Resolving Health Disparities by Changing Lifestyle

1. 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

2. 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.

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

4. Radical

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

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

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

8. 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

9. 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

10. 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.

11. 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.

12. 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

13. Stress Management • Stretching exercises • Breathing techniques • Meditation • Imagery • Progressive relaxation • Group support

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

15. HOW MUCH EXERCISE? Women Men Low High Low High JAMA 262:2395, 1989 Fitness levels

16. Can Lifestyle Changes Reverse Coronary Heart Disease?

18. 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

19. Adherence and Change in Coronary Atherosclerosis after 5 years

20. 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.

21. $20 billion were spent last year on statin drugs, most of which could be avoided by making comprehensive lifestyle changes instead.

22. The Multicenter Lifestyle Demonstration Projects

23. 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?

24. 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.

25. 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

26. 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

27. 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.

28. 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.

29. 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.

30. 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

31. Change in Event Rates – Cumulative Two Year Follow-Up O = 104 C = 36

32. 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

33. 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

34. 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

35. 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

36. All Participants (N = 1,908) p < .000

37. All Participants (N = 1,908) p < .000

38. All Participants (N = 1,908) p < .000

39. All Participants (N = 1,908) p < .000

40. 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

41. 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

42. Diabetics - HbA1c (%) All p<.001 Data to be presented at APS, 2005 Data for patients who have reached 1 year of testing

43. 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

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

45. Most angioplasty and bypass surgery are performed on white upper middle class males.

46. However, angioplasty and bypass surgery are not very effective.

47. 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.

48. 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.

49. 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.

50. 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.