Author’s note: This is the third of four articles that share the discovery of how combining a plant-based, whole food, no fat added diet, aerobic exercise, Integral Hatha yoga (stretching, breathing techniques, deep relaxation, meditation, and imagery), and social support can reverse coronary heart disease, prostate cancer, and perhaps even aging. In the first article, the author recounts how he became acquainted with a yogic lifestyle approach from a medical student named Dean Ornish. The second article shares the challenges and successes in conducing the first clinical trial. But there were doubters, those who could not believe that it was possible to coax patients to make comprehensive lifestyle changes for the long-term. And then there were physicians and scientists who doubted that lifestyle changes could open the blockages that reduced blood flow to the heart muscle. This article describes the challenges and successes in countering these doubts. The author is an organizer and participant in the upcoming First Latin American Congress on Lifestyle and Health (El Congreso Internacional Hábitos de Vida Saludable) to be held at the Mall del Rio Conference Center, November 11-13.
By Larry Scherwitz, PhD
Our first clinical trial to evaluate the benefits of lifestyle changes for heart patients was a smashing success. Those who made lifestyle changes not only reduced their risk factors, and chest pain, but their heart could respond more forcefully to exercise.
After analyzing the results, Dean and I worked feverishly to get the discovery published in a top journal, The Journal of the American Medical Association, a mainstream, very well-read journal. To read the full text, click here. In addition, while he was finishing medical school, Dean wrote the book, Diet, Stress, and Your Heart.
At this point, in 1981, I thought that this was the end of our collaboration because we had moved to separate coasts for study and work. Dean moved to Boston to do an internship and residency as a fellow at Harvard Medical School. Deborah and I moved to San Francisco where I continued to pursue my work of identifying a new risk factor for heart disease called self-involvement. Deborah and I had met and fallen in love in San Francisco seven years earlier, and we were thrilled to return to this beautiful city by the bay.
In San Francisco, I worked hard to persuade my institute director what a great recruit Dean Ornish would be. You have never seen a guy that is so bright and works so hard, I told him, and we have evidence that lifestyle can dramatically reduce risk factors and even the way the heart functions—at least for the short term. But Dean had every intention of living and working in Boston until nearing the completion of his residency when he encountered obstacles to continuing with the lifestyle research. I pleaded with Dean that he should come to San Francisco because there was a much greater openness to our approach at the institute. I said we would find him a place to live and work and I knew some of the best people in the country that could collaborate with us.
After I prevailed on him, Dean moved to San Francisco and Deborah found him a great apartment near the medical center and I helped assemble a topnotch team to coach heart patients to make lifestyle changes as well as to evaluate the benefits of the program. Except for being long-term, the design of the San Francisco Lifestyle Heart Trial was similar to our first study, a two-group, randomized clinical trial with one group making the same comprehensive lifestyle changes as before and the other group continuing with their regular cardiac care. We continued the strategy of using yoga, and measuring its effects with the most sophistical techniques available at the time.
This time, we doubled up on the main outcome measures. First, there was the coronary angiogram, which involved threading a catheter into each of the major coronary arteries, squirting dye into the arteries and watching it flow through the arteries while the heart was beating; the blockages would look like a river with large rocks obstructing the flow. These images were recorded and digitized to come up with a quantitative measure of coronary artery blockage for each patient.
A second measure is called a PET scan, or Positron Emission Tomography. This procedure calls for injecting radioisotopes and following their trajectory with a scanner into the heart muscle. In the normal heart, these radioisotopes would show up proportionally to show blood flow in the various areas of the heart muscle. Where there was blockages in the arteries there would be reduced blood distribution to the muscle the vessel was designed to supply. These two measures captured both the structure and function of the heart and it would be, by far, our most rigorous tests of the benefits of lifestyle change. These measures were done without the technician being aware of who had made lifestyle changes and with the use of a computer program that calculated the blockages and blood flow objectively.
The challenges to pull off this very difficult study were like running an obstacle course. We realized that each challenge required successful resolution or the quality of the entire study would be compromised.
The first challenge was getting those assigned to the treatment group to make intensive lifestyle changes that no study had ever tried before. Then, once we had convinced them, we had to make sure they, along with the patients assigned to the control group, showed up for three days of testing, which including taking the angiogram.
We recruited patients who had angiogram results showing they had blocked coronary arteries, but who had not had bypasses or who had had arteries reinforced with stents. All patients, when they volunteered for the study, already had had one angiogram. We were asking them to undergo another angiogram for the study. Then, there was the challenge that the best PET scanner in the country was in Houston. We decided to have each heart patient flown from San Francisco to Houston at the beginning of the study and one year later for this test.
Dean was very convincing in getting the cooperation from cardiologists to allow us access to their patients. To get patients to follow the program we took them to the Claremont Club Hotel and Spa, a wonderful Victorian-era hotel in the foothills above Berkeley for a 10-day retreat. There, they “lived the program,” taking twice-a-day, one-hour yoga classes, eating the recommended food, listening to presentations from our prior work about the benefits of the program, engaging in supervised exercise, and participating in a group support meeting every night. Every component of the program had an expert to help patients learn and practice each component. The strategy was to have participants feel so much better it would provide the incentive to continue once they went home.
We went all out to get participants to follow up the program at the Claremont when they returned home. We had a top chef cook enough food for a week and distribute it to the participants in the lifestyle group when they came for the twice a week group meetings. Our meetings were right on San Francisco Bay, in Ft Mason, in a building that had been used during WW II to recharge submarines. I always thought that was symbolic of what we were doing for the participants’ hearts. The meetings would begin with an hour’s walk along a path with views of Alcatraz and Ghiradelli Square. We had an hour of doing yoga and meditation, followed by a potluck vegetarian meal, and finally we circled chairs and had a group support meeting that focused upon, not on advice, and lectures, but personal expression and empathy among group members.
When we began the study we did not have the money to complete it. We were betting the whole project on our belief that we could raise the money as we went along. I wrote dozens of grant proposals to foundations and corporations and Dean contacted dozens of potential private donors. When we submitted a grant to Continental Airlines they turned us down flat. So Dean flew to the company headquarters and had a 45-minute talk with the CEO. He came out of the meeting with an agreement to provide free airfare for patients and staff to Houston and back.
I understood the importance of maintaining good relationships with the patients assigned to the control group if we had a chance of getting them to come back for the three-day follow-up testing after one year. While our intervention team was working with the group assigned to the treatment group, my job was to stay in close contact with the control group. Another miracle: we succeeded in getting a great majority of the patients to return for all medical testing.
Now, to answer the first question posed after our first test: can patients follow this program for the long term? We asked those in the lifestyle change group to exercise three hours a week; in fact, we got them to exercise 4.4 hours. We asked them to practice yoga a least one hour a day; they averaged 1.3 hours a day. Finally, we asked patients to restrict fat and cholesterol intake. They reduced the percentage of calories from fat from 31% to 7% and their cholesterol intake from 213 to 12 mg/day. The control group was pretty much following the American Heart Associations recommendation for exercise (2.5 hrs/wk) and diet (29% of calories from fat), and few adopted the yoga practice (4 min/day).
What were the benefits of the program? Those in the lifestyle changes group lost an average of 22 lbs. and their chest pain episodes decreased by 91%; further, they reduced their bad (LDL) cholesterol by 37% (without drugs). In contrast, those in the control group gained an average of 1.4 lbs., reduced their cholesterol by only 6%, and their chest pain episodes increased from 2.3 to 6.2 times per week.
Most telling was the angiogram results, which showed a significant reduction in blockage for those in the lifestyle change group, and a galloping progression for those in the control group. Click here for the full text of the report. In addition, the PET scan results showed a marked improvement in the lifestyle change group compared with no changes in the control group.
As a researcher, I had the opportunity to statistically “look under the hood” on what was going on with how lifestyle may be contribute to these dramatic improvements. I argued that we needed to see if the degree of life change was related to the degree of improvement, and we needed to identify which of the lifestyle components may be contributing to the treatment benefits. I took the initiative and developed the measure of adherence to the combination of diet, exercise, and yoga practice. Boy, I am glad that I did!
What we found in this study is that the more you change your lifestyle the more benefits you get. We also found that the daily duration of practicing yoga was the strongest predictor of who reversed their coronary blockages. In fact, it took an hour of yoga, along with the other components of the program to stop the progression of the disease; it took 1.5 hours a day to open the blockages. These results show that it requires rather extreme lifestyle changes to open the coronary arteries.
When we presented the results at the American Heart Association meeting in New Orleans in 1990, there was a press conference and the findings made front-page headlines in USA Today and other newspapers. With these findings we went on to get a $2.5 million dollar grant from the National Institutes of Health to continue the study for another four years to see if these changes and benefits could be extended. The results of this longer-term follow-up are described in our 1998 JAMA publication. Click here to read it.
By this time the word was getting out and Dean was traveling all over the country giving countless presentations on the test results. His book Dr. Dean Ornish’s Program for Reversing Heart Disease became a New York Times best seller and he began to be recognized in the media. For example, Forbes named him as one of the seven most powerful teachers in the world, and Life Magazine named him one of the 50 most influential men of his generation. When we presented the results at the International Society of Behavioral Medicine in Upsala, Sweden, I was offered a guest professorship in Germany, which I took; Deborah and I moved to Germany for two years to repeat the work with German and Dutch heart patients.
In the next article we will summarize further studies of the benefits of lifestyle change in Europe and the USA as well as to answer the question, “Can comprehensive lifestyle changes halt or reverse prostate cancer?”