I’ve had a hectic past few days what with switching the website, blog and bulletin board to a new server and a new tech person along with all the other trials and tribulations of simply maintaining life on a somewhat even keel. I didn’t even get to play golf once.
In catching up on my reading I came across an article in last Tuesday’s Wall Street Journal that set my teeth on edge. The piece was entitled: Meditating for Heart Health. It was a balanced take on the idea that Transcendental Meditation (TM) improves heart health. Followers of TM have claimed that its practice can help reduce blood pressure, reduce arterial plaque, reduce the incidence of heart attack, and even reduce mortality. And they have the studies to prove it. One of the studies mentioned in the article is found in an issue of last year’s American Journal of Cardiology and presents data showing that subjects with high blood pressure who took up TM and other behavioral stress reducing interventions had reduced rates of all-cause mortality and cardiovascular mortality after a follow up of 7.6 years. The references at the end of this paper list a number of other studies purporting to show the same thing. I pulled down a few of these and thumbed through them and they all pretty much indicated the same thing. I didn’t go over the statistics with a fine-toothed comb like I usually do simply because I didn’t have the time, and the studies all told me what I wanted to know, which is that there is evidence that TM and other sorts of meditation and stress reduction decrease mortality, or at the very least, don’t appear to increase it.
Why does all this stick in my craw? Because it reminds me of the paper that put Dean Ornish on the map, the one he’s been running around crowing about since.
Dr. Ornish published a paper in The Lancet, the prestigious British medical journal, in 1990 that purported to show that his program of lifestyle modification reversed the progression of coronary artery disease. He has lived off that paper since. And he continues to trumpet the idea that his program is the only one that has been shown to actually reverse coronary artery disease.
And guess what? I believe him…sort of.
Ornish and his group divided subjects with mild, radiographically-proven coronary artery disease into two groups, the experimental group, which got intensive interventional attention, and the control group who got “usual care.” The subjects in the treatment group started and followed a low-fat vegetarian diet, stopped smoking, started meditating and undergoing stress management, and began a regimen of moderate exercise. After one year, 82% of the subjects in the treatment group (23 of 28) showed a regression (a very slight regression) of their coronary artery narrowing while those in the usual-care group showed a very slight increase in arterial narrowing. And subjects in the treatment group had fewer episodes of chest pain and other cardiac symptoms than their compatriots in the other group.
Ignoring the most bogus part of this study, which is the fact that it is virtually impossible to determine the slight differences in arterial narrowing shown in this study and ignoring the fact that there were a number of patients “lost” to follow up in the treatment group (losing the right subjects can make data look a lot better statistically) and ignoring the fact that the randomization process wasn’t exactly according to Hoyle and ignoring the fact that the only death in the study was in the treatment group, I still believe the subjects in the intervention group got better and probably did improve their coronary artery disease (I say this with one caveat that I’ll address in a moment). I just don’t believe they improved for the same reasons that Dr. Ornish does.
If we look at how the study was structured, we see that the subjects were put on a lifestyle modification program. In fact, the study was called “The Lifestyle Heart Trial.” The subjects modified their lifestyles in four basic ways.
The went on a low-fat vegetarian diet
They stopped smoking
They began meditation and stress management
They started to exercise
We know that smoking is disastrous for people with coronary artery disease and that stopping smoking helps immeasurably. We know that exercise improves coronary blood flow and all around fitness and decreases mortality. And we suspect from the studies above mentioned in the Wall Street Journal article that meditation and stress reduction improves cardiac function and decreases cardiac mortality. If you have heart disease and you do these three things, odds are you’re going to get better.
But what about the low-fat vegetarian diet? The low-fat diet by itself, unlike the other three activities, hasn’t been shown conclusively to improve cardiac function. In fact, based on the recent accumulation of studies comparing low-fat diets to low-carbohydrate, higher fat diets, the low-fat diet has faired poorly. It is my opinion that the subjects in the Ornish study took three steps forward and one step back. The three steps forward, i.e., the smoking cessation, exercise, and meditation improved their cardiac function more than the low-fat diet they followed damaged it, leading to an overall improvement in their condition.
What evidence do I have to make that assertion? If you take a look at the lipid values of the subjects following the low-fat vegetarian diet you notice a fairly sinister finding (the caveat mentioned above): triglycerides went up markedly while HDL-cholesterol levels fell. Exactly the opposite of what you would like to see in patients with heart disease.
When this paper was published in 1990, the lipid focus was on total cholesterol and LDL-cholesterol, both of which fell in this study. Over the intervening years some pretty conclusive evidence has accumulated showing that if the lipid hypothesis of heart disease is valid—and Dr. Ornish certainly believes it is—then a rise in triglycerides and a fall in HDL are ominous signs, signs, in fact, that your therapy isn’t working. If this study were published today, one wonders if the lipid values that looked so good to 1990 eyes would even be listed. (Happily, we who prescribe low-carbohydrate diets don’t have to worry because triglycerides always fall and HDL usually goes up.)
Now getting to what agitates me about all this…I’m annoyed because Ornish, who never fails to mention that he has “proven” that he can reverse heart disease, always attributes the improvement of the subjects in the treatment group to the low-fat diet they followed. Whenever anyone brings up the fact that it was a comprehensive program of lifestyle modification that did the trick (if the trick was really done), he always minimizes the role of the three activities known by everyone to improve vascular disease and emphasizes the role his diet played.
I believe that if this same study had been carried out using the same interventional modalities except that a low-carb diet had been substituted for the low-fat diet, the results would have been significantly better. The subjects in the treatment group would have taken four steps forward.
Three steps forward