Statement of Dean Ornish, M.D. Founder and President Preventive Medicine Research Institute
Committee on Senate Appropriations Subcommittee on Labor, HHS, Education
July 15, 2004
Mr. Chairman, distinguished colleagues, thank you very much for the privilege of being here today. My name is Dr. Dean Ornish, founder and president of the non profit Preventive Medicine Research Institute and Clinical Professor of Medicine at the School of Medicine, University of California, San Francisco (UCSF). I appreciate the opportunity to appear before this Committee.
Chronic diseases such as coronary heart disease, diabetes, cancer, and obesity are the leading causes of death and disability in the United States. Approximately $1.8 trillion were spent last year on health care in this country, and 75% of this amount was spent on treating Americans with chronic illnesses, including heart disease, cancer, obesity, and diabetes. However, less than 2% of this was spent on preventing these diseases. Clearly, more can be done. According to Secretary Tommy Thompson, who has been a visionary leader in promoting prevention and healthy lifestyles, ``If current policies and conditions hold true, by the year 2011 our nation will spend over $2.8 trillion annually on healthcare.``
There is an epidemic of obesity facing America as well as in much of the industrialized world. Over 300,000 Americans each year die from illnesses caused or worsened by obesity, a toll that may soon overtake tobacco as the chief cause of preventable deaths. Approximately 65% of adults and 15% of children are overweight or obese, and that number is increasing. The costs of obesity may exceed $100 billion per year.
Obesity is a major cause of the epidemic of diabetes. In 2000, approximately 17 million Americans had diabetes, costing approximately $132 billion. Complications of diabetes include heart disease and damage to the eyes, nerves, and kidneys. When people lose weight, they are often able to reverse the progression of diabetes and reduce or discontinue insulin and other medications.
While there is a genetic component to chronic diseases, increasing scientific evidence documents that the primary determinants of these illnesses are the lifestyle choices that we make each day. Many people tend to think of breakthroughs in medicine as a new drug, laser, or high-tech surgical procedure. They often have a hard time believing that the simple choices that we make in our lifestyle--what we eat, how we respond to stress, whether or not we smoke cigarettes, how much exercise we get, and the quality of our relationships and social support--can be as powerful as drugs and surgery, but they often are.
During the past 27 years, my colleagues and I at the non-profit Preventive Medicine Research Institute and the University of California, San Francisco School of Medicine have conducted a series of randomized controlled trials and demonstration projects showing that these changes in diet and lifestyle are both medically effective and cost effective. We used the latest in high-tech, state-of-the-art diagnostic technology to prove the power of these low-cost and low-tech interventions.
We initially focused on coronary heart disease as an example of the power of diet and lifestyle changes because cardiovascular disease is the leading cause of premature death in men and women in this country. Since 1900, it has been the number-one killer in the United States every year but 1918. Heart disease claims more lives each year than the next five leading causes of death combined, including cancer. Coronary heart disease is the single largest killer of American males and females. Every 26 seconds an American will suffer a coronary event such as a heart attack, and every minute someone will die from one.
In addition to its prevalence, heart disease is a model for understanding the benefits of preventing and addressing the underlying causes of a chronic disease rather than only literally and figuratively bypassing it. We don`t have to wait for a new breakthrough in technology to prevent it. Knowing what we now understand, coronary heart disease could be prevented in the vast majority of Americans if they were willing to make sufficient changes in diet and lifestyle. For example, one study of 84,129 women in the Harvard Nurse`s Health Study found that women who did not smoke, were not overweight, exercised moderately, and ate a healthful diet had 82% fewer coronary events than other women. Additional changes in diet and lifestyle could reduce this number even further.
In 2001, more than one million coronary angioplasty procedures were performed at a cost of more than $30 billion, and more than 500,000 coronary bypass operations were performed at a cost of another $30 billion. 1,314,000 diagnostic cardiac catheterizations were performed in the United States at a cost of more than $23 billion.
Despite these costs, bypass surgery prolongs life in less than 3% of patients who receive it, and no randomized controlled trial has ever proven that angioplasty prolongs life or prevents heart attacks. Also, approximately one-third of angioplastied arteries restenose (clog up) again after only six months, and one-half of bypass grafts reocclude (clog up) within only a few years.
This is somewhat akin to changing the oil filter in your car without also changing the oil, or mopping up the floor around an overflowing sink without also turning off the faucet. Dr. Denis Burkitt used to show a slide of people raising money to pay for ambulances and a hospital at the base of a cliff rather than for a fence at the top to keep cars from falling off.
In addition to these costs, more than $20 billion were spent last year in the United States on cholesterol-lowering drugs, including statins. This number is likely to increase substantially given a report this week that encouraged more aggressive treatment of elevated cholesterol levels using these drugs. While cholesterol-lowering drugs have clear therapeutic benefits, patients should also be offered more intensive diet and lifestyle interventions that have been proven to lower LDL- cholesterol by approximately the same amount at a fraction of the costs and with similar therapeutic benefits.
The major clinical benefit of bypass surgery and angioplasty is to reduce angina (chest pain), and this can be accomplished in most patients by changing diet and lifestyle. Instead of a ``quick fix`` that often recurs, diet and lifestyle may cause continued improvement in coronary heart disease.
Your body often has a remarkable capacity to begin healing itself if you give it a chance to do so by addressing the underlying causes of chronic diseases. In our research, we documented, for the first time, that the progression of coronary heart disease can be reversed in most patients simply by making comprehensive lifestyle changes. These include a low-fat, whole foods diet, moderate exercise, stress management techniques, and support groups. In our randomized controlled trials, published in the Journal of the American Medical Association and other major journals, we found that 99% of people with severe coronary heart disease were able to stop or reverse it by making comprehensive lifestyle changes, without drugs or surgery. There was some reversal of coronary atherosclerosis after one year and even more improvement after five years, and there were 2.5 times fewer cardiac events.
Most of the patients with severe angina (chest pain) because pain- free within only a few weeks, and quality of life improved dramatically. Also, we found a 40% reduction in LDL-cholesterol after one year without cholesterol-lowering drugs, comparable to what can be achieved with drugs but without the costs or side- effects. They lost an average of 25 pounds in the first year and kept off half that weight for at least five years. In contrast, the diet recommended by the National Cholesterol Education Program and American Heart Association lowers cholesterol by only 3-5% and is not sufficient to stop the progression of coronary heart disease in most patients.
Other studies of our comprehensive lifestyle program have replicated these findings, including demonstration projects in hospitals throughout the country. In a demonstration project involving eight hospitals, Mutual of Omaha found that almost 80% of people who were eligible for bypass surgery or angioplasty were able to safely avoid it for at least three years by making comprehensive lifestyle changes instead. Extrapolating these findings nationwide would have saved approximately $50 billion.
At Highmark Blue Cross Blue Shield of Pennsylvania, Dr. Don Fetterolf (Vice President and Senior Medical Officer) and his colleagues found that medical claims utilization was reduced by 50% in only one year in patients who went through our program of comprehensive lifestyle changes when compared to a matched control group of patients who did not.
We now have collected data on more than 2,000 patients who have gone through our program in hospitals throughout the United States who have shown similar improvements. 389 of these patients are at least 65 years of age. The Centers for Medicare and Medicaid Services is now in the process of conducting a demonstration project of this lifestyle program in the Medicare population.
Increasing evidence links diet and lifestyle changes with reducing the risk of the most common cancers, including breast cancer, prostate cancer, colon cancer, and lymphoma. We recently completed the first randomized controlled trial demonstrating that the progression of early prostate cancer may be modified by making similar changes in diet and lifestyle. What is true for prostate cancer is likely to be true for breast cancer as well.
In addition to preventing and reversing disease and lowering health care costs, comprehensive lifestyle changes often cause significant improvements in quality of life. We have found joy of living to be a much more powerful motivator for people to make and maintain changes in diet and lifestyle than fear of dying.
In general, my colleagues and I have found two basic approaches are effective. The first is to make small, incremental changes such as walking 2,000 steps more per day and to consume 100 calories less per day. Over time, these small changes add up and make a meaningful difference. This is the approach popularized by Dr. James Hill in his program, ``America on the Move.``
A second approach is to motivate people to make more intensive changes in diet and lifestyle. Paradoxically, some people find it easier to make big changes than small ones because when they make comprehensive changes in diet and lifestyle, they often feel so much better, so quickly, that it reframes the reason for making these changes from fear of dying to joy of living.
Alterations in diet, for example, may affect blood flow within hours, for better and for worse. After a whole foods, low-fat meal, blood flow to the brain may improve, so people often describe feeling more alert and aware. Blood flow to the heart often improves; in our studies, most patients reported dramatic reductions in the frequency of angina within a few weeks. Erectile dysfunction may improve as blood flow increases to sexual organs. Most patients are able to lose weight and keep it off.
One of the most effective anti-smoking campaigns was organized by the California Department of Health Services. Billboards featured a ``Marlboro Man`` character with a limp cigarette hanging out of his mouth with the headline, ``Smoking causes impotence.`` For many men, this is more motivating than ``smoking causes heart attacks and emphysema,`` which are too frightening to contemplate.
Many patients say that there is no point in giving up something that they enjoy unless they get something back that`s even better- -not years later, but weeks later. Then, the choices become clearer and, for many patients, worth making. They often experience that something beneficial and meaningful is quickly happening.
The benefit of feeling better quickly is a powerful motivator and reframes therapeutic goals from prevention or risk factor modification to improvement in the quality of life. Concepts such as ``risk factor modification`` and ``prevention`` are often considered boring and they may not initiate or sustain the levels of motivation needed to make and main comprehensive lifestyle changes.
In our experience, it is not enough to focus only on patient behaviors such as diet and exercise; we often need to work at a deeper level. Depression, loneliness, and lack of social support are also epidemic in our culture. These affect not only quality of life but also survival. Several studies has shown that people who are lonely, depressed, and isolated are many times more likely to get sick and die prematurely than those who are not. In part, this is mediated by the fact that they are more likely to engage in self-destructive behaviors when they feel this way, but also via mechanisms that are not well-understood. For example, many people smoke or overeat when they are stressed, lonely, or depressed.
I have been consulting with some of the large food companies such as PepsiCo, ConAgra, and McDonald`s during the past few years, and I have been encouraged by what they are doing. Their concerns about litigation and legislation combined with the awareness of a growing market for healthier foods have created new opportunities. When companies like these use their considerable advertising and marketing resources to educate people about the benefits of healthy lifestyles and to provide more healthful products that are fun, convenient and tasty, then the health of our country is likely to improve. Also, worksite health promotion programs have shown considerable cost savings and improvements in productivity.
Given the enormous cost savings, dramatic improvements in quality of life, and objective medical outcomes that result from changes in diet and lifestyle, why is there so much more emphasis on treatment than on prevention?
The primary determinant of medical practice and medical education is reimbursement. The primary determinant of reimbursement is Medicare, since almost all insurance companies follow Medicare`s lead in deciding what to cover. We doctors do what we get paid to do and we get trained to do what we get paid to do.
Therefore, if Medicare would begin to reimburse diet and lifestyle programs on a certified but non proprietary basis, this would put much more emphasis on prevention of chronic diseases and would motivate physicians and other health professionals to use diet and lifestyle interventions as treatments for coronary heart disease, obesity, diabetes, hypertension, hypercholesterolemia, and other chronic diseases. Of all legislation that Congress could enact, this would have the most impact in changing the emphasis of medical practice from treatment to prevention. Reimbursement for preventive services is an important part of Senator Harkin`s HeLP America Act. An ounce of prevention really is worth a pound of cure.
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