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Resolving Health Disparities by Changing Lifestyle. Dean Ornish, M.D. President, Preventive Medicine Research Institute Clinical Professor of Medicine, UCSF Health Disparities: Progress, Challenges, and Opportunities 19 th National Conference on Chronic Disease Prevention March 1, 2005.

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resolving health disparities by changing lifestyle

Resolving Health Disparities by Changing Lifestyle

Dean Ornish, M.D.

President, Preventive Medicine Research Institute

Clinical Professor of Medicine, UCSF

Health Disparities: Progress, Challenges, and Opportunities

19th National Conference on Chronic Disease Prevention

March 1, 2005

slide2

The way to make health care affordable and accessible is to address the more fundamental causes of illness rather than literally or figuratively bypassing them.

slide3

Providing health insurance to the 48 million Americans who do not have it will create painful choices unless causes of illness are also addressed.

slide5

Comprehensive lifestyle changes save money for the individual:-third world diet-walking-meditation/yoga-quitting smoking-community/support groups

comprehensive lifestyle changes save money for the payer government corporations insurance

Comprehensive lifestyle changes save money for the payer (government, corporations, insurance)

your body often has a remarkable capacity to begin healing itself if you give it a chance to do so

Your body often has a remarkable capacity to begin healing itself if you give it a chance to do so.

optimal lifestyle program
Optimal Lifestyle Program
  • Diet (low-fat, whole foods, plant based)
  • Stress management training (includes yoga and meditation)
  • Moderate exercise
  • Smoking cessation
  • Psychosocial support groups
  • Supplements
high fat low fat meat based plant based
High in cholesterol

High in saturated fats

High in oxidants

Low in antioxidants

Inflammatory

Low in fiber

No cholesterol

Low in saturated fats

Low in oxidants

High in antioxidants

Prevents inflammation

High in fiber

High fat, Low-fat, Meat-based Plant-based
slide10

What you include in your diet is as important as what you exclude. At least 1,000 protective substances in fruits, vegetables, whole grains, legumes, and soy foods.

an optimal diet is
An optimal diet is—
  • Low in refined (“bad”) carbohydrates
  • High in unrefined (“good”) carbohydrates
  • Low in meat-based proteins
  • High in plant-based proteins
  • Low in saturated fats and trans fats
  • 3 grams/day of omega-3 fatty acids

To the degree you move in this direction on the food spectrum, you lose weight, feel better, and gain health.

omega 3 fatty acids good fats
Omega-3 Fatty Acids (“Good Fats”)
  • May reduce sudden cardiac death by 50-80% or more
  • May reduce risk of prostate cancer, breast cancer, colon cancer, and arthritis
  • Only 3 grams/day provide protective benefits
stress management
Stress Management
  • Stretching exercises
  • Breathing techniques
  • Meditation
  • Imagery
  • Progressive relaxation
  • Group support
slide14

Moderate exercise (walking) provides most of the benefits of more intensive exercise while reducing the risks.

slide15

HOW MUCH EXERCISE?

Women

Men

Low High

Low High

JAMA 262:2395, 1989 Fitness levels

slide18

Conclusions:   More regression of coronary atherosclerosis occurred after 5 years than after 1 year in the experimental group. In contrast, in the control group, coronary atherosclerosis continued to progress and more than twice as many cardiac events occurred.

JAMA. 1998;280:2001-2007

slide20

There was a 40% reduction in LDL-cholesterol in the Lifestyle Heart Trial after one year without drugs.

Ornish D et al. JAMA. 1998;280:2001-2007.

slide21

$20 billion were spent last year on statin drugs, most of which could be avoided by making comprehensive lifestyle changes instead.

objectives of demonstration projects
Objectives of Demonstration Projects
  • Can physician-supervised teams be trained to implement this program of comprehensive changes in diet and lifestyle?
  • Can diverse patients in different parts of the U.S. make and maintain comprehensive changes in diet and lifestyle?
  • Is this approach cost-effective as well as medically effective?
  • Can payment mechanisms be developed to prevent fraud and abuse?
medical effectiveness demonstration projects
Medical Effectiveness: Demonstration Projects
  • Three demonstration projects
  • More than 2,000 patients
  • Greater changes in diet and lifestyle, larger improvements in risk factors and quality of life, and bigger cost reductions than have ever before been reported in an ambulatory group of patients.
implementation of demonstration projects
Implementation of Demonstration Projects

A physician supervises and directs the behavioral intervention, assisted by a team of health professionals:

  • Nurse case manager
  • Registered dietitian
  • Clinical psychologist (support groups)
  • Exercise physiologist
  • Stress management instructor
  • Program director
implementation of demonstration projects26
Implementation of Demonstration Projects

Patients meet twice/week during the first three months and once/week for the remaining nine months for four hours/session:

  • 1 hour of supervised exercise
  • 1 hour of stress management techniques
  • 1 hour support group
  • 1 hour lecture and group meal
1 the multicenter lifestyle demonstration project
1. The Multicenter Lifestyle Demonstration Project
  • Diverse academic and community hospitals
  • Funded by Mutual of Omaha, which provided a matched control group
  • Data coordinating center at Harvard Medical School and the Massachusetts General Hospital
  • One year intervention with 3-year follow-up
  • 194 CHD patients in the experimental group were compared with 139 CHD patients in the control group
  • Patients were matched for age, gender, left ventricular ejection fraction, and severity of coronary atherosclerosis

Ornish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998;82:72T-76T.

Koertge J, Weidner G, Elliott-Eller M, et al. Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 2003;91:1316-1322.

1 the multicenter lifestyle demonstration project sites
1. The Multicenter Lifestyle Demonstration Project Sites
  • Alegent Immanuel Medical Center
  • Beth Israel Deaconess Medical Center/Harvard Medical School, Boston
  • Beth Israel Medical Center/New York, NY
  • Broward General Hospital, Ft. Lauderdale, FL
  • Franciscan Health System, Cincinnati, OH
  • Highmark Blue Cross Blue Shield, Pittsburgh, PA
  • Mercy Hospital/Iowa Heart Center, Des Moines, IA
  • Mt. Diablo Medical Center, Concord, CA
  • Palmetto Richmond Memorial Hospital, Columbia, SC
  • Scripps Institute/ScrippsHealth, La Jolla, CA
  • SwedishAmerican Health System, Rockford, IL
  • Swedish Medical Center, Seattle, WA
  • University of California, San Francisco, School of Medicine

Ornish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998;82:72T-76T.

Koertge J, Weidner G, Elliott-Eller M, et al. Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 2003;91:1316-1322.

1 the multicenter lifestyle demonstration project29
1. The Multicenter Lifestyle Demonstration Project
  • Almost 80% of patients in the experimental group who were eligible for revascularization were able to safely avoid it for at least three years with comparable health outcomes when compared with the control group
  • Mutual of Omaha calculated saving $29,529 per patient

Ornish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998;82:72T-76T.

Koertge J, Weidner G, Elliott-Eller M, et al. Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 2003;91:1316-1322.

slide30

2. The Highmark Blue Cross Blue Shield Demonstration Project:Cost Comparisons After 3 Years

Experimental Group (CAD) (N=75) Baseline vs. 3 year average = 8.7% decrease in costs

Matched Cohort Members (CAD) (N=75) Baseline vs. 3 year average = 47.2% increase in costs

2 the highmark blue cross blue shield demonstration project
2. The Highmark Blue Cross Blue Shield Demonstration Project
  • Costs were approximately the same at baseline in the experimental and control groups
  • Costs were significantly lower in the experimental group in each of the next 3 years, decreasing 8.7% in the experimental group but increasing 47.2% in the control group
  • Total costs over 3 years were $14,734/patient in the experimental group and $23,600 in the control group, resulting in a net savings of $8,865/patient
summary of these two demonstration projects
Summary of These Two Demonstration Projects:

“Although my experience as a health actuary has left me with a healthy skepticism regarding the ability of Medicare benefit expansions to save money for the program, I concluded that Medicare coverage of this program would reduce Medicare expenditures even under a set of more pessimistic assumptions then I felt were appropriate.”

--Roland E. (“Guy”) King

Chief Actuary, HCFA, 1978-1994

3 the medicare lifestyle demonstration project mlmpd
3. The Medicare Lifestyle Demonstration Project (MLMPD)
  • Patients in the MLMPD improved as much as patients > 65 years old in the two earlier demonstration projects and in the earlier randomized, controlled clinical trials
  • Patients >65 improved as much as younger patients in all three demonstration projects and in the randomized, controlled clinical trials
3 the medicare lifestyle demonstration project mlmpd35
3. The Medicare Lifestyle Demonstration Project (MLMPD)
  • The risks of bypass surgery & angioplasty increase with age but the benefits of comprehensive lifestyle changes are as great in older patients as in younger ones
  • Therefore, comprehensive lifestyle changes are especially beneficial in Medicare patients
hypertensives systolic bp mm hg
Hypertensives – Systolic BP (mm Hg)

All p<.001

N at 1 year is not comparable to baseline because many patients have not yet finished 1 year of intervention

hypertensives diastolic bp mm hg
Hypertensives – Diastolic BP (mm Hg)

All p<.001

N at 1 year is not comparable to baseline because many patients have not yet finished 1 year of intervention

diabetics hba1c
Diabetics - HbA1c (%)

All p<.001

Data to be presented at APS, 2005

Data for patients who have reached 1 year of testing

diabetics fasting glucose mg dl
Diabetics - Fasting Glucose (mg/dl)

All p<.001

Data to be presented at APS, 2005

Data for patients who have reached 1 year of testing

slide44

Comprehensive lifestyle changes are equivalent to or better than bypass surgery or angioplasty for the treatment of coronary heart disease in stable patients.

angioplasty vs lipid lowering therapy the avert trial
Angioplasty vs. Lipid-Lowering Therapy:The AVERT Trial
  • There were 36% fewer cardiac events after lipid-lowering therapy than after angioplasty
  • “In patients with stable coronary artery disease, aggressive lipid-lowering therapy is at least as effective as angioplasty and usual care in reducing the incidence of ischemic events.”

Pitt B et al, NEJM 1999;Jul 8; 341(2): 70-6.

angioplasty vs exercise
Angioplasty vs. Exercise
  • 101 male patients ages ≤ 70 years, post PTCA
  • Randomized to 12 months of exercise training (20 minutes of bicycle ergometry per day) or to PTCA.
  • “Compared with PTCA, a 12-month program of regular physical exercise in selected patients with stable coronary artery disease resulted in superior event-free survival and exercise capacity at lower costs, notably owing to reduced re-hospitalizations and repeat revascularizations.”

Hambrecht R, Walther C, Mobius-Winkler S, et al. Circulation. 2004;109:1371.

coronary artery surgical study cass
Coronary Artery Surgical Study (CASS)
  • 24,958 patients with ischemic CAD
  • Randomized to bypass surgery or medical therapy
  • 16 year follow up
  • Only 2.1% of bypass operations yielded improved mortality: only in those with left main coronary artery disease and poor left ventricular function

Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation. 1995;91:2325-34.

summary
Summary
  • Angioplasty (including stents) has never been shown to prolong life or prevent heart attacks in stable patients with coronary heart disease
  • Bypass surgery prolongs life only in 2% of patients with severe left main coronary artery disease and poor left ventricular function. For the other 98%, bypass surgery has not been shown to prolong life or prevent heart attacks.
summary51
Summary
  • These findings are consistent with the latest understanding of the pathophysiology of CHD, which reveals that the less severe coronary artery lesions are more likely to cause MI and sudden cardiac death than the more severe ones, and these moderate lesions are not bypassed or angioplastied.
  • In contrast, diet and lifestyle interventions, as well as lipid-lowering drugs, affect all lesions.

Ornish D. “Intensive Lifestyle Changes in Management of Coronary Heart Disease. In: Braunwald E. Harrison’s Advances in Cardiology. New York: McGraw Hill, 2002.

summary52
Summary
  • Thus, an evidenced-based approach reveals that the most justifiable reason for undergoing revascularization is to reduce angina.
  • However, this reduction in angina can be accomplished to a greater degree in only a few weeks (91% reduction in angina) by making comprehensive lifestyle changes with much less trauma and at lower cost.

Ornish DM, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. The Lancet. 1990; 336:129-133.

summary53
Summary
  • At best, revascularization provides a temporary benefit, but lesions tend to reocclude and/or restenose.
  • In contrast, diet and lifestyle interventions, as well as lipid-lowering drugs, cause continued regression of coronary atherosclerosis over time.

Ornish D. Concise Review: Intensive lifestyle changes in the management of coronary heart disease. In: Harrison’s Principles of Internal Medicine (online), edited by Eugene Braunwald et al., 1999.

summary54
Summary
  • Therefore, comprehensive lifestyle changes are equivalent or superior to angioplasty and bypass surgery for reducing angina and event rates at lower costs and morbidity

Ornish D. Concise Review: Intensive lifestyle changes in the management of coronary heart disease. In: Harrison’s Principles of Internal Medicine (online), edited by Eugene Braunwald et al., 1999.

slide56
Principal Investigator:
  • Dean Ornish, M.D.

Clinical Professor of Medicine, UCSF

Co-Principal Investigators:

  • Peter Carroll, M.D.

Chairman & Professor, Dept. of Urology, UCSF

  • William Fair, M.D.

Chairman & Professor, Dept. of Urologic Surgery

Memorial Sloan-Kettering Cancer Center

patient selection criteria
Patient Selection Criteria
  • 90 men with biopsy-proven prostate cancer, PSA 4-10, Gleason <7
  • All patients chose to do watchful waiting for reasons unrelated to this study
  • Randomly assigned to comprehensive lifestyle changes or usual care
slide58

None of the experimental group patients but six control group patients had conventional treatment during the first year.

women heart disease
Women & Heart Disease
  • Coronary heart disease is the leading cause of death in women
  • Women are less likely to undergo surgery
  • Women have higher morbidity and mortality following surgery or angioplasty
  • Women can reverse heart disease easier than men
women heart disease65
Women & Heart Disease
  • Estrogen may lower heart disease risk (although this is controversial) and osteoporosis but increases breast cancer risk
  • In contrast, lifestyle changes lower heart disease risk, osteoporosis, and breast cancer, without painful choices
how to change your diet lifestyle
Incremental changes:

2,000 more steps per day

100 fewer calories per day

Comprehensive changes in diet & lifestyle: feel better quickly, big improvements, benefits are clear and immediate

How to Change Your Diet & Lifestyle
the spectrum of choices
The Spectrum of Choices
  • A way of eating, not a diet to get on or off
  • Freedom of choice, not food police
  • Recognizes biological variability
  • Help people customize a diet and lifestyle program that is just right for them (including some indulgences)
slide68

Myth: “Adherence to statins is easy but adherence to comprehensive lifestyle changes is very difficult if not impossible. Small, gradual changes in diet and lifestyle are easier than big, rapid changes.”

lessons learned
Lessons Learned
  • “Risk factor reduction” and “prevention” are borrrrrrrrrrrring to many people
  • “I don’t care if I live longer, I just want to have fun”
  • Joy of living is a much better motivator than fear of dying
slide71

There’s no point in giving up something you enjoy unless you get something back that’s even better– and quickly!

epidemic of depression loneliness
Epidemic of Depression/Loneliness
  • Loneliness, depression, and isolation increase mortality by 3-7 times
  • Effect persists even when controlling for known risk factors
  • Mediated by unhealthful behaviors
  • Also mediated by other factors
seeman te syme sl psychosom med 1987 49 4 341 54

Scientists studied 119 men and 40 women who were undergoing coronary angiography. The more people felt loved and supported, the less coronary atherosclerosis they had at angiography, independent of other factors.

Seeman TE, Syme SL. Psychosom. Med. 1987; 49(4): 341-54.

slide74

Patients who scored above average in loneliness had significantly lower immune functioning.Kiecolt-Glaser J, Glaser R, Adv. Biochem Psychopharmacol. 1988; 44:217-224.

slide75

Patients who were HIV positive that were depressed had more than double the mortality rate of those who had a more positive outlook.Chesney MA, et al, The Fourth International Congress on Behavioral Medicine, 1996.

mcclelland dc kirshnit c psychology and health 1988 2 31 52

Students who watched a movie of Mother Teresa’s service to the sick & dying of Calcutta showed a significant increase in salivary immunoglobulin A compared with those watching a more neutral film.

McClelland DC, Kirshnit C. Psychology and Health. 1988;2:31-52.