>!endif>/span>/span>/span>/a>"span stylefont-size:10.0pt>Decision Memo for Intensive CardiacRehabilitation (ICR) Program - Dr. Ornishs Program for Reversing Heart Disease(CAG-00419N)," August 12, 2010, Centers for Medicare & MedicaidServices, accessed July 2, 2016, a hrefhttp://www.cms.gov/>http://www.cms.gov//a>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn14>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn14 href#_ednref14 name_edn14 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>14/span>/span>!endif>/span>/span>/a>Amy Lynn Sorrel, "Medicares new approach to familiar diseases," istylemso-bidi-font-style:normal>American Medical News/i>, (May 14, 2012), ahrefhttp://www.amednews.com/article/20120514/government/305149956/4/>http://www.amednews.com/article/20120514/government/305149956/4//a>./p>/div>div stylemso-element:endnote idedn15>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn15 href#_ednref15 name_edn15 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>15/span>/span>!endif>/span>/span>/a>Caldwell B. Esselstyn Jr. et al., "A way to reverse CAD?" istylemso-bidi-font-style:normal>The Journal of Family Practice/i> 63 (July2014)./p>/div>div stylemso-element:endnote idedn16>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn16href#_ednref16 name_edn16 title>span classMsoEndnoteReference>spanstylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>16/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt>"Success Stories," Dr. McDougalls st1:placew:ston>st1:PlaceName w:ston>Health & Medical/st1:PlaceName> st1:PlaceType w:ston>Center/st1:PlaceType>/st1:place>, accessed July 2, 2016, ahrefhttps://www.drmcdougall.com/health/education/health-science/stars/>https://www.drmcdougall.com/health/education/health-science/stars//a>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn17>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in;mso-layout-grid-align:none;text-autospace:none>a stylemso-endnote-id:edn17 href#_ednref17name_edn17 title>span classMsoEndnoteReference>span stylefont-size:10.0pt>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>17/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> John McDougall et al., "Effects of 7 days on anad libitum low-fat vegan diet: the McDougall Program cohort," istylemso-bidi-font-style:normal>Nutrition Journal/i> 13 (2014).o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn18>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn18 href#_ednref18 name_edn18 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>18/span>/span>!endif>/span>/span>/a>Philip J. 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"span langEN stylemso-ansi-language:EN;mso-bidi-font-weight:bold>Tobacco Chiefs Say Cigarettes Arent Addictive," istylemso-bidi-font-style:normal>New York Times/i>, April 15, 1994, accessedJuly 2, 2016,/span>span langEN stylemso-ansi-language:EN> /span>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>a nameOLE_LINK5>/a>anameOLE_LINK6>/a>a nameOLE_LINK7>span stylemso-bookmark:OLE_LINK6>spanstylemso-bookmark:OLE_LINK5>/span>/span>/a>ahrefhttp://www.nytimes.com/1994/04/15/us/tobacco-chiefs-say-cigarettes-aren-t-addictive.html>spanstylemso-bookmark:OLE_LINK7>span stylemso-bookmark:OLE_LINK6>spanstylemso-bookmark:OLE_LINK5>http://www.nytimes.com/1994/04/15/us/tobacco-chiefs-say-cigarettes-aren-t-addictive.html/span>/span>/span>spanstylemso-bookmark:OLE_LINK7>span stylemso-bookmark:OLE_LINK6>spanstylemso-bookmark:OLE_LINK5>/span>/span>/span>/a>span stylemso-bookmark:OLE_LINK5>/span>span stylemso-bookmark:OLE_LINK6>/span>spanstylemso-bookmark:OLE_LINK7>/span>./p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>"Reflectingon 50 Years of Progress," U.S. Department of Health & Human Services,accessed July 2, 2016, ahrefhttp://www.surgeongeneral.gov/priorities/tobacco/>http://www.surgeongeneral.gov/priorities/tobacco//a>./p>/div>div stylemso-element:endnote idedn19>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in>astylemso-endnote-id:edn19 href#_ednref19 name_edn19 title>spanclassMsoEndnoteReference>span stylefont-size:10.0pt>spanstylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>19/span>/span>!endif>/span>/span>/span>/a>spanstylefont-size:10.0pt> Mark Huberman, "Best. Interview. Ever. AnInterview with Caldwell Esselstyn, Jr. M.D.," Healthy Girls Kitchen,accessed July 2, 2016, o:p>/o:p>/span>/p>p classMsoNormal stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;text-align:justify;tab-stops:1.0in>anameOLE_LINK3>/a>a nameOLE_LINK4>span stylemso-bookmark:OLE_LINK3>/span>/a>ahrefhttp://www.healthygirlskitchen.com/2012/03/best-interview-ever-interview-with.html>spanstylemso-bookmark:OLE_LINK4>span stylemso-bookmark:OLE_LINK3>spanstylefont-size:10.0pt>http://www.healthygirlskitchen.com/2012/03/best-interview-ever-interview-with.html/span>/span>/span>spanstylemso-bookmark:OLE_LINK4>span stylemso-bookmark:OLE_LINK3>/span>/span>/a>spanstylemso-bookmark:OLE_LINK3>/span>span stylemso-bookmark:OLE_LINK4>/span>spanstylefont-size:10.0pt>.o:p>/o:p>/span>/p>/div>div stylemso-element:endnote idedn20>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn20 href#_ednref20 name_edn20 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>20/span>/span>!endif>/span>/span>/a>Barbara V. Howard et al., "Low-Fat Dietary Pattern and Risk of CardiovascularDisease: The Womens Health Initiative Randomized Controlled DietaryModification Trial," i stylemso-bidi-font-style:normal>JAMA /i>295(February 8, 2006)./p>/div>div stylemso-element:endnote idedn21>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn21 href#_ednref21 name_edn21 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>21/span>/span>!endif>/span>/span>/a> spanstylemso-bidi-font-weight:bold>Philip J. Tuso et al., "/span>NutritionalUpdate for Physicians: Plant-Based Diets," i stylemso-bidi-font-style:normal>Permanente Journal/i> 17 (Spring 2013): 61-66./p>/div>div stylemso-element:endnote idedn22>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn22 href#_ednref22 name_edn22 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>22/span>/span>!endif>/span>/span>/a>"The Plant-Based Diet: st1:Street w:ston>st1:address w:ston>A Healthier Way/st1:address>/st1:Street> to Eat," Kaiser Permanente,accessed July 2, 2016, ahrefhttps://share.kaiserpermanente.org/wp-content/uploads/2015/10/The-Plant-Based-Diet-booklet.pdf>https://share.kaiserpermanente.org/wp-content/uploads/2015/10/The-Plant-Based-Diet-booklet.pdf/a>./p>/div>div stylemso-element:endnote idedn23>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn23 href#_ednref23 name_edn23 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>23/span>/span>!endif>/span>/span>/a>T. Colin Campbell and Thomas M. Campbell, i stylemso-bidi-font-style:normal>Thest1:country-region w:ston>China/st1:country-region> Study: The MostComprehensive Study of Nutrition Ever Conducted and the Startling Implicationsfor Diet, Weight Loss and Long-term Health/i>, (st1:City w:ston>st1:place w:ston>Dallas/st1:place>/st1:City>: BenBella Books, Inc., 2004), 287./p>/div>div stylemso-element:endnote idedn24>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn24 href#_ednref24 name_edn24 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>24/span>/span>!endif>/span>/span>/a>Dean Ornish, "Avoiding Revascularization with Lifestyle Changes: TheMulticenter Lifestyle Demonstration Project," i stylemso-bidi-font-style:normal>American Journal of Cardiology /i>82 (1998): 75T./p>/div>div stylemso-element:endnote idedn25>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn25 href#_ednref25 name_edn25 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>25/span>/span>!endif>/span>/span>/a>Sorrel, 2012./p>/div>div stylemso-element:endnote idedn26>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn26 href#_ednref26 name_edn26 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>26/span>/span>!endif>/span>/span>/a>Robert Tagalicod, "span langEN stylemso-ansi-language:EN>AccountableCare Organizations: The Future of Coordinated Care,"/span> Centers forMedicare & Medicaid Services, accessed July 2, 2016,/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>span langENstylemso-ansi-language:EN>ahrefhttps://www.cms.gov/eHealth/ListServ_AccoutableCareOrgs.html>htspanlangEN-US stylemso-ansi-language:EN-US>tps://www.cms.gov/eHealth/ListServ_AccoutableCareOrgs.html/span>/a>/span>./p>/div>div stylemso-element:endnote idedn27>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>astylemso-endnote-id:edn27 href#_ednref27 name_edn27 title>spanclassMsoEndnoteReference>span stylemso-special-character:footnote>!if !supportFootnotes>spanclassMsoEndnoteReference>span stylefont-size:10.0pt;font-family:Times New Roman;mso-fareast-font-family:Times New Roman;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA>27/span>/span>!endif>/span>/span>/a>Code of Professional Conduct, Precept 1, st1:place w:ston>st1:PlaceName w:ston>American/st1:PlaceName> st1:PlaceType w:ston>Academy/st1:PlaceType>/st1:place>of Actuaries./p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>Published July2016./p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>bstylemso-bidi-font-weight:normal>span stylefont-size:12.0pt>ahrefhttp://www.cuthealthcarecosts.org/plantbaseddietresources.html>Clickhere for further resources about a whole food plant-based diet and its ability to reverse chronic disease and improve health./a>o:p>/o:p>/span>/b>/p>p classMsoEndnoteText stylemargin-top:0in;margin-right:66.75pt;margin-bottom:0in;margin-left:1.0in;margin-bottom:.0001pt;tab-stops:1.0in>o:p> /o:p>/p>/div>/div>/body>/html>
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