The Transformative Power of Lifestyle Changes and Supportive Community
Transcript of The Transformative Power of Lifestyle Changes and Supportive Community
Ben Brown, M.D.Medical Director: Ornish Lifestyle Medicine
Associate Clinical Professor of MedicineUniversity of California, San Francisco
Healthways
The Transformative Power of Lifestyle Changes and Supportive Community
My Background
Associate Clinical Professor at University of California San FranciscoMedical Director: Preventive Medicine Research Institute - Ornish Lifestyle Medicine. Started non-profits IM4Us and BRCP (now Community Partners International).
My Medical Training
People Don’t ChangeHeart Disease is Not ReversibleYou Can’t Lower Cholesterol Much With Diet. You Can’t Lengthen TelomeresYou Can’t Reverse Prostate Cancer
Time Travel: 1994
I am a residentI’m working in BurmaBill Moyers Dean Ornish MDThe Reason I went into Medicine…
Optimal Lifestyle Program
NutritionStress ManagementModerate ExerciseSupport
Optimal Lifestyle Program
Eat WellStress LessMove MoreLove More
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Lifestyle as treatment, as well as
prevention.
Right idea,Right time
Convergence of ForcesLimitations of high-tech approaches are more well-documentedPower of intensive lifestyle changes are more well-documentedPayment by diagnosis rather than procedure in Affordable Care Act (e.g., ACOs, IDNs, medical home)Patients are asking for options.
A meta-analysis of all 8 randomized trials of stents (7,229 patients) found “no
evidence of benefit for prevention of death, nonfatal MI, unplanned revascularization, or angina.”
—Arch Intern Med. 2012 Feb 27;172(4):312-9.
In a randomized trial of 1,212 patients, coronary bypass surgery did not prolong life.
—Velasquez EJ et al. N Engl J Med April 4, 2011.
Only 1 of 49 men treated for prostate cancer lives longer.
—Schroder FH et al. N Engl J Med. 209:360:1320.
Is Simple is the new Powerful?
What is theCause?
doing what makes you sick
STOP
doing what makes you well
START
Heart Disease in America
Is Heart Disease = a Lifestyle
Illness?
Stop/Start EatingStart Moving
Start RelaxingStart Connecting
Ornish D, Gotto AM, Miller RR, et al. Clinical Research. 1979;27:720A.
There was a 91% reduction in the frequency
of angina in 24 days.--Ornish D, et al. JAMA.. 1983 Jan 7;249(1):54-9.
Impossible
Lifestyle Heart Trial
48 men and women with moderate to severe CHDrandomly assignedlifestyle changes or usual careEndpoints = quantitative coronary arteriography, PET, and events
Source: Gould KL, Ornish D, et al. JAMA. 1995;274:894-901
99% reversed or stopped progression(82% had improvement and 17% no change)
45% had worsening perfusion defects50% showed no changeonly 5% improved (p = 0.03).
--Gould KL, Ornish D, et al. JAMA. 1995;274:894-901.
experimental
Pet Scan After 5 years
control
There was a 300% improvement in coronary
blood measured by cardiac PET scans after 5 years.
--Gould KL, Ornish D, et al. JAMA. 1995;274:894-901.
Changes in QuantitativeCoronary Arteriography
36% 38% 40% 42% 44% 46% 48% 50% 52%
Baseline (n.s.) 1y (P.02) 5y (P.001)
ControlTreatment
% Diameter Stenosis
Ornish D et al. Lancet. 1990; 336:129 & JAMA. 1998;280:2001.
There was a 40% reduction in LDL-cholesterol in the first
year without cholesterol-lowering drugs.
--Ornish D et al. JAMA. 1998;280:2001.
Lifestyle Heart TrialStatins:
None of the experimental groupmore than 50% of the control group.
Slowed Progression(40.7 to 59.7% vs 45.7 to 51.7% on statin)
Reversal?Lifestyle Did, but Statins Did Not
Adherence and Change in Coronary Atherosclerosis after Five Years
1%0%
-7%-9%
-6%
-3%
0%
3%
6%
Low (<56%) Intermediate (56–88%) High (>88%)
US
Ornish D et al. JAMA. 1998;280:2001
Lifestyle Heart Trial
Five Years later 2.5 times more cardiac events in the control group
3,780 patients24 sites
significant improvementsin all metrics
12 weeks and after 1 year.
Silberman A et al, Am J Health Promot 2010;24[4]:260–266.
HIGH MARK STUDY
LDL, TC, LDL/HDL,Triglycerides,Systolic BP, Diastolic BP,
Hemoglobin A1C, BMI, Weight,Hostility and Depression
Silberman A et al, Am J Health Promot 2010;24[4]:260–266.
All Metrics Included
Highmark BCBS High Cost Study
Year after entering the Ornish program four-fold reduction in claims
in Patients with claims costs greater than $25,000 compared to matched controls
Can Lifestyle Changes Reverse Type 2
Diabetes?
“More than half of Americans will have diabetes or be prediabetic by 2020, at
a cost to the U.S. health care system of $3.35 trillion if current trends go on
unabated.”UnitedHealth Group, “United States of Diabetes,” 2011
Lifestyle changes can be better than drugs at preventing diabetes
Cumulative Incidence of Diabetes
Diabetes Prevention Program Research Group, N Engl J Med 2002;346:393-403
The complications prevented when hemoglobin A1C is
reduced below 7.0%by Lifestyle
American Diabetes Association
329 Diabetics at 24 Sites
150
120125
100
110
120
130
140
150
160
Baseline 12 Weeks 1 Year
Fasting Glucose (mg/dl)
All P<.001
HgbA1c decreased from 7.3 to 6.5% after 12 w(p<0.005) and to 6.89% after 1 year (p<0.005)
Weight Loss
Ornish Lifestyle13.3 pounds in the first 12 weeks
15.9 pounds after 1 year
Weight Watchers11.1 pounds after 1 year
Weight Watchers study: Lancet. 2011 Oct 22;378(9801):1485-92.
Silberman A et al, Am J Health Promot 2010;24[4]:260–266.
Weight Loss
Weight (n= 1,626)Weight decreased from 204.1 to 190.8 to 188.2 lbs
Only 69% of patients were overweight at baseline
180
187.5
195
202.5
210
baseline 12 weeks 1 year
Depression
All Participants (N=1,908)
CED-D Depression Scores
11
6 6
0
3
6
9
12
Baseline 12 Weeks 1 Year
All Participants
P<.000
Quarterly Results – Q3 2015
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Baseline 9 weeks Change
Weight Loss 198.1 187.2 -5.5%
BMI 30.4 28.8 -5.5%
Total Cholesterol* 156.3 131.4 -15.9%
LDL Cholesterol* 84.1 68.0 -19.1%
HDL Cholesterol* 44.3 40.4 -8.7%
Triglycerides* 144.8 120.6 -16.8%
Systolic Blood Pressure 128.7 120.9 -6.1%
Diastolic Blood Pressure 76.4 71.2 -6.7%
HbA1c** 6.6 6.1 -7.7%
Depression Score (CESD)
13 5.8 -55.3%
Data is based off participants in Q3 2015 quarterly report N-275, *107-112 participants, **52 participants
Can Lifestyle Changes Reverse Prostate Cancer?
Principal Investigators: Dean Ornish, M.D. Peter Carroll, M.D. William Fair, M.D.
Clinical Professor of Medicine, UCSF
Chairman and Professor, Dept. of Urology, UCSF
Chairman and Professor, Dept. of Urologic Surgery
Memorial Sloan-Kettering Cancer Center
Patient Selection Criteria93 men with biopsy-proven prostate cancer, PSA 4–10, Gleason <7All chose to do watchful waiting for reasons unrelated to this studyRandomly assigned to intensive cardiac rehabilitation or usual care
Changes in PSA
6.36
6.74
6.23
5.98
5.80
6.05
6.30
6.55
6.80
Baseline 12 MonthsControl (n=41) Experimental (n=43)
P=0.002
Ornish D et al. Journal of Urology. 2005;174:1065
Degree of Lifestyle Changeand Changes in PSA
1%
-5%-6%
-3%
-1%
2%
4%
7%
Low (<48%) Intermediate (48–88%) High (>88%)
US
P=0.001
Ornish D et al. Journal of Urology. 2005;174:1065
Change in Prostate Tumor Growth (LNCaP)
-9%
-70%-80%
-64%
-48%
-32%
-16%
0%
%FBS
Control Experimental
t=6.9, P=.000
Ornish D et al. Journal of Urology. 2005;174:1065
Degree of Lifestyle Change and Inhibition of LNCaP Tumor Growth
-8%
-39%
-72%-80%
-60%
-40%
-20%
0%
Low (<48%) Intermediate (48–88%) High (>88%)
Baseline-12m Change in LNCAP Cell Growth
P=0.0001
Ornish D et al. Journal of Urology. 2005;174:1065
1 year laterPSA—4.5 ng/ml
BaselinePSA—6.4 ng/ml
None of the experimental group patients but six control group patients had conventional treatment during the first year.
Ornish D et al. Journal of Urology. 2005;174:1065
Can Lifestyle Changes Reverse Aging?
Telomerase increased 30%in only 3 months
1.51.61.71.81.9
22.12.22.32.4
Baseline 3 Months1 SEM
Telomerase Activity (Ln)
P < 0.05 (two tailed)
Ornish D et al. Lancet Oncol. 2008; 9: 1048–57.
Mean Changes in Telomere Length After 5 Years)
-0.045
-0.0225
0
0.0225
0.045
0.0675
Exp Group Control Group
p<0.004
There was a significant correlation between adherence and telomere length (p<0.007)
Ornish D et al. Lancet Oncology 2013.
Gene expression in 501 genes was beneficially affected in only 3 months
Ornish et al. Proc Nat Acad Sci USA 2008; 105: 8369.
Heatmap showing 48 upregulated genes (red) and 453 downregulated genes (green) pre- and post-intervention
Ornish et al. Proc Nat Acad Sci USA 2008; 105: 8369.
RAS family oncogenes (RAN, RAB14, RAB8A) that promote
prostate cancer and breast cancer were downregulated.
Ornish et al. Proc Nat Acad Sci USA 2008; 105: 8369.
OUR GENES ARE NOT OUR
FATE
doing what makes you sick
STOP
doing what makes you well
START
Bodies HEAL
And can do so Quickly.
Proven Regression
30-40% blockage in artery had all but disappeared after just 5 weeks on the program.
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Before
Week 5 on the Ornish Reversal Program
50 Years oldPolice Officer2015 alumni from UCLA Heart Attack and Family History of Heart Disease
People do Change!
Adherence was 85-90% in 3,780 men and women at all 24
sites after 1 year
Intensive Cardiac Rehab
Exercise3 hours a week
Stress Management1 hour a day
Community1-2 meetings of group/week
NutritionEating Plant Based Low Fat
Adherence to Statin Therapy% of 37,000 New-to-Statin Patients Remaining on Therapy
0
10
20
30
40
50
60
70
80
90
100
Oct ‘97 Nov Dec Jan ‘98 Feb Mar Apr May Jun Jul Aug Sept
LipitorLescolMevacorPravacholZochor
Source: NDC Health Invormation Services, 1998
There’s no point in givingup something you enjoy
unless you get something back that’s even better—
and quickly!
…anything worth having is worth working for…
If it’s meaningful, it’s sustainable
Medicine Changes,but Does so Slowly….
diffusion of
innovation
Disruptive
HEART DISEASE is aLIFESTYLE ILLNESS
“Lifestyle changes and medical therapy should be the mainstay for most patients with stable CHD... focusing on eliminating all unhealthy behaviors.”
Ann Intern Med. 2012;157:729-734.
Medicare January 1, 2011
new benefit category“Intensive Cardiac Rehabilitation.”
“Dr. Ornish’s Program for Reversing Heart Disease,”
the first time lifestyle changes as treatment
Exercise-based cardiac rehabilitation is effective in reducing total and
cardiovascular mortality, but not total MI or revascularization.
It slows progression of atherosclerosis.--Heran BS et al. Cochrane Database of Systematic Reviews 2011, Issue 7.
SLOWS PROGRESSION
Intensive cardiac rehabilitation causes reversal of coronary atherosclerosis, greatly decreased angina, increased
myocardial perfusion, decreased cardiac events, significant improvements in all
risk factors, and markedly reduced costs.
REVERSAL
Exercise3 hours a week
Stress Management1 hour a day
Community1-2 meetings of group/week
NutritionPlant Based Low Fat Diet
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Qualifications for ICR
Coverage
Acute myocardial infarction within the preceding 12 months
Coronary artery bypass surgery
Current stable angina pectoris
Heart valve repair or replacement
Percutaneous transluminal coronary angioplasty or coronary stenting
Heart or heart-lung transplant*Somecommercialplanshaveexpandedclinical criteria.
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The Participant Experience
Each Session includes one hour of each:
• Supervised exercise with telemetry monitoring as indicated
• Stress management practices based on yoga and meditation
• Support group to create increased social support
• Educational lectures and discussions combined with a group meal
18 four hour sessions
(72 hours of training)
~15 participants per cohort
• Physician oversight
• Nurse case management
• Individual consultation
A comprehensive clinical team, trained and certified by
Healthways
Medical DirectorProgram Director
Nurse Exercise PhysiologistRegistered Dietician
Stress Management SpecialistBehavior Health Professional
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If it’s reimbursable, then it’s sustainable.
My Medical Training
People Don’t ChangeHeart Disease is Not ReversibleYou Can’t Lower Cholesterol Much With Diet. You Can’t Lengthen TelomeresYou Can’t Reverse Prostate Cancer
Science Has Progressed
People Do ChangeHeart Disease is ReversibleYou Can Lower Cholesterol With LS. You Can Lengthen TelomeresYou Can Change Gene ExpressionYou Can Stabilize or Reverse Early Prostate Cancer