A change in diet was prescribed, and in a few days he was able to get out of bed. After four weeks, he was walking eight miles a day and had discontinued his medications and use of oxygen. Currently, he is more active than he has been in years. His blood pressure is normal, and he continues without medications.
This dramatic experience illustrates a new dimension in the treatment of heart disease that medical science is now exploring. The information accumulating is of vital importance to every person in North America.
Good news
Heart disease (coronary artery dis ease) is the leading cause of death in the United States, with a total of about 750,000 deaths per year. Twice as many people die from heart disease as from cancer. Significant symptomatic heart disease occurs in about 20 percent of all men before the age of 60. About one fourth die within the first three hours of the first symptom, and many never reach the hospital! Another fourth die in the first few weeks after a heart attack. It seems unlikely that advances in emergency care will significantly reduce sud den deaths from heart attacks.
During the past thirty years, however, there has been a 30 percent decrease in deaths from heart disease and stroke (cardiovascular disease), with 60 percent of that decline occurring the past ten years! This is indeed good news. Rea sons for the decline include better methods of diagnosis and treatment, in creased public awareness and knowledge of heart disease and its causes, and changes in the American dietary pattern.
Better diagnosis and treatment has no effect on the one fourth of heart attack victims that die within three hours of the first symptoms, since many of these never reach the hospital.
Further advances in intensive hospital care are not likely to reduce sudden death among heart-disease victims. In creased public knowledge and changes in American dietary habits undoubtedly has had some effect on the occurrence of heart disease. Since 1963, the consumption of animal fats declined 57 percent; the consumption of milk and cream declined 19 percent; butter consumption declined 32 percent; egg consumption declined 13 percent. During the same period there was a 4 to 8 percent decrease in the average blood cholesterol level of Americans.
Reducing risk factors
Three major risk factors, when present, significantly increase one's chances of acquiring heart disease—elevated blood cholesterol, elevated blood pres sure, and cigarette smoking. Other lesser risk factors include obesity and lack of physical activity. The basic process leading to heart disease is the deposition of cholesterol in the artery walls forming a plaque that enlarges and causes blood vessel damage, eventually resulting in a hard, "scarred" artery with a very small opening. This process is called atherosclerosis ("artery hardening").
It is now generally accepted that the risk of heart disease can be reduced by altering one's life style, particularly in the areas of smoking and diet. The best approach to heart disease is to prevent it in the first place.
However, there is a growing body of evidence that the process of atherosclerosis is not only almost completely preventable but also substantially reversible. Hardening of the arteries, associated with poor living habits, may be not only arrested but reduced by appropriate changes in life style, including diet. This does not imply that medical and surgical advances in the treatment of heart dis ease should be ignored, but it does indicate that all approaches to the treatment of heart disease must take into account the need for changing one's life style. Experience has shown that supervised exercise and carefully planned dietary changes may have marked benefit for heart-disease victims. Chest pain is reduced, exercise tolerance increased, and recovery from heart surgery enhanced.
Persons with heart disease who are not taking advantage of the benefits of life style change may be overlooking the most important aspect of their problems. Centers are now available in the United States for the life-style approach to heart disease and related problems, yet few take advantage of this help.
Evidence of reversibility
One of the most remarkable findings of the century could well be that the process of artery hardening (atherosclerosis) may be reversible. Since scientists differ on whether hardening of the arteries is reversible, a brief review of the reasons leading to such a conclusion is in order.
Early research on arteriosclerosis demonstrated that the diseased arteries (atherosclerotic plaques) contained a high amount of cholesterol and that when various animals were fed a high-fat diet, their arteries would accumulate cholesterol and become diseased. Sub sequent studies have expanded this ob servation.
Early studies of persons on severely restricted diets gave the first clues that hardening of the arteries may be reversible. Prisoners of war in concentration camps, scientists observed, had little or no atherosclerosis, while age mates not interned showed a high prevalence of the disease process.
A number of studies comparing groups of people in different countries have shown a relationship between diet and heart disease. Data from the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) has shown that the intake of saturated fat, cholesterol, and excess calories is related to an increased prevalence of coronary heart disease. Autopsy studies from various countries indicate a low prevalence of coronary-artery disease in those populations on a low-fat intake. One of the best known population studies is "The Seven-Country Study." Eighteen populations in seven different countries showed that coronary heart disease was associated with a high intake of saturated fat and elevated cholesterol levels.
Also, there are studies showing that people who moved from a less affluent to a more affluent country increased their rate of heart disease, thus discrediting the concept that elevated cholesterol levels and subsequent heart disease may be the result of a "normal aging process." For example, coronary artery disease in the United States is ten times that of Japan, which enjoys the lowest rates in the modern, industrialized world. Yet, when Japanese migrate to the United States, their death rate from heart disease increases significantly, indicating that life style may be a major factor for the observed differences in various population groups. Similar studies have been done on Jews migrating to Israel and certain European groups mi grating to the United States.
A number of studies within the United States have shown the relationship of diet and cholesterol blood levels to heart disease. Those people with elevated cholesterol and those who have a high intake of fat have a higher prevalence of heart disease.
Evidence of regression
The most encouraging evidence for substantial regression of advanced atherosclerosis comes from laboratory work with monkeys. Over a period of time, marked narrowing of coronary arteries can be produced in monkeys by adding fat and cholesterol to their diet. When these same monkeys are placed on low-fat diets, they show marked regression in the narrowing of the arteries and a corresponding decrease in the blood-cholesterol level.
Similar studies, done on dogs and other animals, have repeatedly shown that hardening of the arteries in animals can be reversed by changes in the diet, and, in some cases, by the administration of medication for lowering cholesterol.
The evidence is not so clear-cut in humans. Current X-ray techniques allow physicians to take X-rays of blood vessels following the injection of a special dye and to visualize the size of the arteries and the presence of narrowing. By using such X-rays, one can show that some human subjects do have a reduction of narrowing in response to various forms of treatment, including diet, exercise, medication, and special surgery to prevent absorption of fat (ilio-bypass).
However, scientists are not yet willing to state "unequivocal evidence" that a change in diet can benefit those with heart disease. The reasons are: the studies included insufficient numbers of subjects to make the conclusions reliable; the subjects were not followed for a sufficient amount of time; procedures were not employed in the studies to eliminate the possibility that changes were a result of other factors not recognized by the investigators; observed changes were not of sufficient magnitude to be significant; and observations were often analyzed improperly according to accepted statistical methods.
Centers for life-style change
While the benefit of diet on heart dis ease is being debated, a number of centers in the United States are proceeding with the evidence in hand and are treating with diet and life-style changes a variety of patients with coronary-artery disease. And their success is beginning to catch the interest of re searchers. Although these centers are more interested in helping individuals than in providing data for researchers, a review of their results is very encouraging. These programs usually consist of three basic components—diet modification, supervised exercise, and health education.
One such center has reported improvement in a number of risk factors for heart disease. Data on 900 patients who were at the center for 26 to 30 days showed a cholesterol drop to less than 200 (a low-risk range) in most of the individuals. Decreases in triglyceride, uric acid, and blood sugar were also noted. Of the smokers entering the pro gram, 83 percent stopped smoking. Eighty-five percent of those coming to the center who were on medications for high blood pressure developed normal blood pressure and discontinued their medications. Fifty percent of the adult diabetics on insulin were able to discontinue insulin, and about 80 percent of those on oral drugs for lowering blood sugar were able to discontinue their medication. The long-term effect of these improvements is now in the process of being studied.
While scientists are interested in improvements that can be measured (for comparison and analysis), individual patients are primarily interested in how they feel and function. The stories told by individuals attending these centers frequently have been phenomenal. To the scientist, these testimonials offer clues but are not accepted as proof, since they are not measurable results nor specific in relating a known cause to the stated benefit. To the individual patient, the result of feeling better is more important than the "cause."
I have had opportunity to review the medical records of individuals who have attended some of these health-enhancement centers, and the documented benefit to individual patients demands the attention of any physician working with heart-disease patients. The account of the retired minister mentioned at the be ginning of this article is a good example.
The single improvement mentioned most often by participants in these pro grams is increased endurance. Patients who because of anginal pain could walk only short distances are able to walk several miles without chest pain after participating in the center's program.
Early improvement in symptoms
Interestingly enough, the improvement experienced by these heart-disease patients often occurs before there would be time for reversal of the artherosclerotic process that has narrowed the arteries. It is expected that if reversal does occur, it would take months or perhaps years. One explanation for the rapid improvement is that the diet may cause changes in the blood that increase its ability to carry oxygen from the lung to the body cells. Thus, even though the arteries are not yet opening, the same effect is achieved by more oxygen being carried in the blood that does get through.
The more we learn about the human organism, the more we become aware of its tremendous recuperative powers. An unwholesome life style, including poor eating habits, is taking its toll on modern man. It is now becoming evident that corrective measures can improve health. Patients with heart disease should rejoice in the tremendous advances that medical science can provide; nevertheless, it is now evident that modern science is incomplete without corrective changes in the life style.
Taking medications or undergoing heart surgery does not replace the need for change in our lives. The recipient of the first heart transplant died about a year after surgery. The physician who examined his "new" heart at the time of the transplant stated that it was free of atherosclerosis, as compared to the patient's own heart. A year later, the same physician examined the "second" heart after the patient died, and it was full of atherosclerosis. The patient had not changed his diet significantly.
Waiting for proof may be dangerous
The final proof that diet may reverse the artherosclerotic process in man may be slow in coming, for we lack some advantages of animal researchers. When a number of his sheep became very ill of an unknown malady, my father called the veterinarian. I vividly recall that the veterinarian did not survey the health of the flock and observe them for several years. He did not submit them to a battery of space-age probing and testing; he simply slaughtered one and examined it internally to see the cause of the illness. If we could select two groups of people, change the diet in one group, and then after a period of time "sacrifice" these people to see which group had more atherosclerosis, we could have proof. Since we cannot proceed in this manner, we must be satisfied with the evidence at hand, make our choices, and wait for the long-term results.
As a physician who has seen the results achieved by life-style change, I am convinced that such treatment has a decided place in modern therapeutics. The patient who does not seek or accept this form of treatment is a half-treated individual, like the poison victim taking an antidote but still drinking the poison.
To change one's diet in order to improve the symptoms of heart disease or for possible reversal of the atherosclerotic process is a simple concept, but it must be practiced with a degree of nutritional knowledge. Thus the advantage of participating in a professionally operated health-enhancement program becomes obvious. A second advantage is the benefit of supervised exercise.
The approach to heart disease in these centers is one of the most revolutionary approaches to health in the twentieth century.
