Resolving Health Disparities by Changing Lifestyle
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Resolving Health Disparities by Changing Lifestyle Resolving Health Disparities by Changing Lifestyle Presentation Transcript

  • 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
  • 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.
  • Providing health insurance to the 48 million Americans who do not have it will create painful choices unless causes of illness are also addressed.
  • Radical
  • 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)
  • Your body often has a remarkable capacity to begin healing itself if you give it a chance to do so.
  • 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
  • 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—
        • 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”)
        • 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
    • Stretching exercises
    • Breathing techniques
    • Meditation
    • Imagery
    • Progressive relaxation
    • Group support
  • Moderate exercise (walking) provides most of the benefits of more intensive exercise while reducing the risks.
  • HOW MUCH EXERCISE? Men Women JAMA 262:2395, 1989 Fitness levels Low High Low High
  • Can Lifestyle Changes Reverse Coronary Heart Disease?
  •  
  • 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
  • Adherence and Change in Coronary Atherosclerosis after 5 years
  • 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.
  • $20 billion were spent last year on statin drugs, most of which could be avoided by making comprehensive lifestyle changes instead.
  • The Multicenter Lifestyle 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
    • 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
    • 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 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
    • 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
    • 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 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.
  • 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
  • Change in Event Rates – Cumulative Two Year Follow-Up O = 104 C = 36
  • 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:
    • “ 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)
    • 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 (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
  • p < .000 All Participants (N = 1,908)
  • p < .000 All Participants (N = 1,908)
  • p < .000 All Participants (N = 1,908)
  • p < .000 All Participants (N = 1,908)
  • 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) 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 (%) 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) All p<.001 Data to be presented at APS, 2005 Data for patients who have reached 1 year of testing
  • Comprehensive lifestyle changes are equivalent to or better than bypass surgery or angioplasty for the treatment of coronary heart disease in stable patients.
  • Most angioplasty and bypass surgery are performed on white upper middle class males.
  • However, angioplasty and bypass surgery are not very effective.
  • 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
    • 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)
    • 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
    • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • Can Lifestyle Changes Reverse the Progression of Prostate Cancer?
    • 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
    • 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
  • None of the experimental group patients but six control group patients had conventional treatment during the first year.
  • Changes in PSA P= 0.002
  •  
  • Change in Prostate Tumor Growth t = -6.9, P = .000
  •  
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  • 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 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
  • 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)
  • 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
    • “ 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
  • 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
    • 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
  • 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.
  • Patients who scored above average in loneliness had significantly lower immune functioning. Kiecolt-Glaser J, Glaser R, Adv. Biochem Psychopharmacol. 1988; 44:217-224.
  • 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.
  • 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.
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