March 10

Three steps forward


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.

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  1. Hi..this is a bit of goss but verbatim true. I have it on exemplary unimpeachable authority that no mini bar or minifridge containing booze and choccies is safe from Dr Dean when he’s on a speaking tour.’Oath’ as they say in OZ

  2. Could you please comment on the DASH diet for high blood pressure? I have a male friend whose doctor is recommending that, in addition to his hypertension medicine, he follow the DASH diet.
    My family will always be indebted to the Doctors Eades and Dr. Rosedale. I have learned more from your books(including the Slow Burn book)than from anyone else. I have given your books as gifts to many friends,
    My wife was diagnosed as a Type II diabetic 9 years ago. Our family doctor, an Internist, put her on the ADA diet. There was no change in her fasting BG readings and her Aic readings. After going to your clinic in Boulder, she started on a low carb, adequate protien, and good fat diet and SuperSlow Protocol weight training (before your book came out).
    Today, 8 years later, her diabetes is totally contolled with diet and exercise and with no medications. Her A1c is consistently below 5.0%.
    All because of the Doctors Eades and Ron Rosedale.

  3. Am rather suprised at your level of censoring.
    I think i’ve sent in 4-5 postings over the past 4-5 months and at least 2 and possibly 3 of them never made it;both well afore and after you’ve ‘moved’ and eee gads hardly that inflammatory.
    Though concede the Ornish factoid might be too personal.
    Apologies for that.
    Just shows yee that well functioning biochemistry doesn’t translate necessarily to discussion and debate as i would have believed

  4. Thanks for the kind words. I’m happy to hear that your wife is doing so well.
    I’m not a believer in the DASH diet or in the idea that salt is particularly harmful. Take a look at my post on Feb. 23, 2006 entitled: Another one bites the dust.

  5. It’s not censorship; it’s sloth. Most of the comments that come in seem to require some kind of response from me. I put off posting them until I have time to respond, because if I go ahead and post them, then I’ll forget about answering them. As time goes on, the comments stack up, making it even more time consuming to answer them, so I put them off even longer.
    To top it all off, after moving the blog software to the new server I updated it to the most current version, which has caused problems. I don’t know why but in the newest version the comments have become much more difficult to deal with technically. In the previous version 3.17 there was a button that said ‘Approve,’ which, when selected, published the comment all in one easy step. In version 3.2 it has become a multi-step process that actually took me a little while to figure out as I sat down to deal with all these comments this morning. I still can’t figure out how to get my comment on a specific comment to appear immediately after so that there is continuity.
    And as if that’s not bad enough, some of the comments that I have to deal with come filled with symbols instead of punctuation, which I then have to clean up before posting. We still haven’t gotten all the bugs worked out on that one yet.
    My apologies if I’ve failed to post some of your comments; I can assure you that it was inadvertent.

  6. I’m surprised that HDL went down. I thought exercise raised it. Since I started a low-carb diet and exercise program only 6 weeks apart, I can’t be sure which (or both) effected my HDL. My total cholesterol has actually gone up because my HDL skyrocketed, more than making up for the fall in LDL.
    The triglyceride finding doesn’t surprise me since a low-fat diet is high carb and that will raise trigs.

  7. Although HDL levels are responsive to exercise, in my experience they are much more responsive to diet. Fat in the diet increases HDL levels, while, conversely, removing fat from the diet lowers HDL levels. And lowers them more than adding exercise can bring them back up. Dietary carbohydrates raise triglyceride levels; reducing carbohydrate intake lowers them. So, when you go on a low-carbohydrate diet (which is also a higher-at diet) you virtually always find your triglycerides dropping like a rock while your HDL goes up.
    If you go on an extremely low-fat, high-carbohydrate diet such as the one Dr. Ornish recommends you will find just the opposite, as did the subjects on his study.

  8. My dad, who has been taking meds for years for high cholesterol, is a fan of Dr Ornish and his magazine. We don’t see eye to eye on this issue. He has a dietitian who also agrees with the low fat/high carb diet. When my tryclycerides went to the 300s years ago, and the HDL was in the 30s, my doctor told me to exercise more. Seeing that I was already exercising 4 to 6 days a week, I sought out other alternatives, and ended up discovering the high protein diet. I dropped the pasta, and brought my triglycerides into the 90s, and HDL went into the 40s within 3 months. Yes the LDL did go up, but I was more concerned with the other numbers. The diet was still not perfect as I was still eating some grains in the form of oatmeal and multi grain bread. The next challenge was diabetes, coming from my mother’s side. I had the symptoms for months, and finally diagnosed as a pre-diabetic last fall. Now after losing the grains altogether, I have brought my hA1C from 6.4 to 6.1 over the past 3 months. My HDL is 60, the highest it has ever been, the LDL is holding around 130. I still exercise nearly every day, either weights or if the weather is good, a mountain bike ride or some sprints, and again with no meds. My body fat has dropped from 15% to 11%, and is still going down. My doctor is amazed. Thanks to Fred Hahn for leading me to your site. I have done the Slow Burn Workouts with success in the past. I still use the workouts, but this past winter I have created my own, using a bodysplit type of routine, so I can do more. I feel better doing something nearly everyday.

  9. Regarding how responsive HDL is to exercise, while it does respond in general, there is evidence that the type of exercise plays a role with resistance exercise inducing a higher increase than just plain ‘cardio’. Since HDL is also very sensitive to dietary changes, then combining appropriate nutrition with the right kind of exercise is synergistic and would be, by far, the best thing to do to improve one’s HDL levels.
    With respect to Ornish’s studies, it amazes me that none of the reviewers asked ‘why are you changing so many variables at the same time?’ It’s obvious that the confounding wasn’t even addressed and the best way to deal with that is to actually have different ‘intervention’ groups; one addressing the change in diet, one the change in smoking, one addressing exercise and one addressing meditation and stress management. The results would likely show what you say, either of the three interventions that have nothing to do with diet would have improve the participant’s condition and the confounding would have been minimal. Perhaps the old school ‘one question, one variable, one experiment’ still applies to today’s clinical studies.

  10. I have read the reports about the Atkins diet causing the problem with ‘ketoacidosis’ in the obese lady. I can assure you that it is all hokum. MD and I are have been at a conference for the past couple of days, so I haven’t had the time to devote to a complete post on this issue, but I will as soon as I get back to my desk. Reading about this situation and the attendant hysteria makes it easy to see how the Salem witch trials could have taken place.

  11. The recent most studies tells that chocolates are as good as bypass for CVDs. So get them and stay safe.
    Hi John–
    I would much rather eat chocolate than have a bypass.

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