A Teachable Moment Lost
By: Vance Lehmkuhl
When President Bill Clinton suffered
discomfort recently and had an operation to
clear a blockage to his heart, mainstream
press outlets made it a teachable moment
about heart disease. And the lesson they
taught was: Coronary heart disease is a
There's nothing you can do to stop it.
After all, Clinton was a perfect example
of someone who had "done all the right
things" in terms of diet and lifestyle and
yet his heart disease, after one intervention
in 2004, was still progressing.
The headline of one of the most widely read stories summed up the approach
of the mainstream media: "No cure for heart disease, Clinton's case shows."
If "cure" is taken literally, this may be true - there's no miracle pill or procedure
that unblocks the coronary arteries.
But there are multiple studies showing that heart disease can be reversed -
that its seemingly inevitable progression can be stopped and turned back - by
changes in diet and lifestyle.
For people suffering from heart disease, that's of great importance; yet the
notion is all but invisible in the coverage of this case.
The article mentioned above quotes a parade of physicians confirming the
inevitably progressive nature of coronary heart disease:
Clyde Yancy, M.D., president of the American Heart Association (AHA),
“This kind of disease is progressive. It's not a one-time event so it really points
out the need for constant surveillance.”
Allan Schwartz, M.D. at the New York Presbyterian Hospital, stressed that:
"Heart disease is a chronic condition. We don't have a cure for this condition,
but we have excellent treatments."
The "excellent treatments" include the surgery Clinton underwent in February,
when doctors reopened the clogged artery they had bypassed in his 2004
quadruple bypass operation and inserted, to keep the artery open, two mesh
props called stents.
These invasive surgical procedures are shrugged off as a common, inevitable
part of the routine that patients should expect to settle into.
"Essentially, it's a tune-up," Cam Patterson, M.D., cardiology chief at the
University of North Carolina at Chapel Hill, says in the piece. "We see people
who come in like this every four to five years."
And Dr. Schwartz was quick to add that: "this was not a result of his lifestyle
or his diet." Clinton himself subsequently made a statement blaming his poor
diet when he was younger, but stayed mum on whether he had indeed, as
Schwartz claimed, been "toeing the line" since his 2004 bypass.
What's going on? Why is a well-documented option to reverse coronary heart
disease not mentioned by medical spokespeople?
Wasting no time, John McDougall, M.D., founder and medical director of a well-
known diet and lifestyle modification program (www.drmcdougall. com),
weighed in with his explanation in an open letter to Clinton.
McDougall deftly summarized the situation:
"With all their good intentions, and the use of sophisticated, expensive
technologies, your doctors are allowing your heart disease to progress as if it
were a runaway train destined for a wreck.
Your cardiologist, Dr. Allan Schwartz, at New York Presbyterian Hospital is
telling you further blockage is the normal course of your disease, and your diet
and lifestyle are not involved.
Medical experts expressing their opinion in the news since your surgery are
misleading the public into believing that the proper management of this disease
is through constant surveillance and repeated surgical interventions.
This is big business talking, and in addition to mismanagement of your
personal care, one result will be an increase in the already more than one
million angioplasties and 500,000 bypass surgeries performed annually in the
McDougall quickly got to the point:
"You had two bare metal stents placed in your heart following a few days of
mild chest discomfort. This history will continue to repeat itself until you
seriously change your eating habits and get these meddling doctors out of your
You are missing another 'teaching moment' and bypassing another chance to
change health and health care in America."
Clinton is no heart expert, of course. By and large, he was listening to his
physicians - but he apparently wasn't listening to his friend Dean Ornish, M.D.,
whose name inevitably comes up in discussions of heart disease and its
Ornish, president and founder of the nonprofit Preventive Medicine Research
Institute (www.pmri.org), oversaw the Lifestyle Heart Trial, a randomized
controlled study published in The Lancet in 1990 and in The Journal of the
American Medical Association in 1983 and again in 1995 and 1998.
Patients who stuck to a low-fat vegetarian diet, stopped smoking, exercised
regularly and also practiced yoga and meditation not only stopped the
progression of their disease, but actually reversed it, in contrast to a control
group who followed standard medical advice.
This was the first randomized controlled trial proving that comprehensive
lifestyle changes can reverse the progression of even severe coronary heart
disease, without drugs or surgery.
Ornish recently published a study in the American Journal of Health
Promotion reporting the results of almost 3,000 patients who went through his
reversing heart disease program in 24 different hospital sites.
They found statistically significant improvements in all clinical metrics after 12
weeks that were still significant after one year.
His most recent research proved, for the first time, that comprehensive
lifestyle changes "turn on" disease-preventing genes and "turn off" disease-
promoting genes, as well as increasing telomerase by 30 percent.
Telomerase is the enzyme that lengthens telomeres, the ends of our
chromosomes that control aging (in collaboration with Dr. Elizabeth
Blackburn, who recently received The Nobel Prize in Medicine).
So far Ornish has not made many public statements about the lessons to be
learned from Clinton's situation since he is one of President Clinton's
consulting physicians and considers doctor/patient confidentiality to be
But he did appear on Larry King Live along with Sanjay Gupta, M.D., and
Wayne Isom, M.D. Ornish chose his moment and his points carefully and, as
the segment was ending, got the facts out:
Larry King: "Dean, his doctor said that it [the bypass graft clogging up] was not
due to lifestyle or diet. How do they know?"
Dr. Ornish: "Well, you know, I have a different perspective. I can't talk about
the President directly. But I can say, in general, for them to say that lifestyle,
diet, exercise, stress really don't have anything to do with whether a bypass
clogs up is just not what the facts show.
We've done studies, and others have replicated them, showing that when you
change your lifestyle, you can stop and even reverse the progression of heart
But if you just put a bypass in but you don't change your lifestyle, it's a little like
mopping up the floor around a sink that's overflowing without also turning off
the faucet, or putting a new oil filter in without changing the oil. It's just going
to clog up again.
It doesn't have to be that way. And I say that not to blame, but to empower,
because when we make our lifestyle choices, when we change our lifestyle
more than most doctors recommend, we can stop and even reverse the
progression of heart disease.
And we can keep those bypasses open without necessarily having to have
another stent. You are missing another 'teaching moment' and bypassing
another chance to change health and health care in America.
Randomized trials, like in The New England Journal of Medicine two years ago,
the COURAGE study, showed quite clearly that stents do not prolong life. They
don't even prevent heart attacks, unless you're in the middle of having one,
which 95 percent of people who receive stents are not.
And so the main reason for getting them is to make the angina, or chest pain,
better. But we've shown, and others have shown, that if you change your
lifestyle sufficiently, you can reduce angina or chest pain by 90 to 95 percent in
just a few weeks - simply by changing diet and lifestyle."
At this point Larry King turned to cardiac surgeon Dr. Wayne Isom with a
quick: "Do you agree with that, Wayne?"
Before Isom answered, Ornish inserted, "And it's a lot cheaper and the only
side effects are good ones."
And that's pretty much the sum total of the highest profile mention of this
basic fact about heart disease and its treatment among all the mountains of
coverage Clinton's surgery generated.
Why so little reporting on heart disease reversal? Is the mainstream media
showing extreme tunnel vision, or are they just reflecting what's coming out
from the biggest names in cardiology? Even the press release issued by the
AHA in the wake of Clinton's operation is relatively silent.
In the official statement, AHA President Clyde Yancy touts the usefulness of
stents in reducing pain and says Clinton's angina "is not unexpected." Heart
trouble is a disease, he stresses, and "diseases do progress and must be
managed and where possible prevented."
Yancy apparently means that coronary heart disease must be "managed" by
surgical procedures, given that this is the only management technique
mentioned in the release, which winds up with statistics on coronary
angioplasty and stenting. No notion of regression or reversal makes any
appearance in the release.
I checked in with AHA headquarters to find out why this might be and Richard
Stein, M.D., a cardiologist at New York University, spoke on behalf of the
"Does the AHA recognize the reversal of coronary heart disease as a real,
achievable, reproducible treatment approach?" I asked. His answer was
"There are certain patients for whom aggressive prevention techniques -
including everything from lowering LDL cholesterol, raising HDL cholesterol
and controlling diabetes - with such techniques we can in certain patients see
things that suggest regression."
Defining reversal as being chiefly concerned with stopping the build-up of
artherosclerotic plaque, Stein seemed to argue (1) that the benefits in this area
are fuzzy and (2) that any advocacy or recommendation risks convincing
patients that they'll be 100 percent cured.
"In such cases there's good evidence that in some people we can look at some
indicators and show we're stopping plaque from forming," he allowed, but
"We are not consistently able to do it with everyone. Using good
Mediterranean diets and many of the other techniques, we can in some patients
cause a regression, stabilize the plaque. By doing so, these techniques reduce
the likelihood of having a heart attack. But they don't eliminate it."
Stein added that:
"Patients who follow these [measures] can reduce their risk but you can't
reduce the risk to zero. Clinton still had additional plaque."
Well, yes, but Clinton wasn't following a regimen designed to reverse heart
disease, so additional plaque would simply have been seen as par for the
And the implication that reversal or regression techniques will inevitably be
presented as all or nothing, or that they'll give false hope to patients who
might not wind up seeing maximal results, seems shaky.
Why wouldn't doctors recommending this be as candid and rigorous about
this prognosis as anything else?
Because risk cannot be eliminated, Stein says:
"People who follow this lifestyle might delay an event, lower their risk, but
ultimately, it could still happen."
Still, even if reversal did get "oversold" to some patients, the total harm from
this disappointment in falling short of the optimal benefit (or this potential
delay in getting surgery) would, it seems, pale in comparison to all the lives
lost by people who never heard a word about a different way to address their
As presented by Dr. Stein, the AHA does recommend lifestyle changes, but
only as part of a suite of "techniques" that includes drugs and surgery.
"Our guidelines consistently call for these steps," he says, but added that:
"If the idea is healthy longevity, it's going to involve all these [different
approaches]. They all can help in different ways. The best approach is
combining these - drugs, surgery and lifestyle."
Dr. Hans Diehl, a clinical professor of preventive medicine at Loma Linda
University and the founder of the successful Coronary Health Improvement
Project (CHIP), commented:
"The AHA has steadfastly adhered to their concept that coronary heart disease
is incurable. They admit that coronary risk can be reduced, but don't consider
regression through a lifestyle medicine approach as a viable option."
Dr. Diehl stressed that focusing only on plaque reduction, whether in Clinton
or in the patient community at large, is misleading since the lifestyle approach
pays off in other ways, as well.
He pointed out that it usually reduces the plaques and enlarges the diameter
of the arteries within a year, and that it thins the blood, getting more
oxygenated blood to the heart muscle, as well as diminishing or completely
relieving anginal pain.
In addition to these heart-disease benefits, Diehl points out that the lifestyle
approach, unlike the pharmaceutical/surgical emphasis, will generate other
clinical improvements. He says:
"Since heart disease keeps close company with diabetes, hypertension, kidney
disease, overweight, elevated cholesterol, acid reflux and depression, when
heart disease is treated with this lifestyle medicine approach, then these other
chronic conditions usually improve very quickly as well."
Dr. Diehl draws a distinction between the watered -down diet
recommendations of the AHA and those of researchers who have
documented heart-disease reversal.
In reference to Stein's citation of "Mediterranean diets," he responded that:
"The Mediterranean diet does not go far enough to contribute to the reversal
process in a consistent manner, if at all."
Diehl also draws a key distinction in the big picture:
"When the right diet and lifestyle is applied and encouraged ... this process can
be most rewarding for all concerned. It does not cause pain, it has no on the-
table mortality and it is very cost-effective.
All these things cannot be said for the more aggressive surgical approach or
the pharma approach that considers coronary heart disease as 'incurable' and
offers nostrums and pills and stents and bypass surgeries where the results
erode often all too quickly with time."
It's not that cholesterol-lowering drugs have no role to play. The most
dramatic work of heart disease researcher Caldwell B. Esselstyn, Jr., M.D.
involved drugs along with dietary change.
But Diehl points out that they are at best a subordinate partner in the equation:
"Cholesterol-lowering drugs only do that - they lower cholesterol. Diet therapy,
on the other hand, comprehensively treats many conditions simultaneously.
All their markers go down with these programs."
Diehl's CHIP program does not totally eschew drugs, but recommends them:
"Only if diet alone does not succeed in bringing down cholesterol below 170 or
And he points out that of his 50,000 CHIP participants, "86 percent respond
effectively to diet therapy within four weeks." (See www.chiphealth.
So while Stein isn't off base suggesting there's a place for all three - drugs,
surgery and lifestyle - in heart disease treatment, two of those are very
And for all the talk about diet not having the same success for everybody,
neither do drugs and surgery.
Diehl notes that:
"By-pass surgeries cost in the neighborhood of $150,000 with a venous graft
closure rate during the first year of 15 percent to 30 percent and stenting runs
easily into $35,000 with a non -functionality rate of 35 percent to 45 percent for
the procedure within the first six months."
As might be expected, Dr. Esselstyn himself takes issue with the priorities' or
lack thereof, in the AHA's guidelines.
One of his best-known success stories is a 12-year study published in The
American Journal of Cardiology in 1999.
Angiograms clearly showed the regression of atherosclerotic plaques brought
about by his recommendations - a carefully designed, very low-fat, no oil
vegan diet, with cholesterol-lowering medication used only in a few cases.
"They (the AHA) think our diet is extreme," he observes wryly. "The extreme
diet is actually the one that is creating this epidemic of a 'foodborne' illness
called coronary artery disease."
Esselstyn emphasized that the techniques he's been using are of a wholly
different order than recommending a Mediterranean diet.
"We have studies where we started with the walking dead, those 'too sick' for
intervention," he says. "We had striking examples of heart attack reversals."
As indicated by the successes of Ornish, Diehl and Esselstyn with thousands
of people, the idea that patients are unwilling to make comprehensive lifestyle
changes is not true for everyone (In contrast, two thirds of people who are
prescribed statin drugs are not taking them after just three months, according
This is echoed by John H. Kelly Jr., M.D., a board-certified expert in preventive
medicine (see lifestylehealthdoc.com) who has overseen lifestyle intervention
studies at the Carilion Clinic in Roanoke, Virginia and elsewhere.
Informed of the AHA's "can't get it to work for everybody" rationale, Kelly
"The fact is, there is evidence indicating the majority of individuals with
artherosclerotic heart disease can open up their narrowed arteries rather than
continuing to close them. Now, there are some individuals, less than 50
percent, where this reversal is much reduced. But we can indeed arrest it, stop
He continues with an example:
"We have a documented case of a patient, a 60-year old white male, who came
with a stress echo (a stress test plus an echocardiogram) from his cardiologist
showing S-T-segment depression, reduced blood flow and blood-vessel
His cardiologist had recommended an angiogram.
But the patient didn't want to do the angiogram. Though it's only diagnostic,
it's an invasive procedure that can't be done unless an operating room is
available - 1 in 500 being fatal - so instead he chose to make lifestyle changes.
He went vegetarian and his cholesterol dropped.
We showed him how to starkly reduce the fat, oil, salt and sugar in his diet and
to eat more whole foods. He also moved progressively toward walking four to
five miles a day, and his cholesterol came down wonderfully.
After a five-week CHIP lifestyle intervention program he wanted to get a
second test, because he wanted to know the possible clinical outcome.
In 99 percent of patients, ordinarily a second stress test is going to show
further deterioration. What we found in this fellow was so remarkable that
when his cardiologist saw it he said maybe the first test was 'artifactual' - i.e.,
maybe he didn't have heart trouble at all, but it was just an artifact of the
What he found was:
"A reduction in the artherosclerotic plaque from 3 millimeters to 1, and the S-T
segment no longer showed up, suggesting more oxygen throughout the heart
muscle. His cardiologist gave him a clean bill of health and sent him home with
some baby aspirin."
Although this is just one dramatic case, it resonates with the peer-reviewed
studies of Esselstyn and Ornish that show that such clinical outcomes are
achievable by patients.
Given that this result is a far cry from the occasional surgical "tune-up"
presented as the norm (and indeed, the only possibility) by AHA
spokespeople, one has to wonder what is behind the apparent disregard for
such programs among mainstream cardiologists.
Could the low-fat vegetarian diet that is a central component of all of these
methods of reversal be seen as a threat to entrenched industries whose
representatives at the top of the medical pyramid discourage their adoption by
the doctors "on the ground?"
Esselstyn implied as much in our conversation:
"Of course there's a huge amount of money behind continuing the status quo,"
he noted and quickly followed up:
"Organizations against [lifestyle change] include the USDA, which is stacked
with former members of agribusiness, ex-cattlemen, pork producers and so
Dr. Kelly is a bit more diplomatic in his assessment:
"Lifestyle treatment is still in its infancy, because there's not much money to
fund research into it. After all, who will benefit financially from it?"
But Dr. Kelly pointed to another explanation:
“Physicians are simply not as familiar with the science behind heart- disease
regression through dietary lifestyle changes. And until there is an institutional
push for it, they are unlikely to immerse themselves in learning how to
prescribe a process that's utterly foreign to the approaches they've been
exposed to in their years of medical training.
One study looked at the frequency of lifestyle-change recommendations for
chronic conditions and the results were dismal. Fewer than 20 percent of the
patients had doctors recommending lifestyle changes. When asked why they
had not done so, doctors responded that they felt they didn't have enough
knowledge or experience in that area that it was outside their expertise.
They're reluctant to prescribe treatments they don't understand well or know
how to use.”
Speaking as a physician, Kelly says:
"We're not that good at 'volitional' treatment. There's a need for us to learn how
to educate, empower and motivate our patients."
Good luck with that. As Hans Diehl puts it:
"Therapeutic nutrition in medicine is a wasteland."
Even after decades of criticism from all sides, there's little argument with the
fact that doctors' education is still lacking in this area.
Dr. Kelly is optimistic that physicians can acquire the knowledge needed to
become champions of dietary and lifestyle treatments.
"I do think that doctors and health professionals who have personal
experience with the power of lifestyle change do become passionate about it.
And the effectiveness of a recommendation is largely tied to a physician's
conviction or belief in it.
It's like smoking-cessation studies. Doctors who were smokers were terrible at
getting their patients to quit.
The most successful were ex-smokers. Doctors who make changes
themselves will be more likely to talk about them."
For now, in the absence of much institutional support, doctors such as
McDougall, Ornish, Diehl and Esselstyn are at the forefront of educating their
Dr. Esselstyn sees hope in the reception he's gotten from Kaiser Permanente,
an integrated managed care organization in California that serves nearly nine
"Kaiser called and wanted to know if I would speak and educate their doctors
about this. I went out there and gave two lectures, a demonstration of the
counseling involved. They mobilized, got together, and they're running their
first group through now. If they pull it off, this will be big because they keep
such good records."
Even though the teachable moment Clinton's case presented did not pan out,
such doctors, as John Kelly will continue their work with the satisfaction of
making a difference for the better, knowing that the truth will be borne out over
time. The notion that heart disease is treatable by diet and lifestyle change is
"a minority opinion," he says, adding "but it's a scientific one. And it's
By: Vance Lehmkuhl