Heart of New Ulm Project: A Community's Quest to Eliminate Heart Attacks
How the town of New Ulm joined together to lose weight, lower cholesterol levels and eat healthier.
In 2008, Jackie Boucher, a fit blonde who swims every morning in the summer and runs or walks 5 to 7 miles daily in the bitter Minnesota winters, was given a tall challenge: Could she come up with a plan to eliminate heart attacks in a community? That question was on the minds of her boss, Kevin Graham, M.D., then-president of the Minneapolis Heart Institute, and Dick Pettingill, then-CEO of Allina Health.
Heart disease causes one in three deaths in the U.S. If you smoke, are overweight, are inactive or have high blood pressure or cholesterol, you add to your risks. Two-thirds of Americans are overweight or obese, and people who are 25 to 50 pounds overweight are 50 percent more likely to have a heart attack.
Theoretically, then, if people changed their behaviors, they could reduce their risk of heart attacks. If they did, it would not only save lives but could also save millions in health-care costs.
The two men asked Boucher, a registered dietitian and educator, to write up a plan and focus on one particularly tough town: New Ulm, Minnesota, home to a brewery, a butter packager and what was, at the time, the world's largest Velveeta plant.
The Guinea Pigs
On a winter day, as snow swirled outside, Tanya Horner placed everything she owned into cardboard boxes. Despite months of working overtime, Horner's job in Minneapolis had been outsourced and she was moving home to live with her mother and go back to school. In the past year, take-out food and pizza had become her mainstays. She had ballooned to nearly 300 pounds and developed sleep apnea.
Meanwhile, 90 miles away in New Ulm, her mother, Mary Koch, sat on her couch, eating potato chips, mourning the loss of her husband. She had stopped cooking for herself, was 40 pounds overweight and had high cholesterol. Living together again, they realized how unhappy they were with their health. "We got together one day," Horner remembers, "and said, ‘We've got to do something better.'"
One morning Mary Koch went to work as usual at her desk job at the Kraft Foods headquarters just on the edge of town. Instead of going on her coffee break, she walked into one of the conference rooms, where the one local medical center, owned by Allina, had set up stations for free heart-health screens. Koch settled into a cushioned swivel chair next to a table covered with clipboards, wipes and plastic vials for blood. A series of nurses weighed her, checked her blood pressure and took blood to test her cholesterol and triglyceride levels. Fifteen minutes later she was back at work.
Koch had joined 5,200 other people (more than one-third of the town of 14,000) who had voluntarily attended 109 screening sessions at worksites, community centers, churches and recreation centers as part of the first free health screenings for the "Heart of New Ulm" experiment. This initial screening gave Jackie Boucher, vice president of education at the Minnesota Heart Institute Foundation, and her colleagues a 2009 baseline of the town's health, allowing them to monitor whether or not their efforts could improve health.
Fast-forward to this past August: Tanya Horner, now 37, has lost 76 pounds, her mother, Mary Koch, 56, has lost 38. Horner no longer has sleep apnea, Koch's cholesterol has improved, and both women like the way they look and love their new life.
Though they are successful by any account, they hardly stand out in New Ulm: Their neighbor, Pat Novak, 52, has lost 20 pounds and stopped using insulin to control his type 2 diabetes. His wife, Sharie, 51, is 30 pounds lighter. Nearby, John Holmquist, 57, has lost 35 pounds, dramatically dropped his blood pressure and cholesterol, and feels stronger than he did in his thirties. In fact, all around town people are posting lower weights, getting more exercise and lowering cholesterol and blood pressure.
So what changed in this formerly bratwurst-eating, beer-drinking, butter-spreading town? The answer is the Heart of New Ulm (HONU) Project, a 10-year effort with the outrageous goal of eliminating heart attacks and persuading the people of New Ulm to drastically reduce their weight. In the past few years HONU has saturated the town with exercise programs, health screenings, healthy cooking classes and other campaigns. It's infiltrated homes, restaurants and workplaces.
Horner, Koch, the Novaks and Holmquist are participating guinea pigs in this giant experiment, and, so far, it seems to be working: Just three years since the program began, New Ulmites have less hypertension, lower cholesterol, are eating more fruits and vegetables, and getting more exercise. Among the program participants, 981 people have lost a collective 7,961 pounds. And very preliminary results show a 24 percent reduction in heart attacks after 15 months of the project. (Boucher warns that they need many years of data to know if there has been real improvement.)
Boucher, the HONU project director, sees it like this: "If you can, make the healthy choice the easy choice-so that wherever you go it's easy to be active or find healthier foods. That's where you can really start to change social norms." And that's just what she and her team set out to do. But there were roadblocks, namely the very essence of the town itself.
The Town That Butter Built
New Ulm was settled in 1854 by German immigrants and today claims to be statistically the most German town in America. But this is the just the first in a long line of the town's claimed superlatives: New Ulm is home to the second-oldest family-run brewery in the U.S., the August Schell Brewing Company; what may have been the world's largest processed cheese factory; and the largest butter-packaging plant in the U.S.
The butter plant is locally famous because, in 2004, an explosion blew melted butter all over the town center. "We literally had a million pounds of butter running through the streets of New Ulm," says HONU's Rebecca Fliszar, R.D., who is in charge of local nutrition initiatives. "The city was coated in it, and it just smelled like popcorn."
Targeting an entire community's health isn't a novel concept: big National Institutes of Health-funded studies like California's Stanford Five City Project, the Pawtucket Heart Health Program in Rhode Island, even the Minnesota Heart Health Program have screened residents for cardiovascular risk factors and then intensively educated them about changing their behavior-eating better, exercising, stopping smoking.
But if it were as easy as education, we'd all be slimmer, fitter and healthier. These older programs posted ambiguous results or effects that didn't last once the intervention ended.
Boucher wanted to do more than the big NIH-funded studies, even though she had far less money to work with. After studying scores of other attempts to improve community health, Boucher proposed to not only educate folks and teach them about the changes they need to make, but most importantly, she wanted to envelop them in a supportive environment. "The environment [unhealthy food options, little opportunity for exercise] works against you," says Boucher. "That's why I think it's so important to focus on environmental changes."
In the first four years of the project, Allina Health (a not-for-profit health-care system) invested about $5 million (some of the NIH projects cost upwards of $80 million). With about 80 heart attacks in New Ulm every year, direct costs of treating the heart attacks is about $4 million a year. If HONU could reduce the number of heart attacks by just one-quarter, it could save $10 million over 10 years. If you take into account the indirect costs of missed work, decreased productivity and short-term disability, the savings are even greater.
And when you consider that the risk factors for heart disease (the ones that HONU is trying to reduce-cholesterol, blood pressure, smoking, obesity) are also risk factors for several other major diseases (cancer, type 2 diabetes, chronic kidney disease), the town should see substantial reduction in risk for those diseases as well.
Studies have shown that the return on investment for programs that help promote healthy living and prevent disease is consistently 3:1. HONU is expected to be similar, thus saving a lot more money with prevention than would be spent on treatment.
Boucher and her team have also won a federal appropriation plus about $1.4 million in grants from the U.S. Department of Agriculture, Centers for Disease Control and United Healthcare. The latter grant includes a more intensive approach to reducing obesity, including creating a community challenge for everyone to maintain or lose weight; if the town succeeds, it can earn up to $100,000 toward a project citizens would vote on, like a new park.
The team chose New Ulm, a town of about 14,000, because, despite the brats, butter and beer culture, the town's Chamber of Commerce recently listed health as one of the town's top three goals for the community, and its people are easy to study since they are served by a single medical center with electronic health records. Plus, New Ulm, with its biggest-this, oldest-that mentality, was ripe for a challenge. Boucher says, "There's this social pressure and competitiveness, that we want to show that our community can do this."
It Takes a Village
To help citizens get a jump-start, HONU created the Take Five! Community Health Challenge. As part of the program, it mailed out a full-color booklet outlining a 12-week program to successfully lose weight- complete with logbook, scores of tips and goals and methods-to every household in the town.
The Challenge encouraged small changes and daily self-tracking of these changes: losing 5 pounds, being physically active 5 days a week, eating 5 times a day (3 meals, 2 snacks), eating at least 5 fruits and vegetables a day, taking 5 minutes each day for yourself. The program promoted free phone coaching for individuals at high risk for heart disease, and no-cost events, such as square dancing classes in the park, cooking classes at the medical center and neighborhood walking clubs.
HONU also developed and produces a weekly cable-access healthy-cooking show, "What's Cooking New Ulm?" with dietitian Rebecca Fliszar. She visits the kitchens of home cooks and works with them to demonstrate how to make healthier meals, often using EatingWell recipes. (In fact, EatingWell recipes are used in almost all the materials HONU publishes, on its website and in cooking classes and demonstrations.)
Restaurants were encouraged to revamp their menus and the town's two grocery stores put up signs in their aisles encouraging healthy swaps, such as water for soda.
To really make a difference, however, HONU knew it had to approach people at work, where they spend most of every day. HONU collaborates with 38 worksites, including J&R Schugel Trucking, Inc., which employs 600 truck drivers and 87 office workers.
The 2009 HONU health screen of the J&R Schugel office staff showed that 32 percent of workers had metabolic syndrome, 29 percent were smokers and 79 percent were overweight or obese. Consulting with HONU's dietitians, Leah Peck, the company's human resources director, started trying to improve the company's work environment in small ways.
The company organized a 5K walk/run, complete with training calendars and a healthy cooking contest at the end. Peck arranged for a CSA to deliver fresh fruit and vegetables to work. And, after the company's president put it out for a vote, the campus went tobacco-free.
Peck also harangued her vending-machine company: since there are no places to get food close by, employees and truckers rely on the vending machines. "So I said, ‘I want baked meals at eye level, and they should be less expensive than fried items, and there needs to be dry snacks that are high in protein, low in saturated fat.'"
For truckers who are sedentary up to 11 hours a day and whose only meal options are often fast-food joints or roadside convenience stores, Peck had to be creative. She gives truckers the HONU grocery store packet that helps them "choose this, not that," emphasizing healthier options in each area of the store. She also hands out brochures with 300- to 500-calorie healthier meal options at fast-food places. As for exercise? "I tell them, park at the farthest end of the rest area, go to the bathroom, walk around the whole rest area, a big loop, it will take you 10 minutes to get back to your truck. Do that three times, and you've gotten in your 30 minutes," she says.
J&R Schugel's truck drivers and office workers are starting to show improvements in their health: metabolic syndrome has been reduced by 3 percent and overweight has declined by 3 percent. "If our company can show any success-a high-stress environment with a lot of tobacco use, sedentary lifestyle and eating on the run-imagine what you can do in your office," Peck says.
With their motto, "a well-driver is a safe driver," the company sees employee health as part of its duty. "We're spending more time with employees than they do with their family. And if we don't have a positive impact on some choices in their life, shame on us!" Peck declares. "We are the best opportunity to learn about healthy eating."
Changing for Good
On a day last August, Tanya Horner and her mom pull back wood-spindled chairs and sit at a white-clothed table in the New Ulm Turner Hall, surrounded by muted murals of European castles. Once a month, the two splurge on a meal at the club. Mary Koch orders the black bean burger and Horner gets a salad at the salad bar. Today though, she notes, "There are two pita sandwiches that I want to try; Moroccan Chicken Pita is one. They also offer a side salad instead of fries-that's new."
In fact, the Turner Hall menu has been completely revamped. For its restaurant program, HONU's dietitians created a list of criteria for a bronze, silver or gold restaurant (offering a healthy side dish, like a steamed vegetable, or salads as a French fry substitute, or using olive oil instead of butter) and worked with restaurants to highlight heart-healthy menu items, and then create even healthier ones.
Turner Club manager Virginia Suker Moldan was skeptical when she first talked to Boucher and others in 2009. "It sounded like a fine idea but I didn't think it would work here," she remembers. "We have an older demographic; we're known for having humungous portions of both American and German food."
Two years later, much has changed and she proudly displays the made-over menu, complete with salads and heart-healthy fish. "I don't know when it seemed to be cost-effective to [take part in HONU], but suddenly it was. We were starting to lose customers because we had this heavy meat-and-potato menu. When we started adding salads, I was blown away at how many we went through. It was like somebody flipped a switch. HONU has changed the town."
Horner and Koch have changed how they cook and eat at home too. Koch stopped mindless snacking and started planning and cooking healthy meals. "We use shredded zucchini now as noodles," says Horner. They go on to talk about using ground cauliflower as rice; this amazing grilled tuna steak with veggies that they made.
The mother and daughter could talk all day about food-healthy food-and how to buy it, how to cook it, how to eat it. But exercise was their biggest challenge. "Last winter it was so cold, we were not getting our exercise," said Horner. HONU started sponsoring free nights at the indoor walking track. "So we started doing those twice a week and challenging ourselves to run the corners. It would be packed some nights: young people, college students, some elderly folks, everyone."
Just as important is the community mindset: the mother and daughter keep each other in check. "I mean, put that chocolate bar down now!' says Horner, with a laugh. And they forgive themselves when they slip up.
After months of eating better, exercising and just generally changing her life, Horner remembers her first big triumph. "About 30 pounds in, I noticed that my throat was really sore. I came in to the hospital and said, ‘My CPAP [sleep apnea machine] isn't working.' The doctor said, ‘You can just put that thing in the closet, you don't need it anymore,'" she remembers. "I was ecstatic. Nervous, but ecstatic. That's been awesome, not having to lug that thing around anymore."
Her mother concurs. "I just had my cholesterol tested," Koch said. "I dropped 10 points. My goal was my cholesterol, because I don't want to take pills." Her BMI has also dropped another 5 points.
"And my blood pressure has dropped," Horner added. "Now it's on the low side of healthy."
As the conversation continues, mother and daughter talk about how far they've come. Eating right, finding their passion for healthier foods, supporting each other, trying new things. "I want to lose about another 35 pounds," says Horner. "I'm still losing, it's just slow."
"Well, I think it's slowed down because we aren't so geared to ‘Let's lose the weight,' we're geared towards health. We're still trying to lose but in a much more sustainable way," says Koch with a laugh.
Inspired by HONU, the duo walked their first 6K, the Schell Brewery Lager Lauf, last May. HONU helped the brewery get that event off the ground. Prior to HONU, only one annual walk/run was held in New Ulm. Now there are eight.
"The run/walk events here have been promoted as fun things, not races," said Koch. "Because for people like us who just want to stay healthy, you don't want to do the race as a competitive thing."
"Yeah," says Horner, skeptically, pointing a thumb at her mom. "And as she's booking up that hill, she's saying, ‘Don't let the old lady kick your butt!'"
After all, a little competition can be healthy.