BY VANCE LEHMKUHL When President Bill Clinton suffered discomfort recently and had an operation to chear a blockage to his

heart, mainstream press outlets made it a teachable moment about heart disease. And the lesson they taught was: Coronary heart disease is a death sentence. Theres nothing you can do to stop it. fter all, Clinton was a perfect example of someone who had done all the right things in terms of diet and lifestyle and yet his heart disease, after one intervention in 2004, was still progressing. The headline of one of the most widely read stories summed up the approach of the mainstream media: No cure for heart disease, Clintons case shows. If cure is taken literally, this may be true theres no miracle pill or procedure that unblocks the coronary arteries. But there are multiple studies showing that heart disease can be reversed that its seemingly inevitable progression can be stopped and turned back by changes in diet and lifestyle. For people suffering from heart disease, thats of great importance, yet the notion is all but invisible in the coverage of this case. The article mentioned above quotes a parade of physicians confirming the

inevitably progressive nature of coronary heart disease: Clyde Yancy, MD, president of the American Heart Association (AHA), explains that this kind of disease is progressive. Its not a onetime event, so it really points out the need for constant surveillance. Allan Schwartz, MD, at the New York Presbyterian Hospital, stressed that heart disease is a chronic condition. We dont have a cure for this condition, but we have excellent treatments. The excellent treatments include the surgery Clinton underwent in February, when doctors reopened the clogged artery they had bypassed in his 2004 quadruple bypass operation and inserted, to keep the artery open, two mesh props called stents. These invasive surgical procedures are shrugged off as a common, inevitable part of the routine that patients should expect to settle into.

Essentially, its a tune-up, Cam Patterson, MD, cardiology chief at the University of North Carolina at Chapel Hill, says in the piece. We see people who come in like this every four to five years. And Dr. Schwartz was quick to add that this was not a result of his lifestyle or his diet. Clinton himself subsequently made a statement blaming his poor diet when he was younger, but stayed mum on whether he had indeed, as Schwartz claimed, been toeing the line since his 2004 bypass. Whats going on? Why is a welldocumented option to reverse coronary heart disease not mentioned by medical spokespeople? Wasting no time, John McDougall, MD, founder and medical director of a well-known diet and lifestyle modification program (www. drmcdougall.com), weighed in with his

explanation in an open letter to Clinton. McDougall deftly summarized the situation: With all their good intentions, and the use of sophisticated, expensive technologies, your doctors are allowing your heart disease to Dr. John McDougall progress as if it were a run-away train destined for a wreck. Your cardiologist, Dr. Allan Schwartz, at New York Presbyterian Hospital, is telling you that further blockage is the normal course of your disease, and your diet and lifestyle are not involved. Medical experts expressing their opinion in the news since your surgery are misleading the public into believing that the proper management of this disease is through constant surveillance and repeated surgical interventions. This is big business talking, and in addition to mismanagement of your personal care, one result will be an increase in the already more than one million angioplasties and 500,000 bypass surgeries performed annually in the U.S. McDougall quickly got to the point: You had two bare metal stents placed in your heart following a few days of mild chest discomfort. This history will continue to repeat itself until you seriously change your eating habits and get these meddling doctors out of your life. You are missing another teaching moment and bypassing another chance to change health and health care in America. Clinton is no heart expert, of course. By and large, he was listening to his physicians but he apparently wasnt listening to his friend Dean Ornish, MD, whose name inevitably comes up in discussions of heart disease and its reversal. Ornish, president and founder of the

nonprofit Preventive Medicine Research Institute (www.pmri.org), oversaw the Lifestyle Heart Trial, a randomized controlled study published in The Lancet in 1990 and in The Journal of the American Medical Association in 1983 and, again, in 1995 and 1998. Patients who stuck to a low-fat vegetarian diet, stopped smoking, exercised regularly and also practiced yoga and meditation not only stopped the progression of their disease, but actually reversed it, in contrast to a control group who followed standard medical advice. This was the first randomized controlled trial proving that comprehensive lifestyle changes can reverse the progression of even severe coronary heart disease without drugs or surgery. Ornish recently published a study in the American Journal of Health Pro-

since he is one of President Clintons consulting physicians and considers physician / patient confidentiality to be sacred. But he did appear on Larry King Live along with Sanjay Gupta, MD, and Wayne Isom, MD. Ornish chose his moment and his points carefully and, as the segment was ending, got the facts out. LARRY KING: Dean, his doctor said that the bypass graft clogging up was not due to lifestyle or diet. How do they know? DR. ORNISH: Well, you know, I have a different perspective. I cant talk about the President directly. But I can say, in general, for them to say that lifestyle, diet, exercise, stress really dont have anything to do with

You are missing another teaching moment and bypassing another chance to change health and health care in America.
motion reporting the results of almost whether a bypass clogs up is just not 3,000 patients who went through his what the facts show. Weve done studreversing heart disease program in 24 ies, and others have replicated them, different hospital sites. They found sta- showing that when you change your tistically significant improvements in lifestyle, you can stop and even reverse all clinical metrics after 12 weeks that the progression of heart disease. But were still significant after one if you just put a bypass year. in but you dont change His most recent research (in your lifestyle, its a litcollaboration with Dr. Elizatle like mopping up the beth Blackburn, who recently floor around a sink thats received the Nobel Prize in overflowing without also Medicine) proved, for the turning off the faucet, or first time, that comprehensive putting a new oil filter in lifestyle changes turn on without changing the oil. disease-preventing genes and Its just going to clog up Dr. Dean Ornish turn off disease-promoting again. genes, as well as increasing It doesnt have to be telomerase by 30%. Telomerase is the that way. And I say that not to blame, enzyme that lengthens telomeres, the but to empower; because when we ends of our chromosomes that control make our lifestyle choices, when we aging. change our lifestyle more than most So far, Ornish has not made many doctors recommend, we can stop and public statements about the lessons even reverse the progression of heart to be learned from Clintons situation disease. And we can keep those by-

heart disease and its treatment among all the mountains of coverage Clintons surgery generated. Why so little reporting on heart-disease reversal? Is the mainstream media showing extreme tunnel vision, or are they just reflecting whats coming out from the biggest names in cardiology? Even the press release issued by the AHA in the wake of Clintons operation is relatively silent. In the official statement, AHA President Clyde Yancy, MD Dr. Hans Diehl notes that bypass surgeries cost in the neighbortouts the usefulness of hood of $150,000 with a venous graft closure rate during the first stents in reducing pain year of 15 to 30%. and says Clintons angina is not unexpasses open without necessarily having pected. Heart trouble is a disease, he to have another stent. stresses, and diseases do progress and Randomized trials, like in The New must be managed and, where possible, England Journal of Medicine two years prevented. ago, the COURAGE study, showed Yancy apparently means that coroquite clearly that stents do not prolong nary heart disease must be managed life. They dont even prevent heart atby surgical procedures, given that this tacks, unless youre in the middle of is the only management technique menhaving one, which 95% of people who tioned in the release, which winds up receive stents are not. And so the main with statistics on coronary angioplasty reason for getting them is to make the and stenting. No notion of regression angina, or chest pain, better. But weve or reversal makes any appearance in shown, and others have shown, that if the release. you change your lifestyle sufficiently, I checked in with AHA headquarters you can reduce angina or chest pain by to find out why this might be and Rich90 to 95% in just a few weeks simard Stein, MD, a cardiologist at New ply by changing diet and lifestyle. York University, spoke on behalf of the At this point King turned to cardiac organization. surgeon Dr. Wayne Isom with a quick Does the AHA recognize the reDo you agree with that, Wayne? versal of coronary heart disease as a Before Isom answered (a quasi-dipreal achievable, reproducible treatlomatic hedge), Ornish inserted, And ment approach? I asked. His answer its a lot cheaper and the only side efwas careful: There are certain patients fects are good ones. And thats pretty for whom aggressive prevention techmuch the sum total of the highest-proniques including everything from file mention of this basic fact about

lowering LDL cholesterol, raising HDL cholesterol and controlling diabetes with such techniques we can in certain patients see things that suggest regression. Defining reversal as being chiefly concerned with stopping the build-up of atherosclerotic plaque. Stein seemed to argue (1) that the benefits in this area are fuzzy and (2) that any advocacy or recommendation risks convincing patients that theyll be 100% cured. In such cases, theres good evidence that in some people we can look at some indicators and show were stopping plaque from forming, he allowed, but added, we are not consistently able to do it with everyone. Using good Mediterranean diets and many of the other techniques, we can in some patients cause a regression, stabilize the plaque. By doing so, these techniques reduce the likelihood of having a heart attack. But they dont eliminate it. Stein added that patients who follow these measures, can reduce their risk; but you cant reduce the risk to zero. Clinton still had additional plaque. Well, yes, but Clinton wasnt following a regimen designed to reverse heart disease, so additional plaque would simply have been seen as par for the course. And the implication that reversal or regression techniques will inevitably be presented as all or nothing, or that theyll give false hope to patients who might not wind up seeing maximal results, seems shaky. Why wouldnt doctors recommending this be as candid and rigorous about this prognosis as anything else? Because risk cannot be eliminated, Stein says, people who follow this lifestyle might delay an event, lower their risk, but ultimately, it could still happen. Still, even if reversal did get oversold to some patients, the total harm from this disappointment in falling

short of the optimal benefit (or this potential delay in getting surgery) would, it seems, pale in comparison to all the lives lost by people who never heard a word about a different way to address their progressive disease. As presented by Dr. Stein, the AHA does recommend lifestyle changes, but only as part of a suite of techniques that includes drugs and surgery. Our guidelines consistently call for these steps, he says. But then he added, If the idea is healthy longevity, then its going to involve all of these different approaches. They all can help in different ways. The best approach is combining these drugs, surgery and lifestyle. Hans Diehl, DrHSc, MPH, a clinical professor of preventive medicine at Loma Linda University and the founder of the successful Coronary Health Improvement Project (CHIP), commented, The AHA has steadfastly adhered to their concept that coronary

ease keeps close company heart disease is incurable. with diabetes, hypertenThey admit that coronary sion, kidney disease, risk can be reduced, but they overweight, elevated chodont consider regression lesterol, acid reflux and through a lifestyle medicine depression, when heart approach as a viable option. Dr. Diehl stressed that disease is treated with focusing only on plaque rethis lifestyle medicine apduction, whether in Clinton proach, then these other or in the patient community chronic conditions usuDr. Hans Diehl at-large, is misleading since ally improve very quickly the lifestyle approach pays as well. off in other ways as well. He pointed Dr. Diehl draws a distinction between out that it usually reduces the plaques the watered-down AHA diet recommenand enlarges the diameter of the arteries dations and those of researchers who within a year, and that it thins the blood, have documented heart disease reversal. getting more oxygenated blood to the In reference to Steins citation of Mediheart muscle, as well as diminishing or terranean diets, he responded that The completely relieving anginal pain. Mediterranean Diet does not go far In addition to these heart disease ben- enough to contribute to the reversal proefits, Diehl points out that the lifestyle cess in a consistent manner, if at all. approach, unlike the pharmaceutical/ Diehl also draws a key distinction surgical emphasis, will generate other in the big picture: When the right diet clinical improvements. Since heart dis- and lifestyle therapy is applied and encouraged, this process can be most rewarding for all concerned. This apImproved Cholesterol Levels with Patients in Dr. Diehls CHIP Program proach does not cause pain, it has no on-the-table mortality and it is very cost-effective. All these things cannot be said for the more aggressive surgical and pharmaceutical approachs that consider coronary heart disease as incurable offering nostrums and pills, and stents and bypass surgeries, where the results erode often all too quickly with time. Its not that cholesterol-lowering drugs have no role to play. Esselstyn used statin drugs and diet therapy in his eminently successful heart disease reversal program. But Diehl points out that they are at best a subordinate partner in the equation: Cholesterol-lowering drugs only do that they lower cholesterol. Diet therapy, on the other hand, comprehensively treats many conditions simultaneously. All their For every 1 percent drop in LDL cholesterol, the coronary risk drops by three times that markers go down with such a diet and much. This graph shows how a shift toward a more optimal, cholesterol-free diet can lower lifestyle approach. the LDL cholesterol regardless of the initial risk category. For instance, 121 male CHIP participants with an initial reading between 150 and 190 mg/dl dropped their average Diehls CHIP program does not toLDL cholesterol from 162 to 125 mg/dl within four weeks. Thats a drop of 23%, and this tally eschew drugs, but recommends
translates into a coronary risk reduction bewtween 50 and 75%.

different order than recomthem only if diet alone mending a Mediterranean does not succeed in diet. We have studies bringing down choleswhere we started with the terol below 170 or 160. walking dead, those too And he points out that of sick for intervention, he his 50,000 CHIP particisays. We had striking expants, 86% respond efamples of heart attack reverfectively to diet therapy sals. (See heartattackproof. within four weeks. (See com.) www.chiphealth.com/ As indicated by the succhipvideo.) Dr. Caldwell, B. So while Stein isnt off cesses of Ornish, Diehl and Esselstyn, Jr. base suggesting theres a Esselstyn with thousands of place for all three drugs, people, the idea that patients surgery and lifestyle in heart disease are unwilling to make comprehensive treatment, two of those are very dispro- lifestyle changes is not true for everyportionately represented. And for all the one. (In contrast, according to Dr. Dean talk about diet not having the same suc- Ornish, two-thirds of people who are cess for everybody, neither do drugs and prescribed statin drugs are not taking surgery. Diehl notes that bypass surger- them after just three months.)

Physicians are simply not as familiar with the science behind heart disease regression through dietary lifestyle changes.
ies cost in the neighborhood of $150,000 with a venous graft closure rate during the first year of 15 to 30% and stenting runs easily into $35,000 with a nonfunctionality rate of 35 to 45% for the procedure within the first six months. As might be expected, Dr. Esselstyn himself takes issue with the priorities, or lack thereof, in the AHAs guidelines. One of his best-known success stories is a 12-year study published in The American Journal of Cardiology in 1999. Angiograms there clearly show the regression of atherosclerotic plaques brought about by his recommendations a carefully designed, very low-fat, vegan diet, with cholesterol-lowering medication used only in a few cases. They (the AHA) think our diet is extreme, he observes wryly. The extreme diet is actually the one that is creating this epidemic of a food-borne illness called coronary artery disease. Esselstyn emphasized that the techniques hes been using are of a wholly This is echoed by John H. Kelly, MD, MPH, a board-certified expert in preventive medicine (see http://lifestylehealthdoc.com) who has overseen lifestyle intervention studies at the Carilion Clinic in Roanoke, Virginia and elsewhere. Informed of the AHAs cant get it to work for everybody rationale, Kelly says, The fact is, there is evidence indicating the majority of individuals with atherosclerotic heart disease can open up their narrowed arteries rather than continuing to close them. This is a disease that we can arrest in its progression, and often show regression. But we need to treat its causes and not merely its symptoms. He continues with an example: We have a documented case of a patient, a 60-year-old white male, who came with a stress echo (a stress test plus an echocardiogram) from his cardiologist showing S-T-segment depression, reduced blood flow and blood-vessel blockage. His cardiologist had recommended an angiogram.

But the patient didnt want to do the angiogram. Though its only diagnostic, its an invasive procedure that cant be done unless an operating room is available 1 in 500 being fatal. So instead, he chose to make lifestyle changes. He went vegetarian, and his cholesterol dropped. We showed him how to substantially reduce the fat, oil, salt and sugar in his diet and to eat more whole foods. He also moved progressively toward walking four to five miles a day, and his cholesterol came down wonderfully, Kelly says. After a five-week CHIP lifestyle intervention program, he wanted to get a second stress echo test because he wanted to know the possible clinical outcome. Now in 99% of patients, ordinarily a second stress test is going to show further deterioration. What we found in this fellow was so remarkable that when his cardiologist looked at this second test, he said maybe the first test was artifactual i.e. maybe the patient didnt have heart trouble at all, but it was just an artifact of the imaging process. What he found was a change in the ST-segment from 3 mm of depression to Dr. John H. Kelly, Jr. less than 1 mm, which is a negative or normal exam, indicating better oxygen delivery throughout his heart muscle. His cardiologist gave him a clean bill of health and sent him home with some baby aspirin. Although this is just one dramatic case, it resonates with the peer-reviewed studies of Esselstyn and Ornish that show that such clinical outcomes are achievable by patients. Given that this result is a far cry from the occasional surgical tune-up presented as

the norm (and indeed the only possibility) by AHA spokespeople, one has to wonder what is behind the apparent disregard for such programs among mainstream cardiologists. Could the low-fat vegetarian diet as a central component of all of these reversal methods be seen as a threat to entrenched industries whose representatives at the top of the medical pyramid discourage their adoption by the doctors on the ground? Esselstyn implied as much in our conversation: Of course, theres a huge amount of money behind continuing the status quo, he noted. And quickly he added: Organizations against lifestyle change include the USDA, which is stacked with former members of agribusiness, ex-cattlemen, pork producers and so forth. Dr. Kelly is a bit more diplomatic in his assessment. Lifestyle treatment is still in its infancy, he explains, largely because theres not much money to fund into research into. After all, who will benefit financially from it? But Kelly pointed to another explanation: Physicians are simply not as familiar with the science behind heart disease regression through dietary lifestyle changes. And until there is an institutional push for it, they are unlikely to immerse themselves in learning how to prescribe a process thats utterly foreign to the approaches theyve been exposed to in their years of medical training. One study looked at the frequency of lifestyle change recommendations for chronic conditions offered by physicians. Fewer than 20% of the patients had doctors recommending lifestyle changes. When asked why they had not done so, doctors responded that they felt they didnt have enough knowledge or experience in that area, that it was outside of their expertise. Doctors are reluctant to prescribe treatments they dont understand well or know how to use.

Speaking as a physician, Kelly says, Were not that good at volitional treatment. Theres a need for us to learn how to educate, empower and motivate our patients. Good luck with that. As Dr. Hans Diehl puts it, Therapeutic nutrition in medicine is a wasteland. Even after decades of criticism from all sides, theres little argument with the fact that doctors education is still lacking in this area. A recent study found that the average amount of nutrition training that medical students receive falls short of the 1985 minimum recommendations of the National Academy of Sciences (NAS), and far short of the 1989 recommendations of the American Society for Clinical Nutrition (ASCN). Kelly is optimistic that physicians can acquire the knowledge needed to become champions of dietary and lifestyle treatments. I do think that doctors and health professionals who have personal experience with the power of lifestyle change do become passionate about it. And the effectiveness of a recommendation is largely tied to a physicians conviction or belief in it. Its like smoking-cessation studies, he offered. Doctors who were smokers were terrible at getting their

patients to quit. The most successful were ex-smokers. Physicians who make changes themselves will be more likely to talk about them. For now, in the absence of much institutional support, doctors such as McDougall, Ornish, Diehl and Esselstyn are at the forefront of educating their colleagues. Esselstyn sees hope in the reception hes gotten from Kaiser Permanente, an integrated managed care organization in California that serves nearly nine million people. Kaiser called and wanted to know if I would speak and educate their doctors about this. I went out there and gave two lectures, a demonstration of the counseling involved. They mobilized, got together, and theyre running their first group through now. If they pull it off, this will be big because they keep such good records. Even though the teachable moment Clintons case presented did not pan out, such doctors as John Kelly will continue their work with the satisfaction of making a difference for the better, knowing that the truth will be borne out over time. The notion that heart disease is treatable by diet and lifestyle change is a minority opinion, he says. But, its a scientific one. And its growing.

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This article was used with permission from The North American Vegetarian Society. Excerpted from Vegetarian Voice magazine Vol. 31, No. 4. For more information about Dr. Diehl and the CHIP program, please go to www.CHIPonline.org, or call 909-796-7676.