Dean Ornish, MD, is founder and president of the nonprofit Preventive Medicine Research Institute, clinical professor of medicine at UCSF, and author of several books which demonstrate how to reverse heart disease and obtain optimal health through diet and lifestyle.

Bart Brodsky: Your clinical studies were the first to show that diet and lifestyle could be used to reverse heart disease. People who could barely walk more than a few steps were practically jogging after a week or so.

Dr. Dean Ornish: That's true.

Brodsky: The reversal was dramatic and you really turned the medical world on its ears. Your heart healthy diet is high carbohydrate and very low fat, about 10% fat. What do you say to people who say they just don't feel filled up on 10% fat?

Ornish: Let me talk about the diet first, because there are a lot of misconceptions about it. There's a prevention diet and a reversal diet. The old adage about an ounce of prevention and a pound of cure is really true. In other words, it takes more to reverse the progression of a disease like coronary heart disease and other illnesses than to prevent it in the first place. The reversal diet is a very low fat, approximately 10% of calories from fat diet, that's low in fat but high in the good carbs or complex carbs, predominantly fruits, vegetables, whole grains like whole wheat flour, brown rice, legumes, and soy products. The advantage of the diet is that you can eat whenever you're hungry. You can eat until you're full and still, if you need to lose weight, and keep it off without hunger and deprivation. Most weight loss approaches rely on eating less food.

Brodsky: What percentage is the prevention diet?

Ornish: Well, I'll come to that in just a moment. Most weight loss diets rely on eating less food, and so you're hungry because if you eat less food you eat fewer calories. It's hard to sustain that and they feel deprived and get off the diet and gain the weight back. On a very low fat diet you can, because fat has nine calories per gram and protein and carbs have only four. When you eat less fat you are eating fewer calories without having to eat less food. So for many people that's a bonus. Rather than having the feeling of deprivation there's the feeling of abundance because people generally do eat more often and even a larger quantity of food, and yet they are able to lose weight because the food is less dense in calories. For most people being able to eat more frequently is an advantage if you're able to lose weight at the same time. The prevention diet is a spectrum of choices. There is a genetic variability in, for example, in how efficiently a person can metabolize dietary fat and cholesterol. Some people are so efficient they can eat almost anything and they are never going to get heart disease. Everybody knows somebody who is 85 years old and says they have bacon and eggs for breakfast, cheeseburger for dinner. Then you think maybe diet's not that important, look what they are eating, they're 85.... When you think about it not everyone who was eating that rich a diet was so genetically lucky. That's one of the reasons most studies have shown that if you have heart disease and you only make the moderate dietary changes recommended by the US government and the American Heart Association that the majority of patients show continued worsening of their coronary blockages.

Brodsky: And theirs is about 30% fat?

Ornish: Yes, about 30% fat. But the good news is that even if you're genetically on the inefficient or unlucky end of the spectrum, if you reduce your intake of fat and cholesterol sufficiently then your body has a remarkable capacity to begin healing itself. Most people are somewhere in the middle, so in practical terms, from a cardiac standpoint, you can begin by making moderate changes. If that's enough to bring your cholesterol level and other factors down into the range you want, great. If not, it doesn't necessarily mean that your diet failed. It means that you may need to make bigger changes to achieve that goal.

Brodsky: For most people do you even give a percentage?

Ornish: No, because it's variable and there's no way to predict it. Eventually, with genomics it will be possible to help people customize a diet based on their DNA. But, in the mean time, the best, the easiest way to do it is just start by making gradual changes and if that's enough to help you attain your goals of whatever cholesterol level or weight or other things you're trying to do, great. If not, you can just make bigger changes. Most people, if they make sufficient changes, are able to achieve those goals.

Brodsky: How would you compare your diet to the so called "Mediterranean diet" which allows perhaps a little more fat but emphasizes fruits and vegetables as preventative?

Ornish: Well, the Mediterranean diet is a much better diet than the typical American diet. It may not be sufficient to reverse heart disease. Part of the studies like the Lyon study that showed a reduction in heart attacks and cardiac events most of that can be attributed to the use of omega-3 fatty acids which I have been recommending for many years that can help reduce sudden cardiac deaths and heart attacks by over 50% in some studies. It turns out that you only need about 3 grams a day of fish oil or flaxseed oil to provide you a sufficient amount of the omega-3 fatty acids to be protective and more than that provides little, if any, additional benefit. When most people think of the Mediterranean diet they actually think of olive oil, which has almost no omega 3 fatty acids. It's predominantly Omega-6, which are not deficient in the American diet. In fact, most people get 10 times more Omega-6 than they need. Canola oil has some Omega-3s and in the studies, like in the Lyon study I mentioned, the people were actually eating more canola oil than olive oil, as well as eating fish. That's probably what provided the protective benefit. One of the advantages of taking fish oil or flaxseed oil rather than eating fish is that the fish that are the highest in the Omega-3, like the salmon, mackerel, halibut, and other cold water, deep water fish, also tend to be highest in mercury, dioxins, PCBs and other toxic substances.

Brodsky: Welcome to the modern world!

Ornish: Well, those can be removed from the better brands of fish oil and that way you get the benefits without the toxic substances and the additional fat and calories that you don't need.

Brodsky: My wife said she saw you on a program where you said you ate egg whites for breakfast. Is this true, and do you have a personal preference for a vegetarian diet or a diet which includes low fat animal protein or other food?

Ornish: I became a vegetarian when I was 19 because I felt better when I began eating that way and for a variety of reasons. I began eating a small amount of fish on occasion a few years ago. And I also began using more soy milk on my cereal than non-fat dairy and found that made me feel better, as well. These are individual choices that people need to make based on their own values, needs and preferences.

Brodsky: Low carb diets are still very popular, although there have been some concern about long-term health effects. Recently the nationally syndicated radio doctor, Dr. Dean Edell, said, "At least Dr. Ornish has conducted clinical studies demonstrating the reversal of heart disease with his diet. The Atkins people are still trying to prove that their diet doesn't kill you." Is that too harsh?

Dr. Ornish: No, not at all! First of all, anyone named "Dean" you have to believe!

Brodsky: (laughs).

Dr. Ornish: Second, I've debated Dr. Atkins many times, before he died, and I'm very familiar with their approach. The problem with the diet is a.) it tells people what they want to hear and b.) it's based on a half truth. The half truth is that Americans do eat too many simple carbohydrates: white sugar, white flour, white rice. When you eat a lot of simple carbs you get a double-whammy. You get these calories that don't fill you up, because you remove the fiber and the bran that otherwise would have made you full before you got too many calories. For example, you can only eat so many apples before you're going to get full, but you can consume large amounts of sugar without getting full. So, you get all these calories that don't fill you up. And second, they get absorbed quickly so they make your blood sugar spike. Your pancreas makes insulin to bring your blood sugar down, but the insulin accelerates the conversion of calories into fat, which is not good. So, when people go on an Atkins diet they may lose weight by virtue of the fact that they're eating fewer calories because they're eating fewer carbs. So, the diagnosis is accurate, but the prescription is not, because instead of going from simple carbs to T-bone steaks and cheeseburgers, and pork rinds, and bacon and sausage—I'd love to be able to say that these are health foods, but they're not—you want to go from simple carbs to complex or good carbs: the fruits, vegetables, whole wheat flour, brown rice, legumes, soy products. These are rich in fiber [which] fills you up before you get too many calories, and the fiber slows the absorption so you don't get these rapid spikes in your blood sugar. In addition, there are at least 1000 substances that are protective, that have anti-cancer, anti-heart disease, anti-aging properties. With few exceptions, where do you find these protective substances? You find them in fruits and vegetables and whole grains and legumes. So, it saddens me that so many people are going on Atkins and South Beach and other diets. They may help you lose weight, but you may be mortgaging your health in the process. And, part of the problem is that the studies that have been done have not looked at heart disease, they have looked at changes in blood cholesterol and weight.

Brodsky: The Atkins people refer to studies that indicate people often lose weight and lower their cholesterol. Isn't this proof that they work?

Dr. Ornish: Actually, it isn't.... You can lose weight by lots of approaches that are not good for you. You can smoke cigarettes and lose weight. You can take amphetamines or cocaine or Ephedra or chemotherapy. All of these things will help you lose weight, but they're not very good for you. The goal is not [just] to lose weight but to do it in a way that enhances your health rather than one which may compromise it. The one study that's actually looked at blood flow to the heart in people on an Atkins-type diet found that even while they lost weight their heart disease got worse.

Brodsky: Even though in some cases their cholesterol was lowered?

Dr. Ornish: Well, let's talk about that now. The studies that have looked at the Atkins diet have been flawed for a number of reasons. The first is that the LDL cholesterol, the so-called "bad" cholesterol, does not go down on the Atkins diet. It actually usually goes up a little bit. What does go down are triglycerides, and the reason it goes down is when you eat a lot of sugar and simple carbohydrates, it makes your triglycerides go up, so when you eat fewer of them they go down. But the diet they're comparing it to is not what I would consider a healthy diet. They've been comparing it to the American Heart Association National Cholesterol Education Diet, which is not very low in fat—it's 30% fat—and it's very high in simple carbohydrates. So they're really comparing two diets, neither of which is very effective. And so, the headlines say, "Atkins Diet Is As Good As Low Fat Diet," when what the headline really should say is, "Neither Diet Is Really Very Good!" because neither diet has been shown to help people lose weight and keep it off. And neither diet has been shown to reverse heart disease. If anything, heart disease progresses on both diets. Now, it may progress more slowly on an American Heart Association diet than on the typical American diet. It's a better diet, but it's still not an optimum diet, because it doesn't go far enough for most people to stop or reverse the progression of their heart disease.

Brodsky: You should be happy that the trend toward low carb diets is starting to reverse. I think your message is starting to come through.

Dr. Ornish: It's because people are starting to experience [ill effects]. Even the studies of the Atkins diet found that the majority of people have bad breath, body odor, hair loss, headaches, constipation, because it's a toxic diet. And that's how your body detoxifies—through your breath, your bowels, your perspiration. So you may start to lose weight and attract people, but when they get too close they may be put off by the way you smell!

Brodsky: Some studies indicate that eating less increases longevity. Do you have any comments or thoughts on this?

Ornish: That's another example of why eating a low fat, simple carb diet is helpful. You can force a rat to eat a third fewer calories, but you can't do that with people. It's hard to sustain a diet that cuts your calories by a third by just eating a third less food because you get hungry and sooner or later you get tired of being hungry and you go off the diet. If you change the type of food you don't have to change the amount of food. If you go from a 40% fat diet to a 10% fat diet that has fewer simple carbs, even if you eat the same amount of food you'll get less calories, because the food is less dense in calories. Fat has nine calories per gram, whereas protein and carbohydrates have only four. So, because you're eating the same amount of food, you don't get hungry. You can eat whenever hungry and still get a third fewer calories, which in addition to whatever benefits it has for your heart, may also help you to live longer.

Brodsky: Let's go a little beyond diet. Dr. Larry Dossey once told me that the mood at the dinner table may be as important as what's on your plate. Would you care to comment?

Ornish: Well, someone else once said that what comes out of your mouth may be as important as what goes in and I think that is important, as well. Dr Dossey is a friend and a very distinguished writer and editor, and I have great respect for his work and great affection for him as a human being. What I find frustrating is that most people think diet is the mainstay of what I recommend and actually diet is not that interesting to me. Because we are all going to die from something, the question really is, what. And there's no point in living long, if you're not enjoying life. The more important question is not how long can we live, but how well can we live. My latest book is called Love and Survival, which is about these very issues. It's about not just the epidemic of physical heart disease but the epidemic of emotional and spiritual heart disease. Study after study have shown that people who feel lonely and depressed are much more likely to get sick and die prematurely than those who aren't. In part it is because they will be more likely to smoke, overeat, and drink too much and work too hard as a way to numb or kill or distract this emotional pain that they feel. One woman said, "I've got 20 friends in this package of cigarettes, and they're always there for me. What are you going to give me instead?" But also because of mechanisms that we don't fully understand, loneliness and depression and hostility increase the risk that you may die prematurely. So, it's not enough to focus on behaviors like diet and exercise. We also need to work at a deeper level. And apropos to what Larry Dossey said, what I find most meaningful, and what I think most of the patients find most meaningful who go through our programs, is helping them use the experience of suffering as a doorway to transform their lives that go past the physical—arteries getting less clogged or blood pressure going down or whatever. It's hard to make changes in your life, but if you're suffering, there's an opportunity. People say, in effect, it may be hard to change, but I'm in so much pain I'm ready to try just about anything. If you can guide them into constructive things that they can do, which include not only diet but also yoga and meditation and moderate exercise and teaching people how to form healthy relationships in their lives.

Brodsky: During your clinical trials you did a lot, not only with regard to just diet, but also lifestyle and meditation, getting people to switch from being "Type A," learning to communicate better with their partners. However, I've read one critic of your work that said that all these other things may not have been as important as dietary changes. Have you since factored out what part of patients' health improvement is due to lifestyle and what's due to diet? Is it 50-50? 75-25? Do you have any idea? In other words, could one follow your diet and still be a hard-charging Type A, non-meditating person and get the same results?

Dr. Ornish: Well, you can be a hard-charging person and not get heart disease as long as you don't have a lot of hostility. I'm very Type A, as you probably noticed. That's okay, and that was very reassuring for people like me to learn, that in fact, if you practice yoga and meditation on a regular basis, you can accomplish even more in the world without getting so stressed, and without getting sick in the process. The stress comes not so much from what you do, but more importantly, how you react to what you do, and when people practice these simple stretching and breathing and meditation and imagery and deep relaxation techniques on a regular basis, they often find they can accomplish more because they're not getting so stressed in the process. But the ancient swamis and priests and rabbis and monks and nuns didn't develop these techniques, which you find in all cultures, in all religions, simply as a way of managing or coping or dealing with stress. They're really tools for transformation. They're designed to help you quiet down your mind and body enough to experience more of an inner sense of peace and joy and well-being, and to realize that this didn't come because you thought that you got something you needed, but rather you were temporarily quieting down your mind and body enough to experience what is really our natural state, which is to be peaceful and happy in most cases. And for many people, that is a radical transformation, because it allows them to go back into the world and relate to it very differently, from a position of empowerment and strength. And when they start to get stressed or anxious, to realize, "What am I doing that allows my inner natural state of peace and well-being to get disturbed?" And then "What can I do about it?" rather than feeling like you're a victim of bad genes or bad fate or bad karma or bad circumstance. It's a very empowering situation, not to blame the person, but to empower them. Because, if we are just a victim of factors outside our control, then what can we do? To the degree that we can actually learn from those experiences, then they can be reframed, not as punishment or stressful, but as, "There's something that I can do differently to remind myself that I may be looking in the wrong place for my happiness and well-being."

Brodsky: I couldn't agree more with what you're saying. I think it's absolutely right on. I'm just wondering if any of your clinical studies have factored out what part is diet and what part is lifestyle, with regard to specific impacts on health, cholesterol, longevity...

Dr. Ornish: Well, we've done some multiple regression analyses to look at that, and we find that generally each of the components plays a role, but the relative contribution varies with the individual. For some person who's stressed, stress management may be more important than the diet, and visa versa. But, as I mentioned earlier, it's hard to separate them out because you're never just changing one thing in a behavioral intervention. You may think that you are, but you're not. You may be saying, "We're just going to test exercise alone, and we're not going to change anything else." But when you put a group of people on an exercise program, they're exercising but they're also doing other factors that may affect their health for better or for worse that you not be aware of, but that doesn't change the fact that it's a confounding intervention. Putting people on a program gives them a feeling of control and empowerment. That has benefits above and beyond the benefits of the exercise program per se. When you put people in a group and you exercise them together, the group support has benefits. When you exercise, most people begin to change their diets. It's hard to eat a five pound piece of meat and then go out and run. I'm less interested in trying to separate out the relative contribution of each component, since each of these components has benefit, to some degree, and, unlike most things that we do as doctors, the only side effects are good ones.

Brodsky: What studies are you currently conducting?

Dr. Ornish: We are about to publish the first study demonstrating that similar changes in diet and lifestyle may affect the progression of prostrate cancer in men. What affects prostate cancer also likely affects breast cancer as well. We're working closely with Medicare—we've been doing a demonstration project with them for many years—and we're hoping they'll make this a covered benefit, which will make this much more mainstream than it has been.

Brodsky: That would be wonderful if lifestyle could be covered by insurance!

Dr. Ornish: Well, if Medicare covers it, then the other insurance companies will do so as well. I'm beginning to realize that the conventional approaches of trying to do the drugs and surgery, which can be helpful, don't usually address the underlying causes. And so, the same problem tends to recur, and you tend to get new sets of problems that have painful choices. What we've been able to show is that instead of a model of reducing healthcare costs that addresses the symptoms such as shortening hospital stays and shifting to outpatient surgery and forcing doctors to see more and more patients in less and less time, which is not very satisfying for either the doctor or the patient, we're taking a different approach, where we're actually spending more time with patients, help them change their diet and lifestyle, and we've shown that in a series of, now, three demonstration projects, in over 2,000 patients, that this can cut healthcare costs in half in just a year. But, it's a much more satisfying way to both practice medicine and to be a patient, because you're addressing these underlying causes that cause illness and suffering and giving people the tools and techniques to empower themselves to do something about it.

Brodsky: You are clearly revolutionizing medicine in a very positive way. On behalf of all our readers, thank you for that! You are keynote speaker at the Yoga Journal Conference in January. How does yoga fit into lifestyle? Are you going to be referring to yoga at the Yoga Journal Conference? Are you going to talk about diet and lifestyle and yoga?

Ornish: I've been a contributing editor to Yoga Journal for many years and I really like what they are doing. I really respect them so this is my way of supporting what they are doing.

Brodsky: Thank you again for taking the time to talk with us and for your outstanding work!