The American Journal of Car ology

Reprintedfrom AUGUST 1,2OO2

DEAN ORNISH,MD: A Converscrlion Wifh the Editor

ExctnpuMrorcl DEAN ORNISH,MD: A GonverseitionWirh rhe Edilot*

llean Omish was born on 16 July 1953in Dallas, Deon Ornish, MD+ (hereofter, DOI: I was bom tsTexas, and he grew up there.He attendedRice herein Dallasin 1953.I went to elementaryschool at University and thenthe Universityof Texasin Austin Arthur Kramer,junior high at Ben Franklin, and high where he receiveda BA in Humanitiessumma cum schoolat Hillcrest.My parentskept trying to get me to ktude and gave the baccalaureateaddress. He gradu- go to St. Mark's (a private school),but I just decided atedfrom Baylor Collegeof Medicine in Houstonin I would ratherstay in public schoolsbecause that was 1980and did his internshipand 2 yearsofresidency in wheremy friendswere. I regrettedthat decisionwhen internal medicineat the MassachusettsGeneral Hos- I went to college. pital in Boston(MGH), wherehe was a clinical fellow My falher,Edwin Ornis,lr,is a dentisthere in Dallas in medicineat HarvardMedical School.For the past and still practicing.My motherNalalie is a historian 25 years Dr. Ornish has directed clinical research and before that wrote children's books, musicals, demonstrating,for the first time, that comprehensive plays, and records,and was a joumalist. She wrote, lifestyle changescan reversethe progressionof even produced,and publishedthem. I got my interestin severecoronary artery diseasewithout drugs or sur- health care from my father and my interest in photog- gery. He is the founderand presidentof the non-profit raphy,journalism, and writing booksfrom my mother. PreventiveMedicine ResearchInstitute in Sausalito, I got my best and worst qualities,such as my relent- California,where he holds the BucksbaumChair. He lesspersistence, from my mother. is alsoa Clinical Professorof Medicineat the Univer- I have an older sister Laurel who still lives in sity of Califomia,San Francisco. He is the authorof 5 Dallas. She was the first woman broadcastjournalist best-sellingbooks, including New York Times' besl in Texas and worked at severalradio and television sellers Dr. Dean Ornish's Program for Reversing stations. I have an older brother Stevenwho pracrices Heart Disease,Eat More, Weigh Less, and Love & psychiatryin San Diego and a younger sisterKcd?) Sunival. A l-hour documentaryof his work was who is currentlyin Michigan,but for many yearswas broadcaston NOVA, the PBS Scienceseries, and was a studioart nrofessorin ceramicsat Notre Dame and featuredon Bill Moyers' PBS series,Healing & The St. Mary's. Mind, and in most major media. Dr. Omish is a WCR: Wherewere you in the hierarchy? memberof the board of directorsof the U.S. United DO: I'm the secondof 4. Laurel is 3 yearsolder. NationsHigh Commissionon Refugees,the board of My brotheris 3 yearsyounger and my sister,10 years vounser.Laurel is 51. the QuincyJones Listen Up Foundation,and the board - of the WheelchairFoundation. He was appointedto Wtn: whar was home like as you were growing The White House Commission on Complementary up? Did you all have dinner togetherat night? Was and Altemative Medicine Policy. He has receiveda that an active conversationtime? Wqs it a maior number of rewardsfor his work including rhe 1994 gatheringfor thefamily each day2 OutstandingAlumnus Award from the Universily of DO: We almost always ate dinner together.That Texas- Austin: the Golden Plate Award from the was the time the family got together.I can't think of AmericanAcademy of Achievemenqa US Amy Sur- a time when our family didn't all get togetheraround geon GeneralMedal, and the BeckmannMedal from dinner. We were encouragedto talk about anything the GermanSociety for Preventionand Rehabilitation and everythingover the dinnertable. Our discussions of CardiovascularDiseases. He was recognizedas got pretty lively sometimes. "one of the most interestingpeople of 1996" by Peo- WCR: Politics, religion, what you were doing in ple magazine,featured in the "TIME 100" issue on school? altemativemedicine, and chosen by IIFE magazineas DO: Not much about politics or religion, more "one of the 50 most influential membersof his gen- about school and what was going on in our personal eration," lives. It was a good time, a solid, groundedback- WilliomClifford Roberts, MDr (hereofter,WCR): ground.It gaveme more comfofi to try thingsI might Dean, I appreciateyour willingnessto spe(rkto me not have done if I didn't have that senseof being and therefore to the rea(Jersof'fhe American Joumal groundedto fall back on. of Cardiology. We are in nry home tn Dallas on WCRzI hqve met your parentsand they are obvi- December19, 2001. Could we start by your talking ously very warm people.I gather that your homewas aboutyour early life, your motherand daddy,siblings, very wqrm and pleasantwith very little arguing. Is and someof lour earlv memories? that Drooer? DO: it was warm but we wereencouraged to speak our minds. There was a senseof disciplinebut in a *Th s seriesof inteNiewsore rnderwrillen by on unreslrictedgronlhom BrisloMyers Squibb. TBoylorHeori & VosculorlnsulLile, Boyor UniversllyMedicol Cenler, +PreveniiveMedlclfe ReseorchInslitute ond ihe Universliyof Colilor Dolas,Iexos75246. nlo,Sousolito, Co ifornio94965.

02002 by ExcerptoMedico, Inc. A1l right reserved. OOO2s 1 4s /o2 / $-seehonr motter 271 TheAmericon Journol of CordiologyVo . 90 Augusil, 2002 PIS0002-9r49{02)024864 park andin people'shomes or offices.I worked ashis apprenticefor about 2 years. When I was 14,he encouragedme to openmy own studioand sold me his usedequipment. He had more businessthan he neededso he would refer peopleto me and I'd chargeabout half of what he did because I was only 14 years old. I had no studio overhead becauseI lived at home.I did weddings,portraits, and any kind of eventsfor people.I loved it. It was a great way to make money, and I enjoyed making people happy. Separateand apart from that, I had a different type of photographythat was really just for fun. The por- traits were designed to make people look better than they really wereby lighting, retouching,and airbrush- ing. The kind of photographythat I loved was on the other end of the spectrum.I useda 35-mm Leica or Nikon and saw things as they were as opposedto trying to changethings that were not so beautifulto what was beautiful or what it was supposedto look like. For me, thatbecame a metaphor,a way of trying to FIGUREl. DOos o boby,1953. see the world without preconceptions.To me, any kind of greatart, whethera painting or a photograph or writing, is when someonecan see the world in a new way andthen sharethat vision with otherpeople. innovative way. Our growth and development very Scienceis the sameway. It was greattraining for me, a certainamount of structure was encouragedwithin leaming how to seewithout preconceptions.Some of that was very reassuring. the best teachersI studied with talked about this your Dal- WCR: Are both motherand father from directly-people \ke Garry Winogrand,who is con- las? sideredone of the great photographers,and Russell DO: My fatheris from Dallas.My motheris from lee in Austin. I studiedwith them when I was at the Galveston. University of Texas.Russell Lee, Iike WalkerEvans, WCR: How did they meetT was one of the great Farm Security Administration DO: A friend of theirs fixed them up. photographers.Their photographsoften were very WCR:. Your mother was alrertdy here in Dallas. stark.direct. black and white. DO: Yes. She'd alreadymoved to Dallas. It was In photoclass, Gany would put a pictureup on the during the World War II. I don't know how they first wall and say, "What do you see?"People would say, met. "I see this." Peoplewould actually project a lot of WCR: Whendid they get married? stuff onto the picture that really wasn't there. He'd DO: They got marriedwhen she was in her early say,"How do you know, maybethere's a personright 20s. outsidethe framethat is pointing a gun at that person. WCR: I understandthat you were a major photog- Or maybethere's something on fire that you don't see. rapher in high schoolantl that you won somephotoS- Therecould be all kinds of thingsgoing on that you're raphy contests.Can you talk ctboutthat? How did you presumingare there,that you project onto the photo- get interestedin photography? You mentionedthat graph,but if you really look at it, are not there.What your mother might haveplayed a role there. do you actuallysee?" There was a lot of emphasison DO: I always loved photography.I probably did leaming to seewithout preconceptions. get my interestin it from her. Sheearned her masters For many years whereverI was, I would take a degreein journalismand pholojoumalism from North- little 35-mm camerawith me and I took picturesall westem when she was 16. which back then was the the time. That also came in handy becauseI was a bestschool for that.I had a darkroomin our bathroom stringer for TexasMonthly, Rolling Stone,Newsweek, from fifth gradeon. WhenI was 12,I went to work for Esquire,Ms. magazine,and a few others.I loved the Tom D'Aquino, a leading portrait photographerwho work, and it also got me a presspass so I got to go to hadbeen one of the headsof GittingsPhotography and all the rock concertsfor free. Bachrachin New York beforethat. I worked for him WCR: Do you still take a lot of photographs? asan apprentice.I worked 10 hoursa day.He paid me DO: I do now, but I went througha time when in for 4 hours a day becausehe said I was learningthe medicalschool, particularly in the clinical years,when other dme, which I was. He paid me $1.60 an hour I knew I hadto stoptaking pictures. I evenhad to stop which was minimum wage,so I earned$5 to $6 a day. seeingpictures. For example,I would be working in I canied his equipment,developed his film, and went an emergencyroom and somebodywould come in with him on photo shoots.We'd take portraitsin the bleedingwith a gunshotwound. It soundsridiculous,

272 THEAMERTCAN IOURNAL OF CARDOTOGY@ VOL. 90 AUGUSTl, 2002 but I would be so struck by the lighting, colors, threatens the paradigm, but mole importantly' it sounds, textures, and the way people were standing threatensthe order that that paradigm provides. Wlen that I would have to say to myself: "Wait a minute. people feel a senseof chaos,they often act inatio- That's not why you're here." I had to actually train nally. It brings out a lot of darkness. myself not to see those things becausethey were A hundredyears later in the 17th centry, Galileo, diitracting, and just focus on heart rate, blood pres- said the same thing as Bruno-the earth revolved sure, vital signs,airway, or whateverit took to deal around the sun-but he gave people a tool, a tele- with the oarticularsituation. It wasn't until towardthe scope,so they could seethe truth for themselvesand para- end of my seniorresidency in Bostonthat I beganto have a direct experience of the anomaly of that actually allow myself to see things again and start digm. By definition, a paradigm takes an infinitely pro- taking photographsagain. I still do that now. Now, I comDlex universe and reduces it to manageable photograph mainly my wife and baby. porti,ons,but there are always things that don't fit- was that WCR: 1s yoar homefilled with your pictures? i.e., the anomalies.In this casethe anomaly DO: It is, mostly with picturesof my wife, baby, the earthrevolved around the sun,not the sun revolv- and friends.In the past,there would be picturesI had ing around the earth. By giving people a tool that taken of other things or other peoples'pictures. showed this, the telescopesuddenly became a real pro- WCR: Do you developyour photographsnow? threat to the order that the prevailing paradigm DO: Now, I've switchedto digital, and I do my vided. able own Drinting.I usedto ]ook down at digital:I wasa Through the Inquisition, the authorities were realcamerainob. I gol a digitalcamera when the baby to get Galileoto recant,but it wastoo late.The catwas was born jusl so I could e-mail picturesto my family out of the bagbecause people could usea telescopeto and friends.I soonrealized that the qualiry of digital seefor themselvesthe limitations of that paradigm. to is as good as film and in someways better and I don't Eventually the prevailing world view began have to go into the dark room. I can do it all on my change.Science became more the predominantworld computerso it's really handY. view, and the split betweenmind and body, headand- ol WCR: Do you use 35-mmanYmore? heart, and scienceand religion really came out DO: Hardly at all. And I neverthought I'd seethat Galileo,Descanes, and the philosophersthat followed day. them. WCR: Drd your photography skills haw a major Pafi of what interestsme is to try to be able to see you and what you have done? beyondthe limitationsof any paradigm,while recog- impact- on finally DO: Yes, but not from the photographyper se,but nizing and respectingthe paradigm,to realize that more as a way of seeing.Learning to see the world there's value in that. Often, if you can hold one without preconceptionsis an ongoingprocess. When I paradigm, but also look at the world through other picture of wasinjunior high school,I went to a NationalScience faradigms, you can get a more complete Foundationsummer program on lasets and hologra- what is closerto the truth. phy. It was a way of combiningall my intereslsin It's a little like the blind man and the elephant, more icienceand in photographyat *le sametime. whereif youjust seeone part of the elephantit's you Thomas Kuhn wrote a book that really influenced like a glimpse.The more piecesof the elephant you are me called "The Structureof ScientificRevolutions." can see, the closel to an accurate lmage you In it, he talked about how the world is an infinitely getting.It's like a digital picture:the more pixels complexand varied place. As humans,we havea hard have,the higher the resolution. was fime managingconcepts like infinity, so we try to Newton Camerp with a view of physicsand it reducethe wodd to moremanageable proportions. We accurate within its limitation, b:|J.rIhen Einstein came get to do that by coming up with paradigmsor models of along and said,"Yes, that's true, but when you world views, and they tend to be shared by the pre- highir speedsapproaching light, things change. It lt vailins culture bv most people. doesn't mean that Newtonianphysics was wrong; Foi thousandiof years.ihe CatholicChurch pro- was just limited. As long as you can understandits vided the world view, the paradigmthat the earthwas limitations,there is still great value in it. If you can the center of the universe and everything revolved also expandit beyondthat, there'salso greatvalue in around it. And the Catholic Church didn't tolerate that too. dissentvery well, just as most paradigmsdon't toler- That's an approachI've ftied to take,which is what atedissent very well, includingmedical paradigms, as has causedme to explorea numberof differentways I can tell you from personalexperience of seeing the world through different eyes-through- I remember once giving a lecture in Texas years meditation,through photography,and other ways ol ago. Someonesaid, "Hey, your researchis really pi- seeingfrom different perspectives.It was helpful to new' oneering. You know how we tell pioneers here in realizethat when you aretrying to do something Texas?By the arrowsin their backs." thenit is likely to threatensome people. Notjust in the In the 16th cent]]ty,Bruno, an Italian philosopher, way most people tend to think of economically- cameup with the ideathat maybethe earthwasn't the prestige,or human jealousies-bul in a more basic it centerbf the universe,but that the earth revolved fundamentalway. It can threatenpeople because around the sun. He was burned at the stake, one threatensthat paradigmwhich providesorder. method of dealing with dissent. Dissent not only WCRzWere either your mother or father photog-

NTERVEWIDEAN ORNLSH 273 DO: I didn't know that. He's done somevery imporlantwork. WCRIHe describedhis father as moreof a family practitionerthan a dentist.He interestedhit son Kenin preventivemedicine. DO: I'm glad you remindedme of thatbecause I also got my inler- estin preventivemedicine from my father. Dentists have been years aheadof doctors (and still are) in terms of prevenlion.They've been talking aboutprevention since I was a child-fluoridation. regular brushingof leelh.dental flors-all of the things that for many people soundso boringand )el havemade suchan impact.Look at the inci- denceof dental caries.They are a fractionof whal ftey were. And dentists.in manyways. have hurl their income by emphasizingpre- vention:yel *reir preventivemea- FIGURE2. DO oi sciencefoir: lemon-powered cryshl rodio, 1964' sureswere lhe fight thinSto do.MY father was a leader in prevention. He always talked about the impor- raphers? Did they take pictures themselvesvery tanceof Dreventivemedicine. I rememberhe'd come much? homefrom work and he'd say one of his patientstold DO: My fathertook home movies of our growing hirn, "Well, I don't care.Let my teethrot. I'll just get up. My mother was a photojoumalistwhen she was dentures."He said peopledidn't appreciatetheir own younger.I don't rememberher actuallytaking pictures teeth. whenI was growingup. That was part of what shedid From a very early age, I worked in his office. I earlier on. developedhis x-rays.I liked hangingwith him, spend- WCR: Whereditl you live in Dallas whenyou were ing time together. very growing up? The nice thing about dentistry is that it is just right DO: We lived about 3 blocks north from where practical.It's like having an erectorset. It's It's much conceptualas practical.You Hillcrest and Royal Lane come together. there. not so are really doing a sewice that gives direct benefitto WCR: What is your mother like? How would you someoneand you can seethe tangibleresults of that. describeyour mother? What I really admire even more now than I fully DO: My mother is very smart,talented, creative, appreciatedthen was that althoughit was economi- and she can be relentless. cally a disincentiveto talk about preventionbecause you meanby "relentless"? WCR: What do much of the money dentistsmake is from fillings, let go of somethingif she DO: I mean she won't restorativework, and dentures,they had no qualmsat wanmlt. all aboutemphasizing prevention. I don't always see WCR: Sfteeets it betweenher teethand shakesit? that in medicinetoday where people,or third-pany DO: That'i a very handy skill to have for me. I reimbursementfor that matter, say preventionis the wouldn't have been able to do the work I've done right thing to do. Let's do it even if it's not econom- without it becausethere have been so many obstacles ically beneficialfor us.You do not seethat asmuch in along the way. It's a greatquality to have as long as medicineas in dentistry. for me one can modulateit. That's been a challenge WCR: Did you and your father do things together overthe yea.rsto leam whenit's useful,when it canbe whenyou were growing up? counterproductive,and when not to be stuck to one DO: We did. One reason my father went into particularmode of thinking or acting. dentistrywas that he wantedto make surehe hadtime W€R: tlow woukl you descibe your father? for his family. We did a lot of things togetheras a DO: My father is much less driven, much more family. We played baseball together, other sports, content,and loves being a dentist.For many yearshe watchedthe DallasCowboys at the CottonBowl, went taught at the Baylor University Dental School. He to Lake Dallas regularly to go water-skiing.Family loves to teach.He loves to practice.He loves to help was very importantto both my parents. people.I get a lot of my servicequalities from him, the It's nice to be interviewedin Dallas becausejust job of just doing things to help people. being here reminds me of a lot of things I don't WCR: Ken Coooer'sfather was a dentist. usually think about these days. Being a new father

274 THEAMERCAN JOURNAL OF CARDOLOGY@VOt, 90 AUGUST], 2OO2 myself has given me a greater apprecialion for how tographer and yearbook photographer in both junior much effort my parentsmade. We just have 1 son. I high and high school. can't imaginehow much effort 4 kids take.You have WCR:Do you srillplav tennisl 4 kids? DO: I do. not as ofien"asI'd like. but I still play. WCR: Zes,but theycame along whenboth my wlft WCR: That probably did you a lot more good than and I were tn our early 20s. It's very differentwhen playing the team sports. you don't start a family until you are 48. I was more DO: My parentswouldn't let me play football, unconsciousabout the efrort, which was not a big deal at the time. When I see the DO: I actually have modulated my life a lot so that chronic injuries that so many of my friends have now I have more time to spend with our son. I'm not from their high schooland collegefootball days,I'm traveling neady as much. When I do travel I try to be gladthat I didn't participatein thatpanicular sport. away for no more than 1 night at a time. It's been a WCR: Were there any teachersin junior high or real changeand has put everythingelse in perspective. high.'DO: school who had a particular impact on you? WCR: Did you go on vacations in the summertime There were.Juiia Jeffries wis the journalism teacherin me as a family? high school and she had an influence on DO: Yes. We usually went to Galvestonbecause and also on many other shrdents.Many went on to my mom was from there. It was affordable, close, and becomejoumalists, like Quinn Matthews.She taught run. us how to write in a focused and direct way and to say WCR: What did your mother'sparents do? the most importantthings up front. Shealso had a lot joumalism. DO: My mother'sparents owned a grocerystore in of integrity in how she approached She Galveston. emphasizedwriting what was actually in front of you, not what you thoughtwas in front of you. Sheurged WCR: Was she the first college graduate in her us not to project our way of seeingon to the events, 'familv? DO:Yes. but to try to seethe eventswithout the preconceptions that we talked WCR: Sftegraduated Northwesternat 16? aboutearlier. from I had an algebra teacher in junior high school DO: With a mastersin journalism. She's a smart namedMr. Boruff. His firstname was always "Mr." to woman. me. Until then,I had alwaysthought mathematics was WCR: Wheredtd your go to dental school? father boring and tedious.He showedme that thereis a real DO: He went to Baylor Universitydental school in beauty in mathematics that I had never appreciated Dallas. Although my parentshave traveled a great before.It becamefun. deal, they have spent most of their lives here. They That becamepart of a real shift in my thinking,that rootshere. My mostrecent book, "Love and havedeep leaming was fun and a joy. It's not a performance- power communityand how Survival," was on the of based,anxiety-based way of leamingto passa test,but is I didn't fully appre- importantit is. That something there'sjust a joy in intrinsically leaming-what the ciatewhen I wasyounger, how importanthaving those physicist Richard Feynman called the "pleasureof kinds of rootsand those long-term relationships over a finr{ino fhinoc nnt " lifetime canbe. Not only in termsof the quality of life, There was Mr Skinner,a scienceteacher. He en- but in terms of one's health and well being. couragedus to think outsidethe box. Scienceisn'tjust WCR: Your motherand father certainlyhatte a lot a collectionof experimentsor facts;it's a process.It's of fiends here in Dallas. As you were growing up, I a way of seeingthe world. It's a way of interacting presumeyour motherand father enturtainedmany oJ with the world. It's a powerful way of helpingpeople their friends in vour home? understandwhat's true, what isn't true, what works, DO: Yes. We'd go to my father's parents for and what doesn't, and for whom and under what brunch every Sunday.We'd eat all kinds of foods. I circumstances.And while not everythingis testable,a have very happy memoriesof a big extendedfamily. lot of things are. He was always encouragingus to The whole family got together on a regular basis. come up with good questions.He'd say, "I'm not so There would always be some excuseor some event interestedin your answers as in your questions." when we'd all get rogether.Family was very impor- RainerMaria Rilke,centuries earlier, said, "Be patient tant to my parents,not just the immediatefamily, but towards all that is unsolved in your heart and try to also the extendedfamily. love the questionsthemselves." Mr. Skinner always WCRzYour father ha.da lot of brothersand sisters tried to get us to ask the most outrageousquestions here in Dallas? and not be limited by "force = mass times accelera- DO: He had 3 sisters,no brothers.Two lived here tion" and would ask, "What are you most interestedin and one lived in Houston. finding out?If you could answerany questions,what WCR: What acttvities did you participate in junior would they be?" high and high school?You won severalphotography I was encouragedto leam to ask questions.It contests.Were you an athlete? wasn't until I got to medicalschool and intemship that DO: I was on the tennisteam, but "athlete"would I was discouragedfrom askingquestions. In my first be a stretch.I played in a baseballand basketball week of intemship, I asked a questionabout a pa- league,and I loved playing tennis.In addition,I took tient's wedgepressure. The residenttold me to never karateclasses for 8 years.I was the newspaperpho- aska questionthat you don't alreadyknow the answer

INTERVIEWDEANORNISH275 FIGURE3. NotionolMerit fthol- ors (DO,frst row .igttil, Hill' cresrHigh School, 1970.

to when you're on rounds.Invariably, they would ask, have that grounding, even if it's somethingto re- "What do yoz think Dr. Omish?" I'd say, "I don't nouncelater. I have a close group of friends and we know, that's why I'm askingyou becauseI'm trying get togetherand talk aboutspiritual issues in our lives. to learn." That was not the right thing to say there. I When I was growing up, there was more of an em- quickly leamed never to ask questions on rounds that Dhasison the form than the content. It was more on the I didn't alreadyknow the answersto. In life, rhough, iitual than the meaningbehind it. It wasn't until I the questionsare what make things interesting for me. becamemuch older that I really understoodmore of WCR: That's a very interestingcomment. I teach the meaningbehind it ratherthan just the form. That, now askingone questionafter another.It's a lot more lo me.was much moreimDonant. fun for me. I think the attentionof the audienceis a WCR:,I gatheryou d.idquite well academicallyin little greater than previously. high school,particularly sinceyou said leaming was DO: Much greater,I imagine. sucha pleasure-Why did you chooseRice Unfuersiry WCR: Two of my kids ask me questionsall the time. for college?I assumeyou could haveSotten into any One of my kid.shas askedme probably one question in collegeyou wantedto? m'v life. DO: I startedat Rice University and had a very - Db: neallyt I wonderwhy? difficult experiencethere. I was at Rice for 18 months, WCR: Zftey are all from the same family, but I and that's when learningbecame "not fun." I wrote a think confidenceis importantin askingquestions. Ask- little about it in chapter 5 of my book "Reversing ing questionsis a sign of a very confidentperson. Heart Disease" and also in chapter 3 of the more DO: It sometimesdrives my wife crazy when she recentbook- "Love andSurvival." The shortversion is thinks I ask too many questions.There is a point that I knew I wanted to be a doctor. I had ro take whereit may not be the most appropriatething, but it organic chemistry like everybodyelse. My college is just part of my curiosity abouteverything. roommate was one of 4 people in the country that year WCR: Whenyou were growing up in your home, who scored1600, a perfect score,on his SATs. One you mentionedconversations arouncl the dinner table half the student body at Rice then had graduatedfirst at night. Did you talk much aboutfeelings with your or secondin their high schoolclass. They put every- mother.for example? body under a bell curve so that no matter how well DO: To somedegree, but not as much as we do in you did (ust about everybodywas making straight familv. A's before they got there),60Vo were going to make mv'WCR:- lVas your fanily religious as you were C's; 157o,B's or D's, and57owere going to makeA's growing up? or F's. My chemistryprofessor was a guy who, I was DO: They were and are still. I went to public convinced,had fled from Nazi Germanyand instead schooland then I went to religiousschool after that 2 of going to Argentina, ended up in Houston so he or 3 timesa week.I got prettygood groundingin that could be my chemistryprofessor. On the first day, he I tendto be more spiritualthan religious these days. I said,"This is a weedout courseand I'm going to weed will teachmy sonabout religion whenhe becomesold you out! Look to the personon your left and to the enoughto understand,because I think it's important10 personon your right and they won't be there by the

276 THEAMERICAN ]OURNAL OF CARDOLOGYo VOL 90 AUGUSTI, 2OO2 end of the semester.Or maybeit will be you andyaz depressed,you see the world through dirt-colored won't be here for very long." He taught the course glasses,to put it in nice terms. purely from notes, purely rote memory. Rote memory I lived in a concrete-jungle,soulless apartment in has never been my strong suit. I think pretty well Houstonright acrossthe streetfrom the HoustonOil- conceptually,but just memorizingunrelated facts has ers football practicelield. They had a big oil derick neverbeen somethingI'm pafticula.rlygood at. therebecause that was their mascot.At first, I wasjust My collegeroommate never studied and he never- going to jump off therebut decidedthat would leave thelessalways madeperfect scores.I did okay, but I my family and friendsupset. Then, I thought,"I'11 get began to worry becauseI really wanted to be a doctor drunk andI'll run my car into the side of a bridgeand and I didn't want to be weeded out. The more I everybodywill think I just got drunk andit'll look like worried, the harderit becameto study.The harderit an accident."That way, they won't feel as bad as if I becameto study, the more I worried. I got into a killed myself. viciouscycle whereI couldn't sleepat night. I got into I was actually ready to do that, but I got so sick a full-blown agitated depressionand became psy- with mononucleosisthat I didn't have the energy to chotic to the point where I didn't sleepfor a week get out of bed. I was simply completely exhausted straight,which itself can make you psychotic.From from being so run down. My roommatecalled my the sleepdeprivation and depression,I becamecon- parents and they came down and saw what a wreck I vinced that I was really stupid, that I had somehow was.I was feeling so agitatedI could hardly sit down. managedto fool everybodythat I was smart.I was They brought me to the campuspsychiatrist and an- able to fool peoplein a public high school,but now other psychiatristto seeme. I told them, "You don't that I was in a placewith really smartpeople, it was understand.I'm really stupid."They asked,"What do just a matter of time before they figured out what a big you wanr?" I told them, "I think I want to be dead." mistakethey'd madeby letting me in. "Do you have a plan?" I said "yes" and all the hall- I felt like I didn't deserveto be there.In fact, I marksof the thingsthat I know now that you look for didn't even deserveto be alive and my day of reck- when someone'sreally seriouswere there. I withdrew oning had arrived.I wasconvinced that I was going to from schooland came home to Dallas.My plan wasto fail organicchemistry, and I would never accomplish get well enoughto kill myself. my dreamofbeing a doctor.I didn't eventhink I was WCR: Zftis was during your sophomoreyear? smart enough to be a janitor. I rememberbeing unable DO: That's right. It was the semesterbreak of my to make a decisionabout anything,even about what sophomoreyear. My older sister, Laurel, had been course to take or what books to read. involved with yoga,which madea positiveimpact on This went on for a while. I rememberbeing in class her life. She'd been studyingwith a spiritual teacher one day and I thought,"Why don't I just kill myself narnedSwami Satchtdananda-He was coming to Dal- and be donewith it? Then I'll be peaceful.I'm going las.and my parenlsdecided that lhey wereSoing to to leavethis miserablelife." In one of thosesleepless havea cocktailpafty for the swami.This was in 1972, nights when I'd lie down and watch the handsof the long before yoga was on the cover of Time magzina clock go aroundand around,I had a spiritual vision, There'san old saying,"When the studentis ready, which was morethan I couldhandle at the time. It was the teacher appears." That was certainly true fbr me. the realizationthat nothingcan bring you lastinghap- He is a very lovingand wise soul. piness. He came into our living room and gave a lecture. I went through all the things that I had been taught He started off by saying, "Nothing can bring you would make me happy-"just marry a beautiful lastinghappiness," which I had alreadyfigured out- woman, make a lot of money, becomefamous, be- but he was serene,radiant, and peaceful,and I was a come a doctor-and then you'll be happy." At that mess. moment, I knew that was not true. Nothing could He went on to say what almostsounds like a New bing lasting happiness;it would always be tempo- Age clich6 but really lumed my life around at the rary. It would be like "I got it. It's mine. Now what?" time: "Nothing can bring you lasting happinessbe- It's never enough. Or, "So what? Big deal." It causeyou haveit alreadyas long as you don't disturb wouldn't provide a lasting senseof rneaning.The it. Not being aware of that, people often run after so double whammy-feeling like I was really stupid and many things that they think are going to make them a fraud and would never amount to anything, and even happy.disrurbing their innerpeace in lhe processis if I was it wouldn't matter anyway-was profoundly one of the greatironies of life." depressing. Somebodyasked him, "What are you, a Hindu?" Oneof the worsethings about being depressed, one He said,"No, I'm an Undo." Spiritualpractices in any of the hallmarks of depressionis the senseof help- religion are really designedto help you stop doing lessnessand hopelessness. This very distortedview of whateveris disturbingyour inner peace.Peace is not the world seemsso real at the time that you're con- somethingyou get from outside yourself; it's there vinced you're seeingthings as they really are for the alreadyuntil you disturb it. The real questionis not, first time, and all the other limes when you thought "How can I get happinessor how canI getpeace?" but you were happy,you were actuallyjust fooling your- rather, "How can I stop disturbing the inner peacethat self. You were deludingyourself. And now, you are is thereall the time in everyone?" finally seeing things cleady. When you are really Whether it's spiritual practicesor religious prac-

INTERVIEWDEANORNISH277 DO: They askedme to do it. WCR: what did you talk about? DO: That was a long time ago (1975)-27 yqrs ago.Since I was an interdisciplinarymajor, I talked about the value of seeingthings from a num- ber of differentperspectives. Trying to find common tbreadsamong appar- ently different disciplines.I also dis- cussed dialectics, how the extreme positionsoften had somethingin com- mon. whetherin oolitics or in science. I usedan examplethen of one of the astronautsbeing blasted into space, that it was one of the ultimate isolat ing experiences,and yet that gavehim the perspective to see the earth as a whole.What he was doing profoundly transfomed him when he came back FIGURE4. Presenldtionof Dr. Ornish'sreseorch ffndings--+he first time heort dis- to the work, even though he came out eosecould be reversedwihoul drugsor surgery""otthe AmericonHeorl A!so.io- of the scienceand engineeringper- tion'sonnuof scientific session in 1990,Frcn l{t ro righr:Dt.W.lliom Cosrelli, Dr. spectiveof the reductionisticperspec- Ornish,Dr. ElliotCordoy, Dr. MichoelE. DeBokenDr. Cloudelenfont, Dr. Tom tive of knowing more and more about Cholmers,Dr. HermonHellerscin, Dr. DovidBlonkenhorn, Dr. Robert Wissler, lessand less. There was also value in seeinghow Lhingsinterrelate and in- terreact.That's what my life's work tices or medicalpractices, ideally theseare designed has really been about. to help you identify what's causingthe disturbanceto WCR: Ioz went to college as a premed student. your inner peace (and health) and to give you a dif- DO: Yes, I was a biochemistrymajor at Rice and ferent way of dealing with it by addressingthese becamea humanitiesmajor at the UniversityofTexas. underlyingcauses. WCR: How did you come to gips with thefact that I decided to give the swami's approacha try. you wantedto be a plrysician?Who influencedyou to That's when I gaveup my Texasdiet of chili, cheese- be a physician? Were there any plrysiciansin your vegetarian burgers, and chalupas and began eating a family? diet, doing yoga, and exercising. I began to get DO: Therewere a lot of physicians,and prominent glimpsesof what he was talking about,just moments onesat that,in my family, but I didn't know that until of feeling peaceful,which for me was a big change much later when I was already a physician. My from feeling depressedand desolate.Just getting those mother did a genealogy of her side of our family. little moments that came out of my direct experience SamuelAlben Levizefrom Bostonwas my cousin.As I for made all the difference, because could experience you know, he was a cardiologist at Harvard and the myself the ftuth of what he was saying. PeterBent BrighamHospital many yearsago. His son, I went back to school and took the other half of Herbert Levine,became head of cardiologyat Tufts. orgadc chemisfy with a different teacher, one who Dr. Levine, who inventedthe Levine stomachtube, is taught it with the Morrison and Boyd textbook. I also a cousin.Dr. Max Levine, who developedand realized that there was a great beauty to organic chem- rebuilt the purification was istry which I had never appreciatedbecause it has its water systemfor the USA, own conceptualbasis. Once I understoodthe concepts, a cousin, I could see the molecules dance and appreciate their When in high school, I really wanted to be a photographer. beauty, how they fit together. I transferred to the I remembersitting in Dallas listening to University of Texasat Austin for my last 2 yearsand a lecture by Philippe Halsman, who had done over gaduated in 1975 with a degreein humanities. 100 covers for "Life Magazine," the premiere maga- WCRI Wat courses did you take that came under zine then. He led a very glamorouslife. He showed " humanities" ? pictures he had taken of Marilyn Monroe and Jayne D0: I took everything from biochemistry to phi- Mansfield, usually nude. I thought, "That seemsilke a losophy, along with photography, English literature, fun way to make a living." All my hormones were poetry,history, and psychology.I figuredthat when I raging at the time. I got to sit next to him after his talk. got to medical school I would get all the scienceI I said,"I want to bejust like you." He said,"Oh, no. needed. Don't do that; it's a terriblelife. Be a doctor." I asked WCR: Ion must have torn the University of Texas him what he meant."Because you're alwayscorrupt- qport to havejust been there for 2 years and to give ing your vision to fit the vision of someeditor and you the baccalaureate address at your gra.duation. How loseyour own perspective.You lose your integrityby did that lctually comeabout? doing that. If you becomea doctor you can always

278 THEAMERCAN JOURNAL OF CARDOLOGY@VOL. 90 AUGUSI], 2OO2 take pictures,but then you don't have to answerto DO: We had a lot of lessons-piano, clarinet,and anyoneelse. You can keep your vision." trumpet. But I really liked the guitar. Any time you My father wanted me to be a dentist and I took the leam somethingwhen you are young, you leam it dentalaptitude test and appliedfor dentalschool. But really well. I'm trying to teachmy son languagesand therewas just somethingin my soul that didn't reso- music while he is young becausekids' brainsare like natewith dentistry.I haddone a lot of work duringthe spongesat thoseages. They can really absorbit. summersin hospitalsand researchlabs and decidedI WCRI It looks like tour exoerience at Rice-the really wantedto go into medicine.So I did. one that causedyou to disconinue going to Rice- WCR: Ioa worked in researchlabs when in high really had a tremendousimpact on you for the good. school? DO: It still does,actually, having survivedit. At DO: Yes, in both junior high and high school.I that time, Rice Universityhad the highestsuicide rate workedat the WadleyInstitute of MolecularMedicine per capita of any school in the country. (That fact when I was in high school.I worked at Yale in New wasn't in their coursecatalog.) Students took booksto Haven in a neuroanatomylab one summerwith Dr. their parties,and there was a 5:l male:femaleratio. David Egger torttring cats. That led me to realize that Socially, it wasn't a whole lot of fun being there. I I really didn't want to do that kind of research(map- understandthat it has changedquite a lot sincethen, ping out the plantal reflexes and things like that) but back then it was difficult. anymore. I worked in Houston at the Texas Institute of That experiencedid have a tremendousimpact on Rehabilitationand Researchdoing researchin cystic me.First of all. it mademe muchmore compassion- fibrosis.I workedbrieflv in a counleof otherlabs also. ate. There's nothing like pain to make you more WCR: Iaa mu$ ha;e decidedto so into medicine compassionateto other people'ssuffering. I also un- early on? der,stoodthat emotionalpain could be as bad as phys- DO: I did. lcar parn,somettmes even worse. WCR: Did you conttinceyour brother Stevento be It also made me very comfortabletalking about a ^oh'vsician? How ditl that comeabout? depression,something a lot of peopleare not comfort- DO: tte decidedthat was somethinghe wantedto able talking aboutbecause there's still a socialstigma do. We shareda lot of common interests.We took associatedwith it. That's why I was really glad to see karateclasses together at the Texas Karate Institute. that Mike Wallace wrole a columl in The New York He also got interestedin photographyand ultimately Times rccently about that, and that Tipper Gore (Al's medicine. wife) talked about it during his campaignor when WCR: Ilaw did you enjoy Houston (when at Rice, William Styron wroie a book, "DarknessVisible," and lnter medical school) and Austin (when at the aboutdepression. University of Texas)?Were thosepleasant environs Depressionis epidernicin our counfly, especially for you? among doctors. Look at the sales of antidepressant DO: I didn't particularlyenjoy living in Houston, drugs. They are among the biggest sellers because but I loved Auslin. Austin felt like freedomto me. It thereis a greatneed for them.I'm sureyou've had the was a liberatingtime for me. I loved the classesand I experience,when giving a lectureto a groupof people loved leaming. The professorswere wonderful and in the generalpublic, of sayingsomething funny and inspiring; it was a greatjoy. I'd anangetime in my they laugh. But when you talk to group of doctors, schedulewhere I'd have all my classeson Monday, they may just sit there.Many peopleare not comfofl- Wednesday,and Friday and Tuesdayand ThursdayI able talking about depression,so they may think could go off and do fun things like skinny dipping in they're the only one with the problem.It looks like the PedemalesRiver with friends.I did all kinds of everybodyelse has it togetherexcept for them when rhings that I had never done before. It was a great no onetalks aboutit. This makesthem feel evenmore t1me. isolated. My otherreal love in life is music.I played guitar When we starteddoing our researchstudies begin- in a rock bald when I was 13, 14, and 15 yearsold. ning in 1977, the support goups were initially a place Later, I switchedto acousticand played in a lot of for peopleto talk about how to stay on the diet and coffeehousesand I continued that through college. I how to exercise.What I unwittingly createdwas a safe would get togetherwith friendsand play music.Aus- environmentwhere people could open up and talk tin alsohad a wonderfulmusic scene-Wlllie Nelson, about they really felt-more often than not, they Stevie Ray Vaughn, and otherc. sharedhow lonely, depressed,isolated, alienated, and WCR:.When did you start playing the guitar? unhappythey were. It was an eye openerfor me. DO: When I was about8 yearsold. When I was a second-yearmedical student leaming WCRzDid you sing too? how to do historiesand physicals, we'd get 2 hoursto DO: Yes. Peopleused to tell me I shouldtake up work up a patient.I could work up someonefaster classicalguitar so they wouldn't haveto listen to me than that so I used the rest of the time just talking. sing.but I've gorfena little better. Often, the patients were really depressedor scared,but WCR: Do you still play the guitar? when they'd starttalking to their doctorsabout it, the DO: I do. I love playingand play a lot with my son. doctors would often start to feel their own discomfort WCR: Wasthere a lot of musicin your homeas you about their own deoressionor lonelinessand often were growing up? would chansethe s;biect. It's even worse now with

INTERVIEW,/DEANORNISH279 In conductingour clinical research,I spenta lot of time with the samegroup of patientsover periodsof time, andwe got to know andtrust each other. I'd ask, "Tell me, why you aredoing thesethings? They seem so maladaptiveto me." They'd reply, "You just don't get it. Thesebehaviors are not maladaplive,they're very adaptivebecause they help us get through the day." One patientsaid, "I've got 20 friendsin this pack of cigarettesand they're always there for me and nobody else is. Are you going to take away my 20 friends?What are you going to give me instead?"Or they may eat when they are depressed.They usefood to fill the void. One patientsaid, "Food is my heroine, and my heroin." Or they may use other drugs like alcohol to numb the pain. They may work too hard (as I've certainly done)to distractthemselves from their pain. It's more socially acceptable(a lot of doctors do this) and it servesthe samefunction. Or they may spendtoo much time on the Internetor watchingtelevision. There are lots of ways of numbing or killing or bypassingor disffactingyourself from pain. What I learnedwhen I was in collegewas that the pain is not the enemy,it's the messenger.It's saying,"Hey! Listen up! Pay at- (hi5 Hofford; FIGURE5, DO wiilr Alexqnder teof, MD menLorol tention! You're not doing somethingthat's in your former Chief of Medicine ol Horvord Mdicol School ond Mosso- chusettsGenerol Hospiiol). best interest." If we just kill the pain or numb it or distract ourselvesfrom it or bypassit without listening to it, managedcare because physicians don't havethe time then it's like clipping the wires to a fire alarm and to discussthe subjectproperly. going back to sleepwhile your housekeeps buming. There's a conspiracyof silencethat often keeps The problemkeeps getting worse, except now you've peoplefrom being able to talk aboutthese things, yet killed the messenger.The next time it's harder.Or you they desperatelyneed to have a place that feels safe may bypassthe problem,but the sameproblem comes enoughto open up. Becauseof my experiencein back again,or you may get a new set of problemsor college, I'm comfortable talking about depression. side effects.or haveoainful choices. That experiencemade me interestedin not just dealing I have studiedyoga and meditationfor )30 years with peopleon their physicallevel, but also the psy- with Swami Satchidananda.an eminentand ecumen- chosocial, the emotional, and even the spiritual dimen- ical spiritual teacher.He taught me to keep asking sions. questions,"What is the cause?What's really going on Over the years,I've learnedthat it's often neces- here?What's causingthis and what is causingthat? sary to addressthese levels to best servethe patients. whar's behind that?" Providing people with health information is important For example,a patient is having a heart attack. but not usually sufficient to motivate them to make Well, why? Becausethey may have coronaryathero- lastingchanges in diet and lifestyle, quit smoking,or sclerosis,their arteriesmay be constricting,and theil even to take their medications. If it were, no one plateletsmay be aggregating.What causesthese to would smoke;il's not a lack of information. occur? Factorsmay include a high-fat diet, cfuonic Two thirds of people who are prescribed statin emotionalstress, and hypertension. drugs are not taking them just 1 year later. Why not? Let's take one of those-what causesstress? Do It's just taking a pill once a day. They don't have you have to choosebetween leading a stressfullife many side effects for most people, and insurance that's productiveand interesting or a boringlife where usually pays for it. you sit under a tree and watch your life go by? Are The problem is that telling somebody who is you going to live longeror doesit just seez longerif lonely, depressed,isolated, and unhappy that they are you changeyour lifestyle? going to live longer if they just take this pill, or quit Fortunately,it's notjust what you do; moreimpor- smoking,or exercise,or changetheir diet, they often tant is how yo]ureact lo what you do. So we go back think, "I don't careif I live longer.I'm just ffying to another step in the causal chain and ask, "Why do get thrcugh the day." They often choosebehaviors peoplereact differently?" You can put 2 peoplein the that we think of as being maladaptive-smoking, samejob, 1 thrives on the stress,and the other getsa overeating,drinking too much, working too hard, heart attack.What's the difference? abusingdrugs, spending too much time watchingtele- That's where it gets really interesting.A lot of it vision- but they'revery adaptive. has to do with your perceptionsabout how you view

280 THEAMERICAN JOURNAL OF CARDOLOGY@VOt. 90 AUGUSTI, 2OO2 yourself and others.In my experience,many people powerlessness,unhappiness, anxiety, fear, worry, with heart diseaseoften feel like they live in a hostile senseof being cut off, their senseof helplessnessor world wherethey feel isolated,depressed, and lonely hopeless,a lack of meaningin their lives. All of these and they have to get their happinessand well being things I experiencedto the nth degree when I was in from somethingextemal in order to prove to them- college. selvesand othersthat they're good, lovable, and re- I've had patientssay to me, "Having a heartattack spectable. was the bestthing that everhappened to me." I would They may say,"If only I hadmore 'whatever',then say,"That soundscrazy. What do you mean?"They'd I'd be happy and I wouldn't feel so stressedand respond,"Because that's what it took to get my atten- lonely." They may fill in this blank with different tion to begin making these changesI probably never things-more money, power, accomplishments, would havedone otherwise that havemade my life so beauty,etc.-but the net effect is the same.Unril they much more rich, peaceful,joyful, and meaningful." get whateverthey think they need,they feel stressed. Paft of the valueof scienceis to helo raisethe level If someoneelse gets it and they don't, then it's even o[ awarenessl'or people so thar t}tet don't have to more stressfuland confirmsthefu belief that they live suffer as much to gain insight.Awareness is the first in a dog-eat-dog,zero-sum game world: the more you stepin healing.They don't haveto wait until they get get, the lessthere is for me. a hea.rtattack to begin taking theseideas seriously and Now, the stakesand the stressesare even higher. making them part of their lives. It's not just winning or losing, it's being a winner or In our research,we initially focusedon heart dis- a loser.If you're a winner, you think peoplewill love easeas an example-in parl becauseit's the leading you andyou won't feel solonely, and if you're a loser, causeof deathin the USA, but alsofrom an emotional nobody wantsto be aroundyou. standpoint,the hearthas always been more than just a Even if you get what you think you need,there is pump. In literatureand poetry and art and music,the a momentarypleasure-"I got it! It's mine!" It rein- heart is a symbol of love, compassion,courage, and forces the misperceptionthat your happinesscame wisdom.In our language,we talk aboutopen-hearted from getting somethingoutside yourself. But it usu- and warmheartedpeople versus hardhearted,close- ally doesn't last very long. "Well, maybethis didn't hearted,or coldheartedpeople. do it, but that w1ll." And the cycle continues. My frrend.Rachel Remen,MD, wrote a wonderful In my experience,that's where the problemsbegin. book called "Kitchen Table Wisdom," which I highly If we want to addressthe morefundamental causes of recommend.She describesthe difference between stressand sufferingand heart disease, then we needto healing and curing. Healing and curing are not the work at this level as well as the physicalone. In this same.Cuing is when the physicaldisease gets mea- context,we teachpatients more than "stressmanage- surably better. Healing is a process of becoming ment techniques." whole.Even the words"heal" and"whole" and"holy" Theseare ultimately profoundly spiritual questions come from the sameroot. Retuming healingto med- involving valuesand meaningand purpose.We often icine is like relurningjustice to law. skirt aroundthem in medicinebecause you can't mea- In my work with peoplewho have heat disease, sure those feelings the way you can measureblood both healingand curing often occur. When the emo- pressureor apolipoproteinA-I. And yet, it's important tional heartand the spiritual heart begin to open,the to addressthese. physical heart often follows. But healing may occur First, as I mentionedea ier, it is very hard to evenwhen curing is not possible.We can movecloser motivate someoneto changetheir lifestyle or take to wholenesseven when the physicalillness does not their medicationswhen they're lonely and depressed. rmprove. Second,many studieshave shown that people are In the processof healing, you reach a place of much more likely to get sick and die prematurely wholenessand deepinner peacefrom which you can when they feel lonely and depressedvia mechanisms dealwith illnesswith much lessfear andsufferins and that are not entirely understood. Patients who are muchgreater clarily and compassion. While curing is depressedfollowing a myocardial infarction are 5 wonderful when it occurs,healing is often the most timesmore likely to be dead6 monthslater than those meaningfulbecause it takesyou to a place of greater who are not depressed,independent of their choles- freedom from suffering. When healing occurs, people terol levelsor other known risk factors. often become more peaceful, centered,happy, and What I try to do with patients,just as in my own joyful. life, is to help patients use t}re experienceof suffering Dr. Remenis medicaldirector of Commonweal,a as a doorwayto help transformtheir lives in waysthat nonprofitinstitute north of SanFrancisco. In her work, can make it so much richer and more meaninsful. as in ours,people are taughthow to use their wounds When mostpeople think aboutmy work. rheyt-hink asdoorways or windowsfor transformation.These are about diet, which is important, but to me the least things we don't learn much about in our medical interestingaspect of the work. training, yet I have found them to be terribly impor- The experienceof sufferingcomes in many forms, tant,in termsof being real physiciansand healersfor whetherphysical (e.g., angina) or the deepersuffering ouf patientsand not just technicians. which is harder to measure and yet ultimately more I'm not againstthe use of statins,stents, bypass meaningfulto someone-their loneliness,depression, surgery, or anything that works in the short run as a

NTERVEWDEAN ORN SH 28I FIGURE6. DOspeoking b fie NovyAdmirols or TheWhile House,| 994.

way of temporizing,but we also have to deal with emotional.and sniritual dimensions which areso often theseunderlying issues. We are missingthe opportu- ignored. nity to be of greaterservice to peopleand we're being Telling peoplewho are lonely and depressedthat reducedto technicians.Because of this, many people they're going to live longer if they take a statindrug, are voting with their feet eventhough there is so little quit smoking,or changetheir diet and lifestyle is not science to support alternative interventions.More that motivating-for who wants to live longer when moneyis spentout of pocketfor altemativemedicine you're in chronic emotionalpain? We needto focus than for conventional,allopathic medicine. on thesedeeper issues if we want to be able to moti- Why? Becausewhatever the modality-e.9., mas- vatepatients to taketheir medicationsand live health- sage, acupuncture,chiropractic, therapeutic touch, ier, happierlives. etc. what they have in common is that they often The reasonthat my colleaguesand I havebeen able touchpeople. They spendtime with them andlisten to to achievesuch high levelsof adherenceto the inten- them.They talk aboutthese issues that you andI have sive changesin diet and lifestyle in our studiesis that beentalking aboutas part of their overall approach. we reframetheir reasonfor making changes.Talking There is a fundamentalbasic human need for a about "risk factor modification" and "prevention"is senseof love, connection,community, ald intimacy, boring to many patients.Telling a patient that he is and this is so often unfulfilled in a typical doctor/ going to live to be 86 insteadof 85 is also not that patientinteraction. More moneyis spentout of pocket motivating-unless they're 85. Insteadof trying to for altemative interventionsthan for conventional motivate patientsout of their fear of dying, we em- ones,even though there is little scienceto prove their phasizethe joy of living. Paradoxically,it is some- efficacybecause those practitioners often fulfill those times easier to motivate Datientsto make intensive basic humanneeds. changesin diet andlifestyle than more moderate ones, If we don't addressthat need,our professionis in becausethey experiencethat signiflcantbenefits often dangerbecause people are going to find other people occur so quickly. who do, even if rhey are not as qualified,are not as Thereis no point in giving up somethingyou enjoy competent,or are not as scientificallybased. Many unless you get somethingback that's even better, physiciansare leavingthe medicalprofession, in part especiallyif the benefitsoccur quickly. When a person becauseit's not fun to practicemedicine ifyou arejust quits smoking,manages stress more effectively,exer- being a technician rather than our time-honoredrole as cises moderately,and eats a low-fat, whole foods, healers. plant-baseddiet, blood flow to their brain often im- I'm a scientist,first andforemost, because I believe provesand they think moreclearly, have more energy, in the power of scienceto find out what works, what and have an improvedfeeling of well-being. doesn't work, under what circumstances,and for Sometimeswhen I lecture,I'll ask, "How many of whom. As an educator,I'm trying to bring this infor- you havekids?" Peopleraise their hands."Was that a mation to a larger group of people both within the big changein your lifestyle?" They respond,"Oh, medicalprofession and in the generalpublic. Provid- yes." "Was it harderthan you thought?""Yeah. Much ing health information is important, but not always harder." "How many have more than one kid?" Sev- sufficient.We also needto bring in the psychological, eral peopleraise their hands."Did you forget?" The

282 THEAMERCAN IOURNAT OF [email protected] AUGUSTI, 2OO2 first time you can plead ignorance;the secondtime werecured and would go homeand eat the samefood, . . . . They respond,"It's one of the hardestthings I not manage stress,not exercise,and smoke. More ever did and one the most meaningful."Many people often than not, they'd come back a few years later are not afraid to make big changesif they understand becausetheir grafts had occluded.We'd do the same the benefits and they understand how quickly the thing all over again,bypassing the bypass,sometimes changescan occur. multiple times. For me, bypass surgery became a They not only feel better, in most cases they are metaphor of an incomplete approach. We were liter- better within weeks in ways that can be measured. ally bypassingthe problem without also addressing Myocardialperfusion improves in only a few weeksas the underlyingcauses. I went throughthe medicaland documentedby exercisethallium scintigraphy,radio- scientificliterature, and it becameincreasingly clear to nuclide ventriculography,and cardiacpositron emis- me that the diet and lifestylechoices that peoplemake sion tomographic(PET) scans.As a result, patients eachday were amongthe most importantunderlying reported a 917oreduction in their frequency of angina causesof coronary heart disease.I wonderedwhat pectoriswithin only a few weeks.Patients sometimes would happenif we addressedthese. say, "I like eating meat, b not that much." Even A numberof studiesreported that a high-fat diet, sexual potency often improves via the same mecha- smoking,chronic emotionalstress, and lack of exer- nismsby which Viagra works, such as nitric oxide. cise could causecoronary heart diseasein animals, In additionto the physicalbenefits, many patients whereaschanging these same factors could reverse are able to quiet down their mind and body to expe- heart disease.If heart diseasecould be reversedin riencemore of an inner senseof peace,joy, and well dogs,cats, pigs, rabbits, and monkeys, then why not in being. They often realize that our nature is io be happy humans?That didn't seem like such a stretch.but and peacefuluntil we disturb it. The supportgroups most peopleat that time said it was impossible. aremore thana way to increasecompliance to behav- We're back to what we were talking aboutearlier, ioralchanges. They enable patients lo re-erperiencea seeingthe world with fewer preconceptions.If you deepersense of connectionand community.The sup- don't have the preconceptionthat it's impossibleto port groups provide a safe place for them to let down reverseheart disease, then when you look at the data, their emotionaldefenses, to connectwith peopleat a it seemedclear that it wasn't impossible.It was like deeperlevel. when it was believedthat the Earthis the centerof the It's not that emotional defensesare bad; they're Universeand everythingrevolved aroundit. How do essentialto protectingus from emotionalpain. The you know? Let's find out. problem comesbecause many peoplehave nowhere I talked to my advisor at the time and I told him I they feel safeenough to let down thosewalls, and no wanted to do a study. He thought it was a really dumb one they trust enoughto open up to. In effect, those idea. He said, "I don't expect it to work, but you'll walls are always up. If they're always up, they not leam something."To me, evenif we showedthat diet only protectyou, they also isolateyou. A numberof and lifestyle had no effect at all on the progressionof studieshave shown that people who feel lonely and coronaryheart disease, that would be usefulinforma- isolatedare many timesmore likely to get sick anddie tion to know. I defined successas conductinggood prematurely than those who have a stronger senseof science,whatever the results came out to be. He connectionand community. agreed,and he supportedit. WCR: Why did you chooseBaylor College of Med' Dr. Tony Gotto, vtho was chief of medicineat the icine for medical school? I assumeyou had your time, donatedthe testing.Dr. RichardMiller, who was choiceand thdt you could havegone anywhere. chief of cardiology,encouraged other cardiologists to DO: Becauseit was not very expensiveand the refer patients.Dr. David Mumford, who is now the clinical trainingwas excellent.Tuition was only $400 headof continuingeducation at Baylor, was my men- a yearthen. At the time I choseit, I wasimpressed by tor andreally encouragedme. He let me usehis office Dr. MichaelDeBakey and people like him. Therewere at night, his copy machine,and his typewriter-things a lot of goodpeople there and I felt I could get a good I didn't have.It was really great.I receiveda $5,000 educationthere. I was able to do things as a fourth- grant from the Franzheim Trust and that was enough year medical studentat Baylor that senior medical to do the study.I went to every hotel in Houstonand residentsweren't allowedto do when I was complet- askedthem if they would donatespace to us so we ing my residencyat the MGH. could housethe patientsfor a month. The last one I Also, the system at Harvard and MGH is very approached,The PlazaHotel, saidthey would. I might hierarchical.I conductedmy first clinical research not havetried the studyif I had waiteduntil I finished study(on reversingheart disease) between my second my training. There's somethingto be said for not and third years of medical school. That probably knowing enoughto know what's feasible. wouldn't havebeen allowed in Boston.There is much WCR:.Did the hotel donate those rooms to you? moreof a pioneeringethos in Texaswhere if you have DO: Thev did. a goodidea and can convince other people, they'll say, WCR: Iliw man\tDatients were involved? "Fine. Do it. We'll help you." DO: There *e." iu.t 10 patientswith no control I rememberwhen I wason Dr. DeBakey'ssurgical group. serviceduring my second-yearsurgery rotation seeing WCR: Exactly what did you do? a lot of coronarybypass surgery. Patients felt like they DO: The diet andlifestyle program was very sim-

INTERVIEW,/DEANORN SH 283 ilar to what we do now. A combinationof didacticand experiential.I gave them lecturesabout the scientific rationalefor what I was recommending.We exercised together.We had supportgroups. I taughtthem yoga and meditation. I hired a chef who made all their meals.It was basicallyjust the cook andI for a month in the hotel with this groupof heartpatients (men and women). They beganto feel betterwithin a few days.These werepeople who were consideredinoperable because they had such bad disease.In Houstonin 1977, yo't had to have very severedisease to be considered inoperable,usually because the diseasewas so diffuse that there were no good distal vesselsto graft onto. Most of them were having 7 to 10 episodesof angina a day. By the end of the month, most of them were pain free and their thallium scansshowed improve- ment in myocardialperfusion. It got me interestedin doins more researchlater. WCRi What diet did you put themon? This was a studyfor I month only? DO: It was a low fat vegetariandiet. It was essen- FIGURE7. DOond wife Molly,1998. tially the samediet that we give peoplenow. WCRzIs that about l}Ea caloriesfrom fat? DO: Yes. beganto realizethat they also had in commona lot of WCR: The one you do now is I}Eo tooT feelingsof depression,loneliness, unhappiness, fear, DO: Yes. It's more thanjust low fat. The diet is concern,being driven,etc. When you bring a groupof predominantlyfruits, vegetables,grains, beans (in- peopletogether and they starttalking abouttheir feel- cluding soy products),in their naturalforms. When a ings, as opposedto their thoughts,it connectsthem in persongoes from a typical Americandiet to a diet like a very deep and powerful way, even in just a few this, there is a double benefit. They are decreasing weeks,particularly if they don't haveanywhere else to their intake of disease-promotingsubstances such as talk aboutthese things. saturatedfat. cholesterol,and oxidantswhile increas- For many years,we have been offering weeklong as phy- ing their intakeof protectivesubstances such retreats,and by the end of the week peopleare often isoflavones, gen- tochemicals,bioflavonoids, retinols, sharingthings with eachother that their friendsdon't hundredsof others. instein,lycopene, and even know aboutthem. We've leamedhow to create a sophomorein meclicolschool WCR: Ioa were a safeenvironment for peopleto openup in. The need when you di.d this study. for connection,community, and intimacy is a funda- DO: Risht.In 1977. mentalneed that many peopledon't get.In the past50 WCR: Dtd you spend the entire day with these years,lhere has been a radical shift in our culture. patients7 Many peopledon't havean extendedfamily or evena DO: Yes. I lived in the hotel with them night and nuclear family that they see regularly. They don't day for a month. a neighborhoodwhere they know their neigh- WCR: What ktnd of mental therapy clid you do at bave a church regularly, that time? bors, or synagoguethat they attend job DO: We did yoga and meditationand we had a or a that feels stableand secure. placespeople get supportgroup. The suppofi group startedout to be a The usedto that senseof com- place for them to stay on the diet, but it quickly munity many peopledon't have any more, so it be- evolvedinto somethingmuch more. comesvery meaningfulto them when they get it. It's WCR: "Supportgroup" meanswhat? part of what enablesus to get high levelsof adherence. DO: We sat around in a circle. Initially, it was This needfor communitycan be exploitedin a dark designedto be a place where they would talk about way by cults to the point that they can sometimesget how they could stayon the diet better,how they could peopleto do hoffible things.It's the dark side of that. exchangerecipes and shopping tips. Instead,we ended Reallygood physiciansknow that if you can spend up creatinga community. a few minutesand really talk with their patientsand I hadbrought a groupof peopletogether who were connectwith them,ask them what is going on in their very different from each other in all the ways we marriage or with the kid who is on drugs or the categorizepeople-different ages, races, religions, problemsat work, and all the thingsthat many people sex, sexualpreferences, socioeconomics, demograph- don't haveany placeto talk about,even for just a few ics, education,etc. At first it seemedlike all they had minutes, you create a bond with that patient that's in commonwas heaft disease,but then they beganto very deep. Then, when you ask them to take their open up to each other and talk to each other. They statindrug or to eat a betterdiet or quit smoking,they

284 THEAMERTCAN IOURNAI OF CARDOLOGY@ VOt. 90 AUGUSTI, 2OO2 are much more likely to do it becausethere's a sense 307o within that month; blood pressuredecreased; of meaningthat surroundsit. medicationsdecreased, and the ejection fraction re- That senseof meaningis absentin a lot of people's sponseimproved in the experimental group and got a lives thesedays. They've forgottenhow to accessrt litde worse in the control group. The differences be- That is part of what we can offer our patientsif we can tween groups were statistically signiflcant. We pub- first find it in ourselves.The more work you do on lished the results of that study in the JAMA in Jan'rary yourself, the more you have to give to others. 1983. I've been seeinga psychotherapistoff and on for Dr. Alexander liaf, lhe chairman of medicine at many years,since I was profoundly depressedwhen Harvard Medical School and the MGH was interested aged19 while in college.Does that meanI am a mess? in our work, so I invited him to visit. Dr. Leaf flew to Somepeople might think so. I prefer to think of it as Houston at his own expenseand saw what we were the more I understandmyself, what really drives me, doing. He later became a mentor to me. He later my own dark places, the more comfortable I am work- sharedwith me that he was so bemusedby the fact that ing with other people when they talk about theirs and, no medical student had ever been presumptuous therefore, the more I can be of service to them. The enough to invite the chief of medicine at Harvard to more aware I become, the less need I have to project visit, so he decidedout of curiosity to come. my stuff onto other people. I think these are things we WCRzThe.first pilot studyof 10 patientswas nerer needto give voice to becausewe don't talk aboutthis -oublished? much in our profession. DO: We oublished an abstract in Clinical Re- WCRI Yoi were24 whenyou did this studyv'ith 10 search,buI not a full manuscript.We never sentit in peopk. They probably averaged 60 years of age. becausemy advisortold me that nobodywould pub- Wouldyou describea day with theseI0 people? lish it becauseit was too controversial,had too few DO: It wasn't so different from our retreatsnow. patients, had no control group, and, therefore, col- We would have a yoga class from 7 to 8 A.M.and leaeueswould not believethe data. breakfastfrom 8 to 9:30r.na. I gavelectures from 9:30 WCR: I assumethat you and Alexander Leaf hit it to 11:00.We'd have an exerciseclass from 11 to 12. off prexy well when he came to Houston? Lunch was at 12 or 12:30 and there was a break after DO: We did. I iust love the man. He's beena real lunch.Then anotherlecture, another yoga class, exer- mentor and inspiration to me in a number of different cise,dinner, and a supportgroup. That was their day. wavs. and he still is. WCR:,That went on for j0 days. Di.d thesepatients WCR: Your meeting Alexander Leaf tn Houston I overall lose weight during that period of time? Were presumewds the thing that led to your intemship in theymuch happier when they left? Did their chestpain medicineat the MGH? disaooear? DO: Yes. He invited me to give medical grand DO: There was a 91Voreduction in the frequency rounds at the MGH as a medical student.Tony Gotto, of angina. They lost weight. They felt better. The the Chief of Medicineat Baylor then,was not inclined difference was like night and day to many of these for me to go because apparently that had not been patients.They'd saythings like, "I feel like I've been done before.He didn't want me to go to Boston and walking around in a fog and I'm waking up. I'm embarrasshim. I said, "I don't want to embarass thinking more clearly. I have more energy. I feel myself either. Let me give grand rounds at Baylor better,I sleepbetter, and my anginais gone." Their first. If I do OK, you can give me your blessing;ifnot, mvocardialperfusion was better,too. I won't go." I did, andhe did, so I gavemedical grand - There was no conhol group, but the improvements roundsat the MGH. This createdits own set of prob- were so striking,I was surprisedat the level of resis- lems for me at MGH later as an intem when I first tancewe got to the databecause they wereso exciting began.It was like, "Wtro the hell are you?" to me. Becausethis studydidn't fit the paradigm,and WCR:,During medi.calschool you must hal)ebeen you peoptedidn't quite know what to make of it. I went incredibly busy doing thesestudies. took a year back to medical school and finished my next 2 years, off;for your secondstudy before intemship? graduatingin 1980. DO: I took a yearoff alsofor the flrst study.I took Before moving to Boston for intemship, I took a year off between my second and third years of anotheryear off in 1980to do a secondstudy. It was medicalschool, and anotheryear off betweenmedical a randomized control trial with 48 patients randomly schooland intemship. assignedto an experimentalgroup or a non-interven- WCR: Ilow did medical schoolstrike you in gen- tion control group. Instead of putting them in a hotel, eral? Whenyou rtrst entered,what v)ere some sur' we got a place in the Hill Country near Austin, called prisesfor you? HorseshoeBay, becausewe found in an earlierstudy DO: It was harder for me during the first year that a couple of the patients were going down to the becauseI didn't have the sciencebackground that bar and having pepperoni pizza and drinks in the most of my classmateshad. The first lectureswere middle of the night. We wanteda more isolatedenvi- about esotericaspects of immunology and I had no ronment. This time, I had a staff of 5 people working conceptof the big picture.It took me a while to have with me. enough of a perspective of how everything fits to- We found again that the angina frequency fell by gether that I could then go back into the details and abolt 90Vo',serum total cholesterol fe71abottt 259o n make senseof it. It was a little overwhelmingat first.

NTERVIEWDEANORNISH285 internal medicine? You mentioned rotcttirugthrough surgery, etc. How did that evolve? DO: If the researchhadn't been successful,I might have gone into surgery or been an interventional cardiologist.I liked intemal medi- cine, the disciplineand the rigor of 1t. WCR: Who had a major impact on you while in medicalschool? DO: Dr. David Mumlord. His training was in OB/GYN but he was,and is, a broadthinking Renais- sanceman. He was interestedin the samekinds of thingsI was-how to take things that are seeminglyunre- lated and find common ground and understandthe interactionsbetween them. I had many long discussions FIGURE8. DOond PresidenrBill Clinion, Moy 2001. with him aboutthat and our discus- sionsinfluenced my thinking. It was very helpful to me, not I loved the camaraderieof medical school and only becauseof the informationI gainedfrom talking leamingnew information.What disappointedme was with him, but the validationthat this process,which the lack of integrationin the basic sciences.It was was different than the reductionisticprocess I was everybodytalking abouthis or her particularresearch leaming in medical school,had value and was worth interestsbut not abouthow it all interacted. nurturingand encouraging, which he did. It alsomeant I went to Boston and did my intemship and resi- a lot to me that he would let me usehis office at night. dencyand then movedto SanFrancisco in 1984.The He enabledme to do the studiesthat I wouldn't have first patient enrolled in the Lifestyle Heart Trial in beenable to do otherwise. 1986. We used quantitativecoronalJ arteriography WCR: Dtd you have much contact with Dr. Mt- and cardiac PET scansas the major measurements.chael DeBakey? You mentioned that you rotated We publishedthe l-year PET and artedographicdata through his service,and that he was an incredibly in The Lancet and the 5-year data in the JAMA. The busy man. experimentalgroup patients got better and better, DO: No. I didn't have much contactwith him. whereasthe control group patientsworsened. WCR: What about Dr. Tony Gotto? We flew the patientsfrom SanFrancisco to Texas DO: I had somecontact with him and he was very for cardiacPET scans,which was a major logistical supportive,always a little skeptical,but appropriately challenge.Continental Airlines donatedthe airfare. so. For me, good scienceis skepticaland yet he was Both the PET scansand quantitativecoronary arterio- always very encouraging. gramswere blindly read.Arteriography revealed that WCRI Did you apply to severalplqces for tntern- minimum diametersof the coronary arteriesgot a little ship or was that sort of automaticafter Dr. Leaf came better. These moderatechanges in coronary athero- to Houston? sclerosiscaused marked improvements in myocardial DO: It wasn't automatic.I did apply to several perfusion,in part becauseperfusion is a fourth-power other placesbut MGH was my first choice.That is function of the diameterand also becauseplaque size whereI was accentedand that is where I went. is only one of many mechanismsthat affects pedu- WCR:In college,you werethe top studentI gather slon. at the Universityof Texts when you graduated.Did Many patientshad dramaticimprovements in clin- you rlo as well tn medicalschool from a grade stand- ical status and quality of life. We found that the point as in college? You mentionedthat your back- primary determinantof improvementwas neitherage ground wasn't quite as good in the sciencesas you nor diseaseseverity but adherence.When I beganthe may have wantedit to be whenyou enteredBaylor. study,I thoughtthe older peoplewho hadmore severe DO: Baylor was pass/fail.It wasn't an issuethere. diseasewould be lesslikely to showimprovement, but I didn't fail. so I was OK. I was wrong. Even with the limitations of self-re- WCR: Ilow did Boston and the MGH strike you porteddata, both at 1 yearand after 5 years,we found beginningan internshipthere? that the more people changed,the better they got. DO: I loved being there,but it was terrifying when According to the PET scans,997oof the patients I first started.First of all, I didn't have the clinical stoppedor reversedthe progressionof coronaryheart experiencethat a lot of internsdid becauseI had spent disease.That study was publishedin JAMA in 1995. a lot of my clinical rotation time doing research.I'd WCR: I4uasit an easy choicefor you to choose beenout of the hospitalfor a year doing research,so

286 THEAMERTCAN IOURNAL OF CARDIOTOGY@VOL 90 AUGUSTl, 2002 I was rusty. The systemat the MGH (I don't know if people I had worked with on the earlier studies in it's still that way) was a team systemso that you were Texas had moved to San Francisco. I got tired of the on call every third night and the 2 intems and I Boston winters, among other things. resident shared all the pafients.You didn't divide Originally, in San Francisco,the plan was to ad- them uD. minister the grant money that we'd raised through one On my first night on call, there were 45 ward of the hospitalsin SanFrancisco. Before I left Boston, Datienlsand 6 others in the critical care unit. I was on the hosoitalsaid it would do it for 107oindirect costs. call my first night. It was an adjustnent, to say the When i got there, however, the hospital wanted 79Vo least. I went to the nursesand said, "I don't really of the glant for indirect costs. (If it's an National know very much. I need your help." That was so Institutes of Health grant you get that in addition, but refreshing to them, they really savedmy butt on more if its private funding it comes out of your funds.) I than one occasion.It took me a while to get my realized. I needed to start my own institute as an grounding and to get my confidence.By the time I was administrativevehicle so that we could keep the indi- a second-yearresident, I was doing pretty well. rect costs monies to use for the researchrather than WCRz Who had major impact on you at the MGH? giving a large amount of it to the hospital. You mentionedDr. Leaf. For a while, the Preventive Medicine Research DC):Dr. Leaf did andDr. RomanDeSanctis. It was Institute was just a file folder in my desk. It was a amazing to me that the people who wrote the text- 501(c)(3)non-profit public foundationthat allowedus books were working with us one on one or in small to begin the study and to use every penny of the groups of people. We would read a chapterin Harri- money for the researchrather than indirect costs.Later son's Textbookof Internal Medicine that Romanhad on, it becamea fu1l-fledgedinstitute. written and he would talk with us about it. To me, he WCR:. What are your goals now? What do you really embodiedwhat a good clinician should be. I want to do? leameda lot from him. I still admire him greatly. DO: I'm trying to havea life first of all. I'm trying WCR: Whnt madehiru such a good physician? to be a good father and a good husband.My priorities DO: Besideshaving tremendousclinical experi- have shifted since our son was born in November enceand an amazingfund of knowledge,he loved his 2000. patients and they loved him. He really integrated and WCR: Whendid you get married? embodiedboth good scienceand a loving, compas- DO: We married31/z yers ago.My wife is Molly. sionate physician. Thafs why a lot of people re- WCR: Is tlrls the first marriage for you? soectedand loved him so muchand still do. Of course, DO: First for her, secondfor me. nbt everybody there was like him WCR: Whendid you marry thefrst time? I felt deeply grateful to be there, but I still had DO: In 1991,for a very shoft time. No children. someold issuesfrom collegethat cameup aroundmy WCR: What is your child's name? own perceivedcapacity to function in that kind of DO: His name is fucas, which means,"one who environment.When I was a second-yearresident, brings light," which he does.I'm trying to spendas somebodyhad the Harvard Medical School course much time as possible with him and Molly. When catalogand I startedreading it. One coursewas "Ad- traveling, I try to be away no more than a night. I tum vancedIntemal Medicine." I thought, "That sounds down a lot of invitationsthat I would have accepted like a scarycourse. I'm probablynot sma.rtenough to before. take a class like that." And then I realized I was WCR: Ilow is the Institute going now? How mnny teqchiny the class. It was just Harvard medical stu- patientsdo you see?How many are in your studies? dents rotating with second-yearresidents at the MGH. DO: I thought the Lifestyle Heart Trial was going It was still easyto get intimidatedby things.For me, to help changemedical practice, but I was wrong and part of the benefit of being there was to realize that nalve.Most peopleaccepted the validity of the science peopleare similarjust about anywhereyou go. and our data. Still, it was not the standardof care for WCR: zft;s wqs 1981.How man\t felhw interns most people.I realizedthat it wasn't enoughto have were there whenyou were there? good science;we alsohad to havereimbursement. We DO: Approximately20. doctors do what we get paid to do, and we get trained WCR:In thefirst-year residencyyou were down to to do what we get paid to do. Thus, if we change how many? reimbursement,then we could help changemedical DO: Most of the peoplestayed for 3 years. practice and, ultimaiely, medical education. We WCR: Ior decidednot to take training in a sub' showed that comprehensivelifestyle changeswere specialty? medicallyeffective; now, we neededto showthat they DO: I knew I didn't want to be a cardiologist were also cost effective. becauseI knew I was going to be doing researchin Initially, I went to insurancecompanies and asked areas besidescardiology. I focused on cardiologic if they would pay for this program.Initially, they said, studiesinitially, but I thought the benefitsmight ex- "No, we won't. We don't pay for diet and lifestyle tend beyondthat. becausethat's prevention."I asked,"What's wrong WCR: Ilow did it come about that you went to with prevention?" They said, "20-30Vo of people California in 19841 changeinsurance companies every year, and it may DO: I wantedto live in SanFrancisco. A coupleof take 5 yea$ or more to see the benefits. Why should

INTERVIEWDEANORN SH 287 here in South Carolina, gravy is a beverage,so this will be a big changein their diet"); Fort Lau- derdale,Florida; Boston, Mas- sachusetts;San Diego and San Francisco,Califomia; and New York City. Dr. Leaf chaired our data-co- ordinating center at the MGH and Mutual of Omahafunded it. Mutual of Omaha was the first insurance company to pay for the program; since then, about 40 others are covering it as a defined benefit or on a case-by- casebasis. We found that we were able to train other teams of people to interveneas well as we did, if not better. The program was only a year long but we fol- FIGURE9. DO ie5tifyingbefore U.S. Senoie Heorings on ComPlemenloryond Alternolive lowed patientsfor 3 years.Al- Medicine.2000. most 807o of the patients who were eligible for coronary by- pass surgery or angioplasty we spendmoney today for future benefits that, even if were able to safely avoid revascularizationfor at least they occur, another company is likely to get?" I said, 3 years.As a result,Mutual of Omahacalculated that "Becauseit's the right thing to do." That wasn't the they savedalmost $30,000 a patient.These data were most persuaslveargument. published in rhe American Jownal of Cardiology \n So, I tried a different approach."It is not just 1998. prevention but also an altemative treatment.For every Basedon those data, Highmark Blue Cross Blue man or woman who would have undergonebypass Shieldof Pennsylvania,which was coveringthe pro- surgery but can avoid it by changing diet and lifestyle, gram,also began to providethe programin 3 sites.In you save$30,000 or $40,000immediately. Real dol- the first 350 patients,348 avoided surgery, saving lars today, not just theoretical dollars years later." >$17,000 a patient. They replied, "That's geat, but most people can't Medicare is now conducting a demonstration follow your programbecause it's too hard.If we pay projectof 1,800patients in the sitesthat we've trained for your program, but most people can't follow it and are continuing to train. Our research institute becauseit's too difficult, then we will end up paying tumed over the hospital programs to Highmark and for bypass or angioplasty anyway and then our costs they created a new company called Lifestyle Advan- would go up becausenow we'd be paying for both." tage to continue to make the program available in I showed them our data from our earlier studies through hospitals and other sites around the country which adherenceto the program was high. They re- (www.lifestyleadvantage.org).I don't personallyben- you live in Califomia. They'll do sponded,"Yes, but efit financially from that arrangement,but I can focus is an altered state; no one anything there. California my time at the Preventive Medicine ResearchInstitute do it. . . ." else can on doing new research, like a study to determine if I went back to the National Heart, Lung, and Blood comprehensive lifestyle changes can affect the pro- Institute becausethey had funded the extension of ihe gression of prostate cancer. Lifestyle Heart Trial from 1 year to 5 years.I proposed WCR::,Dean, could you describeyour institute? to do a multicenter demonstration project. They said, DO: It's located in Sausalitoin a 4-story wood- "After the Multiple Risk Factor Intervention Trial framedbuilding. We have about25 to 30 employees. (MRFIT) where we spent $200,000,000and didn't half are working on the Lifestyle showmuch, we're not going to do any moremultisite/ About of them programs and the multifactoral interventions." Advantage side with the cardiac work- So, we took an entrepreneurial non-profit ap- Medicare demonstrationproject and the rest are proach. We went to hospitals in different parts of the ing on the prostate cancer study and new researchwe country and licensed the program to them in retum for are planning. the data. We used the money to pay for our research WCR: ilow many patients do you see there and costs.(I didn't personallymake any moneyfrom this.) how do you get your patients? They were a diverse group geographically-Omaha, DO: We don't seepatients at the clinic; we just do Nebraska;Des Moines,Iowa; Columbia,South Caro- research there. The hospital programs see patients if lina (where one of the cardiologists told me, "Dean, people want to go through the program and Lifestyle

288 THEAMERICAN JOURNAT OF CARDIOLOGY@VOt. 90 AUGUSTI, 2OO2 those Advantage offers weekend and weeklong reffeats in DO: We see researchpatients there, but only patients different parts of the country. who are in reseatchprotocols. We refer other For the past5 years,we've beenfocusing primarily to our hospital programs and residential retreats. only in on a study to see if comprehensivelifestyle changes W€R: fhz prostate study is being done can affeci the progression of prostate cancer. I think 'vourolace ? " hospitals we we are at a place with prostate, breast, and colon DO: Now that it's working, other programs. cancerthat we were at in 1977 with heart disease. trained will offer more clinical Is this There is every reason to think that intensive lifestyle- WCRI Who is supportingyour research? changes might have an effect on the progression of mainly the National Institutes of Health? National In- thesJcancers,but no one has done randomizedtrials DO: We've gotten funding from the Defense, with an intensive-enough intervention. Whatever we situtes of Health, from the Department of find will be useful becausea lot of men have prostate and ftom individuals and pdvate foundations. cancer.The study is being conductedin collaboration WCR: Yoa spend a lot of time raising money. with Dr. Peter Carrol from the University of Califor- DO: I do. on a- nia San Francisco and the late D/. William Fair ftom WCR: Is it tue for most of us that if we lived oJ Memorial Sloan-Kettering Cancer Center in New 10% of caloriesfrom fat diet, it is likely that cancer of the York. Dr. Fair took mice and injected them with the brbast, cancbr of the prostate 7land, cancer gallbladder disease, Drostatetumor cells and found that wilhin a few weeks colon, ttpe 2 diabetes mellitus, stones' ih" tutott began lo grow when they ate a typical obesity, hemorrhoids,hiatal hemin, kidney would American diet. Then, he randomly divided them into gall itones, osteoat'thritis, and osteoporosis 4OVo.lIVo, and27o fat diets.On the higherfat diet the essentiallyvanish? Clearly, tumors kept growing, but when the fat was down to DO: I think that may be an overstatement. diseases. aboit l0% t}Ie tumors stopped growing and even lifestyle plays a major role in eachof those going vary and how shrank.I said,"Why don't we do a study?" How muih for each diseaseis to pros- We enrolledmen who havebiopsy-proven prostate much for eachindividual is going to differ. Our people with heart cancerbut who haven't beentreated ("watchful wait- tate data are very encouraging.Most quickly than ing"). This designallows us to randomizepatients.and disease do get better, and much more part o[ what to have a true non-intervention control group, which peopleonce thoughtpossible. That is are skep- couldn'tbe donewi*r breastcancer or coloncancer. inakesthe adherenceso high. Many docrors lif,gstyle since almost everyone undergoes conventional treat- tical that patients can make comprehensive ment. The experimental group is asked to make com- changes,but this belief often becomes self-fuIfi1ling. prehensivelifestyle changes similar lo theintervention If th6 doctor says,"Mr. Jones,I know you wouldn't why would ihat we found could reversethe progressionof heart want to changeyour diet and lifestyle, and just prescribe-a statrn disease.The primary end-pointmeasure is prostate- you want to anyway when I can and when the specific antigen.Other. tests include magnettcreso- ilrug?" The patient doesn't change, knew yott n^anceimaging, magneticresonance spectroscopy, ul- patient comes back, the doctor says, ".1 trasound,number of patientsundergoing conventional wouldn'tchange." It becomesself-fulfilling. to seea patientand treatment, and effecls on apoptosis and growth of If you have-only7 or 8 minutes and lifestyle' LNCaP cell lines. So far, the data are very you don't have much training in diet just prescribea statin encouraqing. ihen it becomesall too easyto diet and Anot-heistudy we are planningis with men and drug instead of counseling patients about hyper- women who have ischemic cardiomyopathy who are lifestyle. Statin drugs don't improve diabetes, waidnp,lor hearttransplanls. As you know. theJeis a tension, obesity, rheumatoid arthritis, osteoarthritis, 'i2-month or if they 6- lo wait lor a donor. and a significant gallstones,etc. They don't improve angina, missingan opportunty Dercentaqeof these patientsdie belore a donor be- do, not by much.Again, we're just if we don't also cor.s a-uuitabl".Thiy are all on maximalmedical to be moie than treatinglab values goesback to: What therapv. We have worked with a few patients who help peoplechange their lives. It It's not said,lir effect, "I'm just waiting aroundanyway, let is the fundamentalcause of theseconditions? it's hard. me give this a try." One patientmoved from St. Louis glamorous,it doesn'talways reimburse, and to dmaha to go through our program. Cardiac PET ft is atl of hat, but it's wonh doing. passionate about scansshowed that his ischemicperfusion defect and Part of what has made me so over and his mvocardialviability were significantlybener I doing this work for almost25 yearsis fiat powerful these vear liter. His eiection fractionand his clinical status over,just as you have,I've seenhow it hasto be a new ilso improved, io he got off the heart transplant list. simplechanges can be. Peoplethink high tech to be Several other patients have gotten off the heart trans- stenl or a new laser or somethingreally plart list. We'ie planningto do a randornizedstudy of worth doing. They may have a hard time believing people make in diet and a larqergroup. In a way. it's the ultimalehigh-tect/ that these simple choices that but low-iech-iuxlaposition;after all, what'st}le more rad- lifestyle can make such a powerful difference, ical intervention? they often do. using very high-tech, WCRI,Let me get a betterfeel of your institute.You in our studies,we've been to try to prove don't see patients there. This is purely a research expensive, state of the art measures 1ow-cost, oDeration. how powerful these very simple, ancient,

NTERVIEWDEANORNISH289 FIGURE10. DO wilh lucos(son) ondTenzin {dog), Februory 2002.

and low-techinteNentions can be. They are not only cardiacevents, since these have not yet beenproven. medicallyeffective; they are also cost effective.If we If you can consistentlyget a 9lVo reductionin angina can show this with the Medicare demonstration within weeks simply by making more intensive project and Medicare covers it, then it becomesa changesin diet and lifestyle, then this option should standardof care. be given to patientsalong with the option of revascu- I have no illusions that most people are going to larization. Not that every patient is going to make chooseto make thesechanges, but a lot of peopleare comprehensivelifestyle changes,but at least each if they understandthe benefitsand how quickly they should know about it. Thoseundergoing revascular- occur, and if they understandthe limitations of con- ization may also benefitfrom making comprehensive ventional approaches.Again, I suppoll the use of lifestylechanges to reducethe likelihood of restenosis statins,bypasses, and angioplastieswhen appropriate. or reoccluslon. Mostly, I'm a big supporterof truly informedconsent What concemedme and what I wrote about in the and evidence-basedmedicine. Unfortunately,many editorial for the American Joumal of Cardiology (Sta- patientsdon't receiveall of the facts. tins and the Soul of Medicine, June 1, 2002, page Many peopleare told, "Mr. or Ms. Jones,we need 1286-1290) about the recent National Cholesterol to do an angioplastyor you are going to die." The Education Program/Adult Treatment Panel III guide- evidence doesn't usually support that. There have lines is that they didn't even provide more intensive beenno randomizedcontrol fials showingthat angio- diet and lifestyle changesas an option for people plasty prolongs life or preventscardiac events.The becausethey assumednobody was going to do it. The only randomizedtrial that was done was the Ator- National Cholesterol Education Progran/Adult Treat- vastatin Versus Revasculadzation Treatments ment PanelIII guidelinessaid that if your low-density (AVERT) study by Bertram Pitt and others that, if lipoprotein(LDL) is >130 mg/dl you shouldbe on a anything,showed that statin drugsdid as well, if not statin,because they know that a 3070diet aloneis not better,than angioplasty. Yet this studyhasn't changed going to sufficiently lower LDL for most people. the rate of utilizationof thesetechnologies (1,300,000 Severalstudies have shownthat a step 1 or step2 or coronaryangioplasties and 600,000coronary bypass Adult TreatmentPanel III therapeuticlifestyle change operationsannually at a cost of $30 billion/year). diet will lower LDL cholesterolby only 5Voto l07o, if Severalrandomized controlled trials of bypasssur- that. gery (including the CoronaryArtery SurgeryStudy, In clinical practice,Mr. Jonesand Ms. Smith have the EuropeanCollaborative Study, and the Veteran been diagnosedwith hypercholesterolemia.They go Administration study) showedthat unlessyou have to their doctor and are prescribeda step 2 or Thera- left main diseaseand poor left ventricularfunction, peutic Lifestyle Changesdiet. When they retum on which is a small minority of peoplewho get revascu- their next visit, their LDL cholesterolusually has not larized,bypass surgery neither prolongs life nor pre- declinedvery much. Patientsare then often told that ventscardiac events. they "failed diet," when, in actuality,they just didn't These facts have not reduced the number of coro- go far enough.Most patientsare not told that if they nary angioplastiesor bypassoperations. To me, the hadgone on a morerestrictive diet, they could achieve major legitimate reason to be revascularizedis to a 407o reduction in LDL on averagewithout drugs in reduce angina, not to prolong survival or prevent a freeJiving populationover a year.We publishedthat

290 THEAMERCAN JOURNAL OF CARDOLOGY.OVOL. 90 AUGUSTI, 2OO2 in JAMA in 1998.rAlso, we found that most patients WCRI I thtnk it's a fear of fightening too many. with coronary heart diseasewho followed a step 1 or people. I agree with you entirely. Physicians need to a step2 diet showedoverall progression of atheroscle- talk to patients in terms of how to prerent or arrest rosis when measuredby serialarteriography, whereas atherosclerosis rather than talk only in terms of de- patientswho mademore intensive changes in diet and creasins risk, lifestyle showedoverall regressionof coronaryath- DO:-You talk aboutthat so eloquentlyin so many erosclerosis. olaces. What I tell my own patientsis that you have a WCR: Thank you- The ped.iatricians don't say, rangeof options-bypass surgery,angioplasty, lipid- "Let's decreasethe risk of measles,mumps, whooping lowering drugs, diet, and lifestyle changes.We go cough,and polio." Theysay, "Let's prevent it-" The through the risks, benefits,costs, and side effects of samecan go Jbr atherosclerosis. each approach and whatever they chooseis okay with DO: Why don't you think that is happening? me. I don't try to pressurethem to changetheir life- WCR:.I ;hink thire is a fixation on isk retluction style. I leameda long time ago that even more than by a lot of prominentand siholarly physicians-Their being healthy,people want to feel free and in control. impact is great. As soon as I try to get them to do something,they DO: You believethat atherosclerosiscould be vir- immediatelywant to do the opposite.That's just hu- tually eliminated (with the exceptionof maybe the man nature.That goes back to the very first dietary familial hypercholesterolemics)? interventionthat failed: whenGod said,"Don't eatthe WCR: Exactly. apple."That didn't work andGod was talking.People DO: Knowing what we know now. We don't have needto have informedchoices. to wait for a new breakthrough;we just need to Not everybodyneeds to be on a 1070fat diet. There implement what we already know. Although most is biologic variability in how efficiently a personcan peopletend to think that the only diet I recommendis metabolizedietary fat and cholesterol,as you know a I07o fat diet, we also recommendless restrictive from Brown & Goldstein's work. The more LDL diets for peoplewho don't needto be so strict. I tell receptorsyou have,the moreefficiently your body can people:"If you don't haveheart disease and your LDL do that.Like manythings in biology, it's a bell-shaped is <95 or your total cholesterolis )150 or your curve. On one end of the spectrumyou've got a total-to-high-densitylipoprorein (t{DL) ratio is <4, 95-year-oldman or woman and you ask, "What do then eitheryou're not eatingmuch fat and cholesterol you eat?" They say, "I have 12 eggsfor breakfasl a or your body is very efficientat metabolizingit. Either steakfor lunch, and a cheeseburgerfor dinner." You way, whateveryou aredoing is probablyokay. If not, think, "Maybe diet isn't that important. Look what you can begin by making moderatechanges. If that's they are eatingand they're 95." Of course,everyone enoughto bring it down that may be all you needto elseeating that way wasn't so efficientat metabolizing do. If not, then you can progressivelydecrease the dietaryfat andcholesterol and never made it to 95. On amountof fat and cholesteroluntil you achievethese the other end of the bell-shapedcurve you've got goals." people with hypercholesterolemiaand heart disease In that context there's a Dreventiondiet and a because they have fewer receptors. Reducing your reversaldiet. The preventiondiet isn't a diet as such; intake of Iat from 40Vo to 30Va and your dietary it's a spectrumof dietsbased on what a personneeds. cholesterol intake from 500 mg to 300 mg for people It's not all or nothing.The old sayingabout "An ounce at the other end of the spectrumis not enough.It of prevention"is really true. It takesmore to reverse doesn't lower LDL very much and it doesn't affect diseasethan to helpprevenl il. (www.omish.com.) coronaryatherosclerosis. WCR: Are you i vesetqri(tn? I've beenin an ongoingdebate with the American DO: I was a srict Geeta,rianfrom the dme I was Heart Associationabout this for years.I'm a long- 19 until about 5 yearsag-o. I then beganeating some standingmember of the AmericanHeart Association, fish on occasion.My total cholesterolhas been run- help raisemoney for them,work on their committees, ning between130 and 140since I was 19 becauseI've presentat their scientificmeetings, and love what they beeneating such a strict diet, so I'm a good example are doing in most areas.In this area,however, I think of someone who can be on a orevention diet rather they aremistaken. They say,"We're not evengoing to than a reversaldiet. The only reasonI eat fish some- tell people about a more intensive,'step 3' diet be- times is becausethere's a great sushirestaurant near causewe don't think peoplewill do it." It's like telling my office.I've beenrecommending that people take 3 people who smoke,"We're not going to tell you to to 4 glday of fish oil for many years,as this provides quit becauseit's too hard. Just smokeless." Whether the benefitsof the omega-3fatty acids without the it's hardis not the issue.People need to know whatthe excessivefat and cholesteroland, all too often, mer- facts are so they can make informed and intelligent cury that is often found in flsh. cnolces. WCR: Yoa wrote one time thot if your total cho- Thereis somuch resistance to meaningfulchanges. lesterol was <150 mg/dl you don't have to worry I don't understandwhere it's comins from. Even if muchabout your HDL as long as it's >20- I presame they believelhat only a handfulof plople are moti- 'you still thlnk rhat is aoprooriate. vated, why not at least tell people about that as an DO: It is not iustmi. fnere wasa debalein Ifte oDtion? New EnglandJournal of Merlicinein 1997about this

NTERVEW/DEAN ORNISH 29I issue.One prevalentmyth is that low-fat dietsare bad not the same.you are on a lot of advisoryboanls. You becausethey lower your HDL. In fact,they're not bad, gh)e a lot of talks in yarious cities in the world. When they're beneficial.If you're eatinga typical American working in your hometown,vthat would a day look diet andyour body can't makeas much HDL to get rid like? What time do you get up in the moming? What of the excessivefat and cholesterol,then you are at time do you leaveyour home?What time do you get higher risk than someonewho can make more HDL. homeat night? Whot time do you go to bed? What is However,if you substantiallyreduce your intakeof fat your day-to-clay,hour-to-hour situation? and cholesterol,then, teleologically,it's almost like DO: It varies a lot. When I'm with our baby boy your body says,"There's not as much garbage,so I (my wife and I altemate taking care of him), I might don't need as many garbagemen." 11 has a very be up with him a lot during the night. Having a baby differentprognostic significance to havea low HDL in a little later in life than somepeople has been a real the context of a low-fat diet then in the context of a blessingfor me, as I cherishevery momentwith him. high-fatdiet. Populations eating low-fat dietsand hav- I tum down about 9OVaof invitations to speak as I ing low HDL cholesterollevels do not have an in- would rather be at home with them, so this is a big creasedincidence of coronaryartery disease. changefor me. Lowering HDL cholesterollevels by the consump- I'm usually up by 6:00 e.u. I'll do somemedita- tion of a low-fat diet resultsin morerapid clearanceof tion, yoga, and exerciseand havebreakfast. It usedto HDL and decreasedtransport of HDL apoproteins. be that I'd go to work around8:00 e.M. Since the baby Thereare no datashowing that the physiologicreduc- was born, I try to do as much work as I can from tion of HDL cholesterollevels by a low-fat diet is home. It's a lot easiernow with e-mail. fax. voice detrimental.Diet-induced lowering of HDL choles- mail, and cell phones.I usedto work 90 hours/week. terol doesnot confer the samerisk of atherosclerosis Now I do a lot of work at home and go to the office for as do low HDL cholesterollevels in Americanscon- a few hours for meetings.Then I'll come back and suminga high-fat diet. Dr. Jan Breslow'sgroup from work from home. The advantage of working from (New Rockefeller University York City) said, "In home is that I can be closeto my wife and baby.The assessingcoronary heart diseaserisk it may be inap- disadvantageof working from homeis that I canwork propriateto concludethat dierinduced decreasesin all the time if I'm not careful.Interspersed with spend- given HDL are equivalentto low HDL within a diet." ing sometime with the baby or with my wife, taking initially We found in our studiesthat HDL levels a break,or eatingmeals, I sometimesstill work until period time, they increase, fall, but over a longer of around 8:00 or 9:00 p.u. I usually go to bed around goes staysdown. Triglycer- whereasLDL down and 11:00or 11:30p.M and get up at 6:00l.v. ides that initially increasedwent down over a longer WCR:.What about weekends? period of time. DO: I usedto work on weekends,but now week- There are somepatients ("syndrome X") who are endsare precious.I work a few hourswhen the baby more sensitiveto the effectsof simplecarbohydrates. or my wife is taking a nap.The rest of the time I try It's importantfor themto reducetheir intakeof simple to spendwith them. carbohydrates(sugar, white flour, white rice, alcohol) WCR: Ilow haveyou worked in trawl? You men- and increaseconsumption of complex carbohydrates tioned earlier that you now decreaseyour days away becausethe fiberin complexcarbohydrates slows their home.But in thepast you've beenon the road an absorption.If you reducethe intake of simple carbo- .from lot. you trqvel into your other hydratesand increasethe intake of whole foods or awful How do work complex carbohydrates,increase exercise, reduce al- activities? part I I'm not an "ivory cohol intake,and add fish oil, which we've beendoing DO: It is of what do. get to for many years now, then triglycerideslevels don't tower" scientist.I want to my messageout increase.Even in our earlier studieswhen the HDL people who can benefit from it. It's really all about went down and the triglycerideswent up, thesepa- service, and scienceis one form of service. It is tients still showedregression. equally important to educatepeople so they can take What concernsme is people who say that it's advantageof what we're leaming.Having seenwhat a dangerousto go on a low-fat diet becauseyour HDL powerful differencechanges in diet and lifestyle can goes down and your triglyceridesgo up. They may make,I want to make surepeople know aboutthese discouragepeople from making changesin diet that findings,which really can give manypeople new hope otherwisernight have beenvery beneficial.HDL and and new choicesthat they didn't havebefore. Not to triglyceridesare risk factors;they are not diseases.In push them to change,but to empower them with our study, even in patientswhose HDL went down informationso they can makea truly informedchoice. and triglycerideswent up, they still showed some Interviewslike this one,publishing in scientificjour- regressionof their coronary atherosclerosisafter 1 nals, talking to newspaper,radio, television,lectures year, even more regressionafter 5 years, improve- to scientificmeelings. public lectures.now training ments in myocardialperfusion, and 272 times fewer hospitals through Lifestyle Advantage, doing new cardiac events.I'm aware of no studies,looking at studies, working with the Medicare demonstration actual cardiac end points, that show that lowering project, or doing new researchare all part of service as HDL in this context is harmful. well asthe broadercontext ofjust beinga curiousguy. WCR: I know that probably 2 days in your life are There is a lot of pleasurein finding things out, as

292 THEAMERICAN ]OURNAI OF CARDIOLOGYoVOL. 90 AUGUSTI, 2OO2 well as in trying to make a difference. It soundscorny got a lot of support. As I mentioned earlier, one of the to hy to help people,but theseclich6s are true. greatthings aboutTexas is that if you've got an idea You and I have both had enough public exposure and you want to do it, you're encouragedto go for it. and successto know that thosethings are nice as tools WCR: Couldyou talk aboutyour wife a bit? Where to be able to do service,but they don't really bring did you meet?You are obttiouslya devotedhusband lastinghappiness. Like the Swami saidyears ago, as a and father. tool, it can be incredibly meaningful to be able to DO: That's trxe. We met in a restaurant in Mill know that we can leverage our time to reach many Valley, Califomia. I was with my friend Phillip Mof- people with information that can help them-you as fitt and she was with a girlfriend. We met the old the editor of a majorjoumal or me doing the kinds of fashionedway. Shewas at the bar drinking a glassof things that I'm doing. wine and I was having dinner. I worked up my cour- That really brings a senseof meaning and gratitude age and walked up to her and askedif I could buy her to my life. When I was 19, I felt like saying,"Hey! a glassof wine. She said, "Who are you?" I told her Look what I'm doing, I'm worthy of your love and my name and it meant nothing to her, but she let me resDect."but those intentions and motivations are buy her a glassof wine, and we starteddating. whit almost killed me. The paradoxis that the less One of the nice things about having a baby at the investedI am in needingto do things for my own age of 47 is that I'm really clear about what my senseof who I am, the mote I'm able to accomplish, priorities are. I can't tell myself, "If I just wrote becauseI don't havethe anxietythat I might havehad anotherbook, I'd be happierthan I am now." The time before aboutdoing thosekinds of things. I spendwith our little guy is the mostprecious time WCR: tlaw and when do you do your writing? imaginable.It probablysounds insipid to talk to peo- DO: For a joumal article, airplanesare really a ple about it, but it's true. You know, being a father great place for me to write becausenobody calls me. yourself.I've donea lot of interestingthings in my life For a book, I have a place at home where I write and andnothing has brought me a greatersense ofjoy than where I try not to be interrupted.I can't work with just spendingtime with my wife andson. I'm trying to music or television on becauseI get too distracted; practicewhat I preacha little betterand actuallylive music is so interestingI'd ratherfocus on that. I tum those things I've been writing about for so many the ohonesoff andclose the door.I tell associatesthat years.I've becomequite the doting father. unlessit's somethingreally urgent,please call at an- WCR: That's great! Do you har)etime for nonmed- other time. I don't write at the office becauseit's too ical activitiesin addition to yourfamily? Do you read distracting with people coming in and out. I need much in the nonmedicalsphere? protected time. I'11 spend 4 or 5 hours at a time DO: Yes, I do. I love listeningto music,and I love writine. playing music.My little boy loves music. His godfa- WeR: How do you makea liting? Youdon't make ther is Quincy Jones, the musician, and he has a great a living fia your researchwork. Youhave your books musical ear. He has very strong preferences about and vour soeeches. what he likes and what he doesn'tlike. He likes good DO: night. In a way I've got the worst of both music,good jazz. I like playing my guitar with him a worlds from a perceptualstandpoint because people lot andteaching him to play andalso to play the piano. think that I'm making a lot of money from licensing A lot of what we do is aroundmusic. I like reading our program to hospitals and residential retreats, books that have nothing to do with medicine, al- whereas I don't make anything from that. I make a though, ir a way, all books have somethingto do with living from my books, lectures,and the Intemet site medicine. with WebMD. Also, I do some consultingwith food WCRI You'vebeen here nowfor just over 3 hours comnanies. and I suspectthat you've had l0 telephonecalls since WCR: IIaw much time does the WebMD site take? you've been here. Is this a rypical day? How many DO: It varies. The Intemet is another great tool for phone calls do you get (I'm not talking aboutfrom leveraging my time and reaching a lot of people with your wift) from all activitiesyou are involvedwith? free information that can be useful for them. They can DO: How many do I get or how many do I retum? log into WebMD anywhere in the world at www. I spenda lot of time on the phone. WebMD.com or www.Ornish.com,which is a short- WCR: Tel/ me abour your relation wirh former cut to get to our site at WebMD. I also spenda few PresidentBill Clinton and membersof Congress. hours a week online answeringquestions and partici- DO: A mutual friend introduced me to Hillary pating in dialogues and chats. Clinton in 1993 when she was working on health WCR: Do you have a lot of resistance to your reform. We spent an hour together and talked about efforts in Califumia? I expectyou did initially. I know the researchthat my colleaguesand I havebeen con- Ken Cooper did when he came to Dallas, but he's ducting.She's very smartand understood the concepts built a magnifcent institutionhere. immediately.She then said, "We'd also like you to DO: I agree;Ken's beena real pioneerand is doing work with the chefswho cook for us." I said,"Excuse grealwork. It wasn'tjust in California;it wasin Texas me?" She said, "We'd like you to spendsome time where I first started in 1971. The first 2 studies were with the chefs at the White House so they can cook done in Texas.There was resistancein the senseof healthiermeals for us." I said, "Of course." people'sbeing appropriatelyskeptical, but I actually I brought with me Jean-Marc Fullsack, who has

INTERVIEW/DEANORN SH 293 been working with me for >10 years as a chef and WCR: f President Bnsh asked you to be Surgeon Hubert KeIIer from Fleur de Lys restaurant in San General,would you do it? Francisco. Previously, Jean-Marc was at Lutece, DO: Not until my sonis mucholder, since he is my L'Emitage, and the Califomia Culinary Academy. first priority, but maybe when I'm older, if I were Over the years, I leamed that the best way to make asked.I havehad discussionsabout it before. low-fat food tastegood was to work with greatchefs, WCR: What study will follow the prostate Bland even if they were not usedto cooking that way, and study? ask them to work within certain nutritional parame- DO: Our team has leamed how to motivate many ters. Great chefs know how to make great food. Hu- peopleto makeintensive changes in diet andlifestyle. bert is one of the best chefs in the country. I brought Our cardiac studies, and now our prostate cancer te- them with me to the White House severaltimes and search,indicate that moderatechanges may not be workedwith the White Housechefs. The White House enoughto stop or reversethe progressionof disease, chef in 1993 didn't want to cook low-fat foods, so but more intensivechanges may havean effect. Since they found a new executivechef. Over time, we have we are able to motivate patients to make lifestyle alsoworked with the chefson Air ForceOne, at Camp changesto the degreethat may be necessaryto have David, andthe Navy mess.All of them aregreat chefs. this impact, it makes the work very meaningful for all and When the Presidenthad his first few annualphys- of us who do it. This allowsus to conductstudies to do. icals, they asked me to participate, which was a real test hypothesesthat othersmay not be able prostate cancer research for privilege.Whatever your politics, when the President We may extend our 4 years more definitive measures of the United States and his family make a commit- another to look at as survival, metastases,number of patientsun- ment to exercise and eating more healthfully, it sets a such dergoingconventional treatment, and time to recur- great example for all Americans. rence in those who do, along with surrogatemeasures I also endedup working with a number of members such as prostate-specificantigen, magnetic resonance of Congresson both sides of the aisle, including imaging,magnetic resonance spectroscopy, and uitra- conservativeRepublicans Dan Bunon andArlen Spec- sound.Eventually, we may studybreast cancer, since rer, and liberal Democrats Charles Rangel and Alcee what affects prostate cancer is likely to affect breast Hastings. In a WashingtonPost article, Mr. Rangel canceras well, and perhapscolon cancer.We plan to "This is the only thing Dan Bulon and I ever said, conduct a study of men and women with ischemic is part of what makes this kind of agreed on." This cardiomyopathiesas we discussedearlier, and we are peopletogether. We did a daylong work fun, bringing in the midst of the Medicaredemonstration project. the mem- workshop on diet and lifestyle changesfor WCR: Wfty do you think the medical profession, bers of Congress. when it comesto " atheroscleroticrisk factors," is so Former Speaker of the House Newt Gingrich and hung up on "family history" ? former PresidentBill Clinton don't have a lot in DO: Family history is important,but it's only one common,yet they both becamevery strongsupporters of many risk factors. Too much emphasis on family of our research and the Medicare demonstration history can becomean excusenot to do much about project,and they both becamegood friends. The same diet ald lifestyle. It becomesnihilistic and fatalistic: with Dan Burton and Charlie Rangel-even though "It's all in your genes."There is a predisposition,but their politics are completely on opposite ends of the it's not a death sentence.It just means that some spectrum,I also considerthem friends.I still stay in peoplehave to make bigger changesin diet and life- touch with them,and it's a real privilegeto work with stylethan others. Ofcourse, nothing works all the time peoplelike that. Becauseof their positions,they can for everyone-not drugs, not surgery, and not life- also help inspire other people to make lifestyle style-and thereis an elementof mysteryto all of this. changes. But the value of our researchis to empowerpeople WCR: Whot kind of exercisedo you do now? with information that can make a difference in their DO: We've been renting a house with a pool, lives. Most peopieimprove if they make big enough which we've neverhad before.I've beenswimming a chansesin diet and lifestvle. lot while we remodel our other house to make room WCR: Oar population is getting heatier and for the baby. We don't have a pool at our regular heavier. The atterageAmerican gained 9 pounds in house. I have a treadmill and I work out on that and the last decade. Diabetes mellitus frequency is slcy- then I go to a trainer at World Gym who I seeonce or rocketing.Now, we're treatingpatients with conges- twice a weekto do strengthresistance training (weight tive heaft foilure with a very expensivedevice. Pa- lifting). tients with ventricular arrlrythmias arter an acute WCR: Do you still play tennis? myocardial infarct have a d.efbrillator. The expenseof DO: No, not sincethe babywas born. I love tennis. all this stuff is mind-boggling.How many people in I do walk a lot, especiallywith the babynow. That for governmentwho are in positions of major influence me now is almostmy favoriteexercise because I get to haveyou gotten to seeyour way? You're in an eco- spendtime with the baby. We have a backpack we put nomic situation here. The milk and meat industries the baby in so he is on my back.I'll walk for an hour fight you. So manypeople don't v)ant to chan?etheir or an hour and a half. It's fun for both of us. He loves habits. It's not o populqr campaignyou are waginq. being outdoors,it's bonding,and it's good exercise. DO: I think there is a growing awarenessamong

294 THEAMERICAN .]OURNAI OF CARDIOTOGY@VOL. 90 AUGUSTI , 2OO2 both Democrats and Republicans that our health care of medical practice.Now, I believeeconomics has a system(which is really a diseasecare rysleru)is in lot more to do with it. We doctors do what we're serioustrouble. As the populationcontinues to age,we reimbursedto do, and we're trainedto do what we're simply can't continueas we havebeen doing. Some- reimbursedto do. So, if we can help to changereim- thing hasto change.Like a patientwho hashad a heart bursement,then we may help to help changemedical attack,the medical systemis in crisis. In any crisis, practiceand medical education. there is an opportunity for change and transformation Interventionalcardiologists, who were so critical for the better, but there is also the possibility that of bypasssurgeons for doing bypasssurgery before things can get much worse. they had the evidenceto supportit, still don't havethe The conventionalapproaches to lowering health evidenceto supportthat angioplastyprevents cardiac care costsdo not addressthe more fundamentalrea- eventsor prolongslife. Severalof our hospital pro- sonswhy many peopleget sick and die prematurely. gramsclosed down becausethey didn't have appro- Shorteninghospital stays, limiting capitation,forcing priatereimbursement. They would saythat it's a great doctorsto seemore and morepatients in lessand less program,the patientsare doing great,but becauseit's time-these areprofoundly unsatisfying for both doc- losing moneywe can't supportit becauseso much of tors and patients.As you know, many physiciansare our revenuederives from doing theseinteryentions. It leavingthe profession. puts peoplein an inherentconflict of interestposition. Also, 48 million Americansdon't have health in- A11of the physiciansthat I know are doing what surance.If we simply put theminto oul cuffentsystem they genuinelybelieve is in the best interestof their and do businessas usual,then health care costswill patients.But, as Abraham Maslow oncesaid, "If the increaseexponentially. This leaves us with painful only tool you haveis a hammeryou seeeverything as choices:do we raise taxes,let the deficit increase,or a nail." If you are trainedto use drugsand surgery,if ration? None are politically appealing.So, the 48 you get reimbursedfor usingdrugs and surgery, if you million Americanswho havethe leastpolitical power don't have time to spend with people doing things andinfluence are effectively excluded from the health other than drugs and surgery,if your educationonly care system.This is not right. emphasizesdrugs and surgery,and medicaljoumals In our own small way, my colleaguesand I are derive most of their advertisingrevenue from drugs trying to createa new model of healthcare, one that and surgery,then it's not surprisingthat so much of addressesmany of the lifestyle causesof illnessrather medicineemphasizes drugs and surgery. thanjust literally or figurativelybypassing them. This It's not that drugsand surgery are bad; it's just that model is both more caringand compassionateas well they are incomplete.Using only drugs and surgery as cost effectiveand competent.It is a conspiracyof missesthe deeperopportunity of helpingpeople really love, so to speak,because the medicaland cost-effec- transformtheir lives in waysthat go beyondjustliving tivenessdata justify reimbursementfor our program. longer. This new model would help peopleopen their hearts In some ways, there is more resistancenow than to themselvesand to others. therehas been in the pastfrom the more conventional Cardiologytoday is a good microcosmof what's groups becausewhat we are doing has proven to be going on in medicine in general. As I mentioned medically effective and cost effective.Before, it was earlier,$30 billion was spentlast year on statin&xgs, easiertojust ignore.So, it's easierbecause the science andthe numberis projectedto rise to >$100 billion in behind our work is well accepted,but it's harder the near future. Another $30 billion was spent on becauseit becomesmore threateningto powerful in- revascularization,yet as we discussedearlier, you can terests. accomplishthe samereduction in anginapectoris for WCR: Ar my hospital 40Vo of the profit is from most people by changingdiet and lifestyle without cardiov as cular dis e as e. having to worry aboutgraft closingor restenosis,and DO: How much of the cardiovasculardisease profit regressionof coronaryatherosclerosis continues over is from devicesand orocedures? time. Much of this expensecould be avoidedif people WCR: Mosr of it- How do you handle the Atkins were to make bigger changesin diet and lifestyle. I dicl, sugar busters,and thesegod-aw[ul tliets? think statin drugs are great, and revascularization DO: t've debatedthem severaltimes. although I sometimescan be beneficial.But the same benefits havegrown a little wearyof doing so.The first debate canbe accomplishedat a fractionof the costsimply by occurredbecause of a dinner I had with Dan Glick- making comprehensivelifestyle changes.If only 1070 man, who was then the Secretary of Agriculture, on of peoplewere willing to makethese changes, billions New Year's Eve in 1999.iust beforethe millennium. of dollars could be saved. He asked,"What do you think of the Atkins' Diet?" I I hesitateto criticize our colleaguesbecause I'm thought, "Oh, goodness,even the Secretaryof Agri- trying to build bridgesand not polarize.Yet, how did cultureis thinking aboutgoing on the Atkins' Diet." I we get to a point in medicinewhere interventions such told him what I thought,and he proposeda debate.I asradioactive stents, coronary angioplasty, and bypass told him that would be fine, not thinking that anything surgeryare consideredconventional, whereas eating would ever come of it. vegetables,walking, meditating,and participatingin A coupleof monthslater, I found myself debating supportgroups are consideredradical? Dr. Atkins at the Departmenlof Agriculturein Wash- I usedto think that sciencewas the primarv driver ington, DC. The Secretary of Agriculture's son,

NTERVEWDEAN ORN SH 295 JonathanGlickman, produced the movie "The Sixth To me, the real issueis not only losing weight but Sense."The famousline from that movie was, "I see also enhancinghealth. When you go from a meat- deadpeople." When Dan Glickman introducedus, I based diet to a plant-baseddiet, there is a double mentionedthat his son producedthis movie. I said, benefit:reducing the intakeof disease-promotingsub- "You know, I see deadpeople too. . . they're on the stances(cholesterol, saturated fat, oxidants)and in- high protein diets." creasingthe intake of disease-protectingsubstances Peopleoften moftgagetheir health when they go such as phytochemicals, bioflavonoids, retinols, on thesehigh protein diets. Dr. Richard Fleming in isoflavones.etc. Omahapublished a study in the joumal Angiology in You can lose weight on just aboutany diet. Keep- which he performedmyocardial perfusion scanson ing it off is a lot harder.A few yearsago, the govem- patientsbefore and after a low-fat diet similar to one ment reviewed all the different weight loss plans. I recommend,and before and after an Atkinslype They found that two thirds of peoplegained back all diet. After 1 year,myocardial pedusion improved on the weight they lost within I year, and 97Vagained it the low-fat diet but worsenedon the hieh animal all back within 5 years. -orotein diet. However,we found in our researchthat the aver- I also debatedDr. Atkins last year at an American ageperson lost 24 poundsin the first yearand kept off College of Cardiology meeting before a large audi- more than half that weight 5 yearslater, eventhough ence of cardiologistsand before a large group of they were eating more food, and more frequently than dietitiansat the AmericanDietetic Association annual before,without hungeror deprivation,simply, safely, meeting,and on varioustelevision programs. and easily. It is true that one can lose weighton just aboutany I am distressedthat people are more overweight diet if calories are restricted and/or energy expenditure than ever. A recentstudy by the Centersfor Disease is increased(i.e., exercise). There are 3 major waysof Control and Prevention found that the number of eating fewer calories.One is to eat less food. Most Americans considered obese-defined as being weight loss plans are basedon deprivation:counting )3OVo over their ideal body weight-soared from calories,restricting portion sizes,and eating less food. aboutI in 8 in 1991to nearly 1 in 5 lastyear. Diabetes Sooneror later, most peopleget tired of feeling hun- mellitus in 30-year-oldpersons has increased707o in gry and deprived,get off the diet, gain the weight the past decade. back, and blame themselvesfor not having enough None of the high-protein diet authors has ever disciplineor motivationor willpower-which is why publishedany studiesin any peer-reviewedjournals most diets work in the short run but not in the lons documentingthat their approachcan help peoplelose run.Also. when you restrictthe amount of food.then weight safely and keep it off. Telling people that pork metabolic rate decreasesas well since your body rinds and sausageare good for you is a greatway to thinks you are starving.If you really are in a famine, sell books, but it is inesponsibleand dangerousfor then you want to bum caloriesmore slowly, as this thosewho follow their advice.I would like to be able gives you a survival advantage.But if you are trying to tell you that theseare health foods, but they're not. to lose weight, then this can be frustrating. There is a large body of scientificevidence from Anotherway to reducecalories is to eat foods that epidemiologicstudies, animal research,and random- areless dense in calories(i.e., lower fat) andhigher in ized controlled trials in humans showing that high fiber (i.e., avoid sugar and other simple carbohy- protein fbods, particularly excessiveanimal protein, drates).When you eat lessfat, you eat fewer calories increasethe dsk of breast cancer,prostate cancer, without having to eat less food. Fat, of course,has heart disease,and many other illnesses.In the short over twice as many calories/servingas protein or run, they may also causekidney problems,loss of carbohydrates.So, when you go from a high-fat to a calciumin the bones,and an unhealthymetabolic state low-fat diet, evenif you eat the sameamount of food, calledketosis in maay people.The AmericanDietetic you consumefewer calorieswithout feeling hungry Associationrecently condemned high-protein diets as and deprived.Also, becausethe food is high in fiber, being dangerous,"a nightmareof a diet." Yet many you get full before you consumetoo many calories. peopledo lose weight on high-proteindiets. You can You can eat wheneveryou're hungry and still lose lose weight on chemotherapy,but that doesn't mean weight. And sinceyou are not restrictingthe amount it's a good way to do it. of food, metabolicrate doesnot decrease. The importantdistinction to make is betweensim- Also, it's importantto ea1less sugar. When you eat ple carbohydratesand whole foods, also called com- a lot of sugar and other simple carbohydrates,you plex carbohydrates.Simple carbohydratesmay cause consumea lot of calorieswithout feeling full. Also, you to gain weight, bul complex carbohydrateshelp you provoke an insulin responsethat helps convert you loseweight. The goal is not to switchfrom simple thosecalories into fat. However, a diet high in fiber carbohydratesto a diet consistingmainly of high- and complex carbohydratesdoesn't causea spike in proteinfoods like meatbut from simplecarbohydrates blood glucosebecause fiber slows the rate of absorp- to whole foods, while reducingyour intake of high- tion, andthe fiber fills you up beforeyou get too many protein animal foods. calories.You can only eat so many applesor pears Simple carbohydrates-sugarand other concen- before you get full, but you can consumevirtually tratedsweeteners, and alcohol,which your body con- unlimited amountsof sugarwithout feeling full. verts to sugar-are absorbedquickly, causing your

296 THEAMERCAN IOURNAL OF CARD]OLOGY@VOt, 90 AUGUSTI, 2OO2 blood sugarto increaserapidly. White flour (including When you go from a high-fat, animal, high cho- foods like white flour pasta)and white rice are also lesterol,high animal protein diet to a low-fat, whole absorbedquickly, becausethe fiber and bran have food, plant-baseddiet, you're gettinga doublebenefit. beenremoved. In response,your body secretesinsulin You not only reducethe intake of disease-promoting to lower your blood sugarlevels to normal. Chroni- substances-suchas fat, cholesterol,oxidants, and cally elevatedinsulin levels also acceleratethe con- animal protein-you consumemany protective sub- version of calories into fat, raise your cholesterol stances.Also, caloricrestriction extends life spanand level, and have other harmful effects.Over time, this consistentlyreduces tumor formation in animals.It's can causeinsulin resistance.The high-proteinauthors hardto reducecalories by simply reducingthe amount advise us to avoid all carbohydratesand eat high- of food eatenbecause one gets hungry. Eating foods protein foods, becausethese are less likely to provoke less densein caloriesis a much better way to lose an insulin response.Instead of going from simple weieht. carbohydratesto pork dnds, a better choice is to go WCR: Wnat would be a typical breafust, lunch, from simplecarbohydrates to complexcarbohydrates, and dinner tou would eat when at home? or whole foods. DO: For-breakfastI usuallyhave a bowl of whole- Whole foods (complexcarbohydrates)-including wheat cereal and some non-fat soymilk. I used to whole wheat, brown rice, fruits, vegetables,grains, drink skim milk but I drink soymilk now becauseI beans,and soy products in their naturalform-are rich thinkit's protectiveand I like it. in fiber, which slows their absorption.Since they are WCR: 1r also lastslonser. absorbedslowly, your blood sugardoes not spike,and DO: Yes,it lastslongeiand it probablyhas benefits so your body doesnot needto produceelevated levels for both prostatecancer and heartdisease. Even non- of insulin. Insteadof the rapid swingsin blood sugar, fat dairy may haveproblems, and has been linked with you experiencea more constantfeeling of energy an increasedrisk of prostatecancer. I'll usually put throughoutthe day. You become more sensitiveto some fresh fruit (bananasor berries)on the cereal.I insulin rather than resistantto it; diabeticsoften are usually have decaffeinatedtea, like Earl Grey tea, or able to reduceor discontinueinsulin undertheir doc- herbaltea, and whole-wheattoast. tor's supervisionwhen they eata low-fat, whole foods Lunch and dinner vary. Usually they consist of diet. some combinationof fruits, vegetables,grains, and Why do some people lose weight on the high beans.Occasionally, I have fish. Sometimes,I have protein diets?Most peoplein this countryeat a lot of leftovers from one to the other. I will usually make simple carbohydrates,so there is a lot of room for enoughdinner that I canhave it for lunchthe next day. improvementwhen they switchto a high proteindiet. WCR: You rarely eat between meals and before A recent study showedthat one third of the vegetables you go to bed at night? eaten in the USA are either French fries or potato DO: I almostalways eat betweenmeals. You have chips. And consumptionof sugar, white flour, and to eat betweenmeals if you eat a low-fat diet because processedfoods has increasedsignificantly in the past you get hungry sooner. 2 decades,along with obesity. Eating a lot of meat WCR: What do you eat betweenmeals? instead of all those simple carbohydrateswill help DO: Either fruit or a snack.If you eat more fre- lower their insulin response,causing them to lose quently, it reducesinsulin surges.One advantageof weight.But they may be damagingtheir healthin the eatinglow fat is that you haveto eat >3 mealsa day becauseyou ge1hungry faster. I graze,particularly -Drocess. There is a better way. If you switch from simple when working, throughoutthe day on a pieceof fruit carbohydratesto a whole food, low-fat, plant-based (apple),vegetable, a smoothie,occasionally chocolate. diet, then you don't provoke an exaggeratedinsulin WCRzYou cook? response-so you get the insulin benefit similar to DO: I'm not a very good cook. I eat pretty simply being on a diet high in animal protein without the when I'm. at home, usually just fruits, vegetables, grams. many harmful effects. Also, you are eating whole - ano Deans. foods that are much lower in fat and cholesterol.so WCR: How can you get the food producers to you lose even more weight than on a high-protein diet reducethe quantibtof salt in their processedfoods? and your cholesterollevels come down even further. DO: A nice thing aboutliving in the USA is that If you changethe rypeof food, you don't have to we live in a market-driveneconomy. It's supply and red\ce the amountof food. When you eatless fat, you demand.If customerswant thesethings, manufactur- eat fewer calorieseven if you eat the sameamount of ers will starl making them.Look at the rise in whole food-because low-fat foods are less densein calo- foodsand organic foods. That wasunheard of 20 or 30 ries. If you go from a 40% fat dtet to a 1070fat diet, years ago and now it's a major industry. It comes evenifyou eatthe sameamount offood, you consume down to education.If we educatethe generalpublic almostone third fewer calories.Excess calories of any about the desirability and importance of these kind-whether they come from carbohydrates,fat, or changes,not just to reducethe fear of dying or risk protein-will eventuallybe convertedby insulin into factors but that these alternatives really improve the body fat. The easiestway to reduce your intake of quality of life, not years down the road but weeks calories is to reduce your intake of fat and simple down the road,then more people may chooseproducts carbohydrates. that fit theseguidelines and then they will be manu-

INTERVIEW,/DEANORNISH297 factured.In someways that's alreadyhappening, but every year for the month of June. I do some work thereis a long way to go. there. I still check mv e-mail from time to time. WCR:Are mostof your presentationsto lay public WCR: Is there anything else Dean you would like or to ohlsicinns? to discuss? DO: About half and half. DO: The obstaclesI've encounteredmake me ap- WCR: Youget invitationsfrom someof our major preciatewhat you're doing and how unique that is, compenies? especiallyin the cardiologyworld. No oneelse in your DO: Somerimes.It's an oppofiunityto reacha lot positionin anotherjoumalhas your visionary perspec- of people;it's a way to make a living, and it's a way tive, which makeswhat you're doing so important. to help influencecompanies to make more healthful WCR: Tfutt's very penerous. -ttith. options available. I've been consulting with Mc- DO: That's th" Being here is a tangible Donald's and other companies.It's part of the larger gestureof my respectfor you and my appreciationfor contextof trying to find ways to be useful to people. all that you do. WCRzFast foods produce quick plaques! How can WCR: That's very kind. I appreciate that more than you makeheadway with McDonald's,for example,to you can imagine. produce some healthierfoods? The lower economic DO: You must get youl own shareof resistanceby echelonin this countryeats o high percentqgeoJ their taking positions that are not so different from what mealsqt thesefast food chains.The food tastesgood, we're talkins about.How do vou do it? but i! is disastrousfor our health. WCR: WitenI went to the'Baylor UniversityMed- DO: I'm helpingthem to seethat makinghealthier ical Centerin Dallas and sturted talking aboutflesh, foodsmay providethem a competitiveadvantage, that a relatively raw worcl obviously, I think the adminis- there is a market for it, that it has a lot of public tration was a bit concernedbecause we have on the relationsvalue, and that it canmake a big differencein board I or 2 ranchers,and mostpeopk, of course,do the health of our country. eat the musclesof cows,pigs, sheep,goats, and chick- WCR: Ioa are doing virtually all of your work ens. outsideof the universiryenvirons? DO: Are vou a vesetarian? professorof medicineat the DO: No, I'm a clinical WCR: No. I eatfih. I was a regetarian oncefor Universityo[ CalifomiaSan Francisco. almost 2 years.Since I'm on my own, I open cans of WCR: Do you spendmuch time there? vegetarianbeans too ofien. One little can of Bushes DO: Some. I gave medical grand rounds there VegetarianBakzd Beanscontains "31/zservings," a recently. When I first moved to San Francisco,I very annoyingpresentation of its contents. attendedon the wards.I realizedthat a lot of people DO: You know whv thev do that? can do that as well or betterthan I can, but the kinds WCR: So you, sodium per sening seemssmall. of things that my colleagues and I are doing are The amount of sodiumper sening is 800 mg. The unusual.It makesmore sensefor studentsand trainees sodiumcontent in the entire little can is 2.800 mp! to spend time with us in our facility. We almost DO: That's righr.You know what they do;i*) alwayshave medical students, nursing students, house cholesterol?If they can put <5 mg per sewing, they staff, sometimesattending physicians, who spend a can say its zero cholesterol.They will make the serv- week or a month or even 6 monthswith us. I love to ing so small that they'll get it down to 4 mg and say teach and we have some unique opportunitiesfor they have no cholesterolwhen in fact it has some. teachingthat aren't availablein most places. Becausethe servingis so small you can actuallyget a WCR: Twentyfve to 30 people in a 4-story buiu- good bit of cholesterol.How do you deal with the your ing is a big payroll. You must spend a lot of time criticismsthat you get? your recruittngfinancial supportfor operation. WCR: People say, "Oh, that's just Roberts." h it have the freedomto DO: I do, but it's worth to really doesn't matter,Do you ever eat eggs? pursue interest without the politics, turf new areasof DO: I eat eggwhites. I almostnever eat egg yolks, battles,and bureaucracyfound in many large institu- at leastintentionally. still go throughthe internalreview tions. Our studies WCR: Dean, on behalf ofThe AmericanJournal of board and cancerprotocols committees at the univer- Cardiologythank you allowing its readersto peer I work with faculty closely. In our current for sity and into your lift and your accomplishmentsa bit. researchon prostatecancer, we are collaborating with DO: Thank you. I'm very grateful for the oppor- Dr. Peter Carroll, who is chair of urology at lhe tunity to be of servicein this way. I hope it's been University of Califomia, SanFrancisco, and Dr. Wil- useful. liam Fair, who was Chief of Urology at Memorial Sloan-KetteringCancer Center until he died recently. WCR: Do you take much time off eachyear a for l. Omish D, ScheNitz L. Billings J, Brown SE, Gould KL, Merdtt TA, Spdler vacationuninvolvecl with a presentation? S. Armstrong WT. Ports TA. Kirkeeide RL. Intensive lifestyle changes for DO: My wife andI, andnow our baby,go to Kauai reversal of coronary hearl disease-/AMl 19981280:2001-2007.

298 THEAMERCAN JOURNAL OF CARDOLOGYoVOL. 90 AUGUST], 2OO2 ffi E6inm6 66W*l ".r-Gil.- EISEVIER To orde.reprints, fax: 1-212633-3820 lemail: [email protected]