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Dean Ornish, M.D. Simple Choices, Powerful Changes
Dean Ornish, M.D., a pioneer in linking major lifestyle changes to healing from illness, advocates a low-fat, stress-reduction lifestyle to reverse heart disease. Dr. Ornish is the author of five best-selling books, including Dr. Dean Ornish's Program for Reversing Heart Disease; Love & Survival: 8 Pathways to Intimacy and Health; and Eat More, Weigh Less. Dr. Ornish is the founder, president, and director of the nonprofit Preventive Medicine Research Institute in Sausalito, Calif. Read more about Dr. Dean Ornish.
Dean Ornish was a chat guest on PlanetRx.com on October 26, 1999. The interviewer is Patricia King, the San Francisco bureau chief for Newsweek magazine. This is an edited transcription of the chat.
Patricia King :
Welcome to PlanetRx, Dr. Ornish. Your low-fat and stress-reduction program for reversing heart disease has made a big impact on mainstream medicine. You were a high-achieving, academically oriented student. What led you to veer off the surgery-oriented mainstream to do research in alternatives?
Dr. Ornish :
I first got interested in this area when I was in college and I became profoundly depressed. That was my doorway, and it taught me how suffering can transform our lives in ways that can be profound. It taught me how suffering can be a catalyst for transforming lives in ways that go beyond changing diet or other behaviors. I've even had patients who've said to me, "Having a heart attack was the best thing that ever happened to me. Because that's what it took to get my attention; having survived it, my life is so much more joyful and meaningful than it was."
Later, in medical school, I studied bypass surgery with Dr. Michael DeBakey, the eminent heart surgeon. We would cut people open, bypass their blocked arteries, and then they would go home, eat the same food, smoke, not manage stress, not exercise, and more often than not, their bypasses would clog up again. So we'd cut them open and bypass their bypass, sometimes several times. So, for me, bypass surgery became a metaphor of an incomplete approach. We were literally bypassing the problem without also addressing the underlying causes, so the same problem would often come back, or we'd get a new set of problems or side-effects. So I wondered what would happen if we treated the causes, which are largely lifestyle-related? And in a series of studies beginning 22 years ago, we were able to show that even severe heart disease often can begin to reverse when people make comprehensive changes in diet and lifestyle.
Patricia King :
You write in your book Love & Survival that you had a similar crisis when you were 40. You had learned so much, yet you weren't implementing some of the things you knew. Why is so difficult for people to make the changes that they believe will help their health and their lives?
Dr. Ornish :
That's true. I was able to help other people more than I was able to help myself. I decided I needed to be a better example of what I was teaching. I think it's hard for many people to learn how to open their hearts to each other. When I use that term, I mean the willingness to let down your emotional defenses to allow another person in. You can only be intimate with someone to the degree you can allow yourself to be vulnerable to them. And when you're vulnerable, you can get hurt. The problem is that, when you wall out pain, you also wall out your ability to experience pleasure. So I decided I wanted to spend some time learning how to be more open and intimate. And my life has transformed in ways that are so magical, so amazing, I want everyone to experience that.
Patricia King :
Is being intimate with others more important than eating a good diet?
Dr. Ornish :
Both are important; it's not one or the other. We all know that diet is important -- although there's been a lot of confusion about that lately, which we can address. But many people don't know how much scientific evidence shows that people who are lonely and depressed are many times more likely to get sick and to die prematurely than those who have a sense of love, connection, and community. In other words, love and intimacy affect not only the quality of our lives, as we all know, but also the quantity of our lives -- our survival. And not just a little, but a lot. Awareness is the first step in healing, so I wrote this new book [Love & Survival] in hopes that it could help raise the level of awareness so people can begin to take these ideas more seriously.
Patricia King :
Is it disheartening for you, who have done ground-breaking research on the efficacy of a vegetarian diet, to see that the best-selling books these days advocate high protein and some of them advocate high-fat diets?
Dr. Ornish :
Yes, I do get a little discouraged sometimes. At a time when there is more scientific evidence than ever showing that when you change from a meat-based diet to a plant-based, whole-foods diet you get a double benefit -- you reduce the intake of foods that help cause disease and you get literally thousands of other substances that are protective, having anti-heart disease, anti-cancer, and anti-aging properties -- these books come out that tell people it's healthy to eat steak and bacon. It's amazing to me. Telling people that eating steak, bacon, and sausage is good for you is an excellent way to sell books, but it is irresponsible and dangerous for those who follow their advice. There is a large body of scientific evidence from epidemiological studies, animal research, and randomized controlled trials in humans that high protein foods, particularly animal protein, dramatically increase the risk of breast cancer, prostate cancer, heart disease, and many other illnesses. In contrast, fruits, vegetables, grains, and beans contain literally thousands of other substances that are protective, having anti-aging, anti-cancer, and anti-heart disease properties. These include isoflavones, carotenoids, bioflavonoids, retinols, lycopene, geninstein, and so on. At the same time, many people do lose weight on high-protein diets, and cholesterol levels may even decrease. How can this be?
The dangerous half-truth is this: there is a big difference between simple carbohydrates and complex carbohydrates. Simple carbohydrates -- sugar and other concentrated sweeteners like high-fructose corn syrup and honey, and alcohol, which your body converts to sugar -- are absorbed rapidly, causing your blood sugar to rapidly increase. In response, your body secretes insulin to lower blood sugar levels to normal. Besides lowering your blood sugar, however, chronically elevated insulin levels also accelerate the conversion of calories into fat, raise your cholesterol level, and have other harmful effects. The high-protein authors say avoid all carbohydrates and eat high-protein foods like pork, bacon, and sausage, because these are less likely to provoke an insulin response.
The important distinction to make is between simple carbohydrates and whole foods, or complex carbohydrates. Whole foods (complex carbohydrates) -- whole wheat, brown rice, and fruits, vegetables, grains, and beans in their natural form -- are rich in fiber, which slows their absorption. Because they are absorbed slowly, your blood sugar does not spike, and so your body does not need to produce elevated levels of insulin. Instead of the rapid swings in blood sugar, you get a more constant source of energy throughout the day.
So, why do people lose weight on the high protein diets? Because most people in this country eat so many simple carbohydrates that when they stop eating them, they lose weight. (A recent study showed that one-third of the vegetables eaten are either French fries or potato chips.) But they're mortgaging their health in the process.
If they switch to a whole-foods, low-fat diet, then they don't provoke an insulin response, so they get that benefit. Also, they are eating foods much lower in fat and cholesterol, so they lose even more weight than on a high-protein diet, and their cholesterol levels come down even further.
Fat has nine calories per grams, whereas protein and carbohydrates have only four calories per gram. So if you go from a 40%-fat diet to a 10%-fat diet, even if you eat the same amount of food, you consume one-fourth fewer calories, without hunger and without deprivation. You feel better and you become healthier.
In our studies and writings, published in the leading peer-reviewed journals, such as the Journal of the American Medical Association, The Lancet, Circulation, American Journal of Cardiology, and the New England Journal of Medicine, we found an average weight loss of 25 pounds in the first year, and more than half of that weight was kept off five years later. People who are obese often lose even more weight. In contrast, to the best of my knowledge, none of the high-protein diet authors have ever published any studies documenting that their approach can help people lose weight and keep it off. Also, we found a reduction in LDL-cholesterol levels during the first year in our studies.
Part of the value of science is to help distinguish fact from fancy and what sounds good from what is real. I would like to be able to tell you that steak, pork rinds, and ice cream are health foods, but they're not. I'm not here to tell you what to eat; just to provide scientifically based information so that you can make more informed and intelligent choices.
Patricia King :
Some people say that their cholesterol goes down on a low carb diet. Is that possible?
Dr. Ornish :
Yes -- because chronic insulin secretion stimulates the enzyme in your liver that increases the synthesis of cholesterol. But if you switch to a whole-foods diet like I recommend, one that's very low in fat and cholesterol, then you can lower your cholesterol even more and lose even more weight. In our studies, we found an average reduction in cholesterol of 40% in a free-living group of men and women without drugs. And they lost an average of 25 pounds in the first year. And their heart disease began to reverse, so they became healthier rather than mortgaging their health in the process.
Patricia King :
Most of the books are rabidly anti-sugar. Do you advise absolutely no sugar in the diet?
Dr. Ornish :
It depends. Some people are more sugar-sensitive (or in a general sense, more sensitive to simple carbohydrates) than others. So if you're trying to lose weight, or lower your cholesterol, then the more you can move from sugar, white flour, white rice, processed foods to whole foods -- fruits, vegetables, grains, beans, soy products, whole wheat flour, brown rice, etc. -- in their natural forms, then you don't provoke an insulin response and you feel better, you smell better (smell the breath of someone on an Atkins diet, and it won't do much for your love and intimacy), and you dramatically reduce your risk of illness rather than increasing it.
Patricia King :
What about good vs. bad fat? Yours is an extremely low-fat diet. Should people supplement with essential fatty acids?
Dr. Ornish :
I recommend that everyone take 2-3 grams a day of fish oil or flaxseed oil to provide the omega-3 fatty acids. These come in one-gram capsules, best if refrigerated. Most studies show that more is not better, so four grams per day gives you the protective effects of the omega-3 fatty acids without the excess fat and cholesterol.
The flaxseed oil is rich in linolenic acid that helps to suppress the formation of arachidonic acid (which is a building block for substances that promote heart attacks and inflammation), whereas the fish oil is rich in a substance called DHA that directly protects the heart. Some of the linolenic acid in flaxseed oil gets converted to DHA, so if you're a strict vegetarian, just take four grams per day of flaxseed oil. Flaxseed oil and fish oil are rich in the omega-3 fatty acids, which may dramatically reduce your risk of sudden cardiac death.
The omega-3 fatty acids are found in cold, deep water fish, like salmon, mackerel, and sardines. So, why not just eat fish? Unfortunately, the fish that are the highest in the omega-3 fatty acids are also the highest in fat, cholesterol, and often toxins like mercury, so I think it's better to take them in the form of supplements. The omega-3 fatty acids are also found in certain plant-based oils, especially flaxseed oil and, to a lesser degree, in canola oil. (Olive oil, in contrast, has virtually no omega-3 fatty acids.) Excessive amounts of omega-3 fatty acids, which are found in many vegetable oils, may be harmful. The only caveat is that Dr. Charles Myers at the University of Virginia Medical School has done some studies that flaxseed oil may increase the rate of growth of prostate cancer, so if you're at risk for that, it's better to take fish oil instead.
Patricia King :
Do you recommend any other supplements?
Dr. Ornish :
Yes, I do. If you go to my website on iVillage (on the AllHealth site), which you can reach at www.Ornish.com or www.iVillage.com, I posted a complete list of the supplements I recommend.
Patricia King :
Even doctors who accept your findings sometimes complain that very few patients can stick to such a strict diet. What is the track record for patients who try your program? Can they stick to it?
Dr. Ornish :
For most people, surprisingly, I have found it is easier to make big changes in your lifestyle all at once than to make small, gradual changes. That's because you feel so much better, so quickly, that it reinforces the reasons for changing your lifestyle from the fear of dying to the joy of living.
Almost $20 billion dollars are spent each year in the United States on angioplasty and bypass surgery, much of which could be avoided if people were to make comprehensive lifestyle changes instead. Last November, my colleagues and I reported in the American Journal of Cardiology the results of our five-year Multicenter Lifestyle Demonstration Project. We found that 77% of people who were eligible for bypass surgery or angioplasty were able to avoid it by making comprehensive lifestyle changes instead. So, while it's not for everyone, many people are successful. Most people think that prevention or risk factor-reduction is boring. They say things like, "Am I going to live longer, or is it just going to seem longer?" They say, "I don't care if I die earlier, I want to enjoy my life and have fun."
And so do I! But the very things that we think of as being the good life -- smoking, high-fat foods, excessive alcohol, too much stress -- are the very things that leave so many people feeling tired, depressed, lethargic, and impotent -- how fun is that? When you make big changes in your diet, most people feel so much better so quickly, that it reframes the reason for change from fear of dying to joy of living. People often report having more energy, they feel better, their sexual function often improves, they think more clearly. If they have heart disease, the improvements are often dramatic -- we found a 91% reduction in the frequency of angina, or chest pain, in just a few weeks. There's no point in giving up something you enjoy unless you get something back that's better. And quickly. When you make big changes, you often get big benefits, and they occur very fast.
Patricia King :
How difficult is it to find tasty low-fat dishes these days? Can your patients go out to dinner?
Dr. Ornish :
Of course. It's easier now than ever. Even if it's not on the menu, just ask, "Would you please make me a plate of vegetables without the oil and butter?" You'll be surprised. The food is often more delicious than what others are eating. You don't have to make a big deal about it; it doesn't have to be like the scene in Five Easy Pieces, with Jack Nicholson trying to order some toast. Also, I've been working with a company that has developed a line of foods that fit my guidelines, called Advantage. These are fun, familiar foods, like pizzas, smoothies, veggie burgers, entrees, soups that taste good and look good and are convenient. They're at most natural food stores, like Whole Foods, Wild Oats, Fresh Fields, and some grocery stores. They're also listed on my website at Ornish.com. Having seen what a powerful difference diet can make, I wanted to make it easier for people to eat this way.
Patricia King :
What is the status of insurance reimbursement for your program?
Dr. Ornish :
There are about 42 insurance companies covering our program in the sites my colleagues and I have trained at our nonprofit Preventive Medicine Research Institute (www.PMRI.org). Three weeks ago, we had a major breakthrough. After more than five years of going back and forth with Medicare, they agreed to move forward on a demonstration project, to pay for patients who have severe heart disease to go through the year-long program at the hospitals and other sites (like Highmark) that we've trained. Our hope is that this will become a defined benefit for everyone. We already showed that most people who are told they need to undergo bypass surgery or angioplasty can safely avoid it (under their doctor's supervision, of course) by making intensive changes in diet and lifestyle. Then the savings are often dramatic and immediate.
Patricia King :
Let's turn to some questions from the audience.
elizlewis :
Dr. Ornish, for those of us in relationships with someone with heart disease -- if they won't do your program "all the way," is it still good for them to do parts of it? Will smaller changes help at all with serious heart disease?
Dr. Ornish :
We found a dose-response relationship between adherence to the program and changes in the heart disease. In other words, the more people changed, the better they became. After one month, after one year, even after five years. But it's not all or nothing -- the more you do, the more benefit you are likely to receive. However, people with heart disease generally need to make big changes in diet and lifestyle if they want to reverse it. If, for whatever reason, they don't want to follow the program very closely, then they should consider other options, like cholesterol-lowering drugs, bypass surgery, angioplasty, etc.
Preventing disease doesn't require changes as big as does reversing it. The old saying about an ounce of prevention being worth a pound of cure is true. There is a genetic variability in how efficiently (or inefficiently) someone can metabolize dietary saturated fat and cholesterol. Some people are so efficient at metabolizing dietary fat and cholesterol that it almost doesn't matter what they eat. Those are the people who live to be 90 and talk about the eggs they eat for breakfast and the steak for lunch and the cheeseburger for dinner. People like that may cause you to question if diet even has a role in heart disease, but everyone else who was eating that rich a diet and who wasn't so efficient at getting rid of the fat and cholesterol never made it to 90. It's a selected group.
So -- if your total cholesterol is consistently less than 150 mg/dl [milligrams per deciliter], or if your ratio of total cholesterol to HDL is consistently less than 4.0, then either you are not eating very much saturated fat and cholesterol or you are very efficient at getting rid of it. Either way, your risk of heart disease is low, and you may not need to make any changes in diet, at least from a cardiac standpoint. (There are other good reasons for changing diet, such as losing weight and reducing your risk of many forms of cancer and other illnesses.) If not, then you can begin making moderate changes -- eat less fat and cholesterol. If that is enough to bring your cholesterol values into this range, then that may be all you need to do. If not, progressively reduce your intake of fat and cholesterol until you achieve these values or until you are on the reversal diet.
fr0squeta :
Are you a proponent of "news fast" (à la Andrew Weil), where you abstain from watching or reading news for a period of time for health reasons?
Dr. Ornish :
I would take it even farther. Just as we have immigration officials at the border of our country, we can decide what we choose to let into our body and into our mind. Whether it's food, or drink, or violent news. Just the act of making these choices is itself empowering. And I think Dr. Weil is doing very good work.
Sketcher :
What part does fiber play in reducing heart disease and lowering cholesterol levels?
Dr. Ornish :
As we've discussed, fiber slows the absorption of food, so it helps to keep your body from surges of insulin. There are two types of fiber. We've been talking about what's called insoluble fiber. Soluble fiber, such as that found in oat bran, or Metamucil, helps to lower cholesterol levels. There is virtually no fiber in meat, one more reason why changing from a meat-based diet to a plant-based diet is so healthful.
dacedi :
You said that it's better to move away from sugar, white flour, and processed foods to foods in their natural forms. Does that mean honey and raw sugars are better for you than refined sugars?
Dr. Ornish :
Not really. The only real advantage of honey is that it contains nature's warning signals. You can consume virtually unlimited amounts of sugar without feeling full or like you've had enough, but if you eat a lot of honey, you begin to feel a little queasy. Some people think that honey may have some benefits because it has the local allergens, but from a sugar standpoint, honey is metabolized almost as quickly as white sugar.
smdesantis :
If you had to pick one thing as the major contributing factor of heart disease, what would it be? Poor diet, lack of exercise, stress, depression?
Dr. Ornish :
All of the above. In science, we like to think there is one cause and one effect, but life is so much more complicated and interesting than that. And these all interact. For example, people are more likely to smoke, overeat, abuse alcohol, work too hard, etc., when they're feeling lonely and depressed. My approach is comprehensive, addressing everything I know that affects health and well-being.
pkorwar :
Is doing yoga for 30 minutes a day equivalent to the aerobic exercise of 30 minutes, and will this help in preventing heart disease?
Dr. Ornish :
You can do yoga aerobically, but you miss most of the benefits of yoga by doing so. I think it's better to keep them separate. You can walk for 20-30 minutes a day or do something more strenuous if you want -- as long as you do it on a regular basis. What gets people into trouble is when they're "weekend warriors" -- couch potatoes for six days and then shoveling snow or playing basketball on the seventh. Here's some good news. Several studies have now shown that walking just 20-30 minutes per day may reduce premature death rates by 50% or more in both women and men. And it doesn't have to be all that fast, or even all at once. Moderate exercise provides much of the health benefits of more intensive exercise but with a lower risk of injury or sudden cardiac death during exercise. The greatest reduction in premature death is between those who walk and those who don't do anything. From a fitness standpoint, more is better, but only if you do it on a regular basis. The best way to do yoga is slowly and gently, as a meditation, with awareness, not as aerobics.
Elskag :
What is your favorite recipe in your book, Everyday Cooking?
Dr. Ornish :
I'm thinking ... probably the mixed vegetable enchiladas and the white-bean soup with winter greens. Very hearty and tasty.
Sketcher :
Dr. Ornish, what do *you* eat for breakfast?
Dr. Ornish :
I usually have a bowl of whole grain cereal with some nonfat soy milk, some fresh fruit (berries or a sliced banana), maybe some whole-wheat toast, herbal tea.
Patricia King :
We have several questions from the audience about cancer. What is the status of your research? Are you yet convinced that your program works for cancer as well as heart disease?
Dr. Ornish :
I'm encouraged by our interim findings, but it would be premature to say more than that. At the nonprofit Preventive Medicine Research Institute in Sausalito, we're doing a randomized controlled trial in collaboration with Dr. Peter Carroll from UCSF [the University of California-San Francisco] and Dr. William Fair from Memorial Sloan Kettering Cancer Center. We're studying to see if the progression of prostate cancer may be slowed, stopped, or perhaps even reversed by making intensive changes in diet and lifestyle. We're studying men who have biopsy-proven cancer who've elected not to be treated conventionally -- the "watchful waiting" group. This is an extraordinary opportunity from a scientific standpoint, because we can have a non-intervention control group, something that wouldn't be possible in, say, women with breast cancer. So if we get a treatment effect, we'll know it's due to the intervention and not a confounding treatment. Stay tuned!
Patricia King :
We will! What are the most effective techniques for reducing stress?
Dr. Ornish :
Gosh, there are so many. In my book, Dr. Dean Ornish's Program for Reversing Heart Disease, I outline these in great detail. The most simple technique is also the most powerful, which is meditation.
LittleKahuna :
Do you think people should follow parts of your program or all of your program if they are relatively healthy and in their 20s or 30s? And what parts do you particularly recommend?
Dr. Ornish :
It's a personal decision -- the more you do, the better you feel and the healthier you'll be. It's not all or nothing.
Patricia King :
One final question from the audience.
rkolar :
Is some nutritional value lost in vegetables when you cook them?
Dr. Ornish :
Maybe a little, but not enough to worry about.
Patricia King :
Sorry we're out of time, though not out of questions. Many thanks, Dr. Ornish.
Dr. Ornish :
It's been a great pleasure. Thank you for the opportunity to be of service.
Dr. Dean Ornish is the founder, president, and director of the nonprofit Preventive Medicine Research Institute in Sausalito, Calif. He is a clinical professor of medicine at the University of California-San Francisco, and the founder of the Osher Center for Integrative Medicine there. After receiving an M.D. from Baylor College of Medicine in Houston, Dr. Ornish was a clinical fellow in medicine at Harvard Medical School, and completed his internship and residency in internal medicine at Massachusetts General Hospital in Boston.
For the past 23 years, Dr. Ornish has directed clinical research demonstrating -- for the first time -- that comprehensive lifestyle changes may begin to reverse even severe coronary heart disease, without drugs or surgery.
Ornish is a best-selling author whose books approach health from a variety of vantage points. Eat More, Weigh Less is a nutritional guide and gourmet cookbook, with more than 200 "heart-healthy" recipes. His most recent book, Love & Survival: 8 Pathways to Intimacy and Health, explores the medical basis for the healing powers of intimacy, drawing parallels between an epidemic of heart disease and widespread depression, alienation, and loneliness in modern society.
Dr. Ornish has been featured on the PBS science series "Nova," and Bill Moyers' PBS series, "Healing & the Mind." He has received the 1996 Beckmann Medal from the German Society for Prevention and Rehabilitation of Cardiovascular Diseases, the U.S. Army Surgeon General Medal, and the 1994 Outstanding Young Alumnus Award from the University of Texas-Austin. He has been published in the Journal of the American Medical Association, Lancet, Circulation, the New England Journal of Medicine, and the American Journal of Cardiology.
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