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Health Talk:
Hearts and Minds
Hosted by Abigail Trafford
Washington Post columnist
Thursday, July 26, 2001; Noon EDT
Join Post Health columnist Abigail Trafford and her guest, Dean Ornish, M.D., and talk about the Post's Health coverage "Hearts and Minds," focusing on Ornish's 25-year campaign on diet and exercise in treating heart disease.
As a Harvard-trained physician, Dr. Ornish has directed clinical research and advocates lifestyle changes such as diet, exercising and reducing stress as a way to reverse and combat severe coronary heart disease.
Dr. Ornish is the founder and president of the non-profit Preventive Medicine Research Institute in Sausalito, California, where he holds the Bucksbaum Chair. He is Clinical Professor of Medicine at the University of California, San Francisco. He is the author of five best-selling books, including New York Times' bestsellers "Dr. Dean Ornish's Program for Reversing Heart Disease, Eat More, Weigh Less, and Love & Survival."
Dr. Ornish is a member of the board of directors of the U.S. United Nations High Commission on Refugees, the board of the Quincy Jones Listen Up Foundation, the board of the American Red Cross, and the board of the Wheelchair Foundation. He was appointed to The White House Commission on Complementary and Alternative Medicine Policy.
The transcript follows.
Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.
Abigail Trafford:
Hello everybody. Here's your chance. Ask the expert. How to get in shape and reduce your risk of heart disease. How does it work. Can you do it? Join us now with your questions and ciomments.
Abigail Trafford:
Welcome Dr. Ornish. You have been the maverick pioneer on lifestyle ways to reduce the risk of heart disease. Now, it seems, you're part of the establishment. What are the main features of your program?
Dr. Dean Ornish: Part of the establishment? That's a scary thought... Actually, I'm pleased that our work is becoming more widely available to those who may benefit from it. Having seen what a powerful difference changes in diet and lifestyle can make, I want to make it available to as many people as possible. The program includes a low-fat, whole foods, plant-based diet, moderate exercise, stress management techniques including yoga and meditation, stopping smoking, and support groups.
Abigail Trafford:
How effective is your approach compared to other strategies? How does you diet compare with medications?
Dr. Dean Ornish: We found a 91% reduction in the frequency of angina, or chest pain; most people became pain free. In most cases, people not only FELT better, they WERE better in ways we measured, using state-of-the-art technology. 99% of the patients were able to stop or reverse the progression of heart disease as measured by cardiac PET scans (published in JAMA). There was a 40% reduction in LDL-cholesterol, comparable to what can be achieved with drugs, but without their costs and side-effects.
Abigail Trafford:
Who are the likely candidates for your program?
Dr. Dean Ornish: Just about anyone. There is a prevention diet which is customized to the needs of an individual, and a reversal diet for those with heart disease. For more information on the details of these two approaches, please visit my site at WebMD, www.Ornish.com.
Alexandria, Va.:
There seems to be a genuine schism in the medical community between advocates of a high-carb, low-fat diet (such as yourself), and advocates of a high-protein, low-carb diet (such as Dr. Atkins and Drs. Eades). I've been on both, and prefer your approach (I'm not much of a meat eater). Yours also seems to work better for me. My question, then, is how do you reconcile with your plan the reams of success stories that seem to result from people being on the high-protein/low carb method? People report astonishing weight loss, lower cholesterol levels, etc. It would be one thing if these two approaches shared only minor differences, but they are so radically different in every aspect (except for the common advocacy of green vegetables), how does the consumer/dieter make sense of all of the conflicting information? Thanks.
Dr. Dean Ornish: Part of the value of science is to help people sort out claims from facts. Dr. Atkins has never published a single study in any medical journal, whereas we have spent 25 years conducting rigorous research published in peer-reviewed journals showing that our program works. Part of the confusion is that his diet is based on a half-truth: simple carbohydrates such as sugar, white flour, and alcohol are absorbed quickly, causing a rapid rise in glucose and a surge of insulin. But the goal is not to go to bacon and pork rinds to prevent this; it is to reduce your intake of simple carbohydrates and sugar and focus on whole foods: fruits, vegetables, grains, and beans in their natural forms. These are high in fiber, which slows their absorption, preventing an exaggerated insulin response. You lose weight and keep it off; and rather than mortgaging your health, you enhance it. Just because you can lose weight in the short run doesn't mean it's a good idea. You can lose weight on chemotherapy, but I don't recommend it....
One of those "tried everything" people:
I am morbidly obese but have not been diagnosed with any of the diseases caused by morbid obesity. I am over 40 and a lot of these problems are a part of my family history. I have tried everything short of stapling to get the weight off with no success (I currently do Weight Watchers but am not succesful there either.) What am I doing wrong that causes constant failure in this area of my life. I am getting pretty scared about my health.
Dr. Dean Ornish: Most weigh-loss programs work in the short run but not in the long run. You can lose weight by eating fewer calories or burning more calories (e.g., exercise). You can eat fewer calories by eating less food, which is what you do on most diets. The problem is that you feel hungry; sooner or later, most people get tired of feeling deprived and get off the diet. Instead, I suggest you change the TYPE of food,not just the AMOUNT of food. Fat has 9 calories per gram, whereas protein and carbohydrates have only 4. So when you eat less fat, you eat fewer calories without eating less food. You really can eat more and weigh less, which is why I wrote a book with that name, hoping it would encourage people to eat this way to lose weight AND to enhance their health.
Washington, D.C.:
In your opinion, which cholesterol reading is more important--the total of LDL and HDL, or the ratio between the two? I have a high total but a good ratio because my HDLs are very high. Thanks.
Dr. Dean Ornish: The ratio is probably more important, but if your LDL is below 90, your HDL is much less important. In fact, your HDL may come down on a low-fat diet, but your LDL will come down much more. HDL is like the garbage collector of your body; when you eat less garbage, you need fewer garbagemen. It's a very different prognostic significance to have a lower HDL on a low-fat diet than a low HDL on a high fat diet.
Alexandria, Virginia:
How much can one expect his metabolism to slow down in the early 30s? I'm 33, and I find that yesterday's maintenance calories are today's excess calories. I've always been a big exerciser (running, biking, stairmaster), and a fairly healthy eater (lots of salads, little meat), but I just can't seem to shake the excess poundage the way I could when I was 23. Any suggestions? Thanks.
Dr. Dean Ornish: One of the reasons that eating less food doesn't cause you to lose weight in the long run is that your metabolism slows down. Remember, the real problem for the past several hundred thousand years has been getting enough calories, not too many. So if you just cut your calories by eating less food, your body thinks you're starving and slows your metabolism to burn those calories more slowly. If you really are starving, that can help you stay alive longer, but if you're trying to lose weight, it can be very frustrating. Instead, if you eat less fat, you don't have to reduce the amount of food to get your calories down (see my prior answer), so your metabolism doesn't go down, it may even increase. So you get a double benefit.
Washington, D.C.:
Dr. Ornish, I've read one of your books and loved it. You convinced me to cut out meat and dairy, and it has changed my life--I feel healthier, have more energy, never seem to get sick and my cholesterol has finally gone down. Thank you! Abigail Trafford:
What's a typical day like in the life of a person on your program? The menu, the exercise, the stress management? Do you to do all three parts?
Dr. Dean Ornish: Thanks for your kind comments. It's why I feel so passionate about doing this work, because I receive thousands of letters each year from people like you; it really makes all the effort feel worthwhile. So, thank you. It also helps people to understand that my program is not about deprivation-- "Am I going to live longer, or is it just going to SEEM longer?"-- but about abundance. There's no point giving up something you enjoy unless you get something back that's even better-- and quickly. Most people find that they have more energy, their brain gets more blood so they think more clearly, their heart gets more blood so chest pain decreases, even sexual organs get more blood so potency improves. For many people, these are choices worth making-- not just to live longer, but also to live better.
Rockville, Md.:
I actually spoke to you live on MSNBC a little over a year ago. I was almost 500lbs and miserable. I've lost almost 175 lbs by having gastric bypass. What is your experience with this patients who have had this type of surgery? Have you any idea of the long term effects?
Dr. Dean Ornish: I'm glad you're doing better. Gastric bypass is pretty extreme, but when you weigh 500 lbs., extreme situations may call for extreme remedies. But any type of bypass doesn't address the underlying causes of the problem, so I would encourage you to make the diet and lifestyle changes I recommend so you don't regain the weight again.
Alexandria, Va.:
Dr. Ornish,
I'm a woman in my early 30s...I follow a low-fat diet, more or less (I still eat cheese, but in moderation). I'm extremely active (running 35 miles a week), in good physical shape (5'2", 110 lbs). BUT...my cholesterol is 250, with LDLs at 148 and HDLs at 78, Triglycerides at 118. I'm not changing my eating habits currently b/c I really don't feel that they are terrible. Is it ok for me to ignore this cholesterol situation? (My grandfather died at 72 from heart disease).
Dr. Dean Ornish: Many people don't realize that heart disease is by far the leading cause of death in women. One out of two women die from heart and blood vessel diseases whereas one out of nine get breast cancer. The good news is that by following the program I recommend, you may be able to reduce your risk of both. Also, women seem to be able to reverse heart disease even easier than men, so you can probably prevent it even better as well. A number of recent studies have shown that estrogen does not help prevent heart disease in women and may increase the risk of breast and uterine cancer, whereas the comprehensive changes in diet and lifestyle I recommend may help prevent all of these. More important, you feel so much better, so quickly, it reframes the reason for changing from fear of dying to joy of living.
Rosslyn, Va.:
Dr. ornish,
I want to thank you for all the work you have done to promote healthy living and for your stand against all these cockamamie fad (read: adkins) diets. I always thought you made sense with the low-fat mantra, but upon reading the health section on Tuesday, I'm a little concerned. You blackball avocadoes and olives and nuts. I thought these were healthy food choices? I've been told over and over again that I CAN eat these things, in moderation. Now you say no? I'm so disappointed!
Abigail Trafford:
Me too. I LOVE olives, nuts and avocadoes. Being deprived of these goodies would increase my stress burden. . . Is there no reprieve?
Dr. Dean Ornish: First, it's not for me to "blackball" anything; I'm just here to give you information that you can use to make informed choices. The reversal diet does exclude olives, nuts, and avocadoes because they are so high in fat, but the prevention diet may include these in moderation. There is a lot of misinformation about olive oil, for example. Studies show it lowers cholesterol levels only when you substitute it in equal amounts for butter or for oils that are higher in saturated fat. In other words, if you eat 60 grams of olive oil INSTEAD OF 60 grams of butter, your cholesterol level may decrease, not because it was good for you but because it was less harmful. Olive oil is 100% total fat and 14% saturated fat, so the more olive oil you eat, the more saturated fat you consume and the higher your cholesterol goes. One tablespoon of olive oil (or any oil) has the same amount of fat as a scoop of premium ice cream, so one of the easiest ways to lose weight is to cut way back on all oils. Again, if you're just trying to prevent disease, a little olive oil or nuts or avocadoes isn't going to be big deal, but if you're trying to reverse it, it's better to avoid it.
Abigail Trafford:
Once again, what's a typical day like for someone on your program. What is regimin that you follow?
Dr. Dean Ornish: Again, it depends on whether you're trying to prevent or reverse disease. The old saying about "an ounce of prevention" is really true. You don't have to do as much to prevent disease as to reverse it.
For reversing heart disease, we ask patients to do a total of an hour/day of yoga and meditation: stretching, breathing, meditation, imagery, and progressive relaxation techniques. To walk for 30 minutes/day, and to follow the diet.
If you don't have heart disease, do as little or as much as you want. The consistency is more important than the duration. Even a minute of meditation will bring great benefits. Even a few minutes of walking-- taking the stairs instead of the elevator, for example--will help. Studies show that walking even thirty minutes per day can cut premature death rates in half.
Abigail Trafford:
Do some people with heart disease need a combo approach--a lifestyle program and medications? For example, a person who is following your program and is in very good shape--except that he or she still has high cholesterol levels. Or high blood pressure. Should this type of person get medical treatment, too?
Dr. Dean Ornish: The cholesterol-lowering medications are of proven benefit, but I don't think they're the best first choice for most people. I counsel people that they have a choice. They can begin by making moderate changes; if that's enough to bring cholesterol down to the desired changes, then great; if not, then you have a choice: to make bigger changes, or to go on a lifetime of drugs. Either is fine, as long as people know they have a choice. What concerns me about the new NCEP cholesterol guidelines is that they tell people to follow a 30% fat diet-- less red meat, more fish and chicken-- and then to go on drugs if that doesn't do it. But for most people, that diet will lower LDL by only 5% and then they're told they "failed diet," when, in fact, they just didn't go far enough. We found a 40% reduction in LDL just by diet and lifestyle changes along (published in JAMA 1998)and reversal of heart disease without these drugs. So, you have a real choice. If you're not able to follow the program or don't want to, then I'll prescribe medications, as long as you know all the risks and benefits.
Washington, D.C.:
I do feel that diet and exercise is the key to good health, however, it is more difficult than just saying "eat well and exercise." In terms of socioeconomic conditions, how do you implement this type of lifestyle for people who might not have the ability to join a health club or even run in their neighborhood due to violence. What about people who can't afford to eat healthy. Is your program for everyone or just a select few.
Dr. Dean Ornish: Good question. I designed the program with people in mind who don't have much money, since they usually have the least access to conventional treatments. Over 90% of bypass surgery and angioplasty is done in white, upper middle class men, and yet heart disease is declining in that group but rising in women, minorities, and lower socioeconomic groups. In my program, the diet is essentially a third-world diet: fruits, vegetables, grains, beans; fish if you don't have heart disease. Walking just requires a pair of shoes, yoga requires a mat, it costs less to quit smoking, and support groups can be free. Libraries have my books, as well as computers to go to www.Ornish.com at WebMD, which has lots of free recipes and resources. Also, I'm working hard to get Medicare to cover our program and ones like it so that people will have access to the Lifestyle Advantage sites that offer our program.
Arlington, Va.:
I've been on the high-protein type diets in the past, and know at least 8 other people who have tried them or are currently on them. There's one common thread amongst us all. Not ONE person was able to keep off the weight. Yes, we all had spectacular weight losses, but as soon as we returned to "normal" eating, the weight rushed back on. And I was VERY careful with my diet after coming off the high-protein diet. It's a quick fix that doesn't last.
Now, I'm simply eating smaller portions, making some better food selection decisions, and exercising more. No diet--I've changed how I eat for good. And I still have some of the good stuff--pizza, ice cream, beer, etc. Just not so much and not so often. The weight's coming off slowly, but it's coming off and staying off.
Dr. Dean Ornish: That's the problem: the quick fix doesn't last, whether it's an Atkins-type diet, or an angioplasty, or a bypass. It's a little like mopping up the floor around a sink that's overflowing without also turning off the faucet. "Bypass" is a great metaphor. Much of the weight loss on a high protein diet is water, as your body is trying to get rid of the toxic substances. You may notice bad breath, bad body odor, and foul-smelling bowel movements if you go on an Atkins diet-- because that's how your body excretes toxic substances.
Abigail Trafford:
Why do you think the medical establishment has been so resistent to your program?
Dr. Dean Ornish: It's getting better, albeit more slowly than I would like. We doctors do what we're reimbursed to do, and we're trained to do what we're reimbursed to do. So by changing reimbursement, we may help to change medical practice and medical education. Which is why I've put so much effort into working with Medicare to begin a demonstration project of our program in hopes that they will eventually make it a defined benefit. If Medicare covers it, then most other insurance companies will follow their lead, thereby making this a real option for those who can benefit from it. Over $30 billion were spent last year on bypass surgery and angioplasty in the U.S., and another $30 billion is projected to be spent on cholesterol-lowering drugs. Much of this-- perhaps most of this-- could be avoided if people were simply willing to make the diet and lifestyle changes I recommend. And they have the same reduction in angina (chest pain) as if they went through surgery, but in only a few weeks.
Rockville, Md.:
Dr. Ornish,
Hi! I just read your response about olive oil and needless to say, it nearly knocked me out my chair! I am a vegetarian who eats a healthy diet(w/a cheat here and there) and who excerises/lifts weights if not daily, then 4-5 times a week. I'm 23 and weigh 118, 5'4". but every single night for dinner, except for weekends, I eat vegetables sauted in probably a little less than a TbS of olive oil..and i consider this healthy. but now you're telling me a tablespoon of olive oil has the same amount of fat as a scoop of ice cream??!!?? what can i do to substitute..i don't want my "healthy" dinner to really be a sham b/c i'm using olive oil.. Abigail Trafford:
I'm with you. If I had known a tablespoon of olive oil was the same as a scoop of ice cream, I would have headed for the Hagan Das. . . .
Dr. Dean Ornish: If you're only 23, weigh 118 pounds and 5'4", and your cholesterol level is reasonable, then there is no reason to stop eating olive oil. Enjoy yourself.
Gullsgate:
Dr Dean Ornish: did you have any skepticism about Cheney and his being a 'client' of a first-time implant of a defribbulator and then,instant recovery?
Or could it be his newer high-tech version was a secondary replacement? With a spouse who is living as actively as an 'Aries', and all that personality implies, I do recall some healing period was necessary for 'first time' implantation? Second replacement was more like Cheney's instant return to normal activity.
Second question is on the reversal of heart desease. Will your methodology achieve this to what degree?
Then too,I do wonder if the defribbulator will become, some day, standard equipment for monitoring athletes or high-stress individuals, before-the-fact of heart attack?...let's say the size of such an implant can be reduced to but a monitoring micro-chip (rather than the size of a cigerette pack).. to ensure 'good ticking' rather than out of necessity?
Abigail Trafford:
The vice president has made the implantatble defibrillator a household word! It's recommended for people who are at high risk of sudden death. Dr. Ornish, how effective is your approach in patients who are at high risk of sudden death because they have had a heart attack?
Dr. Dean Ornish: It used to be thought that heart attacks and sudden death were due to the gradual progression of blockages building up in the coronary arteries. We now know that heart attacks are usually caused by a sudden spasm (constriction) of the artery and/or a blood clot suddenly lodging in an artery. It turns out that a high fat diet can cause this to happen; so can smoking; so can excessive emotional stress; so can stimulants such as cocaine or amphetamines. So when you make comprehensive lifestyle changes, you significantly lower your risk of a heart attack or sudden death within hours.
Also, sudden death can occur from what is called ventricular fibrillation, an electrical instability in the heart. This is what an implantable defibrillator is designed to do: to shock the heart back into a normal rhythm. The program that I recommend may help to stabilize the rhythm of the heart to keep that from occurring in the first place.
Also, 3 grams per day of fish oil may reduce the incidence of sudden death due to ventricular fibrillation by 50-80%, so I recommend this for everyone. You can buy it in one-gram capsules, e.g., MaxEPA, made by several manufacturers. A very good idea.
Roundhill, Va.:
What can be done to get the fast food industry to quit "the greasy kid stuff?" Abigail Trafford:
What if we all just didn't go into to fast-food places? I know, dream on. . . .
Dr. Dean Ornish: One of the many wonderful things about America is that we live in a place where there is freedom of choice. Industries respond to what their customers want. If you let them know you want healthier choices, then they will provide them, especially if you "vote with your feet." Don't underestimate your ability to effect change; as Margaret Mead said, "That's how change usually occurs," when a small group of dedicated people come together around a common goal.
Bethesda, Md.:
I'm a woman, 5'6", 215 pounds, and I eat WAY too much fat. Just got my cholesterol test results from my doctor, and I have incredible cholesterol levels. Everything's perfect. So is cholesterol a mainly genetic thing that can be influenced by diet, or am I a freak of nature?
Dr. Dean Ornish: I don't know you well enough to know if you're a freak or not, but there is a genetic variability in how efficiently or inefficiently a person can metabolize or get rid of dietary fat and cholesterol. Like so many things in biology, it's a bell-shaped curve. On one end of the spectrum are those (perhaps like yourself) who are so efficient they can eat almost anything and not get heart disease. They drive people crazy... the 90-year-old who has 12 eggs for breakfast and a steak for lunch and a burger for dinner, causing people to scratch their head and go, "Gee, maybe diet isn't that important, look what they're eating and they're 90."
They forget that everyone who wasn't so efficient at getting rid of their dietary fat and cholesterol who was eating such a rich diet never survived to 90; it's a selected group.
Laurel, Md.:
Does your program also advocate counseling or therapy to deal with why people overeat, or eat unhealty food? It seems like so many people know what to do (eat lower fat, exercise) but so many don't do it. What about the psychological barriers to healthy lifestyles?
Dr. Dean Ornish: Yes-- in all my books, but especially in "Eat More, Weigh Less," I talk about how important it is to address the underlying psychosocial issues. Many people eat when they're depressed, stressed, or lonely, for example, so it's not enough to just tell people what to eat; we need to work at a deeper level.
Reston, Va. 20190:
In January, being 30 lbs (and 2 waistline inches) over the size I was when I was in the Army I did the following: Started walking 3 to 4 miles a day, doing 30 pushups and sit-ups in the morning, replaced coke with diet coke, replaced chips with fruit at lunch, started cutting fat off of the meat I eat at dinner, started grilling instead of frying. Cut out desserts. No more ice cream. (Last two don't apply on Sunday ;-)
Haven't lost a pound. Or any waistline. Though I must admit that my shoulders, arms, and legs are in better shape. How do I lose the waistline? Abigail Trafford:
Wow. What a program. It's not fair you haven't lost a pound. Dr. Ornish, what is going on here?
Dr. Dean Ornish: Hard to know without doing a complete analysis of your diet. But, in general, try following the diet in my books or web site more intensively for a few weeks and see if it makes a difference. You might also add some weight training as well, which can turn fat into muscle.
Bethesda, MD:
This question may seem out of place, but I'm actually trying to gain a little weight (I'm 5'5'' and 100 pounds). I know many easy ways to do it (like eating tons of junk food, ice cream, etc), but I'd really like to do it in a healthy way. Any suggestions on where to start? I usually eat a lot of sugar, so I've been trying to cut down on that already.
Dr. Dean Ornish: You might first go to your doctor and make sure that you don't have any hormonal problems such as an overactive thyroid that's causing your weight to be low. Also, that you're not depressed, which is a common cause of low appetite.
Gaithersburg, MD:
Hi Dean! I had the pleasure of meeting you once in your Sausalito office. I was wondering what you think of the new yoga "combination" programs. Particularly, the yoga and Pilates combo.
Dr. Dean Ornish: Yoga and Pilates is a nice combination.
Abigail Trafford:
We're running out of time. Any closing words of advice for us?
Dr. Dean Ornish: Thanks so much for the opportunity to be of service. You know, we tend to think of advances in medicine as a new drug, surgery, laser, something really high-tech and expensive. Our research has proven that the simple choices you make each day can make a powerful difference in how you feel and in your health. My web site (www.Ornish.com) has lots of free resources and information, as well as a listing of the Lifestyle Advantage sites that offer our reversing heart disease program with Medicare reimbursement. Libraries have free copies of my books. And there are other programs out there as well that can be helpful. You can also reach my office at 1-800-775-7674.
It may seem overwhelming to make changes in diet and lifestyle. Start where you are. If you make even gradual changes, you'll notice a difference. Sometimes, it's actually easier to make big changes, all at once, because you then feel so much better, so quickly, then the benefits come from your own experience, not because some doctor told you. Do what feels right for you. And again, I am very grateful for your time and the chance to help. Bye for now.
Abigail Trafford:
Thank you Dr. Ornish. Thank you all for your questions. Join me next week for a regular Health Talk on Tuesday. We'll discuss that defibrillator that's inside the vice president's chest!
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