During the last two decades, pioneering physician Dean Ornish caught the world's attention when his studies showed that heart disease could be reversed-without drugs or surgery-through the comprehensive lifestyle changes of no-fat added whole food diet, stress management, exercise, and group support. He described the story behind his innovative research in his New York Times bestseller, Dr. Dean Ornish's Program for Reversing Heart Disease (Ivy Books, 1996), while his perceptions about intimacy and its link to health and illness are discussed in his latest book, Love and Survival (Harper Collins, 1998).
Today, Dr. Ornish is Clinical Professor of Medicine at the University of California, San Francisco, and President and Director of the non-profit Preventive Medicine Research Institute. Advantage 10&trademark; is his heart-healthy new line of foods, and Love and Survival is the subject of his PBS series, which airs throughout 1998. Dr. Ornish was recognized by Life magazine as one of the fifty most influential members of his generation.
Veggie Life recently caught up with Dr. Ornish at his office in Sausalito, CA. In addition to an overview of-and rationale for-his heart-healthy diet, Dr. Ornish also addresses some current controversies and criticisms surrounding healthful, optimal levels of dietary fat, carbohydrates, and protein.
THE ORNISH REVERSAL DIET
Veggie Life: What foods are included in the reversal diet?
Dean Ornish: Fruits, vegetables, whole grains, and legumes. And we allow some egg whites or nonfat dairy products for those who prefer these foods. If you're eating a good variety of food, it works out to be about 10 percent fat, around 70 percent carbohydrate-predominantly complex carbohydrates-and the remaining 20 percent is protein.
VL: Why did you include dairy products in your diet?
DO: Because it makes it easier for people to stay on the diet. It's an adherence issue, but also because dairy food is a source of protein and calcium. At the time we began the program, many dietitians were concerned about those issues. Today there is very little evidence that nonfat dairy contributes to coronary heart disease. At the same time, the animal protein, casein, may be a factor in contributing to some forms of cancer, which is why we exclude it in the prostate cancer study we're now conducting. But even today, we include nonfat dairy for those people who want it as part of the heart disease reversal program.
VL: And nuts and seeds are omitted because...?
DO: They're high in fat. And we also exclude those few plant-based foods that are high in fat, whether it's seeds, nuts, oils of any kind, avocados, and so on. We've found that this is what it takes if you're trying to reverse heart disease.
VL: What was your rationale for the diet when you first started the program?
DO: It was a combination of animal data, epidemiological data, and anecdotal case reports from humans, indicating that in countries where a predominantly low-fat vegetarian diet is consumed, there is a fraction of the heart disease that we have in this country. When you put all the data together, it seemed to me that it would be worth conducting experiments to see whether heart disease might not only be preventable, but perhaps reversible by making much bigger changes-not only in diet, but also in other lifestyle factors.
The Complex Carbohydrate Controversy
VL: Why did you include dairy products in your diet?
DO: Because it makes it easier for people to stay on the diet. It's an adherence issue, but also because dairy food is a source of protein and calcium. At the time we began the program, many dietitians were concerned about those issues. Today there is very little evidence that nonfat dairy contributes to coronary heart disease. At the same time, the animal protein, casein, may be a factor in contributing to some forms of cancer, which is why we exclude it in the prostate cancer study we're now conducting. But even today, we include nonfat dairy for those people who want it as part of the heart disease reversal program.
VL: You mentioned that the reversal diet is predominantly complex carbohydrates, yet there recently has been much debate about the role carbohydrates play in our health. Please comment.
DO: I want to distinguish between complex carbohydrates and simple ones, because a number of books are coming out telling us that carbohydrates are bad for you, because they cause your blood sugar to spike. And when your blood sugar spikes, your pancreas makes insulin to bring your blood sugar back down, accelerating the conversion of calories into fat. It will also promote atherosclerosis. And many books are saying that all carbohydrates do this, so you should eat (predominantly high protein, high fat) foods that won't do this, such as bacon and sausage and hamburgers, and so forth, because they won't provoke an insulin response. But complex carbohydrates don't provoke an insulin response.
VL: Define complex vs. simple carbohydrates.
DO: Complex carbohydrates are fruits and vegetables and grains and beans in their natural form. And the fiber and the grain and the bran and the hull all act to slow the absorption of food. So rather than getting this rapid rise in blood sugar and insulin response and the negative effects that go with that, you get a slow, constant rise in blood sugar that gives you a constant source of energy throughout the day.
Simple carbohydrates include sugar in all its forms, such as honey, fructose, and also alcohol, because your body converts alcohol to sugar very quickly. And also foods like white flour and white rice, where you've refined away the fiber and the bran and the hull, which otherwise would slow the absorption. With these, you get the same rapid rise in blood sugar and the insulin response.
VL: How do people prone to heart disease benefit from consuming complex carbohydrates?
DO: First, they benefit because cholesterol is only found in animal products, which also tend to be high in both total fat and saturated fat, which your body converts to cholesterol. Whereas a plant-based diet, a vegetarian diet, has no cholesterol, and with the exception of nuts and seeds, tends to be low in total fat and in saturated fat. As a contrast, meat is high in oxidants that oxidize cholesterol into a form that makes it more likely to wind up in your arteries. But a plant-based diet helps prevent this from happening, because it is low in oxidants and high in antioxidants, such as beta-carotene, vitamin E, vitamin C, and so on.
Rather than being controversial, we are learning that there are literally thousands of compounds that have been identified in the last few years-phytochemicals, bio-flavonoids, carotenoids, retinols, and so on, that have anti-heart disease, anti-cancer, and perhaps even anti-aging properties. And with few exceptions, these healing compounds are found in a plant-based diet.
The Fat Fight
VL: To reverse heart disease, you recommend that no fat be added to the diet. In essence, you're saying that a well-balanced, no-fat-added, plant-based diet provides approximately 10 percent of calories from fat. Depending on caloric intake, this translates into about 1 to 2 tablespoons of naturally occurring fat daily. Given your research and recommendations, what is your response to an article published recently in the Journal of the American Medical Association (JAMA), suggesting that men who consumed a higher fat diet, which included artery-clogging saturated fat, are less likely than men on lower-fat diets to suffer a stroke?
DO: I think it's an unfortunate retro trend. A headline saying that high fat diets protect against stroke makes headlines around the world, but the net effect is that it causes many people to throw up their hands and say, 'These doctors, they can't make up their minds. To hell with them, just bring out the bacon and eggs and don't worry about it.'
This article about the inverse association of dietary fat with the development of stroke, which was published in the December 24, 1997 issue of JAMA, is seriously flawed. It's based on a single 24-hour dietary recall, which is notoriously unreliable. Large-scale epidemiological studies, animal studies, and clinical trials in humans all show a strong direct association of fat intake with coronary heart disease death.
The fact that the authors of the study did not detect the relationship of dietary fat to coronary heart disease only indicates how poor their dietary recall data must be. This is further evident in one chart in particular, which reports similar body mass index (BMI), cholesterol levels, and exercise, for those who consumed almost twice as many calories. Clearly these data are highly suspect.
VL: Another recent study, also published in JAMA, concluded that a fat-restricted diet can bring cholesterol levels down to health-harming levels. Yet you're a strong advocate of low cholesterol levels (around 150). Comment, please.
DO: The authors of this article write that 'agressive fat restriction compared with moderate fat restriction offers no further benefits... Yet they did not look at heart disease, only at changes in lipids. For instance, they measured HDL ("good" cholesterol) and LDL ("bad" cholesterol) levels. And what they found was that HDL levels go down in people who eat a vegetarian diet, which they concluded was harmful.
In our study, HDL decreased as well; yet by every measure, our research participants got better. The implications: We need to move beyond simplistic concepts such as the idea that LDL is bad and HDL is good. The HDL is designed to get rid of excess cholesterol, which usually occurs if a person is consuming a lot of fat and cholesterol, as most Americans do. But if you're not eating much fat and cholesterol, like the people in our program, there isn't much excess to get rid of. It's almost as though your body realizes it doesn't need to make as much HDL to get rid of the excess cholesterol, because there isn't much excess.
The Fat Facts
VL: Why can some people eat a high fat, high cholesterol diet and not get heart disease?
DO:The reason is not a mystery. Some people are genetically lucky; they have lots of LDL receptors, a protein on cells that binds to and removes cholesterol from your blood. On the other end of the spectrum are people who have heart disease or high cholesterol levels; in general they tend to have fewer receptors. In effect, they're eating more fat than their bodies can get rid of. This means that if you're not efficient at getting rid of fat and cholesterol, lowering your fat intake to 30 percent of calories, or your cholesterol to 200 or 300 mg/day (as is recommended by the American Heart Association) might slow down the progression, but it's not enough to stop it or reverse it.
VL: Does this mean that olive oil isn't heart-healthy?
DO: The olive oil lobby has done a tremendously successful job of convincing the public that olive oil is good for them. It's not; it's less harmful for you. But there's a big difference between less harmful and being beneficial.
Olive oil is 100 percent fat and 14 percent saturated fat. So for those who pour olive oil on their food or dip their bread in it thinking it's going to be good for their heart, in reality they're getting a lot of excess calories in terms of grams of fat, and a lot of saturated fat.
VL: So for people with diagnosed heart disease, you would still recommend a no-fat-added, plant-based diet?
DO:Yes. Every study that we've done has only provided additional evidence that these patients on average are getting better. And they get even better after a year than after a month. And even better after four years than after one year. As a contrast, the people who make the more moderate changes in their fat intake (lowering fat intake to 30 or 20 percent)...the majority of them get worse.
VL: Do you recommend any added oil or fat?
DO:If you're going to put oil on your pasta, or oil on anything, I would use flax seed oil. I recommend it because the omega-3 fatty acids (the "good" fat) in it seem to be able to reduce sudden cardiac death by 50 percent, in some studies. Unlike olive oil, which has virtually no omega-3 fatty acids, flax oil is rich in omega-3 fatty acids. I would also recommend substituting nonfat or low-fat soy milk for cow's milk.
Protein Possibilities
VL: Please comment about the role of protein in terms of heart disease.
DO: Soy protein is beneficial not only for people with heart disease, but because animal-based protein (dairy, fish, poultry, meat), independent of cholesterol, is linked with heart disease. Casein, is also linked with many of the more common forms of cancer. When rats with tumors growing are put on a low animal-protein diet, the tumors often shrink; put them back on the high animal-based protein diet, they'll grow again.
VL: Do you have any practical suggestions for including soy-based foods in our diet?
DO: If you have a bowl of cereal in the morning, include a cup of soy milk instead of putting in a cup of skim milk. Then you're getting a double benefit: you're not getting the animal protein that may create problems, and you're getting the soy protein that may be protective against cancer-particularly against breast, prostate, and colon cancer.
Bevy of Benefits
VL: If people follow your program, how long might it take before they see some changes in their lipid profile? Or in angina episodes?
DO: One of the reasons why patients have been able to make these changes, and paradoxically, why it's easier to make big changes than to make small ones-why it's easier to go on a diet such as ours instead of a 30 percent fat diet-is because you feel so much better-whether or not you have heart disease.
If you have heart disease, we found in the first two studies that the frequency of chest pain or angina fell by over 90 percent within a few weeks. And that's a powerful motivator for people; it reframes the reason for changing from fear of dying to joy of living. As a matter of fact, many patients have said that even if they knew they wouldn't live a day longer, they would still do this because they feel so much better.
VL: What is the key concept about health that you want us to know?
DO:People often have a hard time believing that these simple choices, such as choosing to be a vegetarian-can make such a powerful difference in their health, well-being, and survival, but they really do. Choices that you make every day, what you eat, the way you respond to stress, how much exercise you get, whether or not you smoke, and the quality of your social relationships, play a much more powerful determinant in your health and well-being than anything that I or any doctor can provide you.
THE ORNISH REVERSAL DIET
Your body needs energy (calories), vitamins, minerals, phytochemicals (natural plant substances), antioxidants, protein, fat, carbohydrates, and fiber to be healthy. The Ornish Reversal Diet meets all of these requirements, as long as you eat a variety of -and enough-food each day from the food groups of fruit, vegetables, whole grains, legumes (beans and peas), and nonfat dairy products.
GENERAL GUIDELINES
EVERY DAY:
FRESH FRUIT (1-3 servings*/day)
Include color-dense fruit-such as kiwi and oranges-for antioxidants and phytochemicals.
FRESH VEGETABLES (4+ servings/day)
Include dark leafy greens for calcium and other vitamins and minerals.
WHOLE GRAINS (6+ servings/day)
Include multiple grain or whole grain bread.
Include servings of whole grains, such as brown rice or quinoa.
BEANS or PEAS (2+ servings/day)
Include varied beans and peas-from lentils to garbanzos (chickpeas).
OPTIONAL:
NONFAT DAIRY PRODUCTS (milk, yogurt, cottage cheese, cheese, etc.)
TOFU
EGG WHITES (1/day)
CHEESE, nonfat (1-2 slices; 1 ounce/slice)
* As a general guideline, 1/2 cup equals one serving size.
DAILY SUPPLEMENT Rx
While supplements are not a substitute for a healthy diet, "I think the state of the evidence is such that I recommend that most patients take the following supplements," says Dr. Ornish. The optimal dose for each person is determined by a three-day nutritional analysis that reveals the patient's dietary intake of various nutrients.
Daily Supplement Dosage
Flax seed oil 2-3 grams/day OR Flax seed, ground 1 1/2 tablespoons
Vitamin C 1-3 grams
Vitamin E 200-400 I.U.
Beta carotene 25,000 I.U. (15 mg.)
Folic acid 1 mg.
Selenium 200 mcg.
A good multivitamin (to ensure adequate B12)
Dietary LIMITS:
TOTAL FAT:
10 percent or less of daily calorie intake No "added" oils or fat
No nuts and seeds
No avocados, olives, or coconut products
Not more than 1 1/2 cups of
tofu/week
CHOLESTEROL:
5-8 mg/day, from nonfat dairy products ONLY
ANIMAL FOOD:
Egg whites, as desired AND/OR nonfat dairy products.
SODIUM:
Less than or equal to 2 grams/day
for those with heart failure, renal disease, and high blood pressure.
SUGAR:
Not recommended, but may be
used in moderation; avoid artificial sweeteners.
CALORIES:
Unrestricted, unless one has
high serum triglycerides, or is
obese or diabetic.
ALCOHOL:
Not recommended that you start drinking wine. If you choose to
drink, the daily limit is:
1.5 oz. liquor
OR 1/2 cup wine
OR 12 ounces beer
Nonalcoholic wine and beer are not recommended.
wine or beer, the daily limit is 1 serving.
COFFEE/CAFFEINE:
Not recommended;
should be avoided
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