InTouch Magazine - Spring/Summer 1999

Education Update: A Conversation with Dean Ornish, M.D.

Dean Ornish, M.D., founder, president and director of the nonprofit Preventive Medicine Research Institute in Sausalito, California spoke about his program on reversing heart disease through dietary and lifestyle changes on April 29th at the Hopkins Center for the Arts. The event was sponsored by the Minneapolis Heart Institute Foundation and Abbott Northwestern Hospital.

Dr. Dean Ornish, left, with George Kroeninger, director of education at the Minneapolis Heart Institute Foundation.

The Dean Ornish program is one option for individuals to consider for enhancing heart health. We suggest you talk with your physician to determine the best approach for your individual needs. The following is an excerpt from an exclusive InTouch interview with Dr. Ornish.

Q. Dr. Ornish, you have dedicated more than 20 years of your professional efforts towards the area of heart disease reversal. What have been your motivations? Your most significant challenges? Your greatest accomplishments?

A. As a scientist, I try to find out what is true. As an educator, I share information with people both in the medical community - through papers, scientific journals and presentations at hospitals and places like the Minneapolis Heart Institute Foundation - and to the general public - through general interest books, media appearances and lectures. It gives me great personal joy and purpose to know that this information can empower people and make a meaningful difference in their lives. As for accomplishments - 22 years ago the idea that heart disease is often reversible was thought impossible. It was a radical concept then - though now it is mainstream. My colleagues and I were the first to demonstrate that severe heart disease often reverses when people make diet and lifestyle changes. I think that was a meaningful accomplishment. Our work gave many people both renewed hope and choices they didn't have before.

There have been many challenges along the way, but that is the nature of doing something for the first time. In my better moments I see that as part of the fun, rather than part of the difficulties. The major challenges now are reimbursement issues and making our program a standard of care. Currently there are over 40 insurance companies that are covering the program in the trained sites across the country, but until we receive Medicare reimbursement, I think it will remain on the outskirts of medical practice. I used to think that good science was enough to motivate changes in medical practice, but I realize now that it really requires changes in reimbursement.

Q. The readership of InTouch represents both healthy individuals and those with heart disease. Based on your extensive clinical research, what specific recommendations would you have for these two audiences?

A. It takes more to reverse heart disease than it does to prevent it. In my books, I outline a reversal diet and a prevention diet.

Reversal

The reversal diet is much lower in fat than the typical American diet. We know there is genetic variability in how efficient a person is in metabolizing dietary fat and cholesterol. The genetic variability is based in part on how many LDL receptors a person has. The more receptors you have, the more efficiently you metabolize dietary fat and cholesterol. Some people are genetically lucky and they can eat almost anything because they have so many receptors. These are the people who often live to be 95 and when asked what they've eaten, they talk about the 12 eggs for breakfast, a cheeseburger for lunch and one for dinner as well. The other end of the spectrum is people who have heart disease or high cholesterol. In general, these people's bodies tend to be inefficient in removing dietary fat or cholesterol. In simple terms, if you are eating more fat and cholesterol than your body can get rid of, it has to go somewhere. If it ends up in the arteries of your heart it can lead to a heart attack; in your brain to a stroke; in your sexual organs to impotence; in your kidneys to high blood pressure, and so on. It is the same process manifesting itself in different parts of your body. It is for that reason that moderate reductions, say from 40% fat to 30% - as the American Heart Association or the National Cholesterol Education Program guidelines suggest - don't go far enough for most people with heart disease. In fact, virtually every study has shown that the majority of these moderate-reduction patients get worse - because they are still saturating their receptors - eating more fat and cholesterol than their bodies can get rid of. If they were to reduce fat intake to the level I recommend, about 10% fat and no cholesterol, then they wouldn't be saturating their receptors. In other words, their bodies can go to work ridding themselves of years' worth of arterial buildup, rather than working on their last meal.

Prevention
The prevention diet is based on customizing a diet for the patient, based on where he or she is on the spectrum. We begin by making moderate changes that will bring total cholesterol levels below 150, or the ratio of total to HDL cholesterol to less than four - a low-risk level for heart disease. If it doesn't decrease to those levels, I give my patients a choice: take a cholesterol lowering drug or make bigger dietary changes. My concern if a Step 1 or Step 2 diet doesn't work in an average situation - meaning the patient's cholesterol level has only come down 5% or less - the patient is generally given one option by their doctor: cholesterol-lowering drugs for the rest of their life. And the patient doesn't even know that they have another option. Whether or not a person wants to make major changes is a personal decision. But I think people should have all the facts needed to make an informed decision.

Q. Are there books you have published that you would particularly recommend for each of these two different groups: healthy individuals as well as those with heart disease?

A. I've written five books and they all pertain to the same program, which is the first book I wrote, Dr. Dean Ornish's Program for Reversing Heart Disease. This book really isn't just for people with heart disease. It is the most comprehensive book. We focus on heart disease as a model for demonstrating how powerful my recommended changes can be, but it is not limited to that. Then I wrote the book How to Prevent Heart Disease and Cancer and Lots of Bad Things, which reached many people. With Everyday Cooking with Dr. Ornish, I wanted to show that foods can be simple, deliciously presented, and healthy. I should mention that I helped develop a new line of foods called Advantage/10 with 10% fat. Having seen what a powerful difference changes in diet and lifestyle can make, I wanted to make it easier for people to eat healthily and show them that when they are healthy, they feel better. When a person makes the big diet and lifestyle changes my program recommends, they feel better within a week - whether they have a heart problem or not. At that point, the choice becomes clear - not just to live a few months longer or to prevent something bad from happening, but to improve the quality of life.

My fifth book, Love and Survival, really addresses the psycho-social, emotional and spiritual dimensions of health and healing. People tend to think of my work as mainly about diet. It has gotten to the point that I can't go out to dinner without someone either apologizing for what they are eating or commenting on what I'm eating! Diet is important, but psychosocial, emotional and spiritual dimensions have a great impact on health and healing as well. Study after study has shown that people who feel lonely, depressed and isolated are three to five times more likely to get sick and die prematurely than those who have a sense of love, connection and communication. I wrote this book to raise the level of awareness of how much these things matter so that we can begin to take them more seriously.

Q. Do you feel your research and associated lifestyle recommendations have been widely accepted by your medical colleagues and other professionals? Do you feel your research has changed cardiovascular care, treatment and prevention?

A. The answer is yes, most health professionals and medical colleagues accept the validity of our findings. The idea that heart disease is often reversible is now a mainstream concept. I just wrote a chapter in Charles Hennekin and JoAnn Mattson's companion to the Braunwold cardiology textbook called Clinical Trials. I am writing an article for Harrison's Online. I have presented our findings to most of the major medical journals and scientific meetings. Last November, my colleagues and I published a paper in the American Journal of Cardiology in which we reported the results of our multicenter lifestyle demonstration project. So yes, I think we have come a long way and, yes, I think our findings are changing cardiovascular care, treatment and prevention. The skepticism that remains is not "does it work" but "can people do it" - can people be motivated to make and maintain the recommended changes and can we train other teams of health professionals to prescribe these changes and intervene where needed?

Changing treatment - success rates and cost savings
We found that almost 80% of people who were eligible for bypass surgery or angioplasty were able to avoid them by going on my program. Mutual of Omaha calculated saving almost $30,000 per patient, so it really becomes a good business decision. As I mentioned, there are 40 insurance companies that are covering the program and the sites we train. We're hopeful that in the near future, Medicare will cover it, as it's not only medically effective, but also cost effective. We're trying to create a new model in medicine as we go into the next century. It is more caring and compassionate, as well as more cost effective and confident.

Q. Of the many rewards and other professional recognition which you have received, which do you hold most personally and professionally rewarding and significant?

A. The most personally rewarding are the letters or stories I get from people who went on my program, received new hope and choices, and turned their lives around. Many of them have told me how, before my program, they were told to resign themselves to the fact that they were going to be sick for the rest of their lives. What really matters to me is that this work is empowering many, many people - most of whom I will never meet - people who now have choices they didn't have before. All the other recognitions are just background music in comparison.

Q. Through some of your most recent publications, you have broadened your interests beyond your original lifestyle recommendations to include topics involving intimacy and connection with family and community. What encouraged you to redirect your focus and what have you found?

A. This has always been part of my work. I hope that my new book, Love and Survival, will raise the level of awareness about how much these issues matter. They are more difficult to measure than cholesterol and blood pressure, but they are often even more meaningful and powerful. The need for love and intimacy is a basic human need as fundamental as eating, breathing and sleeping - and if we ignore it, it is at our own peril. Throughout the past 50 years, there has been a radical shift in our culture with the breakdown of the social networks that used to provide people with a sense of connection in the community. If we understand that these matters affect both the quality and quantity of our lives, then we can make choices on how we spend our time and perhaps we can reverse that social disintegration.

Q. At a time when technology has been most influential in steering cardiovascular care and treatment, you have promoted fairly low-tech methods. Do you anticipate a gradual reduction in some of the current popular high-tech procedures in cardiovascular care?

A. I think a lot of this depends on information. The major reason people undergo bypass surgery or angioplasty is that they think their angina is back, and that's a legitimate reason. But we've found that there is over a 90% reduction in the frequency of angina within weeks when people go on a program like mine. Our findings mean that you can accomplish the same reduction in angina as bypass surgery or angioplasty at a fraction of the cost and without the trauma, morbidity and potential mortality. Another example is with the lesions that cause angina. Although 90 to 95% lesions are most likely to cause angina, the more moderate lesions, 30 to 40%, may be more likely to cause a heart attack or sudden cardiac death. But few people would do angioplasty or bypass surgery on a 30 or 40% lesion, even though these are the ones that are most dangerous. It's important to understand the limitations in high-tech approaches and the power of low-tech approaches. I want to make it clear, however, that I'm not against the use of drugs and surgery. These measures can be life-saving, particularly in a crisis or when someone is unstable. If one of my patients doesn't want to consider the lifestyle and dietary changes I recommend, I'll find a good surgeon or interventional cardiologist and send them there - or put them on cholesterol lowering drugs. But I don't think that drugs, angioplasty or bypass surgery are the best first choices for many people.

I might add that both bypass surgery and angioplasty are done, for the most part, in white upper-to-middle class men. We are not the only people who get heart disease. One of the reasons why we have a program that is so low-tech is that the people with the least access to interventional care can benefit perhaps the most from going on a program like this - because it doesn't require any special equipment and it costs less to eat this way.

Q. Your research has supported an intense behavioral approach to heart disease reversal. Have you documented any impact on other chronic health conditions and diseases? If so, which ones and to what extent?

A. I focus on heart disease as a model for demonstrating how powerful these changes can be, but the benefits go beyond just heart disease. My colleagues and I, in collaboration with Memorial Sloan-Kettering Cancer Center in New York and UCSF in San Francisco, are conducting studies to see whether the progression of prostate cancer may be affected through a similar type of intervention. If it is true for prostate cancer then it may also be true for breast cancer, colon cancer, and perhaps others. We know that a wide range of illnesses are directly linked to diet and lifestyle choices. For example, we find that most patients with Type 2 diabetes, through dietary and lifestyle changes under their doctors' super-vision, can reduce their need for, and in some cases get off of, insulin. The same is true for many people with hypertension. Instead of prescribing drugs, we find that when we treat the cause of the problem, the need for medication and surgery is often greatly reduced.

Q. Do you have any personal interest stories of patients who have made some significant changes in their lives as a result of adopting your recommendations?

A. I share many of these life-changing stories in two of my books, Dr. Dean Ornish's Program for Reversing Heart Disease and Love and Survival. The stories I have heard from countless patients - including the stories mentioned in my books - are both amazing and inspiring.

Q. As with any innovation, I am sure you've been confronted by your share of critics. What have been their most common criticisms of your program and recommendations? How have you responded to these individuals?

A. Now that the idea of reversing heart disease through diet and lifestyle change has become mainstream, the major skepticism at this point is that people won't do it. As we demonstrated in the article we published last November in the American Journal of Cardiology, although this is not for everyone, when people really understand what the facts are, many are willing to make and maintain these changes over a period of years and in a real world setting. I take issue with the American Heart Association when its representatives say, "We don't tell people to make changes more substantial than a 30% fat diet or a Step 1 or Step 2 diet because we don't think people can do it." To me, that's like telling people who smoke to cut back from three packs a day to two, because it's too hard to quit. Well, it is hard to quit. In fact, it's even harder than we once thought, but doctors still tell their patients to quit. I think we need to tell people the same is true about diet. If you only go on the 30% fat diet and if you have heart disease, there is a very good chance your arteries are going to get worse over time. All the studies show that your cholesterol level is not going to come down very much. Most studies show that it only comes down about 5%. One study from Stanford last year in the New England Journal of Medicine reported that it didn't come down at all unless people went through exercise, and even then it only came down about 5%. Whether or not people want to make the changes is a very personal decision, but I do think that people should have all the facts they can use to make informed and intelligent choices. People deserve to have the facts. What they do with that information is really up to them.

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