The Transformative Power of Lifestyle Changes and Supportive Community

Ben Brown, M.D.Medical Director: Ornish Lifestyle Medicine

Associate Clinical Professor of MedicineUniversity of California, San Francisco

Healthways

The Transformative Power of Lifestyle Changes and Supportive Community

My Background

Associate Clinical Professor at University of California San FranciscoMedical Director: Preventive Medicine Research Institute - Ornish Lifestyle Medicine. Started non-profits IM4Us and BRCP (now Community Partners International).

My Medical Training

People Don’t ChangeHeart Disease is Not ReversibleYou Can’t Lower Cholesterol Much With Diet. You Can’t Lengthen TelomeresYou Can’t Reverse Prostate Cancer

Time Travel: 1994

I am a residentI’m working in BurmaBill Moyers Dean Ornish MDThe Reason I went into Medicine…

Optimal Lifestyle Program

NutritionStress ManagementModerate ExerciseSupport

Optimal Lifestyle Program

Eat WellStress LessMove MoreLove More

7

Lifestyle as treatment, as well as

prevention.

Right idea,Right time

Convergence of ForcesLimitations of high-tech approaches are more well-documentedPower of intensive lifestyle changes are more well-documentedPayment by diagnosis rather than procedure in Affordable Care Act (e.g., ACOs, IDNs, medical home)Patients are asking for options.

A meta-analysis of all 8 randomized trials of stents (7,229 patients) found “no

evidence of benefit for prevention of death, nonfatal MI, unplanned revascularization, or angina.”

—Arch Intern Med. 2012 Feb 27;172(4):312-9.

In a randomized trial of 1,212 patients, coronary bypass surgery did not prolong life.

—Velasquez EJ et al. N Engl J Med April 4, 2011.

Only 1 of 49 men treated for prostate cancer lives longer.

—Schroder FH et al. N Engl J Med. 209:360:1320.

Is Simple is the new Powerful?

What is theCause?

doing what makes you sick

STOP

doing what makes you well

START

Heart Disease in America

Is Heart Disease = a Lifestyle

Illness?

Stop/Start EatingStart Moving

Start RelaxingStart Connecting

Ornish D, Gotto AM, Miller RR, et al. Clinical Research. 1979;27:720A.

There was a 91% reduction in the frequency

of angina in 24 days.--Ornish D, et al. JAMA.. 1983 Jan 7;249(1):54-9.

Impossible

Lifestyle Heart Trial

48 men and women with moderate to severe CHDrandomly assignedlifestyle changes or usual careEndpoints = quantitative coronary arteriography, PET, and events

Source: Gould KL, Ornish D, et al. JAMA. 1995;274:894-901

99% reversed or stopped progression(82% had improvement and 17% no change)

45% had worsening perfusion defects50% showed no changeonly 5% improved (p = 0.03).

--Gould KL, Ornish D, et al. JAMA. 1995;274:894-901.

experimental

Pet Scan After 5 years

control

There was a 300% improvement in coronary

blood measured by cardiac PET scans after 5 years.

--Gould KL, Ornish D, et al. JAMA. 1995;274:894-901.

Changes in QuantitativeCoronary Arteriography

36% 38% 40% 42% 44% 46% 48% 50% 52%

Baseline (n.s.) 1y (P.02) 5y (P.001)

ControlTreatment

% Diameter Stenosis

Ornish D et al. Lancet. 1990; 336:129 & JAMA. 1998;280:2001.

There was a 40% reduction in LDL-cholesterol in the first

year without cholesterol-lowering drugs.

--Ornish D et al. JAMA. 1998;280:2001.

Lifestyle Heart TrialStatins:

None of the experimental groupmore than 50% of the control group.

Slowed Progression(40.7 to 59.7% vs 45.7 to 51.7% on statin)

Reversal?Lifestyle Did, but Statins Did Not

Adherence and Change in Coronary Atherosclerosis after Five Years

1%0%

-7%-9%

-6%

-3%

0%

3%

6%

Low (<56%) Intermediate (56–88%) High (>88%)

US

Ornish D et al. JAMA. 1998;280:2001

Lifestyle Heart Trial

Five Years later 2.5 times more cardiac events in the control group

3,780 patients24 sites

significant improvementsin all metrics

12 weeks and after 1 year.

Silberman A et al, Am J Health Promot 2010;24[4]:260–266.

HIGH MARK STUDY

LDL, TC, LDL/HDL,Triglycerides,Systolic BP, Diastolic BP,

Hemoglobin A1C, BMI, Weight,Hostility and Depression


All Metrics Included

Highmark BCBS High Cost Study

Year after entering the Ornish program four-fold reduction in claims

in Patients with claims costs greater than $25,000 compared to matched controls

Can Lifestyle Changes Reverse Type 2

Diabetes?

“More than half of Americans will have diabetes or be prediabetic by 2020, at

a cost to the U.S. health care system of $3.35 trillion if current trends go on

unabated.”UnitedHealth Group, “United States of Diabetes,” 2011

Lifestyle changes can be better than drugs at preventing diabetes

Cumulative Incidence of Diabetes

Diabetes Prevention Program Research Group, N Engl J Med 2002;346:393-403

The complications prevented when hemoglobin A1C is

reduced below 7.0%by Lifestyle

American Diabetes Association

329 Diabetics at 24 Sites

150

120125

100

110

120

130

140

150

160

Baseline 12 Weeks 1 Year

Fasting Glucose (mg/dl)

All P<.001

HgbA1c decreased from 7.3 to 6.5% after 12 w(p<0.005) and to 6.89% after 1 year (p<0.005)

Weight Loss

Ornish Lifestyle13.3 pounds in the first 12 weeks

15.9 pounds after 1 year

Weight Watchers11.1 pounds after 1 year

Weight Watchers study: Lancet. 2011 Oct 22;378(9801):1485-92.


Weight Loss

Weight (n= 1,626)Weight decreased from 204.1 to 190.8 to 188.2 lbs

Only 69% of patients were overweight at baseline

180

187.5

195

202.5

210

baseline 12 weeks 1 year

Depression

All Participants (N=1,908)

CED-D Depression Scores

11

6 6

0

3

6

9

12

Baseline 12 Weeks 1 Year

All Participants

P<.000

Quarterly Results – Q3 2015

51

Baseline 9 weeks Change

Weight Loss 198.1 187.2 -5.5%

BMI 30.4 28.8 -5.5%

Total Cholesterol* 156.3 131.4 -15.9%

LDL Cholesterol* 84.1 68.0 -19.1%

HDL Cholesterol* 44.3 40.4 -8.7%

Triglycerides* 144.8 120.6 -16.8%

Systolic Blood Pressure 128.7 120.9 -6.1%

Diastolic Blood Pressure 76.4 71.2 -6.7%

HbA1c** 6.6 6.1 -7.7%

Depression Score (CESD)

13 5.8 -55.3%

Data is based off participants in Q3 2015 quarterly report N-275, *107-112 participants, **52 participants

Can Lifestyle Changes Reverse Prostate Cancer?

Principal Investigators: Dean Ornish, M.D. Peter Carroll, M.D. William Fair, M.D.

Clinical Professor of Medicine, UCSF

Chairman and Professor, Dept. of Urology, UCSF

Chairman and Professor, Dept. of Urologic Surgery

Memorial Sloan-Kettering Cancer Center

Patient Selection Criteria93 men with biopsy-proven prostate cancer, PSA 4–10, Gleason <7All chose to do watchful waiting for reasons unrelated to this studyRandomly assigned to intensive cardiac rehabilitation or usual care

Changes in PSA

6.36

6.74

6.23

5.98

5.80

6.05

6.30

6.55

6.80

Baseline 12 MonthsControl (n=41) Experimental (n=43)

P=0.002

Ornish D et al. Journal of Urology. 2005;174:1065

Degree of Lifestyle Changeand Changes in PSA

1%

-5%-6%

-3%

-1%

2%

4%

7%


US

P=0.001


Change in Prostate Tumor Growth (LNCaP)

-9%

-70%-80%

-64%

-48%

-32%

-16%

0%

%FBS

Control Experimental

t=6.9, P=.000


Degree of Lifestyle Change and Inhibition of LNCaP Tumor Growth

-8%

-39%

-72%-80%

-60%

-40%

-20%

0%


Baseline-12m Change in LNCAP Cell Growth

P=0.0001


1 year laterPSA—4.5 ng/ml

BaselinePSA—6.4 ng/ml

None of the experimental group patients but six control group patients had conventional treatment during the first year.


Can Lifestyle Changes Reverse Aging?

Telomerase increased 30%in only 3 months

1.51.61.71.81.9

22.12.22.32.4

Baseline 3 Months1 SEM

Telomerase Activity (Ln)

P < 0.05 (two tailed)

Ornish D et al. Lancet Oncol. 2008; 9: 1048–57.

Mean Changes in Telomere Length After 5 Years)

-0.045

-0.0225

0

0.0225

0.045

0.0675

Exp Group Control Group

p<0.004

There was a significant correlation between adherence and telomere length (p<0.007)

Ornish D et al. Lancet Oncology 2013.

Gene expression in 501 genes was beneficially affected in only 3 months

Ornish et al. Proc Nat Acad Sci USA 2008; 105: 8369.

Heatmap showing 48 upregulated genes (red) and 453 downregulated genes (green) pre- and post-intervention


RAS family oncogenes (RAN, RAB14, RAB8A) that promote

prostate cancer and breast cancer were downregulated.


OUR GENES ARE NOT OUR

FATE

doing what makes you sick

STOP

doing what makes you well

START

Bodies HEAL

And can do so Quickly.

Proven Regression

30-40% blockage in artery had all but disappeared after just 5 weeks on the program.

73

Before

Week 5 on the Ornish Reversal Program

50 Years oldPolice Officer2015 alumni from UCLA Heart Attack and Family History of Heart Disease

People do Change!

Adherence was 85-90% in 3,780 men and women at all 24

sites after 1 year

Intensive Cardiac Rehab

Exercise3 hours a week

Stress Management1 hour a day

Community1-2 meetings of group/week

NutritionEating Plant Based Low Fat

Adherence to Statin Therapy% of 37,000 New-to-Statin Patients Remaining on Therapy

0

10

20

30

40

50

60

70

80

90

100

Oct ‘97 Nov Dec Jan ‘98 Feb Mar Apr May Jun Jul Aug Sept

LipitorLescolMevacorPravacholZochor

Source: NDC Health Invormation Services, 1998

There’s no point in givingup something you enjoy

unless you get something back that’s even better—

and quickly!

…anything worth having is worth working for…

If it’s meaningful, it’s sustainable

Medicine Changes,but Does so Slowly….

diffusion of

innovation

Disruptive

HEART DISEASE is aLIFESTYLE ILLNESS

“Lifestyle changes and medical therapy should be the mainstay for most patients with stable CHD... focusing on eliminating all unhealthy behaviors.”

Ann Intern Med. 2012;157:729-734.

Medicare January 1, 2011

new benefit category“Intensive Cardiac Rehabilitation.”

“Dr. Ornish’s Program for Reversing Heart Disease,”

the first time lifestyle changes as treatment

Exercise-based cardiac rehabilitation is effective in reducing total and

cardiovascular mortality, but not total MI or revascularization.

It slows progression of atherosclerosis.--Heran BS et al. Cochrane Database of Systematic Reviews 2011, Issue 7.

SLOWS PROGRESSION

Intensive cardiac rehabilitation causes reversal of coronary atherosclerosis, greatly decreased angina, increased

myocardial perfusion, decreased cardiac events, significant improvements in all

risk factors, and markedly reduced costs.

REVERSAL

Exercise3 hours a week

Stress Management1 hour a day

Community1-2 meetings of group/week

NutritionPlant Based Low Fat Diet

89

Qualifications for ICR

Coverage

Acute myocardial infarction within the preceding 12 months

Coronary artery bypass surgery

Current stable angina pectoris

Heart valve repair or replacement

Percutaneous transluminal coronary angioplasty or coronary stenting

Heart or heart-lung transplant*Somecommercialplanshaveexpandedclinical criteria.

90

The Participant Experience

Each Session includes one hour of each:

• Supervised exercise with telemetry monitoring as indicated

• Stress management practices based on yoga and meditation

• Support group to create increased social support

• Educational lectures and discussions combined with a group meal

18 four hour sessions

(72 hours of training)

~15 participants per cohort

• Physician oversight

• Nurse case management

• Individual consultation

A comprehensive clinical team, trained and certified by

Healthways

Medical DirectorProgram Director

Nurse Exercise PhysiologistRegistered Dietician

Stress Management SpecialistBehavior Health Professional

91

If it’s reimbursable, then it’s sustainable.

My Medical Training

People Don’t ChangeHeart Disease is Not ReversibleYou Can’t Lower Cholesterol Much With Diet. You Can’t Lengthen TelomeresYou Can’t Reverse Prostate Cancer

Science Has Progressed

People Do ChangeHeart Disease is ReversibleYou Can Lower Cholesterol With LS. You Can Lengthen TelomeresYou Can Change Gene ExpressionYou Can Stabilize or Reverse Early Prostate Cancer

The Transformative Power of Lifestyle Changes and Supportive Community

Documents