'Changes in diet and lifestyle are medically effective'

Print edition : March 13, 1999
Interview with Dr. Dean Ornish.

Dr. Dean Ornish's schedule in India bore few signs of the low-stress lifestyle he advocates. After a brief tour of Tamil Nadu, speaking to both doctors and patients on the transfiguration of cardiac medicine he has helped bring about, Ornish spent a few hours in Mumbai en route to Kathmandu. On his way from the airport to meet some patients in downtown Mumbai, Ornish gave Frontline his only interview to the media during his recent visit to India, the first in two decades. What would otherwise have been a brief interaction was extended by Mumbai's chronically snarled traffic. Excerpts from the interview to Praveen Swami, in which Ornish described both his work and its philosophical foundations:

In essence, your work seems to suggest that a very low-fat diet, quitting smoking and drastic changes in lifestyle can help combat coronary heart disease. These seem on the face of it to be very unexceptionable ideas. Why did the medical establishment in the United States at first react with hostility to your findings?

I think 23 years ago, when I conducted my first study, there was a lot of scepticism that these changes could affect the progression of coronary heart disease. Medicine is by nature conservative, and I think scepticism in science is a good thing. Over time, though, after we've published studies over these 22 years demonstrating that in most people the progression of coronary heart disease can be stopped or even reversed, that scepticism has changed. The idea that heart disease is often reversible has become mainstream. Most cardiologists now accept that idea.

The scepticism now is: can people do it? The issue is not whether reversing heart disease is possible, but whether people can change their lifestyles to this degree.

To address that question five years ago, my colleagues and I at the non-profit Preventive Medicine Research Institute started a multi-centre demonstration project where we began to train hospitals throughout the United States to answer some basic questions. One, is it possible to train other teams of health professionals to be as effective in motivating their patients to change their lifestyles as we were? Two, could people in diverse parts of the country make and maintain comprehensive lifestyle changes? And three, could this be not only medically effective but also a cost-effective alternative to bypass surgery and angioplasty for most patients?

We published our findings in November, in a special issue of the American Journal of Cardiology. The answers to all three questions were yes, for most patients: 77 per cent of patients were able to make and maintain comprehensive diet and lifestyle changes for at least three years and were able to avoid the bypass surgery or angioplasty that they otherwise were eligible for. Insurance companies calculated savings of an average of almost $30,000 a patient, because it is far less expensive to teach someone how to change their diet and lifestyle than to cut them open.

You have also said that you are now achieving similar results for patients with prostate and breast cancers. What is the status of that research?

We are conducting the first randomised control clinical trial to see whether a similar type of diet and lifestyle intervention can slow, stop and perhaps even reverse the progression of prostate cancer. I think we are at a similar stage with respect to prostate and breast cancers and perhaps a few others where we were with respect to heart disease 22 years ago. There is epidemiological data, animal data, and anecdotal case reports in humans suggesting that at least in some patients in the early stages the progression of prostate, breast and perhaps colon cancers may be affected at least to some degree by intensive changes in diet and lifestyle.

In countries where people tend to eat a low-fat, plant-based vegetarian diet, the incidence of prostate cancer is only a fraction of the incidence of such cancer in the U.S. Now, more accurately, they have the same rate of incidence of microscopic prostate cancer that we have in the United States, but there it tends to stay microscopic and of no critical significance. So it seems it may not so much be the initiation of cancer but the progression or promotion of cancer that is affected by diet and lifestyle through a number of factors. When individuals from those countries move to the United States and begin eating and living as we do, the incidence skyrockets. If you look at sub-groups in China and Japan who tend to eat a typical high-fat American-style diet, they also have very high rates of prostate and breast cancers.

We are doing this study in collaboration with the Memorial Sloane-Kettering Cancer Centre in the United States and the University of California, San Francisco. We take men who have biopsy-proven prostate cancer in the early stages, and who have elected not to be treated conventionally for reasons unrelated to our study. They get randomly divided into two groups. Half of them go through my programme and half of them don't and then we compare them and see how they do.

How receptive have audiences in India been to your ideas? There has been an enormous fascination with technology in cardiac and other forms of medicine, both among doctors and patients. You advocate very different approaches to the problem.

I have found people to be very receptive, and I am encouraged by that. This is because so often developing countries like India tend to imitate the American way of living and they are unfortunately imitating the American way of dying. It is so avoidable.

Even in our country we cannot afford to do bypass surgery and angioplasty on everyone who needs it. Last year we spent almost $20 billion on those two operations, which, if they cured heart disease, would be one thing, but they don't. At best they temporise, they buy you time. No study has ever shown that angioplasty prolongs life or prevents heart events in stable patients. Bypass surgery does so in only about 2 per cent of the people who undergo it.

So in most patients the major reason to have bypass surgery or angioplasty is to relieve angina, chest pain. But if people make intensive changes in diet and lifestyle, we have found that similar reduction in angina can occur from these alone. We found a 91 per cent reduction in angina within weeks when people made big enough changes in diet and lifestyle. So changes in diet and lifestyle are equally effective medically, and in some cases more so because in a bypass you temporarily get better and then the problem, more often than not, comes back. It is the same with an angioplasty.

Whenever I lecture, I usually show a cartoon of doctors mopping up the floor from a sink that's overflowing, without first turning the tap off. You're literally and figuratively bypassing the problem. If we don't treat the underlying cause, either the same problem comes back or you get a new set of problems or side effects, which you may not have anticipated. On a health policy level, you may be faced with painful choices. Your body has a remarkable capacity to begin healing itself. In this case of heart disease this process of healing is much quicker than we had once thought possible - if you treat the underlying cause, if you give it a chance to begin.

I'm not against bypass surgery, angioplasty or drugs. In an emergency they can be life-saving. But most people, if they were willing to make big enough changes in diet and lifestyle, have an alternative that is much less expensive, much less traumatic, and in the long run much more effective. Even better, of course, is prevention. So, rather than eating a high-fat, typical American diet and importing our illnesses and our problems, it would be better if people in India and other Asian countries become more aware of the value of what they already have.

Do you find it difficult to persuade patients that just eating better or living happier, more emotionally fulfilling lives can actually help them combat what appears to them to be a life-threatening condition?

No, I don't, because I don't try to convince anyone of anything. I'm not trying to change people. I'm simply trying to give people information that they can use to make informed and intelligent choices. I used to try to change people, and I realised it was counter-productive. This is because even more than feeling healthy, people want to feel free and in control. As soon as I tell them not to smoke and to eat this, to do this and not to do that, they want to do just the opposite. That's just human psychology. The first dietary intervention that failed was when God said 'Don't eat the apple'! That didn't work. And that was God talking. I'm not going to do better than that.

My role as a scientist is to do the best scientific and medical research that I can to find out what's true, and then act as a medical educator, writing in medical journals, and then to get the information out to the general public through interviews like this one. Whether someone decides to quit smoking or not is a very personal decision. It's their business. I don't tell people what to do, but I do believe people deserve to know what the facts are so they can make informed choices. My experience has been that when people really know how much these things matter, not just to how long we live but to how well we live, then I think most people are willing to make these changes.

To me, there's no point in giving up something unless I get back something better. Not just 50 years later, but a week or two later. The paradox for many people, and it certainly was for me, is that when people make big changes all at once, most people find they feel so much better so quickly that the choices become clear and for many people worth making. I found this when I was 19, and I made these changes. I gave up eating meat, which growing up in Texas I had been used to four or five times a day. I had more energy. I could think more clearly. I smelt better. My girlfriend told me I tasted better (laughs). I think one of the most effective anti-smoking campaigns was not pointing to the risks of emphysema or lung cancer, but asking people whether they wanted their lover to feel they were kissing an ashtray. It puts everything in the here and now.

One of the criticisms levelled at the medical establishment in India is that it emphasises methods of treatment that are technology-intensive and expensive because doctors profit from these technologies. Advanced heart medicine has been criticised as pandering to a rich people's disease, which is sucking away resources from more pressing issues that confront the public health system. How would you react to this on the basis of your interactions with doctors here?

I think most doctors are genuinely interested in the welfare of their patients. But these are the things we are trained to do, and at least in the United States these are the things that Medicare and insurance reimburse. So if we are trained to do drugs and surgery and we are reimbursed for doing drugs and surgery, then we do drugs and surgery. It is not because doctors are interested only in money. Most doctors are generally interested in service, in helping their patients, but they don't know any better. And then doctors in India naturally look to the United States as a world leader in medical technology, and they look towards us and want to copy how we do things.

My hope is that people can understand the value of what they have here already. Twenty years ago, when I last visited India, I spoke at the All India Institute of Medical Sciences in New Delhi to a very sceptical and sometimes hostile group of physicians about the value of yoga and a vegetarian diet. It was almost as if these things were their illegitimate stepchild! Now, the All India Institute is offering programmes based on my work. Things have come a long way.

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