A matter of lifestyle

Print edition : March 13, 1999

A U.S. cardiac surgeon, recently on a tour of India, generates interest with his theory that intensive changes in diet and lifestyle are more effective than surgical procedures in fighting, and even reversing, heart disease.

CARDIAC patients surrounded by banks of equipment, popping expensive pills, facing surgery and confronted by the prospect of huge medical bills have one other discomforting thought to engage with: the treatment they are getting might not actually be helping them in the larger term.

For years, cardiac surgeon Dean Ornish was something of a priest pitted against the priesthood. Drastic changes in what patients ate and how they lived their lives, he argued, would be far more effective than cutting them open on the surgical table. Now, as evidence for his proposition has become near-irrefutable, the rewards are pouring in. Author of five books, two of them best-sellers, Ornish has shown that an extremely low-fat diet, moderate exercise, stress management techniques such as yoga and meditation, quitting smoking and building more loving relationships can actually reverse heart disease. He has become something of a celebrity, with his work being featured in major magazines in the United States.

Ornish's scepticism about conventional handling of heart disease dates back to the time when he was with the legendary surgeon Michael DeBakey. In patients with coronary heart disease, the flow of blood to the heart becomes restricted. Arteries taking blood to the heart can become blocked, a phenomenon known as atherosclerosis. Also, constricted blood cells can form clots. The end result is that the heart becomes starved for oxygen. Chest pains and full-scale heart attacks follow. Caused by a high-fat diet, nicotine, stress and other factors, coronary heart disease was for long believed to be irreversible. Surgery to bypass clogged arteries, and techniques such as angioplasty, were seen as the only options.

However, such procedures rarely solved the problem. "Bypass surgery," Ornish said in his 1990 book Reversing Heart Disease, "became for me a metaphor for the inadequacy of treating a problem without also addressing the underlying causes. We would operate on patients, their chest pain would usually go away, and they were told that they were cured. Most would go home and continue to do the same things that led to the problem in the first place. They would smoke, eat a high-fat, high-cholesterol diet, manage stress poorly, and lead sedentary lives." More often than not they would end up in hospital again.

EARLY research conducted by Ornish and others suggested that lifestyle interventions could not only stop the progress of coronary heart disease, but actually lead to the reversal of the condition. In one pilot study carried out in 1977 by Ornish, a group of 10 patients marked tremendous improvement in just one month. But to most doctors, the idea that very low-fat diets and exercise could actually reduce coronary blockages was arrant nonsense. Finally, with $600,000 he had collected as grants, Ornish moved to Sausalito in the U.S. to set up his Preventive Medical Research Institute. He began studies on 48 patients, made up of two groups. One followed his recommendations and the other received conventional treatment.

Dr. Dean Ornish. The cardiac surgeon has shown that a low-fat diet, yoga and meditation can reverse heart disease.-VIVEK BENDRE

Medical evidence that Ornish's programme does work steadily built up from there. In 1990 Ornish reported in the medical journal Lancet that a group of 28 patients who had been following his programme for one year showed a measurable reversal of the blockages in their coronary arteries. The other group of 20 patients who had been following relatively conventional dietary guidelines, typical of those recommended by the American Heart Association (AHA), did not benefit from Ornish's exercise programme, counselling, instruction in stress reduction, or help in stopping smoking. The condition of patients in the second group by and large got worse.

This suggested at the very least that the conventional treatment of heart disease did not really help patients. In papers published in 1992 and in 1993, Ornish described the progress of his patients over time. Twenty-two patients who had followed his programme for four years showed, on an average, less blockage in their arteries and improved blood flow to their hearts. The condition of 18 patients who were treated in the conventional way worsened. They showed increased blockages in their arteries after four years than after one year, and less blood flow to their hearts: and this despite the medical treatment they were receiving.

In an article in the December 16, 1998 issue of the Journal of the American Medical Association (JAMA), Ornish and his colleagues spelled out the long-term benefits of their strategy further. Patients in an experimental group, who made intensive changes in diet, exercise, stress management and other lifestyle factors, showed a higher reversal of coronary heart disease over five years than those who had followed the programme for just one year. By contrast, patients in the control group, who had followed the advice of their physicians, suffered from a further narrowing of blood vessels, a process called stenosis, compared to what they had at the outset. This was despite the fact that unlike the experimental group more than half of the patients had taken medication.

The original one-year trials showed that patients who made intensive lifestyle changes reduced their LDL ("bad") cholesterol levels by 37.2 per cent. Further, the extent of narrowing of the blood vessels was not pronounced in their case. Those patients from the original group who chose to participate in the five-year study were put on Ornish's 10-per-cent-fat vegetarian diet, asked to stop smoking, undergo stress management training and begin moderate aerobic exercise. None of them received lipid-lowering drugs, while 60 per cent of the patients in the control group were prescribed such medication. Angiograms were conducted at the end of the five-year period for both groups.

The experimental group patients, the JAMA article records, saw a 91 per cent reduction in heart pain after one year and a further 72 per cent reduction after five years. The conventionally treated control group patients had exactly the opposite experience. They reported a 186 per cent increase in the frequency of chest pain during the first year of treatment, and a mere 36 per cent reduction after five years. Significantly, the reduction of LDL cholesterol levels in the experimental groups was comparable with those obtained by lipid-lowering drugs in patients who were mobile. Narrowing of blood vessels in patients in the experimental group showed an improvement of 7.9 per cent after the five-year period, while patients of the control group recorded a worsening of 27.7 per cent.

"These findings," Ornish and his colleagues argue in their JAMA article, "support the feasibility of intensive lifestyle changes in delaying, stopping or reversing the progression of coronary artery disease in ambulatory patients over prolonged periods." The authors conclude: "In summary, these ambulatory patients were able to make and maintain comprehensive changes in diet and lifestyle for five years and showed even more regression of coronary atherosclerosis after five years than after one year as measured by per cent diameter stenosis. In contrast, patients following more conventional lifestyle recommendations showed even more progression of coronary atherosclerosis after five years than after one year and had more than twice as many cardiac events as patients making comprehensive lifestyle changes."

Doctors performing a bypass surgery. Lifestyle changes are just as effective as, if not more effective than, surgical procedures in fighting heart disease.-K. ANANTHAN

IF intensive lifestyle changes are just as effective as, if not more effective than, surgical procedures in fighting heart disease, they are also considerably cheaper. Consider the case of lovastatin, a drug used to lower cholesterol levels. A study published in JAMA in 1998 suggested that lovastatin could also prevent heart ailments, not just cure patients. A research was conducted on more than 6,500 men and women with cholesterol levels normal for Americans. Those who took lovastatin cut their risk of heart attacks and angina by 37 per cent. Antonio Gotto, Dean of Cornell University's Weill Medical College, the study's lead author, suggested that the drug would benefit the six to seven million people in the U.S. who are considered "normal" under medical guidelines.

Perhaps lovastatin would benefit such people, but so would intensive lifestyle changes. One important difference is that a year's worth of lovastatin costs between $900 and $1,800 per person. Then, researchers estimate that a group of 1,000 people treated for five years would have only 12 fewer heart attacks. Simply cutting back on LDL cholesterol would reduce heart disease at no real cost, in turn saving money on possible hospitalisation and surgical intervention. Although Ornish is at pains to make clear that medication and surgery can help those most desperately in need of immediate help, giving up smoking, exercising more and eating low-fat diets clearly work better for most patients.

The results of Ornish's programme are forcing important components of the U.S. health apparatus to pay attention. Bypass surgery is a $26-billion operation in that country, and the bulk of the costs are borne by insurance companies. Forty insurance companies, Newsweek magazine reported (March 16, 1998), now support Ornish's programme as an alternative to surgery. If a bypass surgical procedure in the U.S. costs about $50,000, Ornish's year-long programme of classes and group meetings, administered by 11 hospitals, costs just $7,500.

Ornish's findings are being received with growing enthusiasm, but some sections of the U.S. medical establishment are less than convinced by the effectiveness of his methods. On the Web site, the powerful AHA appears to suggest that many patients may not be able to follow Ornish's strict regimen. "It's not clear," the AHA states, "how many heart disease patients could adhere to a treatment plan such as Dean Ornish's on a long-term basis, and how many could benefit from such a programme. If diet and exercise alone do not enable patients to reach the goals they set with their doctors, then medication will be required. And for some people, surgery will be needed."

Ornish's research, the AHA believes, "has shown that, with a motivated patient population willing to follow the regimen and a skilled group leader able to inspire adherence to it, significant benefits on lesion progress can be achieved." But, it says, many questions remain. For one, which component of the lifestyle changes had the most impact on heart disease? Did the lifestyle changes demanded by Ornish's programme have a negative impact on the "day-to-day quality of life of patients and their families"? Since patients, despite the improvement in their arterial blockages, still have heart disease, will Ornish's programme actually prolong or improve the quality of their lives? And were his study groups large enough to allow generalisations for other patients?

To at least some of these questions, anecdotal evidence suggests that the answer is yes. Patients on the Ornish programme have stated that the lifestyle changes they were asked to make improved the quality of their everyday lives and their relationships with their families. Citing his own experience, Ornish argues that making such changes offers such profound rewards that their benefits become immediately evident.

It is interesting that at least some of Ornish's ideas have their origins in India, a country where the incidence of coronary heart disease is beginning to rise alarmingly due, in part, to the adoption of a First World lifestyle by its upper middle class and rich. This, in turn, has generated a need for growing numbers of specialised medical facilities, which at least indirectly pull away monetary resources, such as doctors and nurses, that could otherwise be channelled to improve the public health system. Ornish has recorded the influence that his spiritual teacher Swami Satchidananda's ideas on yoga, meditation and a low-fat vegetarian diet were to have on his own life and the development of his medical ideas (see box). Whether one takes the spiritual aspects of Ornish's work seriously or not, the scientific evidence does make clear that there are now options other than the purely technological to prevent and treat coronary heart disease.

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