Q: Were people surprised that heart disease can be reversed?
A: Yes. When I did my first study 22 years ago, the idea that heart disease was reversible was thought impossible because most people viewed heart disease as primarily the amount of blockage, or stenosis, in the arteries.
Wed known that those blockages take decades to build up. So the idea that they could change in a short time was radical. But in my first two studiesin 1977 and 1980my colleagues and I found that blood flow to the heart, angina and chest pain, and the ability of the heart to pump blood improved after only one month. In later studies, we saw 90-percent reductions in the frequency of chest pain within weeks.
Q: But you didnt know why?
A: No. Over time, it became clear that heart disease is a dynamic process. Its not just the rust building up in the pipes over many decades. The blockage is only one of several mechanisms that affect blood flow to the heart.
When an artery constricts, it might damage its lining. That makes a blood clot more likely to form, which can lead to a heart attack. These small blood clotscalled micro-thrombican not only clog up the major arteries in the heart. They can also clog the collateralsnew blood vessels that can grow around clogged blood vessels.
Q: And lifestyle can influence those minute-to-minute changes?
A: Yes. If you eat more saturated fat and cholesterol than your body can get rid of over time, it tends to build up in the arteries. But even a single meal thats high in saturated fat and cholesterol can cause your arteries to begin to constrict and your blood to clot faster.
Q: Why do smoking and stress matter?
A: The nicotine in cigarettes causes the arteries to constrict and the blood to clot faster. Stress management and support groups reduce emotional strife, which can make your blood clot faster by releasing circulating stress hormones like adrenalin that can constrict your arteries. This mechanism is designed to protect you. If you get wounded in battle, your blood clots faster and your arteries constrict so you wont bleed as quickly. But in modern times these mechanisms are so frequently activated that they can threaten your survival.
Q: And surgery only fixes blockages?
A: Yes, but the moderate blockages are more dangerous than the severe ones. The 80- or 90- or 95-percent blockages are more likely to cause the chest pain or angina. But the 30- or 40-percent blockages are more likely to cause the heart attacks. Because theyre less stable, theyre more likely to go into spasm or to hemorrhage.
Most doctors wouldnt do an angioplasty or a bypass on a 30-percent blockage. When you change diet and lifestyle, it affects all blockages.
Q: And the blockages become stable?
A: Yes, within days or weeks. So the risk of having a heart attack falls strikingly, whether a person goes on a program like mine or whether they go on cholesterol-lowering drugs.
In studies on statin drugs, the amount of reversal is small, yet the reduction in heart attacks is huge. In one study there was just a one-percent reversal in the blockages, but a 73-percent reduction in cardiac events.
Q: Does surgery prevent heart attacks?
A: Not many. Bypass surgery prolongs life only for about two percent of people who get operated on. Theyre the people who have left main coronary artery disease and poor ventricular function. And no studies have found that angioplasty prolongs life or prevents heart attacks. So the major reasonand its a legitimate reasonthat people undergo surgery or angioplasty is that it relieves chest pain. But most people can accomplish the same or better results simply by changing diet and lifestyle, if the changes are intensive enough.
Q: How do you know that most people can stick to the program?
A: Weve tested large numbers of people. In December, we reported the results of the Multicenter Lifestyle Demonstration Project.2 We found that most people who think they can follow our program are successful if they have proper support.
I thought that if it became scientifically accepted that heart disease was reversible, a program like mine would become the standard of care. But I was naive. The primary determinant of medical practice is not only science but reimbursement. Doctors have to make a living and its hard to make a living telling people how to change their lifestyles.
So I went to the insurance companies and they said, We dont pay for prevention. Twenty to thirty percent of people change insurance companies every year, so why should we pay to prevent some future event? It may take years before the insurer saves money. And that insurer will likely be another company.
Then I told them that its not just prevention, but an alternative treatment. For every man or woman who avoids bypass surgery, you save $40,000 or $50,000 immediately. Those are real dollars today.
Q: But they were still skeptical?
A: They said, Its too hard. If people cant follow your program, were going to pay for the bypass anyway and our costs go up, not down. When I told them that our patients did it, they said, You can get people to change but no one else can. Only people in California can change that much. So I said, Lets find out.
Through the non-profit Preventive Medicine Research Institute, my colleagues and I began training sites around the country. Mutual of Omaha was the first major insurance company to cover the program. Weve trained about 15 sites and now that its working, there are over 40 insurance companies that are covering at least parts of our program.
Q: How many patients are being treated at those sites?
A: We looked at 333 patients with severely clogged arteries. The lifestyle treatment lasted a year, but we followed them for longer. After three years, 77 percent of the patients had avoided the bypass or angioplasty they were eligible for. Mutual of Omaha calculated saving $30,000 per patient.
I would be the first to say that the program isnt for everyone. Surgery isnt for everyone. Angioplasty isnt for everyone. But right now surgery and angioplasty and a lifetime of cholesterol-lowering drugs and other medications are covered by insurance companies andexcept for the drugsby Medicare.
Most patients who want to go on an intensive lifestyle program have no coverage. For many, the denial of coverage is the denial of access.
Q: Do diet and lifestyle changes work with older people?
A: When I began doing this work I thought that the younger patients with milder heart disease would be more likely to show reversal, but I was wrong. The primary determinant of improvement was not how old or how sick someone was, but how well they followed the program.
In other words, the more people changed, the cleaner their arteries got. Thats a very hopeful message. And it has particular implications for older people because the risks of surgery, whether bypass or angioplasty, increase with age, but the benefits of diet and lifestyle changes dont seem to be age-related.
Q: Are you against drugs and surgery?
A: No. In a crisis, they can be life-saving. I tell my patients, If you arent interested in making these lifestyle and diet changes, you should be on statin drugs.
Most people with heart disease are put on a 30-percent-fat diet and they get worse. Then theyre told, Im sorry, you failed diet, so now we have to put you on a lifetime of statin drugs or we have to cut you open again. And they didnt even know they had another choice.
Q: Why doesnt a 30-percent-fat diet work for many heart disease patients?
A: Because it still has too much saturated fat and cholesterol for most people to get rid of. The 1985 Nobel Prize in Medicine went to two researchers who discovered the LDL receptor. This protein on the surface of cells binds and removes LDL (bad) cholesterol from your blood. And the number of LDL receptors you have determines how efficiently your body can get rid of cholesterol.
Some people are lucky. They live to be 95 and they say, I have 12 eggs for breakfast and a cheeseburger for lunch and a steak for dinner. And people say, Gosh, maybe diet isnt that important. But those are the people who have so many LDL receptors that it doesnt matter what they eat.
Q: And the people who cant get rid of cholesterol never make it to 95.
A: Right. They often die earlier, usually from heart disease. These people have fewer LDL receptors. When they cut back to a diet that gets 30 percent of its calories from fat and seven to ten percent from saturated fat, theyre still saturating those receptors. If you eat more saturated fat and cholesterol than your body can get rid of, its got to go somewhere, so it ends up in your arteries.
If its the arteries to your brain, you get a stroke. If its the arteries to your heart, you get a heart attack. If the arteries go to your kidneys, you get high blood pressure. If its the arteries in your sexual organs, youre at risk for impotence. If its arteries in your legs, you get the pain and limping associated with claudication. Its all the same process.
Q: What about people who dont have heart disease?
A: Ive always had two versions of my diet: one for reversal and one for prevention. The reversal diet is predominantly fruits, vegetables, whole grains, and beans. It limits simple carbohydrates, like sugars, and has moderate amounts of non-fat dairy and egg whites.
The prevention diet allows you to customize a way of eating based on the number of your LDL receptors. You gradually reduce your intake of saturated fat and cholesterol until your total cholesterol is consistently below 150 and your ratio of total to HDL (good) cholesterol is consistently below 4 to 1.
Q: Do you recommend supplements?
A: Yes. I recommend two to three grams a day of flaxseed oil and fish oil to provide the omega-3 fatty acids that are so protective to the heart. Also, for most people I recommend antioxidant vitamins, folic acid to reduce homocysteine levels, selenium, a multivitamin, and soy.
Q: Why does your diet include only whole foods?
A: You can eat white Wonder bread and soft drinks and SnackWells cookies. Is that a low-fat diet? Yes. Is that a healthful diet? No. My diet is not just about avoiding harmful substances like fat, saturated fat, and cholesterol. Youre also getting thousands of substances that have anti-cancer, anti-heart-disease, and even anti-aging propertiesphytochemicals like bioflavonoids, carotenoids, retinols, isoflavones, and so on. Research is showing us many more reasons why a plant-based diet is the most healthful.
Q: Do the small amounts of fat and cholesterol in your diet lower HDL (good) cholesterol?
A: Yes, in some people. But even they ended up with cleaner arteries. If you eat a low-fat vegetarian diet, lower HDL isnt necessarily harmful. Your body makes HDL to get rid of excessive saturated fat and cholesterol. So if someones eating a typical American diet and they cant make enough HDL to get rid of the fat and cholesterol, they are at higher risk. But if there isnt excess fat and cholesterol, you dont need so much HDL to get rid of it. You have less garbage, so you need fewer garbage men.
Q: Do the carbohydrates in your diet raise harmful triglycerides?
A: In some people. We have become more mindful over time that some people are carbohydrate-sensitive. Those people need to be even more careful to reduce simple sugars, white flour, and alcohol and to exercise more. When they do, their triglycerides usually come down.
Q: So people neednt cut way back on all carbohydrates?
A: The Dr. Atkins Diet Revolution, Protein Power, The Carbohydrate Addicts Diet, and some other popular diet books say that all carbohydrates are bad, so you should only eat foods like sausage and bacon and pork. Its a wonderful way to sell books, telling people that these are health foods. But theyre not.
The goal isnt to avoid all carbohydrates, but to avoid refined carbs like sugars and white bread. Fruits, vegetables, beans, and whole grains in their natural forms are rich in fiber. And the fiber slows the absorption of carbohydrate.
Q: Dont exercise and weight-loss help unclog your patients arteries?
A: Yes. And the program is an optimal way to lose weight. The government did a survey of weight-loss programs a few years ago and found that in one year, two-thirds of the people who lost weight gained it all back. In five years, 97 percent gained it all back.
But in our most recent study, we found that the average person in our Lifestyle Heart Trial lost 25 pounds in the first year and kept about half that weight off five years later, even though we werent trying to get them to lose weight.
If you change the type of food you eat, you dont have to be as concerned about the amount of food you eat. Most weight-loss diets dont work because theyre based on deprivation, counting calories, and restricting portion sizes.
Sooner or later, people get tired of feeling hungry and deprived and they go off the diet. They gain the weight back and they blame themselves for lack of discipline.
If you eat fruits, vegetables, and whole grains, you can eat whenever youre hungry and until youre full. You can reduce calories without being hungry. And youll keep the weight off safely without going to destructive diets like the Atkins diet.
Q: Why should people without heart disease follow your program?
A: Because theyll feel better. Theres no point in giving up something you really enjoy unless you get something back thats betternot 50 years later, not the heart attack that didnt come, or living until 86 instead of 85, which doesnt motivate most people even when theyre 85.
When people change their diet and lifestyle, they often have more energy, they think more clearly, and their sexual function often improves. We know that impotence is largely vascular, not so much psychological. Its not just the heart that gets more blood flow when people change their diet and lifestyle. Those are the changes that make this diet worth it.
And paradoxically, its often easier to make big changes than small ones. If you make big changes, you feel better in a week or two. And it comes out of your own experience, not because some doctor said something you can always argue with.
Q: Is your diet inconvenient?
A: Ive developed a line of foods called Advantage\10 to make it easier for people to eat this way.
These are foods like pizza, veggie burgers, entrees, and smoothies. Theyre mostly available in natural food stores. They make it possible for people to try the diet for a week and see how they feel.
Q: Why is it so hard for people to change?
A: Ive asked patients in the Lifestyle Heart Trial, Why do you smoke or overeat or drink too much or work too hard? And they say, It helps us get through the day.
For many people, getting through the day is more important than living to be 86 instead of 85. I believe that the real epidemic in our culture isnt just physical heart disease, but also spiritual and emotional heart disease. By that I mean that loneliness, depression, isolation, and alienation are rampant, in part because of the breakdown in social networks that used to give people a sense of connection to the community.
Q: And drugs or diet dont help?
A: No. Telling people who are lonely and depressed that theyre going to live longer if they take their medication or change their diet doesnt motivate a lot of people. One woman said, Ive got 20 friends in this pack of cigarettes and theyre always there for me and nobody else is. If you take away my friends, what else are you going to give me?
They often talk about using food to fill the void or using alcohol or drugs to numb the pain or they work too hard or spend too much time on the Internet or watching TV to distract themselves. There are lots of ways to numb, or kill, or distract ourselves from emotional pain.
Q: Is that the point of your new book, Love & Survival?
A: Yes. Study after study has shown that people who feel lonely and depressed are three to five timesand in some studies ten timesmore likely to get sick and die prematurely than those who have love and connection to a community, even if you account for the effects of cholesterol, diet, blood pressure, exercise, smoking, and so on.
Few things in medicine have that powerful and across-the-board an impact on survival. Yet these are things we dont learn about in our medical training, and we dont value them in our culture. Our program addresses these deeper issues.
1 J. Amer. Med. Assoc. 280: 2001, 1998.
2 Amer. J. Cardiol. 82: 72T, 1998.