Jan. 3, 2007 -- Dr. Dean Ornish has spent the past 30 years studying the effect exercise, a low-fat diet and stress reduction can have on health. Ornish was the first to show that these lifestyle changes could actually reverse severe heart disease without drugs or surgery.
Ornish's latest book, "The Spectrum," offers advice on how to personalize a health plan to fit your goals and preferences — without diets, deprivation or guilt.
Read the first chapter of "The Spectrum" below.
Chapter One: It Works!
The one thing more difficult than following a regimen is not imposing it on others. -- Marcel Proust
I just had a piece of chocolate. Dark chocolate. Really high-fat gourmet dark chocolate. It was delicious. I have a little chocolate almost every day.
Now, you may be wondering if I'm cheating on my very own diet. Well, no, I'm not. I'm enjoying my very own diet.
I'm writing this book to help you understand that you have a broad spectrum of choices when it comes to what you eat, how much you exercise, how you manage stress, and how you live. It's not all or nothing. In the process, I hope to dispel some misconceptions about what I recommend.
In short, this book will show you how to personalize a way of eating and living that's just right for you, based on your own needs and preferences. It has been scientifically proven to help you feel better, live longer, lose weight, and gain health.
It works! Why? Because it's based on pleasure, not pain; abundance, not deprivation; science, not myth; freedom and power, not restriction and manipulation. Joy of living is sustainable; fear of dying is not.
There are many myths and false choices that are confusing to many people. These include:
If I live and eat healthfully, am I going to live longer or is it just going to seem longer?
Is it fun for me or good for me?
Low-fat or low-carb?
Fast food or good food?
Atkins indulgent or Ornish ascetic?
You really don't have to make these choices.
This is a book about how to enjoy life more fully while enhancing your health and well-being. It's based on our latest research showing that you can actually change how your genes are expressed just by changing what you eat and how you live.
In short, this book can empower you to transform your own life.
By now, many people are thoroughly exasperated by the seemingly contradictory information they read about what a sound nutrition and lifestyle program should be. Nowhere are the claims more conflicting than in the area of diet. I often hear, "Those damn doctors! They can't make up their minds. To hell with 'em, I'll eat and do whatever I want and quit worrying about it!"
I understand why many people feel that way. It can be really confusing when even the experts don't seem to agree.
Fortunately, at a time when people are more confused than ever, there is an emerging consensus about what to eat and how to live. The jury is in: a convergence of scientific evidence can help us resolve conflicting claims and distinguish what just sounds good from what is proven to be true.
Now it is possible to cut through the confusion and to customize a diet and lifestyle program just right for you based on your own needs and preferences. You have a spectrum of choices.
People have different needs, goals, and preferences. The medicine of the future is personalized medicine, which this book brings you today.
The recipes and cooking instructions, by the renowned chef Art Smith, are for foods that taste good and also make you look good and feel good. Many of them have several versions, so you can customize them to meet your own needs and preferences.
It seems that many people have misconceptions about what I eat and how I live my own life. For example, a few years ago, the playwright and producer Mike Nichols came up to me at a benefit for a foundation and said, "Hey, Dean, I'm on your diet -- if it tastes good, I can't eat it"-- echoing Mark Twain, "The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not."
This is the most common misunderstanding about my work -- that I recommend one really strict diet and lifestyle program for everyone. "Yes, it works, but it's almost impossible to follow."
It's understandable why so many people believe this. Many of the media stories on the work my colleagues and I have conducted have focused on our research showing that heart disease and other chronic diseases can be reversed--and they often can!--just by making comprehensive lifestyle changes. Reversing a disease does require the stricter version of the diet and lifestyle program--the pound of cure--whereas if you're just trying to feel good and stay healthy you need only the ounce of prevention. However, for people who aren't sick, I recommended a spectrum of choices.
In this book, I'm not trying to get you to do--or not do--anything. Food and lifestyle choices are deeply personal decisions. Having seen what a powerful difference changes in diet and lifestyle can make, I want to share these findings with you so that you can make intelligent choices in what you eat and how you live. How much or little you want to change, if at all, is entirely up to you. More on this later.
Whenever I go out to dinner, people often comment on what I'm eating or apologize for what they're eating--"I have to be careful what I eat around you"--as though I'm going to be the sheriff or the vice principal of the high school waving my finger at them, judging them, and shaming them into eating differently.
In reality, nothing could be further from the truth. So I usually make a sign of the cross and say, jokingly, "You are forgiven," and we all have a good laugh about it. I then tell them that it doesn't matter to me what they eat or how they live as long as they're happy. When I order dessert, they often feel both surprised and relieved.
What makes this book unique is that it's based on three decades of research proving what works, what doesn't, for whom, and under what circumstances. Most books are written based on anecdotal testimonials (which are often unreliable), or on the experience of others, or on wishful thinking. They may make promises that often remain unfulfilled.
Instead, this program is grounded in science, and it's been proven to work:
My colleagues and I at the nonprofit Preventive Medicine Research Institute have proven that this program works to help prevent, and to slow, stop, and even reverse the progression of the most common and most deadly diseases, including coronary heart disease, prostate cancer, diabetes, hypertension, obesity, elevated cholesterol levels, arthritis, and many other chronic diseases.
We recently conducted the first study in men with prostate cancer showing that our program of comprehensive lifestyle changes may change how your genes are expressed--in general, turning on (upregulating) the good parts of the genes and turning off (downregulating) the harmful ones. More on this in chapter 4.
We recently conducted the first study showing that comprehensive lifestyle changes may improve how quickly your cells age. Telomeres are the ends of your DNA, and they affect longevity. As they become shorter and their structural integrity is weakened, cells age and die more quickly. In simple terms, as your telomeres get shorter, your life gets shorter. In our new study, we found that the telomerase enzyme (which repairs telomeres) increased significantly in those who went through our diet and lifestyle program after only three months.
We learned what really works to motivate people to make and maintain comprehensive lifestyle changes in the real world. We've consistently shown that our program can motivate many people to make and maintain bigger changes in diet and lifestyle, and to achieve better clinical outcomes and larger cost savings in diverse groups of people than have ever before been demonstrated.
Let's examine these.
The program works to prevent and even reverse disease.
People often think that advances in medicine have to be a new drug, a new laser, or a surgical intervention to be powerful--something really high-tech and expensive. They often have a hard time believing that the simple choices we make in our lives each day--what we eat, how we respond to stress, whether or not we smoke, how much we exercise, and the quality of our relationships--can make such a powerful difference in our health, our well-being, and our survival, but they often do.
Awareness is the first step in healing. When we become more aware of how powerfully our choices in diet and lifestyle affect us--for better and for worse--then we can make different ones. It's like connecting the dots. In my experience, many people are not afraid to make big changes in their lives if they understand the benefits of doing so and how quickly they may occur.
Part of the value of science is to raise our awareness by helping us understand the powerful effects of the diet and lifestyle choices we make each day and how changing these may significantly--sometimes dramatically--improve our health and well-being. In many cases, these improvements may occur much more quickly than people once believed possible.
In our studies, we used the latest in high-tech, expensive, state-of-the-art measures to prove how robust these very simple, low-tech, and low-cost interventions can be.
For more than thirty years, I've directed a series of scientific research studies showing, for the first time, that the progression of even severe coronary heart disease can often be reversed by making comprehensive lifestyle changes. These include a very-low-fat diet including predominantly fruits, vegetables, whole grains, legumes, and soy products in their natural, unrefined forms; moderate exercise such as walking; various stress management techniques, including yoga-based stretching, breathing, meditation, and imagery; and enhanced love and social support, which may include support groups.
In these studies, we also documented that other chronic diseases may be reversible simply by making comprehensive lifestyle changes. Our findings are giving literally millions of people worldwide new hope and new choices, options that are more caring and compassionate as well as more cost-effective and competent.
More recently, we published the results of a randomized controlled trial in collaboration with Peter Carroll, M.D. (Chair, Department of Urology, School of Medicine, University of California, San Francisco) and William Fair, M.D. (Chief of urologic surgery and Chair of urologic oncology, Memorial Sloan-Kettering Cancer Center, now deceased) showing that the progression of early-stage prostate cancer may be slowed, stopped, or perhaps even reversed by making similar changes in diet and lifestyle. This may be the first randomized controlled trial showing that the progression of any type of cancer may be modified just by changing what we eat and how we live. What's true for prostate cancer may be true for breast cancer as well, as I describe in chapter 14.
Our research has been conducted in collaboration with the most credible scientific investigators at major academic medical centers. Our findings have been published in the leading peer-reviewed medical journals, including The Lancet, The Journal of the American Medical Association, The American Journal of Cardiology, Circulation, Journal of Cardiopulmonary Rehabilitation, Journal of Urology, Yearbook of Medicine, Yearbook of Cardiology, The New England Journal of Medicine, Homeostasis, Urology, Journal of the American Dietetic Association, Hospital Practice, Cardiovascular Risk Factors, World Review of Nutrition and Dietetics, Journal of Cardiovascular Risk, Obesity Research, Journal of the American College of Cardiology, and others.
Our program has also been featured in the leading standard medical textbooks, including Harrison's Principles of Internal Medicine, Clinical Trials in Cardiovascular Disease (companion to Heart Disease, the Braunwald standard cardiology textbook), Harrison's Advances in Cardiology, and Clinical Trials in Cardiovascular Disease (second edition), as well as a number of general-interest books, including Bill Moyers's Healing and the Mind, among others.
Research findings documenting the benefits of our program have been presented at numerous scientific meetings, including the annual scientific meetings of the American College of Cardiology, beginning in 1982; the American Heart Association, beginning in 1983; and the Society of Behavioral Medicine, beginning in 1988, as well as many other scientific and medical conferences. On several occasions, our research was highlighted at these meetings and featured at press conferences convened by these organizations.
I say this just to emphasize that the program described in this book has been proven to work in the most rigorous and credible peer-reviewed evaluations. And that matters. A lot.
I have spent so much of my time conducting scientific research because it's important to be able to substantiate and validate whatever health promises are made. In 2000, I was appointed to the White House Commission on Complementary and Alternative Medicine Policy. More than a thousand people testified before our committee.
I learned that more money is spent out of pocket for alternative medicine than for traditional medicine. Why? Many people have become disenchanted with conventional medicine and have embraced a variety of alternative interventions. However, they may find themselves disillusioned with some of these approaches as well because many of them do not have scientific evidence to support their claims.
Seen from this perspective, our program is (as of this writing) one of the most scientifically documented alternative medicine approaches. It integrates the best of traditional and nontraditional approaches to health and healing.
I also understand the limitations of science. As Albert Einstein once said, "Not everything that can be counted counts; and not everything that counts can be counted"--for example, love and joy, as I'll describe later--but many things that are meaningful are also measurable. Also, part of the reason that the public receives so much conflicting information is that there is a lot of bad science out there. In this book, I'll show you how to critically analyze some of these studies.
In our cardiac studies, beginning in 1977, we found that there was a 91 percent reduction in the frequency of angina (chest pain) after only a few weeks, and most of these patients became pain-free. These were patients with very severe coronary heart disease, many of whom literally could not walk across the street without getting severe chest pain and shortness of breath when they began.
After one year, there was a 40 percent average reduction in LDL cholesterol levels. This is comparable to what can be achieved with statin drugs like Lipitor without the costs (more than $15 billion last year) or side effects (both known and unknown).
In the Lifestyle Heart Trial, there was significant reversal in coronary artery blockages in the group that went through our program after only one year, whereas those in the randomized control group, who made more conventional changes, showed a worsening of their coronary artery blockages.
Based on these findings, we received peer-reviewed funding from the National Heart, Lung, and Blood Institute of the National Institutes of Health to extend the study intervention for four additional years. We wanted to find out if patients could continue to maintain these comprehensive lifestyle changes for five years and, if so, what the long-term effects would be. We found that most patients continued to follow this program for five years even though they had initially volunteered only for a one-year study.
There was even more reversal in coronary artery blockages after five years than after one year, whereas patients in the randomized control group showed even more worsening after five years than after one year. These differences were highly statistically significant; see the following graph.
There are two basic ways of measuring the severity of coronary heart disease: anatomical (which measures the severity of coronary artery blockages) and functional (which measures the amount of blood flow to the heart and also how well it pumps). In our research, we used state-of-the-art tests: quantitative coronary arteriography to measure the degree of coronary artery blockages and cardiac PET (Positron Emission Tomography) scans to measure blood flow to the heart.
The following figure shows a representative patient in our study. This is what reversing heart disease looks like. He entered our study in 1986 at age 64. At that time, he had severe coronary artery disease involving all of his major coronary arteries and was advised to undergo coronary bypass surgery due to severe angina. When he entered the study, he was unable to walk more than a few steps without severe chest pain.
After six weeks, he was pain-free and was no longer advised to undergo bypass surgery. By the end of the first year, he was able to climb 130 floors per day on a StairMaster with no angina. His PET scan revealed a 300 percent improvement in blood flow to his heart, and his angiogram revealed reversal of coronary atherosclerosis. He also lost 30 pounds.
The picture in the upper-left-hand corner is the "before" picture of his angiogram, showing a significant narrowing in the coronary artery. One year later, in the upper-right-hand photo, that area is significantly wider.
The PET scans of the same patient are shown in the bottom two pictures. Different shadings correspond to how much blood flow each region of the heart received--the darker areas are receiving very little blood flow to the heart, whereas the brighter ones are receiving the most blood flow.
The picture at the lower left revealed that much of this patient's heart was not receiving adequate blood flow, as shown by the large dark areas. One year later, in the lower-right-hand picture, you can see that most of the darker areas are now gone, replaced by brighter ones, showing substantially more blood flow.
These tests were read by scientists who did not know which group the patient was in--in other words, whether or not the patient had changed his or her lifestyle. This helped prevent any possible bias from affecting how the studies were read and interpreted.
Amazingly, 99 percent of patients on our program were able to stop or reverse the progression of their heart disease. There were also 21/2 times fewer cardiac events such as heart attacks, bypass surgery operations, angioplasties, and hospital admissions.
We found a direct correlation between the amount of change in diet and lifestyle and the amount of change in these patients' coronary artery disease after one year and also after five years.
In other words, the more people changed, the better they got. This is a theme that I will be repeating throughout the book, and it is one of the foundations of The Spectrum.
Similar findings were published five years later by Dr. Caldwell Esselstyn and his colleagues at The Cleveland Clinic. In a follow-up medical journal article, he reported that none of the patients who remained adherent to the nutrition and lifestyle program showed progression of their coronary heart disease.
The program works in the real world.
When I first began conducting research as a second-year medical student in 1977, the idea that the progression of heart disease could be reversed was thought to be impossible by most doctors. They thought that, at best, diet and lifestyle changes might slow down the rate at which the disease progressed, but it could only get worse over time. Equally improbable was the belief that most people would be able to change their diet and lifestyle.
After we and others proved that the progression of coronary heart disease and other chronic diseases could often be reversed by making comprehensive lifestyle changes, these misconceptions slowly began to change. Now most doctors believe that heart disease is reversible.
Then the skepticism shifted. Although most physicians believe that the diet and lifestyle program I recommend works, they often think that the majority of people can't follow it because it's too strict, too hard, and too boring. So why bother? "Okay, your patients changed, but you live in California. It's an altered state. They'll do anything there. And you're some kind of guru; you can somehow brainwash people to change."
All About the Benjamins
When we published our research findings, I thought these would significantly change medical practice, but I was a little naive. With all the talk about evidence-based medicine, we really live in an era of what I call "reimbursement-based medicine."
I realized that it wasn't enough to have good science; we also needed to change reimbursement. We doctors do what we are paid to do, and we are trained to do what we are paid to do. Therefore, if we could change reimbursement, then we would improve both medical practice and medical education. As Sean Combs sings, "It's all about the Benjamins" (Benjamin Franklin on hundred-dollar bills).
Beginning in 1993, my colleagues and I began training personnel in more than fifty hospitals and clinics around the country in our diet and lifestyle program via our nonprofit research institute. We conducted three demonstration projects--one with Mutual of Omaha, a second with Highmark Blue Cross Blue Shield, and most recently with Medicare.
We began in 1993 with a demonstration project sponsored by Mutual of Omaha. The questions we wanted to answer were: (a) Could people in Omaha, Des Moines, and South Carolina (where they told me "gravy is a beverage") follow this program as well as those in San Francisco, Boston, or New York? (b) Could we train other health professionals to intervene with their patients as effectively as we could? (c) Was this medically effective as well as cost-effective?
In this first demonstration project, we trained personnel in eight hospitals: Beth Israel Medical Center in New York; Beth Israel Medical Center at Harvard Medical School in Boston; the University of California, San Francisco; Scripps Institute in La Jolla; Alegent Medical Center in Omaha; Richland Memorial Hospital in Columbia, South Carolina; Broward General Hospital in Fort Lauderdale, Florida; and Mercy Hospital in Des Moines, Iowa. Our data-coordinating center was at Harvard Medical School, directed by Alexander Leaf, M.D., who was chair of the Department of Medicine at Harvard Medical School.
Reimbursing comprehensive lifestyle changes is not only medically effective, it's also cost-effective.
In brief, we found that almost 80 percent of patients who were eligible for bypass surgery or angioplasty were able to safely avoid it for at least three years. Mutual of Omaha found that it saved almost $30,000 per patient in the first year! We published these findings in the peer-reviewed The American Journal of Cardiology.
By then, more than forty insurance companies besides Mutual of Omaha were covering our program, on either a defined-benefit or case-by-case basis. One of these was Highmark Blue Cross Blue Shield, which had such great results that it decided to provide the program in three sites as well as to reimburse it.
Highmark Blue Cross Blue Shield conducted its own demonstration project. As in the Mutual of Omaha demonstration project, it compared people who went through our program with similar patients who did not (called a "matched control group study").
Highmark found that its overall health care costs were reduced by 50 percent in the first year and by an additional 20 to 30 percent in subsequent years. At a time when health care costs (really, disease care costs) are reaching a tipping point, these findings are even more important today.
After the success of these two demonstration projects plus the earlier randomized controlled trials, we approached Medicare to see if it would provide coverage. It initially said no.
In 1995, Chip Kahn (who was then the staff director of the House Ways and Means Health Subcommittee) introduced me to Bruce Vladeck, Ph.D., who was the administrator (Director) of Medicare at the time. In that meeting, Dr. Vladeck said, "Dean, before I'll consider doing a Medicare demonstration project, you first need to get a letter from the director of the National Heart, Lung, and Blood Institute of the National Institutes of Health stating that your program is safe."
"You mean that it's safe as an alternative to bypass surgery or angioplasty?"
"No, just that it's safe."
I was incredulous. "You want me to get a letter saying that it's safe for older Americans to walk, meditate, quit smoking, and eat fruits and vegetables?"
So I met with Dr. Claude Lenfant, who was Director of the National Heart, Lung, and Blood Institute at the time, and his colleagues, and we reviewed the medical literature. Not surprisingly, we found that these are not high-risk activities--especially when compared with having your chest sawed open for a bypass operation. In our earlier research, we had found that older patients improved as much as younger ones, whereas the risks of bypass surgery and angioplasty increased in older patients. So these lifestyle changes are especially beneficial for older patients in the Medicare population.
Dr. Lenfant then sent a letter to Dr. Vladeck saying that the nutritional program I recommend is safe, whatever the age of the patients following it.
A month went by. Dr. Vladeck then wrote a letter back to Dr. Lenfant saying that although he had said that the nutritional program is safe, is it okay for people over sixty-five to do moderate exercise and stress-management techniques?
Not surprisingly, Dr. Lenfant replied that these were of "minimal risk" provided that patients are offered all proven treatments.
Four years later, in 1999, with strong bipartisan support from then President Clinton, then Speaker of the House Newt Gingrich, Representatives Nancy Pelosi, Charles Rangel, Alcee Hastings, Lynn Woolsey, and Dan Burton, Senators Barbara Boxer, Arlen Specter, Dianne Feinstein, Ted Stevens, Hillary Clinton, Bill Frist, Maria Cantwell, Chuck Robb, Jay Rockefeller, and Barbara Mikulski, and others across the political spectrum, Medicare agreed to conduct a demonstration project.
We've gotten to a point in medicine where it's considered "conservative medicine" to cut open someone's chest or to inflate balloons and put stents inside his or her coronary arteries even in the absence of data showing that these approaches prevent heart attacks or extend life in stable patients with heart disease, yet it's considered high risk or even radical to ask people to walk, meditate, quit smoking, and eat fruits and vegetables.
In January 2005, after we completed our Medicare demonstration project, a Medicare Coverage Advisory Commission hearing was convened at the Centers for Medicare and Medicaid Services headquarters in Baltimore to peer-review our findings. I presented data from more than 2,000 patients who had participated in our three demonstration projects (with Mutual of Omaha, Highmark Blue Cross Blue Shield, and Medicare). At this daylong hearing, seventeen experts who were on the Medicare Coverage Advisory Commission reviewed data from our program and others similar to it.
At the end of that day, these experts voted that there was sufficient scientific evidence for Medicare to cover our program for reversing heart disease.
Based on these findings, the Centers for Medicare and Medicaid Services recently agreed to provide Medicare coverage for our program for reversing heart disease and other programs like it. This was a major breakthrough, as it was the first time that Medicare covered an integrative-medicine program of comprehensive lifestyle changes. Since reimbursement is a major determinant of medical practice and medical education, Medicare coverage may help make programs of comprehensive lifestyle changes much more sustainable and widely available to those who most need them.
Now my colleagues and I at the nonprofit Preventive Medicine Research Institute are training health professionals worldwide and providing free licenses to them in an open-source model. These include physicians, nurses, registered dietitians, yoga and meditation teachers, clinical psychologists, chefs, exercise physiologists, and so on. Those we train are making our program available in hospitals, clinics, and other venues and sharing their data with us so we can collect data on large numbers of people at low cost.
This allows us to learn from the experience and best practices of many other people on an ongoing basis, thereby enabling us to continue to refine and improve our program in an organic process. Over time, we can collect data on large numbers of patients and gain greater insight about the effects of comprehensive lifestyle changes in large numbers of people around the world.
Our research has shown that your body often has a remarkable capacity to begin healing itself--and much more quickly than people once realized--when we address the underlying causes of illness. For many people, the choices we make each day in what we eat and in how we live are among the most important underlying causes.
When most people are prescribed medications to lower their blood pressure, cholesterol, or blood sugar, they are usually told, "You will have to take this for the rest of your life," often in ever-increasing dosages. Why? Because the underlying causes are not being addressed. When I lecture, I often show a slide of doctors busily mopping up the floor around an overflowing sink without also turning off the faucet.
It's important to treat not only the problem but also its underlying causes. Otherwise, the same problem often recurs (for example, bypass grafts or angioplastied arteries clogging up again), a new set of problems may happen (such as side effects from medications), or there may be painful choices (such as keeping 47 million Americans from having health insurance because it's too expensive to treat everyone with the drugs or surgery that they may need).
We found that many people with coronary heart disease, diabetes, high blood pressure, elevated cholesterol levels, and other chronic conditions are able to reduce or even discontinue these medications (under their doctor's supervision) when they make the diet and lifestyle changes that are outlined in this book.
With the legitimate concerns about pandemics of AIDS and avian flu, it's easy to forget that cardiovascular disease kills more people each year worldwide than any other disease. It's the biggest pandemic of all time. Heart disease is so common that we've become accustomed to it, thinking of it as a natural cause of death. Yet there's nothing natural about it.
Diabetes and obesity are also becoming pandemic. In just the past ten years, the incidence of diabetes in the United States has increased 70 percent among people in their thirties, in large part because of the obesity pandemic. In India, a recent study conducted by the Delhi Diabetes Research Centre among schoolchildren ages 10 to 16 found nearly one in five to be either overweight or clinically obese. A major complication of diabetes is heart disease, along with nerve, eye, and kidney damage.
However, coronary heart disease, type 2 diabetes (once known as adult-onset, though an increasing number of younger people are now getting it), and obesity can be prevented in almost everyone simply by making sufficient changes in diet and lifestyle. We don't have to wait for a breakthrough in technology or a new drug; we just need to put into practice what we already know. If we did, these pandemics could be as rare as malaria is in the United States.
In addition to our research, the landmark INTERHEART study, led by Canadian scientists, followed 30,000 men and women in fifty-two countries on six continents. It found that nine factors related to nutrition and lifestyle accounted for almost 95 percent of the risk of a heart attack in men and women in almost every geographic region and in every racial and ethnic group worldwide. These factors were: smoking, cholesterol level, hypertension, diabetes, obesity, diet, physical activity, alcohol consumption, and psychosocial issues such as emotional stress and depression.
In other words, the disease that kills the most people each year worldwide and accounts for the single largest expenditure of health care dollars is almost completely preventable just by changing diet and lifestyle in ways described in this book.
Despite this, relatively little of the money spent by most insurance companies has gone toward teaching people how to prevent or treat cardiovascular disease and other chronic diseases by changing their diet and lifestyle. Much of it goes to pay for surgical procedures such as angioplasty and bypass surgery.
You may be surprised to learn that angioplasty does not reduce the risk of a heart attack and does not prolong life in patients with stable coronary heart disease. This was the remarkable conclusion of a study published in June 2005 in Circulation, the American Heart Association's lead scientific journal, in which researchers reviewed all eleven randomized controlled trials of angioplasty. The same conclusion was found in a recent large-scale randomized controlled trial published in The New England Journal of Medicine.
It's hard for many people to believe that comprehensive lifestyle changes work even better than drugs and surgery in treating heart disease, but they often do. For example, a major study, also published in Circulation, found that regular physical exercise worked even better than angioplasty for preventing heart attacks, strokes, and premature deaths. Another study, published in The New England Journal of Medicine, found that those taking the cholesterol-lowering statin Lipitor had 36 percent fewer cardiac events after eighteen months than those undergoing angioplasty.
Several randomized controlled trials have shown that coronary bypass surgery prolongs life only in those with the most severe disease, which is only a small percentage of those who receive it. Angioplasty and bypass surgery may reduce the frequency of angina (chest pain), but most people can reduce angina at least as much in only a few weeks just by changing their diet and lifestyle, if these changes go far enough in the healthy direction on the Spectrum.
In short, most insurance companies have been paying billions of dollars for surgical procedures that are invasive, dangerous, expensive, and largely ineffective, whereas they pay little or nothing for the diet and lifestyle interventions described in this book, which are noninvasive, safe, inexpensive, and powerfully effective in treating coronary heart disease as well as many other chronic diseases. And the only side effects are good ones.
The managed care approach of shortening hospital stays, limiting reimbursement, capitation, and forcing doctors to see more patients in less time leaves everyone frustrated and unhappy because this approach does not address the more fundamental causes of why people get sick. It's a different type of bypass.
Last year, more than one million coronary angioplasties and more than 400,000 coronary bypass operations were performed in the United States at a cost of more than $100 billion. Among Medicare beneficiaries, the number of these operations increased 543 percent between 1984 and 1996 despite the absence of clear outcome benefits. This challenges the sustainability of Medicare.
These health care costs (as mentioned earlier, these are really disease care costs) are also challenging the viability of many businesses and corporations. General Motors spends more on medical care for its employees than it does to buy steel. Howard Schultz, the founder and chairman of Starbucks, said that he spends more on health care for his employees than for coffee beans. As the population ages and health care costs continue to outpace inflation, many corporations project that they will reach a tipping point in only a few years in which health care costs exceed their entire profits. Clearly, this is not sustainable.
At Safeway, this has already happened. Profit margins are lower in the grocery business than in many others, so grocery stores are like the "canary in the coal mine" that sees trends before they affect other businesses.
According to Steven Burd, the chief executive officer of Safeway, "In 2005, our health-care costs for our employees reached $1 billion and were exceeding our net income by about 20 percent." Clearly, this was not sustainable. I consulted with him and his colleagues there (including Kenneth Shachmut and Michael Minasi) to help develop incentives for wellness and prevention services in their health plan. The following year, Safeway's health care costs declined by 11 percent and remained flat in 2007.
What I especially like about this approach is that it is bringing together Democrats and Republicans and labor and management toward a common goal of lowering health care costs, providing universal coverage, and improving the quality of care.
Unfortunately, most insurance companies pay only for drugs and surgery, not for diet and lifestyle. They will pay $30,000 to amputate a diabetic foot, for example, but not a few hundred dollars for foot care and nutrition counseling that can prevent the need for amputation in most people. Most diabetes-related amputations are preventable with scrupulous care, but foot care is not usually covered. Similarly, they'll pay $40,000 for an angioplasty and stents or for coronary bypass surgery but won't cover comprehensive lifestyle changes that can prevent the need for these. I see perverse incentives and disincentives that reward surgical procedures and drugs over preventive approaches throughout medicine.
All of the doctors I know are genuinely interested in helping their patients. However, since we're trained to use drugs and surgery but not lifestyle interventions and preventive approaches, and we're reimbursed to use drugs and surgery but not lifestyle interventions and preventive approaches, it's not surprising that most physicians rely primarily on drugs and surgery. As the pressures of managed care cause doctors to spend less and less time with more and more patients, there is not enough time to talk about diet and lifestyle issues. This is profoundly unsatisfying for both doctors and patients.
Thus, at a time when the limitations and unaffordable costs of high-tech interventions such as angioplasty and stents are becoming better-documented, the power of and cost savings from low-tech interventions such as the diet and lifestyle changes described in this book are also becoming clearer--when they are most needed.
In one of the more extreme examples of how powerful changes in diet and lifestyle can be, my colleagues and I worked with a few men and women who had such severe coronary heart disease that they were waiting for a heart transplant.
Patients with especially severe coronary heart disease sometimes require cardiac transplantation because the heart is pumping blood so inadequately. Unfortunately, there is a shortage of organ donors, so the average waiting time for a donor to become available in most parts of the country is one to two years. (Unlike giving blood, most people are not willing to donate their hearts.) Approximately half of the patients waiting for a heart transplant die before a donor becomes available. And heart transplantation is quite expensive, costing from $250,000 to $500,000 per patient.
Also, in perhaps the ultimate example of what happens when you don't address the underlying cause of a problem, patients who undergo heart transplants often need another one just a few years later. It's a little like changing your oil filter without also changing the oil--it just clogs up again fairly quickly.
Since these patients were just waiting around for a new heart anyway, we offered a few of them the opportunity to go through our program of comprehensive lifestyle changes while waiting for a donor. After one year, some improved so much that they no longer needed a heart transplant! It's amazing to me that these low-tech interventions of comprehensive lifestyle changes may be, at times, even more powerful than the most high-tech interventions such as a heart transplant. Unlike our other research, this is anecdotal data but it is still intriguing.
We published findings on a larger number of patients with impaired ability of their hearts to pump and found that they improved as much as those with hearts that were not as impaired when they entered our program.
Art Smith (no relation to Chef Art Smith) is a seventy-one-year-old man with heart disease so severe that he was told that he was a candidate for a heart transplant in 1992. "I had trouble walking even twenty feet then, I was so short of breath."
In 1994, he entered the program for reversing heart disease based on my work at the Alegent Immanuel Medical Center in Omaha (in other words, the healthiest end of the Spectrum). "I followed it to a 'T,' " he said. "I had so much more energy and was feeling so much better that I was able to go on a heart walk for four miles around the lake. My wife and son were with me, and they couldn't believe how well I was doing."
According to his wife, Shirley, "He had more pep. He was a new man. It gave us new hope. I couldn't believe how much our lives changed for the better. I didn't think he'd ever go back to work again."
As Art explained, "I went back to work driving a bus and wheeling wheelchairs for handicapped people for five years, twelve-hour days, four to five days a week. It was a really big change from when I couldn't walk more than twenty feet. Now, even fifteen years after I started your program, I never get short of breath."
Art not only felt better, he was better. A state-of-the-art test called a PET scan revealed that his heart was receiving significantly more blood flow after one year of being on the program for reversing heart disease.
Also, the PET scan showed that a lot of his heart muscle that had looked as if it were dead, or scar tissue, was actually "hibernating"--some dead tissue interlaced with heart muscle that was alive but not functioning. After a year of making comprehensive lifestyle changes at the healthy end of the Spectrum, much of his heart muscle that was hibernating began to "wake up" and function again. Another test called an echocardiogram confirmed that his heart muscle was pumping blood so much more effectively that he no longer needed a heart transplant!
Unlike our earlier studies, which were randomized controlled trials, these heart-transplant patients are only anecdotal case reports. Nevertheless, they indicate just how powerful these simple, low-tech, low-cost changes in diet and lifestyle can be.
In other words, when you go all the way to the healthy end of the Spectrum, your body often has a remarkable capacity to begin healing itself.
In a related investigation, we studied forty patients whose hearts were pumping blood poorly, many of whom were on the way to needing a heart transplant. All of these patients were eligible for surgery (bypass surgery or angioplasty). We compared twenty-seven patients who chose our program as an alternative to surgery with thirteen patients who underwent surgery. The two groups were comparable in age, disease severity, and heart function.
After three months, there were six cardiac events (cardiac death, congestive heart failure, stroke, heart attack) in the thirteen patients who had surgery compared with only one cardiac event in the twenty-seven patients who chose our program of comprehensive lifestyle changes. Put another way, there were six events in thirteen patients (46 percent) in the surgical group but only one event in twenty-seven patients (4 percent) in the lifestyle-change group--in other words, ten times fewer cardiac events in the lifestyle-change group than in the surgical group. Not surprisingly, these differences were statistically significant.
After three years, 96 percent of the patients in the lifestyle-change group were still alive, and only three had undergone surgery. In the surgical group, only 77 percent of the patients were still alive, and these differences were also statistically significant.
Thus, even really sick heart-disease patients were able to safely avoid bypass surgery and angioplasty and, if anything, did even better than those who were operated on. Although this is a small sample of patients without a randomized control group, the differences are striking and encouraging.
In the next chapter, I'll describe why these patients were able to make and maintain comprehensive lifestyle changes in the real world--and how you can do so as well.
Excerpted from The Spectrum by Dean Ornish, M.D. Copyright © 2007 by Dean Ornish, M.D.. Excerpted by permission of Ballantine Group, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.