The Telltale Hearts

Is it possible for a city to completely eliminate heart attacks? New Ulm is trying.

The Telltale Hearts

On December 1, 2004, the city of New Ulm made headlines when the butter plant downtown exploded, melting three million pounds of golden goodness and sending a fragrant flow of molten ooze down Center Street and into the Minnesota River. As the fire spread, plumes of burning butter coated the city in a cholesterol glaze, and the cold December night slowly solidified the mess by the river into giant blobs of congealed animal fat.

The butter plant incident happened outside. But a mile away, at the New Ulm Medical Center, a similar catastrophe happens once or twice a week, inside residents of New Ulm—to people who smoke too much, eat gobs of saturated fat, and grease their arteries with liquid death. Roughly 80 people a year die from heart attacks in New Ulm, a city of 13,500 where more than half the population is either overweight or clinically obese, and the prevailing German predilection for the three Bs—beer, brats, and butter—is a distinct point of civic pride. Or at least it used to be.

A remarkable transformation has taken place in New Ulm over the past five years. In local restaurants, more salads accompany meals than fries do these days. Walkers and joggers are everywhere. Gym memberships have never been higher. The local farmers’ market is adding an extra day this year to meet the growing demand for fresh produce. Participation in locally organized 5K runs is regularly in the hundreds, and heart-healthy trends that Twin Citians take for granted—like walking and biking to work—are suddenly becoming fashionable.

Collectively, the citizens of New Ulm have lost more than 8,000 pounds in the past three years, and every measure of the town’s overall health—blood pressure, cholesterol levels, triglycerides, fruit and vegetable consumption, exercise levels, even the number of heart attacks—is improving. In fact, New Ulm—once home to the nation’s largest Velveeta factory—is well on its way to establishing itself as a national model for sustainable civic health.

How did a town full of belly-over-belt bratwurst lovers transform itself into a Midwestern haven of higher health consciousness? Not by accident.

An Impossible Goal

For 20 years, Dr. Kevin Graham, a cardiologist with the Minneapolis Heart Institute, made the 90-mile trip from the Twin Cities down Hwy. 212 through the Minnesota River Valley to the New Ulm Medical Center, where he helped patients fight the slow ravages of heart disease. Frustrated at being on the back end of the health care system, where tragedy is an all-too-frequent outcome—and knowing that heart disease is preventable in most cases—he started wondering how it might be possible to keep people out of his office altogether.


Coincidentally, New Ulm’s civic leaders had come to recognize that the health of New Ulm’s citizens was a problem that needed solving—somehow. The reason: The city is trying to expand everything but its waistline.

“It’s important for us to have a healthy workforce,” says New Ulm mayor Robert Beussman, whose own quadruple-bypass surgery four years ago was as scary as it was motivational. “Healthy workers mean local companies don’t have to spend as much on health care. Businesses interested in operating here are also more likely to do so if they know the workers they hire here are going to cost them less in the long run.”

Allina Health runs the New Ulm Medical Center and is one of the largest employers in town. Former Allina CEO Dick Pettingill shared Graham’s interest in the preventive aspect of health care, not only for his own workforce but also for the town of New Ulm in general. Together, they brainstormed a ridiculous, outlandish-sounding, probably impossible idea—and presented it to a steering committee of community leaders.

Their proposal: If the city of New Ulm had the money and resources to do so, could it completely eliminate heart attacks in 10 years? Or, at any rate, would it be willing to try?

The steering committee voted, and its answer was a resounding yes.

As soon as New Ulm accepted the challenge, Jackie Boucher, a dietician and education expert at the Minneapolis Heart Institute Foundation, got a memo from Graham, her boss, telling her that they needed a plan—and fast.

Now it was her turn to have a heart attack.

The problem: No one quite knows how to go about reducing, let alone eliminating, heart attacks in an entire city, and she only had one week to figure it out. Minnesota’s own Statewide Health Improvement Program targets diet and exercise, but its success is mostly anecdotal, told in stories more than statistics. Dozens of other programs around the country have tried to improve civic and/or cardiovascular health as well, but most have posted inconclusive results or, at best, seen only temporary gains.

“I studied other programs around the country and concluded that we had to do more than just tell people to eat better and exercise more,” says Boucher. Everyone already knows that anyway, she says. “The challenge is motivating them to do it and providing people with a supportive environment in which to make those kinds of lifestyle changes—and that requires a change in culture.”

Social researchers Nicholas A. Christakis and James H. Fowler are famous for a study they published in 2007 in the New England Journal of Medicine arguing that obesity is contagious. In short, they found that obese people tend to associate with each other, reinforce their excessive eating habits, and pick up and pass along bad habits from person to person like a disease. But in their latest book, Connected: The Surprising Power of Social Networks and How They Shape Our Lives, Christakis and Fowler argue that this same network-contagion principle can, in theory, be applied to influence social networks in positive ways, nudging people to quit smoking, say, or adopt healthier eating and exercise habits.

Applying this idea to the situation in New Ulm, Boucher figured that if she could get enough people—particularly obese people—to change their diet and exercise habits, and create a civic environment that supported and encouraged those changes, heart-healthy living might itself become contagious. A week later, the Heart of New Ulm project was born, and so began the city’s lifestyle revolution.


Kale, Anyone?

It’s 9 am in a squat yellow box of a building on the outskirts of New Ulm, where employees of the Minnesota Valley Testing Laboratories are shuffling into the break room to hear a presentation on—well, they don’t exactly know yet. On one side of the room are a few vending machines stocked with Cheetos, Cheez-Its, Funyuns, and several popular beverages on the ever-growing list of “things that ought to be banned.” On the other side of the room is a small cork “Wellness Board” with a few flyers for an exercise class and upcoming 5K run tacked in place with pushpins.

In attendance is a representative sample of New Ulm’s overall population—some younger, some older, some fat, some skinny, some in between, almost all white, and all willing to listen, sort of, to someone talk to them for 45 minutes on the glories of community supported agriculture, or CSAs—known, as one aspiring comedian in the bunch observes, as the “weird vegetable of the week club.”

Tracie Vranich is the presenter. Energetic and earnest, she runs the Putting Green EcoCenter, an odd combination of minigolf course and environmental learning center (“caring for the planet one putt at a time”). She’s been hired by the Heart of New Ulm project to help educate citizens on the benefits of buying and eating locally grown produce. It has not escaped her that this is a tough room.

She tells a story about evil green tomatoes that are picked in Mexico, shipped 1,700 miles to the local supermarket, and then gassed with a chemical called ethylene to redden them up. She talks at length about understanding the ecosystem that our food comes from and how the food circle of life—herbicides, fertilizers, chemicals, soil and water quality, pollution, etc.—all ends up in your mouth. She pulls out a display board showing the U.S. government’s dreaded new “pie plate” nutritional guidelines and discusses the wisdom of “eating a rainbow,” by which she means foods of different colors, particularly the green, yellow, and red ones.

“Has anyone here ever eaten kale?” she asks, hopefully. One guy raises his hand.

“Did you like it?”

He lifts his palm a few inches and wiggles it. “Meh.”

At the end of the presentation, the participants are given a list of farmers in the area who have CSA openings, plus a free plastic cutting board for slicing up all those fresh, locally grown vegetables they now know they’re supposed to eat. Sitting next to me is Rachel Hoffman, a mother of two kids, ages 6 and 3. I ask her if she has been persuaded to join a CSA.

“I’d say she certainly gave us a lot to think about,” she chirps, letting me know with her eyes that she really means “No, but I don’t want to say anything bad.”

“What would it take for you to feed kale to your family?” I ask.

She smiles and says, “Well, I’d have to like it first.”

Virtually every decent-sized business in New Ulm has received a presentation like this, or similar ones on the value of exercise, the importance of setting achievable goals, managing diabetes, or any number of other topics related to a healthier lifestyle. It’s just one aspect of the multipronged Heart of New Ulm project.

Persuading people to give up pizza and potato chips in favor of kale and kohlrabi will always be a hard sell, of course, but in New Ulm the task is made especially difficult by the prevailing culture of the town itself. How do you advocate for a Mediterranean diet rich in fruits, vegetables, nuts, fish, and whole grains in a town where a significant chunk of the local economy is based on foods specifically designed to shut down aortas and prevent people from making the U.S. Olympic team?

Take butter, for instance. “Butter is a sensitive topic in New Ulm, because butter means jobs,” says dietician Rebecca Fliszar. Indeed, the Associated Milk Producers Inc. butter plant employs about 185 people. “So we can’t really tell people to stop using butter altogether. Instead, we encourage them to use less butter and inform them about healthier substitutes, like olive oil. It’s baby steps.”


New Ulm calls itself “The City of Charm and Tradition,” and 66 percent of its residents identify German as their primary heritage, so they’ve got the meat and starch quadrants of the dinner plate covered. But until recently, the town’s traditions did not include much in the way of fruits and vegetables. When the Heart of New Ulm team first surveyed restaurants, only 19 out of 32 offered a non-fried vegetable dish, and more than half offered no fruit whatsoever. Dieticians met with restaurant owners to discuss how they might include healthier options on their menus. Some were open to the idea. Others resisted. Some even laughed.

Virginia Suker-Moldan runs Turner Hall, the oldest bar and restaurant in New Ulm (est. 1856) and the central gathering spot for the city’s German residents. “I didn’t think there was any way it was going to fly here,” she says. “They asked us to come to a meeting, and I laughed at the other restaurateurs because they were so on board with it,” she recalls. “I thought they were being silly. I agreed to try it if they could make it profitable, but I was really just doing it to be nice.”

Fast-forward three years and Suker-Moldan is now one of the program’s most enthusiastic champions. In 2006, her menu offered only a few items—burgers, steak, ribs, chicken, walleye, brats—prepared unimaginatively and served in volume. “We’re known for our generous portions,” she says. But now there are dozens of menu items, including dinner salads and pita-bread sandwiches. And the most popular side dish is no longer fries—it’s salad. And guess what: The restaurant is more popular and profitable than ever.

Oh, My Aching Heart

Apparently, I’m not quite as healthy as I thought I was. You may not be, either.

There are only a few things that can motivate a man older than 40 to change his daily diet and exercise habits, and one of them is a death sentence from his doctor. Since I happen to fall into the primary age range for participants in the Heart of New Ulm project (40–79), I agreed to get my own health screened.

Going in, I’ll admit, I was cocky. I don’t drink (much) or smoke, I make it to the gym a couple times a week, and I eat oatmeal for breakfast. I own a juicer, too, and have even used it once or twice, so I figured my superior health was a foregone conclusion.

After giving some blood and filling out a questionnaire about my lifestyle, diet, exercise habits, stress level, etc., I sat down with the Minneapolis Heart Institute’s director of preventive cardiology, Dr. Thomas Knickelbine, to discuss my test results. He proceeded to inform me that my fasting blood sugar is high enough to be in the pre-diabetic range; my “good” cholesterol is too low; my “bad” cholesterol is too high; my waistline is a couple inches too large for my height; and, in his estimation, I could do myself a favor by losing 15–20 pounds. Furthermore, all of this put me in the “at risk” category for something called metabolic syndrome, which gives me a 9.1 percent higher chance of having a heart attack in the next 10 years and a 34.8 percent higher chance my heart will stop in 30 years.

“Most people overestimate their overall health,” Knickelbine told me dryly. “They come in here saying, ‘Hey, I’m just doing what I’ve always done,’ without realizing that’s the problem.”

Fortunately, he told me, if I cut the starch and fat in my diet, eat smaller portions, and exercise a little more, I could get my 10-year risk down to 2.8 percent and my 30-year risk lower than 10 percent.

“People don’t realize how much of a difference diet and exercise can make,” he said. He also told me that he included the 30-year number to scare me. “Telling people their 10-year risk doesn’t work—it’s not dramatic enough. But that 30-year number gets people’s attention.”

It got mine. The first thing I did was go buy a bag of carrots and blow the dust off my juicer.

—T. S.


Win-win-win or Lose

None of this would be working, however, if people weren’t ordering more fruit, vegetables, and salmon by choice. “We had to focus on the demand side of the equation in the first few years,” says Boucher, who is now the project’s director. “It had to be a win-win proposition for everyone. Win-win-win, really. Customers had to want it, businesses had to see a profit from it, and local farmers wouldn’t grow more fresh fruit and vegetables unless they had somewhere to sell it.”

To kick-start this demand, the project saturated New Ulm with heart-healthy messages, slogans, and information about events and programs in every possible medium: radio, TV, billboards, newspapers, magazines, Facebook, Twitter, you name it. “We want to reach people where they work, play, eat, and live,” says Boucher. But it’s not about twisting people’s arms or guilting them into eating leafy greens, she insists. “It’s about offering people choices, letting them know what their options are, and making the healthy choice the easy choice.”

Billboards on either side of town encourage citizens to “Swap It to Drop It!”—that is, have a salad instead of fries, or an apple and some nuts instead of a Snickers bar. Programs such as “Girls and Moms on the Move” and “Holiday Trimmings” encourage folks to work together toward their weight-loss goals. Restaurants display their Heart of New Ulm health ranking—gold, silver, or bronze—on decals prominently in the front window. At George’s Fine Steaks & Spirits, the first restaurant in town to receive the coveted gold ranking, there is a separate menu with smaller portions, less fat, and all of the meal’s nutritional information broken down for all to see. The town even has a cable-access TV show called What’s Cooking, New Ulm? dedicated to heart-healthier cooking. And people actually watch it.

“It’s amazing,” says CSA farmer John Knisley. “People will come up to me and say, ‘Hey, weren’t you on that cooking show?’” Knisley grew up in New Ulm, went to college in Bemidji, and two years ago moved back home to start a sustainable organic farm specializing in heirloom produce. He and his wife, Brooke, are now the proud proprietors of Alternative Roots Farm, one of several community supported agriculture ventures that have sprouted up as the demand for locally grown produce has increased.

A thoughtful, earnest, surprisingly young man, Knisley says it’s not just the older folks in town who are changing their habits and demanding better food. “Since the Heart of New Ulm started, we’ve definitely seen a change in the age demographic shifting to younger people. More younger people are wanting to eat healthier food, and they know that it’s here now.”

Knisley approaches his craft with the sort of idealism and generosity of spirit that makes you feel as if the future—or at least the future of New Ulm—is in good, if dirty, hands. Alternative Roots Farm will feed 27 families in its CSA program this year, twice as many as last year, but profits from the farm can’t support Knisley’s family yet, so he works full-time in the county’s planning and zoning department. “It’s not about picking up a box of vegetables every week, and it’s not about running a business,” he insists. “It’s about creating a relationship with these families. It’s about serving the community.”

Big Data

That said, one of the other reasons the Heart of New Ulm project is working so well—and a key factor that distinguishes it from other community-based health programs—is that it also provides counseling and support tailored for individuals. In fact, one of the main reasons New Ulm was chosen for the project is that 96 percent of its population uses one hospital, Allina’s New Ulm Medical Center. Because most of the city’s health records are contained in a single database, doctors, dieticians, and researchers can track the population’s health metrics—weight, blood pressure, cholesterol, etc.—and determine what effects, if any, their programs are having on people’s individual and collective health.

They also know if you’ve been bad. If a health screening reveals that you are clinically obese, have high blood pressure or cholesterol, or are otherwise at risk for what is known as metabolic syndrome, which puts you at higher risk for a heart attack, you will get an e-mail and/or personal call from a nurse or dietician. If you do not hang up on them, they will offer to work with you to develop a health-improvement plan that specifically addresses your needs. All for free.

Jane Soukup, a longtime resident of New Ulm, has been trying to lose weight most of her adult life. But nothing worked, she says, until she sat down with a dietician to discuss her eating and exercise habits. “I’d tried everything,” says Soukup. “My body has just always fought me.”

At her free consultation, Soukup learned that many of her lifelong eating habits had been shaped by myths about healthy eating she’d been misinformed about since childhood. “I grew up on a farm, and one of the things I’d always heard was that you shouldn’t eat after 6 pm.” And that’s how she lived, because even though she often went to bed hungry, she was afraid she’d gain even more weight if she snacked at night.

“The dietician asked me when I felt best in my life, and I told her it was when I was pregnant and eating every two hours,” Soukup recalls. “She recommended that I eat that way full-time, eat fewer carbs, bump up the vegetables, and—here’s the kicker—that I should eat a sandwich before going to bed.”

Soukup was surprised by that last piece of advice and didn’t think it would work, but it did. She’s lost 65 pounds in the past three years and is close to reaching her goal weight. “That sandwich made all the difference,” she says. “It turns out my body thought it was starving at night, and the sandwich kept my blood sugar and metabolism up.”

Everyone alive is at a different stage in the arc of their personal health, so this sort of one-on-one advice is crucial, both to the patient and the project in general. “In New Ulm, we have access to an extraordinary amount of data and permission to use it for outreach and intervention,” says Dr. Thomas Knickelbine, director of preventive cardiology at the Minneapolis Heart Institute and head research cardiologist for the project. “That’s huge,” he says, because most cities are served by multiple hospitals and health care networks, all of which use different computer systems, making it difficult to share patient information. Consequently, even if patients consent to share their personal health records, compiling data for entire city populations can be extremely difficult, if not impossible.


The Expensive Killer

Cardiovascular diseases cause one in three deaths in the United States, and heart attacks in New Ulm cost an average of $50,000 each to treat. Including indirect costs such as absent workdays, decreased productivity, and short-term disability, the total economic burden of heart attacks in New Ulm is estimated to be about $8 million annually, or $80 million over the course of a decade.

The goal, of course, is to eliminate heart attacks. But even if the Heart of New Ulm project can reduce the town’s rate of heart attacks by 25 percent in 10 years (in other words, prevent two additional heart attacks each year, relative to the previous year), it’s estimated the program will save $10 million over 10 years—about the same amount Allina is investing in it. The bonus prize is that the risk factors for a heart attack are the same for a host of other chronic diseases (diabetes, cancer, stroke, kidney disease, and perhaps even dementia), so a reduction in those areas could yield more savings—and, theoretically, improve the local economy.

Toward that end, the project appears to be working better and faster than anyone could have hoped. Blood pressures have dropped 4 percent, cholesterol levels have dropped 3 percent, and the average weight of New Ulm-ites has been trimmed from 184 pounds to 181. “A few percentage points may not sound like much,” says Knickelbine. “But to move the needle like that across an entire population, that’s significant.”

The number of heart attacks and deaths due to heart attack has also dropped—as much as 24 percent in one 15-month period—but researchers are reluctant to claim credit for this rather remarkable result until more data is on the books. The only blemish on the program so far is that folks appear unwilling to give up their cigarettes. “That’s one area where we haven’t had much success,” admits Knickelbine. “And it’s an important one, because smoking is one of the top three risk factors for a heart attack.”

One person who did stop smoking is Donna Oeltjenbruns. One of the biggest motivators for her was the fact that so many other people in town and at work were getting involved. “Everyone wants to be part of a group,” she says. “When you see a large group moving in a direction and you’re not moving in that direction with them, you feel left out. I might have dug in my heels at first, but then I got behind it.” Which is an excellent description of how social contagion works.

Pride and Permanence

The Heart of New Ulm project still has five years to go, and even the project’s leaders caution that 10 years of data, while nice, is only a beginning. Will the changes that are happening now be permanent? Can people keep the weight off? Will New Ulm’s next generation pick up the reformed diet and exercise habits of their parents and grandparents? Check back in 25 years.

For now, New Ulm is in the middle of one of the most interesting and potentially important social engineering projects in the country. And if it works in the long run, the project could have broad implications for those trying to grapple with the country’s runaway appetite for lousy food and increasingly expensive health care. Last year, the United States spent roughly $500 billion treating cardiovascular diseases and another $400 billion treating obesity and diabetes—costs that are projected to go nowhere but up unless people change the way they eat and live.

“We really want to be known as a healthy place to live,” says New Ulm mayor Robert Beussman, whose own bypass surgery happened on his wife’s birthday, of all days. “If we can prevent even one family from going through what mine had to, it’ll be worth it,” he says.

You can still get beer, brats, and butter in New Ulm, of course. But now you have to really want them—and at least consider going for a run afterward.