Comprehensive lifestyle changes save money for the paye

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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

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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.
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Providing health insurance to the 48 million
Americans who do not have it will create painful
choices unless causes of illness are also
addressed.
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Radical
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Comprehensive lifestyle changes save money for
the individual-third world diet-walking-medita
tion/yoga-quitting smoking-community/support
groups
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Comprehensive lifestyle changes save money for
the payer (government, corporations, insurance)
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Your body often has a remarkable capacity to
begin healing itself if you give it a chance to
do so.
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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

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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

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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.
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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.

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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

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Stress Management

• Stretching exercises
• Breathing techniques
• Meditation
• Imagery
• Progressive relaxation
• Group support

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Moderate exercise (walking) provides most of the
benefits of more intensive exercise while
reducing the risks.
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HOW MUCH EXERCISE?
Women
Men
Low High
Low High
JAMA 2622395, 1989
Fitness levels
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Can Lifestyle Changes Reverse Coronary Heart
Disease?
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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. 19982802001-2007
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Adherence and Change in Coronary Atherosclerosis
after 5 years
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There was a 40 reduction in LDL-cholesterol in
the Lifestyle Heart Trial after one year without
drugs.

• Ornish D et al. JAMA. 19982802001-2007.

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20 billion were spent last year on statin drugs,
most of which could be avoided by making
comprehensive lifestyle changes instead.
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The Multicenter Lifestyle Demonstration Projects

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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?

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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.
  

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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

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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

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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. 19988272T-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. 2003911316-1322.

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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. 19988272T-76T.

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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. 19988272T-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. 2003911316-1322.

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2. The Highmark Blue Cross Blue Shield
Demonstration ProjectCost Comparisons After 3
Years
Experimental Group (CAD) (N75) Baseline vs. 3
year average 8.7 decrease
in costs Matched Cohort Members (CAD) (N75)
Baseline vs. 3 year average 47.2
increase in costs
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Change in Event Rates Cumulative Two Year
Follow-Up
O 104 C 36
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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

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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

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3. The Medicare Lifestyle Demonstration Project
(MLMPD)

• Patients in the MLMPD improved as much as
  patients gt 65 years old in the two earlier
  demonstration projects and in the earlier
  randomized, controlled clinical trials
• Patients gt65 improved as much as younger patients
  in all three demonstration projects and in the
  randomized, controlled clinical trials

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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

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All Participants (N 1,908)

p lt .000
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All Participants (N 1,908)

p lt .000
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All Participants (N 1,908)

p lt .000
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All Participants (N 1,908)

p lt .000
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Hypertensives Systolic BP (mm Hg)
All plt.001
N at 1 year is not comparable to baseline because
many patients have not yet finished 1 year of
intervention
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Hypertensives Diastolic BP (mm Hg)
All plt.001
N at 1 year is not comparable to baseline because
many patients have not yet finished 1 year of
intervention
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Diabetics - HbA1c ()
All plt.001
Data to be presented at APS, 2005
Data for patients who have reached 1 year of
testing
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Diabetics - Fasting Glucose (mg/dl)
All plt.001
Data to be presented at APS, 2005
Data for patients who have reached 1 year of
testing
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Comprehensive lifestyle changes are equivalent to
or better than bypass surgery or angioplasty for
the treatment of coronary heart disease in stable
patients.
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Most angioplasty and bypass surgery are
performed on white upper middle class males.
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However, angioplasty and bypass surgery are not
very effective.
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Angioplasty vs. Lipid-Lowering TherapyThe 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 1999Jul 8 341(2) 70-6.

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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. 20041091371.

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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.
  1995912325-34.

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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.

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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. Harrisons Advances in
  Cardiology. New York McGraw Hill, 2002.

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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 336129-133.

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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 Harrisons Principles of Internal
  Medicine (online), edited by Eugene Braunwald et
  al., 1999.

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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 Harrisons Principles of Internal
  Medicine (online), edited by Eugene Braunwald et
  al., 1999.

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Can Lifestyle Changes Reverse the Progression of
Prostate Cancer?
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• 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

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Patient Selection Criteria

• 90 men with biopsy-proven prostate cancer, PSA
  4-10, Gleason lt7
• All patients chose to do watchful waiting for
  reasons unrelated to this study
• Randomly assigned to comprehensive lifestyle
  changes or usual care

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None of the experimental group patients but six
control group patients had conventional treatment
during the first year.
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Changes in PSA
P 0.002
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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

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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

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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

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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)

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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.
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Lessons Learned

• Risk factor reduction and prevention are
  borrrrrrrrrrrring to many people
• I dont care if I live longer, I just want to
  have fun
• Joy of living is a much better motivator than
  fear of dying

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Theres no point in giving up something you
enjoy unless you get something back thats even
better and quickly!
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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

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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.

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Patients who scored above average in
loneliness had significantly lower immune
functioning. Kiecolt-Glaser J, Glaser R,
Adv. Biochem Psychopharmacol. 1988 44217-224.
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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.
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Students who watched a movie of Mother Teresas
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.
  1988231-52.

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