What I want to talk about is not just what to eat and how to manage stress and exercise, although these are all very important. I'd like to put them in a broader context of the areas we've been working on: reversing heart disease is one, being able to lose weight by eating more food is another, and health policy is another.
So often in our culture, we end up literally or figuratively bypassing a problem. If you don't address the cause of a problem, then the same problem seems to keep coming back or you get a whole new set of problems and side effects that you hadn't counted on or you're faced with painful choices. That's as true on a health policy and social level as it is on a personal level. On the other hand, if we can deal with the underlying causes of a problem, the solutions can be more powerful, the healing can be much more effective, and we often find that we have many more alternatives than we had considered.
Bypassing the Problem
Cardiology is a good example of how to look at these issues. First of all, more people die in this country from heart and blood vessel diseases than from all other causes combined - that includes all forms of cancer, AIDS, infectious diseases, and even murders, accidents, and suicides. Yet I believe strongly that knowing what we know now, heart disease is completely preventable for the vast majority, probably 95 percent of people or more. And in most cases, heart disease is even reversible once you have it - if we can make much bigger changes than conventional wisdom has indicated and deal with the underlying causes of the problem.
More money is spent on heart and blood vessel diseases than on everything else combined. More money is spent on bypass surgery than on any other operation - more than $18 billion last year in the U.S. alone. But bypass surgery doesn't cure the problem; you're literally. just bypassing it. You're cutting open your leg, taking out a vein, splicing it around the blocked arteries in the heart; at best, you're buying time. Studies have shown that within five years, half the bypasses have clogged up again.
Angioplasty is a technique where you blow a balloon up inside an artery and squish the blockage to try to make more room for the blood to flow. It sounds good; if you can fix it, why bother to change your life ? Because you're not dealing with the problem. It's like mopping up the floor without turning off the faucet. Over $6 billion was spent last year on angioplasty, and studies show that within six months some of the angioplasted arteries have clogged up. So you're paying for it over and over again, and not just in dollars, but also in psychosocial and emotional trauma. On the other hand, if people are willing to make much bigger changes in their lifestyle than most people have been recommending, the need for drugs and surgery is greatly reduced. We've found that people begin to feel better very quickly - if they make big changes. On our program, there was a 91 percent reduction in chest pain, even for those who had been incapacitated by pain for years. They not only felt better, they also were better, in ways we could measure.
Preventable and Reversible
Ironically, in our research we're using the latest in high-tech, expensive, state-of-the-art techniques, like cardiac positron emission tomography (PET) scans and quantitative coronary arteriography, to measure how powerful these very low cost, low-tech interventions can be. It's important to do that, because we sometimes have a hard time believing that simple choices such as what we eat, how we respond to stress and how much exercise we get, whether or not we smoke, and the quality of our social relationships can be such a powerful determinant in our lives.
In the area of heart disease, we've been able to show that reversal can occur much more quickly than we had thought. Within a few days, most people notice a marked reduction in the amount of chest pain they have. Within a month, we've been able to measure that blood flow to the heart has improved, and the heart begins to pump blood more normally. Within a year, we ve found that even severely blocked coronary arteries can become measurably less blocked. Within four years we've found that there was even more reversal than there was at one year. Instead of getting worse and worse over time, which is the so-called natural history of heart disease, we're finding that people can get better and better. Those findings are giving people new hope and new choices.
We've learned a lot about what does and does not work. What doesn't work is trying to scare someone into changing. It might work for a couple of weeks - after a heart attack, people will do just about anything. But efforts to motivate people to change out of fear of dying or something bad happening just don't work.
What Works
What we have found, paradoxically, is that big changes are easier than small ones, because you feel so much better. Conventional wisdom is that small, gradual changes are easy, and big, rapid changes are hard. That's part of why the government, the American Heart Association, and others only recormmend a 30 percent fat diet. But when you make moderate changes, you get the worst of both worlds. You feel deprived because you're not getting to eat and do everything that you enjoy, but you re not making changes big enough to get much benefit.. Your blood pressure, cholesterol, and weight don't come down much, and if you have heart disease, your arteries get more clogged over time. Every single study has shown that if a person who has heart disease only follows the Heart Association's guidelines - less red meat, more fish and chicken, etc.- they will get worse. They may get worse more slowly than if they made no changes, but they will still get worse. But when people make comprehensive changes, they begin to feel so much better that they find that the changes are worth making. For someone who can't walk across the street, shower, or shave without chest pain, the choice is clear.
We tend to think of diet as only affecting health over the long-term. But studies now that show that even a single meal that's high in fat and cholesterol causes arteries to constrict and blood to clot more quickly. So you feel sleepy, tired, and sluggish. The opposite happens when you get your fat down low enough. Within a day or two, you'll notice a difference.
Emotional Heart Disease
The real epidemic in our culture is not just physical heart disease. but what I call "emotional" or "spiritual" heart disease-the loneliness, isolation, and alienation that is so common in our culture. How many of us have lived in the same neighborhood for many years, worked at the same job for many years with the same co-workers, and worshipped in the same church or synapgue? Not many. How many of us have close family within a short driving distance? Again, not many. A hundred years ago, this was true for most everybody. We've lost something along the way.
What I've been struck by, in looking at all the scientific data, is that people who feel isolated and lonely -that means not necessarily that they live alone, but whether they have people who care about them and would drive them to the hospital if they got sick - have 2 percent to 500 percent higher rates not only of premature death, not just from heart disease, but from all causes when compared to people who have a sense of connection and community. That is true in studies done from the Bay Area to Finland, from the New England Journal of Medicine to the New Age Journal, and everything in between.
It's not enough to talk just about cholesterol and diet and cigarettes. We have to ask why people do these things: why they make these choices. The answer is that it helps them deal in many cases with isolation and loneliness. Imagine if a new drug came out that affected mortality rates by 2 percent to 5-10 percent? It would be malpractice not to prescribe it. But because this area is considered "soft" and "fuzzy" - even though the research is published in highly regarded journals - we don't know what to do with it.
When I asked one woman why she smoked, she said, "I've got 20 friends in this pack of cigarettes. They're always there for me, nobody else is." A man said that he goes to the bar to talk to his friends: Jim Beam, Johnny Walker, Old Granddad. "They always listen," he said. "Nobody else does." One well-known food writer said that fat "coats her nerves and numbs the pain." Others sit in front of cable TV and "channel surf." There are a lot of ways of dealing with it
The Ornish Program
What we're learning is that health information is important but it usually isn't enough. When I was a medical student, the chief of pulmonary medicine smoked, and so did the head of oncology. It wasn't because they didn't know any better. Everyone who smokes knows that it's not good for them. Still, about one-third of Americans and about half of Europeans smoke. The question is why, and we come back to the same emotional issues.
Our program is designed to give people the direct experience of what it's like to feel more connected to other people. Our research participants often tell me, "I really feel lonely and isolated. I must be doing something wrong, or people would love and respect me." Once they set up that view of the world - of perceiving themselves as lonely and isolated - they begin to engage in a series of behaviors that are self-destructive. The stakes go way up, and the stresses go up with it. What we're trying to do is use the experience of pain, whether it's physical pain, from heart disease, or societal pain, from health care costs going up, or emotional pain, from depression - as a catalyst for transforming our lives in ways that go beyond just unclogging our arteries or losing weight. In our culture we are taught that if you have pain, you have to kill it as fast as you can, either with drugs or with something else. But if we use the quick fix, we miss an opportunity to transform the pain in ways that can enrich our lives.
We teach people a variety of things to help them find inner sources of peace, joy, and well-being. Yoga and meditation are two powerful tools. There are so many misconceptions about meditation; people think it's about living in a cave and avoiding the world, but it's really about embracing the world more fully.
Health Care Reform
The goal of Clinton's visionary health care reform is to increase access for the 39 million Americans who don't have health care in a way that can keep costs down and maintain quality. If you look at this in the old paradigm, those goals seem to be mutually exclusive, because if you put more people in, then costs will go up, or you'll have to ration care. We have a de-facto system of rationing now for those 39 million Americans.
But there's a third alternative. If you address the cause of why people get sick then you have new alternatives. Nowhere is this more apparent than in the area of heart disease. In the past, insurance companies and the government were reluctant to pay for lifestyle programs like ours; they said it would increase costs in the short-run. They'd say, "Why should we spend today's dollars for some potential benefit that may come five or 10 years from now?" But there's been a real shift in medicine; most doctors believe that heart disease can be reversed if someone's willing to make big enough changes. They also know that angioplasty and bypass surgery prolong life in only a fairly small subset of people who undergo them. That reframes the health policy debate because instead of viewing lifestyle change programs as something that will increase costs, doctors and insurers are beginning to see that for every patient who can follow a program like ours and avoid surgery, there is an immediate savings. There is a potential long-term savings, because many of the angioplasties and bypass surgeries have to be done again.
For that reason, major insurance companies are beginning to pay for our program, and we've set up in six major hospitals, including Beth Israel in New York, Emmanuel in Omaha, and Mercy Hospital in Des Moines. If we can train other physicians to administer our program - and if they can motivate their patients to follow it - we can determine the medical and other cost outcomes. If we can really save money, the program opens up new arenas for taking the 39 million Americans who aren't insured and providing them with tools they can use to lower costs and increase the quality of care they receive, rather than compromise it.
There's no shortage of choices to make, and there are so many things that we can use to distract ourselves.
But what I'm learning is that choosing not to do certain things, by making choices, we can free ourselves from the pain of loneliness and isolation and help us connect to other people. It's this kind of "open-heart surgery" that I find the most rewarding.
Printed with the kind permission of the Commonwealth Club of California, 595 Market Street, San Francisco, CA 94105. Editor.- Gail Burns-Wax, Assistant Editor.- Naomi Stern.
Dean Ornish graduated from Baylor College of Medicine, and completed his internship and residency at Massachusetts General Hospital and Harvard Medical School. He is an assistant clinical professor of medicine and a practitioner in the San Francisco, California area.
He wrote Stress, Diet, and Your Heart, in 1982. In 1984 he founded the Preventive Medicine Research Institute where his wife, a nutritional expert, co-directs his research. Dr. Ornish has pursued theories about heart disease that other doctors have deemed "radical. " Among those ideas is his belief that there is a link between the causes of depression and heart disease and that conventional medical therapy only treats the symptoms, not the causes, of heart disease. In 1990 he gained international attention for publishing the results of his research showing that atheroscleroticpatients, through his treatment program, could reduce the overall blockages in their arteries without either drugs or invasive surgery. He is author of Dr. Dean Ornish's Program for Reversing Heart Disease. His most recent book is Eat More, Weigh Less: Dr. Dean Ornish's Life Choice Program for Losing Weight Safely While Eating Abundantly published in 1993.