Heartbeats for Life Support for your healthy life style.

Transcript of December 1998 Rochester NY
Teleconference with Dr. Dean Ornish

JIM/LEE: Dean is in his office, he'll be here momentarily. He is being inundated with requests for interviews which I'm sure he'll talk a little bit about for the paper that's coming out tomorrow in the Journal of the American Medical Association which is the five-year follow up of the original life style heart trial. That coupled with the article that came out two weeks ago in the American Journal of Cardiology on the multi center life style heart trial which is a multi center replication study...well it's not exactly a replication study cause we made a few small changes in the program delivery but both of those publications have just come out and there is a lot of media attention. So Dean will join us momentarily and Lee Lipsenthall who is our medical director is in Des Moines working on some insurance contracts and he will join us momentarily as well.

ED: O.K., Jim (Yes) Before we get started let me explain the set-up. I've got a speaker-phone and a microphone here and about a hundred people so I want to make sure and adjust the volume to maximize that they can hear me and hear you so let me just take a minute or two to test... To ask my audience Was everybody able to hear. I'm getting a lot of head shakes so I guess they can hear both of us so everything is OK.

DEAN: Hi everyone. It's Dean, I just came into the room.

ED: Hi Dean, Ed Ehlers here, how you doing?

DEAN: Hi Ed. What you all have done is so remarkable and extraordinary I just want you to know you are really making history and kind of redefining for people what is possible. I've spent all day on the phone. We have this article coming out in the Journal of the American Medical Association tomorrow afternoon and I've just been doing interviews with a lot of national media. I'll be on All Things Considered tomorrow night and the Today Show probably on Wednesday morning and a lot of the evening news shows and a lot of the print media: The Wall Street Journal and the Associated Press, UPI and Reuters and on and on and on. So there is a lot of interest in the work, and I appreciate so much what you are doing and a question I get over and over in almost every interview is: Well yeh you've shown it but people can't follow this program, it's way too hard and no one can do it and I want to just give them your name and say, just call these people and see what they have to say.

ED: We'd be happy to hear from some of them, I'm sure. Ha ha. I don't know about all of them.

DEAN: No, no I don't know that you'll be getting calls. The point being is that what you are doing is redefining what's possible for many people.

ED: I appreciate that. We've got a great crew here, we've got about a hundred people in the audience right now, 20 of them are here for the first time, so about 80 are regular members we're anxious to...

DEAN: In the interest of time (can you all hear me O.K.?).

ED: Yeh, they're shaking their heads, Dean.

DEAN: Is this better or worse?

ED: Uh, Better

DEAN: OK great. I'll just talk closer to the microphone then. I know that you sent this FAX that has a bunch of questions on there: 14 questions on it. Do you want to spend the time going through that or would you rather spend the time doing something else?

ED: Well I'd like to start with those questions as people in the audience all have copies of it and then we're also setting up to have some additional live questions after that. So why don't you take a shot at the questions that are there.

DEAN: OK well given the time I am going to go through this in a fairly directed way and then if you have further questions about this, let me know. The first question is about: Why do we recommend supplements like flax-seed oil when I didn't recommend it before?

It's not because of Omega 3 fatty acid deficiency. My mentor when I was at Harvard is Dr. Alexander Leaf and he has done some rather extraordinary work. He was the Chief of Medicine when I was there and has since later became the first Chairman of Preventive Medicine at Harvard...did some extraordinary work where they found that just 3 grams a day of either flaxseed oil or fish oil can raise the threshold for ventricular fibrillation (sudden cardiac death) and reduce the incidence of that by 50-70% which is huge. And so given that I think that the scientists are at the point now where it's worth recommending that to people.

ED: Dean, Dean are you still there. We had a request that you speak a little slower.

DEAN: OK. Did you all get that information or do you want me to repeat it?

ED: I think 90% have it so keep going.

DEAN: OK. You can buy flaxseed oil in the health food stores in 1 gram capsules which is, I think, the easiest way to take it. And more is not better. If you just take 3 grams a day that will give you the essential fatty acids that most people need without giving you too much fat. So some people say, well I thought you didn't allow any oils but, again, the program is not the Sermon on the Mount, it's scientifically based and as the science evolves and as we learn more, we'll have to change it. So that's the first one.

Can you review the essential supplements of vitamins and minerals and their justification.

Well here again I didn't used to recommend these because I didn't think there was enough evidence but for the ones I recommend now, I do. They include (and these are outlined in the Newsweek article that came out on March the 16th) so I am just going to go through these fairly quickly but we can get you a list of them if you need them. They include:

- somewhere between 100 and 400 units a day of Vitamin E

- 2-3 grams a day of vitamin C

- 10-20,000 units a day of Beta Carotene which your body converts to Vitamin A

- about a milligram a day of folic acid, also called folate, which can reduce homocysteine levels which has been linked to heart disease

- 3 grams a day of flaxseed oil which I mentioned

- somewhere between 100 and 200 micrograms a day of selenium which is a powerful antioxidant that can substantially reduce the incidence of prostate and colo-rectal cancers

- wherever possible substitute soy protein for animal protein because you get a double benefit

Did that answer the question OK?

ED: Yes it did Dean, thank you.

DEAN: The third is: Is there a minimum of fat intake essential for health. Are we who are following the Reversal Diet at risk for not meeting that?

Yes there is a minimum fat intake. It's about 4-5% of calories from fat, so if you are getting 10% there is a nice margin for error there. I mean you can get a diet that is too low in fat and in fact in the Reversing Heart Disease book, in chapter 10 I gave an example of someone who wasn't getting enough fat in their diet, so it is possible. But again, it usually happens when people think of this as just a low-fat diet. It's not. It's a whole foods diet. You can eat Snack Well cookies and Wonder bread and tea and toast and end up with a low fat diet but it's not a very healthy diet. Whole foods include things like fruits and vegetables and greens and beans and if you eat a diet that is predominantly those things in good proportions that's what you are going to end up with about 10% especially if you exclude the oils which are pure fat. So there is nothing so much magical about 10% fat. You don't have to take a calculator around every time you eat something. It's really more a whole foods/plant based diet and if you eat that way then that's pretty much what you end up with most of the time.

Number 4 is: How can we get more local area doctors interested in this program. How can we get a hospital or out-patient Ornish program going here?

Well I'm hoping that the articles that came out last week in the American Journal of Cardiology and this week in the Journal of the American Medical Association, if you can encourage your doctors to read it I think it'll add a lot of credibility. The JAMA (or the Journal of the AMA) some would say it is one of the most prestigious journals in the country...and some would say the world...it goes to 185 other countries as well. And we found even more reversal after five years than after one year of the patients on this program whereas the control group actually got worse after five years than after one year, even though they were following the American Heart Association guidelines. So as more science comes out there I think more and more doctors may be interested in it. But the key really is getting reimbursement. I met last Friday with the head of Medicare in Washington D.C. and we've had really strong bipartisan support from some of the most right wing Republicans and left wing Democrats and everything else in between and I'm encouraged. I think we're really making a lot of progress now from where we were before and I'm hoping we can have a favorable decision about Medicare in the not too distant future. And also we are training hospitals and other sites around the country and so we would be delighted to explore the possibility of working with a hospital in the area. If you can find an internal champion, listen if you've got, you know, several hundred people in your support group, hospitals respond to that, they are very competitive for patients. If a couple hundred patients come to them and say, look we'd like this program. That goes a long way and if you can find a Board Member or the CEO or an internal champion we'd be more than happy to work with you. I mean we would love that.

Number 5: Have any other researchers attempted to replicate our studies of the Reversal Program? Why wasn't the original study repeated with a larger crew?

Well it was. Over the past five years we've trained now 15 sites around the country and we published our findings last week in the American Journal of Cardiology and we'd be happy to send you a copy of that so that you have it and you can duplicate it amongst yourselves. We had 333 patients in the study. We also had a control group matched from Mutual of Omaha and we found that 78% of the people...almost 80% were able to follow the Program in a number of sites around the country, well enough that they didn't need the bypass surgery, angioplasty, that they were otherwise eligible for. We don't know for sure that all of those patients would have actually had a bypass or angioplasty but they were all sick enough to warrant one and they would have been covered by Mutual of Omaha if they had had one. Even though they avoided the operation they didn't have any higher adverse events and Mutual of Omaha estimated a savings of almost $30,000 per patient. Now, you know, I can go to an insurance company and talk about love and opening your heart and they're going to show me the door but if we can show them that for every dollar they spend they're saving several more then it just becomes a good business decision. And I think that's part of the reason why we now have about 40 insurance companies that are covering our Program in the hospitals that we train and the sites that we train. I mean, Highmark, which is Western Pennsylvania Blue Cross and Blue Shield, is both providing and covering the Program. So I am encouraged and I really think that we are close to a major breakthrough with Medicare so, you know, send those cards and letters in.

Number 6: What is the best way to address the depression which follows heart disease.

I think that is an important question because more and more studies are showing that people who are depressed have much higher rates of subsequent heart attacks and death than those that aren't which in itself, I guess, is pretty depressing. So you can make yourself more depressed by looking at studies like that or you can say gee, this is an important issue, we need to deal with it. One way to deal with depression is through the support groups that you have. I think it's so extraordinary to be able to meet together and to really try to create a safe environment in your support groups where people are encouraged to talk about how they feel. You know, if you're depressed you're generally not alone. There are a lot of depressed people out there and so often you think you are the only one who feels this way because most people don't talk about depression and so it looks as if everybody else has it together but you. But in a support group, if it's run properly, you can create a sense of safety where people are encouraged to talk about their feelings, whatever they are, in this case depression, you may find that other people are depressed too. Now it might seem that it will make you more depressed having a bunch of depressed people saying how depressed they are but, in fact, it's not. It's something very powerful about being able to give voice to these feelings and to find that other people share them in many cases and more importantly that you can be authentic, you can share this burden with other people and find that they are still there for you. So often the fear is that if you talk about how you really feel then people will reject you. To find that you can be open and authentic and that people actually allows them to be open and authentic then the intimacy can be very powerful and very deep and that community can really help a person bear suffering so much better than doing it alone. Then psychotherapy is also an option if the depression is incapacitating or if you just want to try and deal with it in a more intensive way. I certainly found it to be helpful in my own life. Antidepressant drugs are helpful for some people or some combination of all these things but whatever it takes it's really important to address the depression because the depression itself is a major risk for bad things happening.

Number 7: Have the dietary guidelines changed since the 1990 book was published? Is all oil other than flaxseed oil still prohibited?

The answer is, no the guidelines really haven't changed other than that except that we have become more mindful of the role of sugar and simple carbohydrates which I did address in there but not as intensively as I will when I revise the book. There's increasing evidence that simple carbohydrates like white flour, white rice, white flour pasta, sugar in all its various forms, high fructose corn syrup, alcohol which your body converts to sugar-- that these all cause your blood sugar level to rise quickly, your pancreas makes insulin to bring the blood sugar back down but the insulin also accelerates the conversion of calories into body fat and that can cause the blockages to build up faster. So we have become even more mindful about whole foods: whole wheat flour, brown rice, whole foods in general. The fiber that is in them that you refined away as when you turn them, as say, whole wheat flour into white flour, the fiber slows the absorption of the food so you don't get those rapid rises in blood sugar and you don't get those insulin surges which can cause problems. In fact, some books are even coming out now like the Atkins book and others: The Zone saying all carbohydrates are bad because they all make your blood sugar go up and therefore you should eat really healthy foods like steak and sausage and bacon because that won't provoke an insulin response which is just silly. The goal is to make sure you focus on whole wheat foods and whole foods in general: fruits, vegetables, grains and beans with moderate amounts of non-fat dairy and egg whites. If you do that then you get the best of both worlds. You don't get the rises in the blood sugar but you also don't get all that fat and cholesterol and other stuff that you don't need. So other then that the guidelines have stayed pretty much the way they were. To digress there is a new line of foods that I helped develop called Advantage 10. These Advantage 10 foods are available in...or can be available through most mainstream natural food stores like Whole Foods and Wild Oats and Fresh Fields and places like that. They are fun foods like pizzas and smoothies and entrees and so on. So those times that you don't have the time or energy to cook you can just have one of these and that can make it easier to stay on the program.

(No Number 8 mentioned)

Number 9: Does the Ornish Prevention Reversal Program work for women as well as men?

If anything it works better for women. There are studies that have come out that show that women have as much heart disease as men. They don't get access to conventional treatments as much as men do. When they do get operated on either a bypass or an angioplasty they don't do as well as men. Yet if anything, women may be able to reverse heart disease, if anything, easier than men can. We found that in our study and in the studies of even cholesterol lowering drugs twice as many women as men showed reversal and they showed twice as much reversal. And also if you go on a program like this you're not only reducing your risk of heart disease but perhaps of breast cancer and osteoporosis. So instead of taking estrogen to lower heart disease rates which increase the risk of breast cancer you can accomplish the benefits of that without the negative side effects and also osteoporosis is lower in people who go on this Program.

Number 10: How important is weight loss to the Program if one is overweight?

Clearly weight is a risk for heart disease. We generally haven't worked to get people to lose weight as a goal in and of itself. But if you really adhere to the Program, you're probably going to lose weight anyway. The average person lost 25 pounds in the first year in our Program. Now there is a subset of people who are more insulin resistant. They are the people whose triglycerides tend to be high and who have low HDLs and who are overweight and sometimes they even have high blood pressure. If you fall into that category you might be even more strict about the fat free desserts which are often high in sugar and the alcohol and the white flour and white rice and things like that. And if you do you'll probably lose weight and then you can break that vicious cycle cause most people who are overweight have excessive insulin floating around in part because of the things we've been talking about.

Number 11: We want to encourage more small groups to form for the psycho-social component. Any ideas about what works?

Well what works is forming small groups to deal with the psychosocial component. I would strongly urge you to do that. In my new book, Love and Survival you know, cites hundreds of studies that talk about why that's so important. If you talk with the people who've been to a Life Study Heart Trial or been to our retreats, they'll often tell you that was the most meaningful part of what we did. Yet it's often the part they had the most difficult time with at first but once they did it, because it is such a unique experience, it's often the most meaningful. So I would strongly encourage you to do that.

Do you have to have a professional support group leader. I think it's better if you can. What many of the people do when they go through the hospital programs at the sites that we've trained, after a year they go into what is called the self-directed community and they'll often pay a group support leader and a yoga teacher...those are the two things that people have a hard time doing on their own out of pocket. But you know if you have 15 people in a group, and a group support leader is $125, $150 it costs you $10 a person, most people can afford then. If you then take a yoga teacher, which is, I don't know, $50 to $70 or sometimes less and divide that by 15 that's only 4 or 5 bucks a person. So it's not that expensive to do it on your own. Now you can do it without a leader but I think it's better and easier if someone has that kind of training but it's not essential. What's really essential is to create that sense of community and to implement the principles that we have.

Number 12:The media are frequently sources of information and recommendations that contradict or challenge the Ornish principles or program, is there some way I can comment or rebut those claims in a newsletter or internet format.

I am about to sing an agreement with a group called i-village which is ivillage.com on the internet. They have 70 million page hits a month, it's a very well traffic'd site. It's one of the reasons I chose it because I wanted us to have a place to do just what you are asking. We also have a Website now called www.Ornish.com and that's under construction now and hopefully that'll be finished soon. And I'm talking about the possibility of doing a newsletter but it's also why it's so important when we publish articles like the Journal of AMA or the American Journal of Cardiology why there is so much media interest. I'm doing so many interviews and part of what I'm talking about is to say the American Heart Association guidelines are wrong for people who have heart disease. I think that we are at a point now where the data really support that and people need to know that so I'm taking that on very directly. Especially in light of the article that came out a few of months ago where they reported that diets lower in fat than ours are not that efficient/official (?) and may be harmful because HDL's come down. And if fact as you'll see in these articles that come out in the next few days that no one's really looked at the...when you actually look at the American Association diet in people who have heart disease, in virtually every study the majority of people get worse. In fact the control group in our study were on the American Heart Association diet and they got worse and worse. So part of what we're trying to do is get information out there that is scientifically based and accurate. But it's all for good. It turns out that if the Heart Association hadn't come out with a statement the Journal of the AMA probably wouldn't have accepted our paper because it became more controversial and they like controversy. The media likes controversy.

Number 13: Is there any evidence that the Reversal or Prevention Program reduces atherosclerotic constrictions in vessels other that coronary like carotid arteries?

And the answer is clearly yes. That's been shown in several studies now. And even a lot of men who suffer from impotence because most impotence is vascular as well, often report that their sexual function improves when they go on this program. In part because they can often, under their doctor's supervision, reduce or get off of medications that in themselves interfere with potency. But also because the blood flow improves to other organs besides just your heart when you follow this program strictly in many cases.

14: Can Tai Chi be a substitute for Hatha Yoga in stress reduction?

It depends on how it's done. I think that Hatha Yoga has particular benefits if you believe the Hatha Yogies, and I think they're right that Tai Chi doesn't provide so I would like to do that as an addition rather than a substitute for it. So, I think we've covered all these questions, are there any others or comments about what we've talked about so far?

ED: Boy Dean, that was terrific. You got an awful lot in in a fairly short time. Coming to the mike now is our medical advisor, Dr. Bob Klein and there some questions that came up from the audience. He's digested that and he's going to ask them now.

DEAN: Good

BOB: Dr. Ornish, can you hear me all right.

DEAN: Yes, Dr. Klein.

BOB: These are questions from the floor. Is the prostate cancer study you are currently conducting studying the same as the Heart Reversal Program?

DEAN: Almost, but not quite. We've a...the diet is even stricter if you can believe that. It's no animal. We've excluded the egg whites and the non-fat dairy because some animal studies, at least, suggested that animal protein may promote cancer of the prostate and probably breast cancer too, but otherwise the Program's pretty much the same as it was. We're taking men who have biopsy proven prostate cancer who've elected not to be treated conventionally and we randomly divide them into two groups. Half of them go through our program and half of them don't and then we compare them. We're doing it in collaboration with Dr. William Fair from Memorial Sloan Kettering Cancer Center who until recently was their Chairman of Urology and Dr. Peter Carroll who is the Chairman at UC, San Francisco. So we'll keep you posted of our progress.

BOB: Thank you. Another question, we have friends who have heart attacks and have no blocked arteries. They were told they have spasms. Does the Ornish Reversal Program help this type of problem?

DEAN: It does, and I'll put your question in a broader context. It used to be thought that the more severely blocked your arteries were the more your risk of having a heart attack. And we now know that generally is not true. Believe it or not, the 30 or 40% blockages actually may be more dangerous than the 95% ones. And the reason is, that if you have a 95% blocked artery, chances are it's stable, it's calcified, you have new blood vessels that have grown around it called collaterals, and even if it should go to 100%, which is not likely, you may not even get a heart attack because of the built-in bypasses around it. But a 30 or 40% blockage is more fresh, it's more unstable, it's more likely to go into spasm or have plaque hemorrhage or a blood clot forming or all of the above. And you can get a 30% blockage that then turns into 100%. Now what's interesting is that first of all, no one is going to bypass or angioplasty a 30% blockage and yet those are the ones that may be the most dangerous. Second is, when you change your life style and go on our Program it stabilizes along/aligning (?) the artery in a number of different ways because emotional stress can make the arteries constrict even when there aren't severe blockages as happened to your friend. Emotional stress can make your blood clot faster inside your arteries. Nicotine in cigarettes can cause the blood to clot faster and the arteries to constrict. A single meal that's high in fat and cholesterol can cause that to happen (my emphasis/crt). So when you go on this program, you don't have to wait for years for the blockages to begin to regress, you can, very quickly, reduce the incidence of sudden cardiac death and heart attacks because the program stabilizes the arteries so quickly. And even cholesterol lowering will help to do the same thing for those who don't want to change their lifestyles.

BOB: Thank you. Are there any East Coast sites for the weeklong retreat that you offer in California?

DEAN: Not at this time although we may be offering them later in the year. At the current time, the only place that offers the week long retreats are here in the Bay Area.

BOB: Another question on a different topic. If someone is on anticoagulants such as coumadin, is there any contraindication to the use of flaxseed oil?

DEAN: No, but I think not only flaxseed oil but this Program in general may effect your prothrombin time because just as emotional stress and high fat meals make your blood clot faster,

the opposite is true so if you go on this Program with or without flaxseed oil or if you go on flaxseed oil with or without this Program, you should get your prothrombin time checked to make sure they can titrate it at a right range otherwise you may be getting more than you need.

BOB: Thank you. What is your recommendation about decaf. coffee that's supposed to be 99.7% caffeine free?

DEAN: Is that like Ivory soap? You know, again, it's not all or nothing. I think that caffeine potentiates stress. For me, even decaf. I can feel the effects. I don't like feeling...having my fuse get shorter. But, you know coffee is not that strongly linked with heart disease unless you have an irregular heart beat so it's a personal choice how strictly you follow the program. I think optimally it's best to eliminate caffeine altogether, but that's a personal choice.

BOB: How are you doing for time?

DEAN: I've got about 10 more minutes.

BOB: O.K. Short of an invasive angiogram, what is the best way to evaluate the status of the coronary arteries and how reliable are these other methods?

DEAN: Well actually I don't think that an angiogram is the gold standard the way that many cardiologists often believe. I think that the blockage is only one of several mechanisms that effects blood flow and it may not even be the most important one, and so I think measures of blood flow are actually are better than an angiogram. Unless you are planning to have a bypass or an angioplasty, in which case you need one, I think a PET scan for most people is a better test. I don't know if you have a PET scanner that can do hearts in Rochester. I know there is one in New York at Beth Israel Hospital with Dr. Horowitz but I think especially for diagnosing disease and especially for looking at changes over time to see if you are getting better or not, I think the PET scan is the best test available. As a screening test for large numbers of people the ultrafast CT scanner can, in just 10 minutes, look for coronary calcifications, but it is not a very good for looking precisely at how much heart disease you have or for changes over time but I do think that the PET scan is the best for that.

BOB: Thank you. Is there any chance we can get you to come to Rochester with a combination of a visiting professorship at the University Medical School and an evening with our group?

DEAN: It's possible. You know, I'm conflicted, on the one hand there is nothing I'd rather do, on the other hand, I traveled 130,000 miles last year and I didn't even go overseas last year. That was just domestically, that's too much. For those of you who read my new book last year, Love and Survival I'm really trying to do something that I never did before which is to have a life and to have a relationship and start a family and all those things that I write about. I'm basically trying to be a better example of what I preach. So that involves me saying no to a lot of things that I would like to do because I'm making my wife my number 1 priority which is a new thing for me. So if I don't make it there this year, please understand that it's not because of a lack of appreciation or interest, it's because I'm trying to be a better role model of what I am writing about.

BOB: That marriage sounds very important.

DEAN: It is. It's the most important thing in my life right now.

BOB: Another different subject. Is it only refined sugar we need to be careful of or do we also need to watch foods such as dates, figs, and honey or other items like that.

DEAN: Yes, to the second part. Any concentrated sweeteners: high fructose corn syrup, dried fruits, any of the alcohol all of those things especially if you have a problem with your triglycerides or if your HDL is particularly low or if you have a weight problem. Now if your triglycerides are low, if your weight is low and you have an occasional fat-free treat, it's no big deal. About a quarter of people need to be more careful about that.

BOB: Thank you. One of our members or one of our guests is on the Pritikin diet, would you compare that to the Ornish diet.

DEAN: Yes. Robert Pritikin is a dear friend and I like what they're doing. I think they're doing important work. I think his father made an important contribution to this field. The difference is that the Pritikin diet isn't as strict as this diet. There are actually two versions of the Pritikin diet. There's the diet that they serve in the Centers, which is very close to our diet, and then there's the diet they write about which has about 4 ounces of meat a day. So I think that, here again, if you want the optimal chance of reversing heart disease, then I think it's better to avoid meat altogether and animal products except for the non-fat dairy and egg whites. We also put a lot more emphasis on the psycho-social aspects than they do. But here again I think they're doing very good work and very important work.

BOB: I recently looked through Pritikin's book and the word psychological or social was never in the index.

DEAN: Nathan Pritikin never really thought that stress had...he said very vocally...he and I actually had some debates about this before he died, that stress had nothing to do with heart disease that it was all diet and exercise but I think that although he was a visionary in a lot of ways, in that particular area he was off track.

BOB: Thank you. How would you modify the Ornish diet for a diabetic person?

DEAN: In the same ways that we've been talking about, by really limiting the simple sugars, and the white flour and alcohol and increasing the exercise levels. Weight loss is particularly beneficial for diabetics.

BOB: Thank you. One question concerns: How long have you followed patients on the Reversal Diet now?

DEAN: Well it depends by what you mean by followed. The Life Style Heart Trial was five years but many of the people have continued so that now it is over ten years since we actually started. It was started in January of 86. In the more recent multi-centered demonstration project we've included them for a minimum of three years and some of them have been going as long as five. We're finding that the adherence after three years has been really quite remarkable.

BOB: Why don't I make this the final question unless you have more time.

DEAN: Well because there are so needing interviews. CNN is on hold, for example. They called a few minutes ago, I need to return their call. I'd ordinarily have more time but I think I also need to take care of these things because we have the potential to reach so many people with this information. So if I can have a rain check, I'd really appreciate that. Doing this by phone is easy for me and I'm happy to do this, you know, later in the year as well.

BOB: Well we'd like to thank you very much for your time and we hope we will be able to do it again and we wish you continued luck in your work.

DEAN: Well thank you. Can you wish me continued luck in my personal life too.

BOB: Yes

ED: Dean, I'd like to just offer you a nice round of applause and before you hang, (Applause) is Jim Billings about still.

DEAN: That was a tape of people applauding wasn't it!

ED: Yeh there's nobody here but Bob and I.

DEAN: Is Lee Lipsinthal still on the line?

LEE: Yes I am.

DEAN: Oh, hi Lee. I didn't realize that or I would have referred some of these questions to you.

LEE: That's fine.

DEAN: But Lee is also available to do these kinds of things. He knows more about some of these things than I do. Jim, you want to say a few words.

JIM/LEE: Well I know that Lee was going to train us. He's been working hard in Iowa and I know Ed you asked to have Lee on the call and I didn't know if there were specific issues that you'd like Lee to respond to.

DEAN: Yeh, I would strongly suggest (this is Dean) that even though I have to go, Lee, if you could pick it up and take over, that would be really great.

LEE: Yeh that'd be fine.

DEAN: O.K., by the way Lee, I had a good talk with Chris today, things are on track.

LEE: Beautiful, we'll catch up.

DEAN: Good. Good. Bye everybody. Keep up your great work and I look forward to the next time we talk again.

ED: Right, thanks again, Dean. Bye now. OK, so I guess we have Jim and Lee on the other end, is that correct?

JIM/LEE: We have Glenn Harrelson's here as well.

ED: Oh, O.K. Glenn.

GLENN: Hi, How are you doing, Ed?

ED: Doing just fine, thank you Glenn. Maybe it'd be good to take a second and you three gentlemen can explain your roles in PMRI. That would help our audience understand who they're talking to and who's responding. Anonymous voice: (Jim you want to start?)

JIM/LEE: I am Jim Billings. I'm a psychologist and a chronic disease epidemiologist. I've been with Dean for 14 years the Chief Operating Officer and Director of Clinical Services and Programs at PMRI. That's my role and Lee Lipsenthal is a lipidologist and our Medical Director and Glenn Harrelson is our Director of Network Development. And Glenn and Lee together are the people who are primarily responsible for developing prospects for new program sites and working with insurance companies to develop peer (?) relationships and to get contracts to cover the service. So if there are questions about program sites how that happens, if there are questions about the process of getting insurance coverage those would be things that I and Glenn could also talk about.

ED: Lee you're there too right.

LEE: Yes.

ED: Lee is a physician, as he explained. Bob has a few more questions. Let me ask him to ask them to you guys.

BOB: One of the questions is, why not eat fish?

JIM/LEE: It's a good question, Bob. I think Dean alluded to it just a little bit earlier. Fish does have cholesterol in it, it has animal protein in it and it has saturated fat. The benefit of fish are the Omega-3 fatty acids and that you can get from the flaxseed without the cholesterol and the saturated fat or much less saturated fat. So if you're looking for it strictly as a benefit, flaxseed gives you more than fish without any potential harm. Fish, on the other hand, if you're talking about a prevention situation, and I would put that in quotes because, you know, depending on somebody's risk for coronary disease, prevention could start at age 5 or age 40. I would be wary of fish in someone with coronary disease or with prostate cancer or breast cancer. The cancer, because of the animal protein, the coronary disease because of the saturated fat and cholosterol content.

BOB: Thank you. Regarding flaxseed oil. can you take a daily aspirin with flax seed?

JIM/LEE: You can and what you might, just to clarify, Dean had talked a little about coumadin before, flaxseed decreases the stickiness of the platelets. Platelets are the little particles in the blood that cause clots. Now that's actually a good thing. You don't want those platelets to be hyper- sticky because that's part of what happens in an acute heart attack situation--you get a clot forming within the artery. That's why aspirin is good at decreasing the acute heart attack event rate. Flaxseed, the Omega-3 fatty acids, will do the same. Can you take them in combination. Yes, although, I would say, if you notice that you're having some bleeding, for instance if you get a lot more bleeding when you brush your teeth, or floss your teeth, that sort of thing, then you may want to back off on one or the other. It's not usual that someone has to. Most people can do that very well together.

BOB: Thank you. Is the 14 grams of fat in the flaxseed oil a concern to you?

JIM/LEE: No, in that it is metabolized very differently than the fat that causes coronary disease. That fat consumption is not used as direct metabolite for energy. It's not going into the usual system, if you will. Where it's used is at different parts of the body to make hormones, prostoglandin production, which is part of your inflamation response, so it's metabolized very differently. It does not get converted to triglycerides or cholesterol or any of the harmful particles.

BOB: Thank you. How do you feel about medical research finding that olive oil can be helpful in a cardiac disease treatment program.

JIM/LEE: I have a concern about it. And the reason I do is because when you look at what they're comparing it to they are comparing it to the average population who is eating much worse things than olive oil. So if you're substituting olive oil for animal fat or if you're substituting it for other higher saturated oils, it certainly is better. Is it good for someone who has coronary disease, no, I would disagree. But when it is compared to the standard population...what the standard population eats, than olive oil is much better than margarine or than butter or than other saturated fats.

BOB: Thank you. Someone says that a recent report from the media showed that nuts, I guess these are the kind of nuts you eat, are beneficial to heart health, do you have any comment about that?

JIM/LEE: Yeh, I sure do. The study that's referring to is the study on walnut consumption done at Loma Linda University. What walnuts have are very high Omega-3 fatty acids. So the benefit from that was from the Omega-3. So if you compare walnuts and flaxseed, flaxseed has a much higher concentration of Omega-3 in regard to lower saturated fat. The benefit from that was the Omega-3. There are still better sources out there than walnuts.

BOB: Some people say a glass of wine a day is good. Is that in conflict with what Dean was just saying about alcohol?

JIM/LEE: No, the question with alcohol is really a question. If you look at what alcohol does physiologically, it increases the HDL subfraction 3. There are 3 different subfractions of HDL cholesterol. Subfraction 2 is the one that's really beneficial in regards to coronary disease. So if you are increasing subfraction 3, are you benefitting coronary disease, no one knows the answer. Then everybody says, or it's often said, well what about in France where they consume more red wine, the HDLs are higher etc. etc., less coronary disease. In many ways that is an epidemiologic glitch. Meaning if you look at the population, it's a glitch. What happens in France is that they under report heart disease death. So that if somebody gets admitted to a hospital and they have, say, lung cancer and then during their admission they have a heart attack, in this country the primary cause of death is going to be heart attack, the secondary cause lung cancer. In France lung cancer first, heart disease second. It may just be an epidemiologic glitch as to why there is less heart disease reported in France. And as I mentioned the direct physiologic benefit of alcohol is questionable in that it raises a subfraction of HDL that's not terribly useful. And I would add to that that alcohol has other detrimental effects on the body: on the stomach on the brain cells. So if someone is a non- drinker would I recommend starting to drink, absolutely not. If someone is a drinker, what would I recommend? You know, at most one drink a day.

BOB: Thank you. The next question, I think, is directed to Glenn. Can you share some of the success stories on how some sites were able to set up a hospital Ornish program?

GLENN: Sure, typically that's what Lee and I are doing on the road a whole lot. We're currently doing studies in Texas, in Virginia, we've just been commissioned to do another study, and in Chicago. It's the kind of thing that is happening this week with the attention that we get around major announcements. The JAMA article will bring a whole lot of folks...will bring our program more in focus all over the country. Typically what happens is we get a call of somebody in the system, somebody in a hospital system who is a champion of the program, who's been following it for a long time and their sense is that the time is right within that community and they give us a call. Basically how we work these new relationships is that we do it in stages. The first stage is to do a development plan and market analysis to make sure that the community has the right level of resources and interest in the program. Those resources being health plant support, administrative support from the hospital and physician referral support. Once we do the assessment we deliver a report with our recommendations and then the system, the hospital system, decides if it wants to go into the next stage of the relationship which is the implementation phase. We've added three new sites since the beginning of the year and as I said we are doing a number of studies throughout the country. Lee, Dean and I were in Pennsylvania a couple of weeks ago where it was announced that we will be offering our program at Walter Reed in Bethesda Naval Hospitals. And so the interest in the program continues to grow. Just so you all know, I have been in conversations with your group now probably for a year and a half, maybe two years. I'm not sure of the length of time. There have been a number of institutions in your area that have been interested but we have not been able to, sort of, get a sustained interest. Hopefully this recent attention off of the JAMA article will bring institutions in your area a clearer picture of what we might be able to offer there.

BOB: Thank you. I personally missed the reference to the JAMA article. Could you tell me when that article was published.

GLENN: I forget what today is. It's going to be published on the 16th. (Voice: It is in the mail).

It's coming out this week. In fact what Dean is doing and why Dean had to get offline is that there is a press release that was released today. It's going out to 3000 media outlets throughout the country. Lee you might want to describe what the JAMA article was about.

LEE: What it was is a long term follow-up for the Lifestyle Heart Trial to see what happens in people, in this case, five years, following the program and it showed continued benefit as long as people stayed with the Program. There is nothing terribly dramatic more about that. That the regressions in the lesions continued at the same slow rate but in compared to control there was a dramatic difference. The control patient got worse and worse over that same period of time. Worse by PET scan, worse by catheterization of any of the arteries.

BOB: Thank you. We got a few more questions, if we can continue.

VOICE: Just to give you an idea. We have about 5 more minutes in terms of our time on the conference call. We reserved about an hour and we got almost 5 more minutes to go.

BOB: Why don't we do just two more questions and then wrap it up. I don't think the question was answered as to whether it is O.K. to be on coumadin and flaxseed oil.

LEE: The answer is, yes it is but follow the PT-PTT: the blood test to look at how effective the coumadin is because your dosage needs may change.

BOB: O.K. Thank you. There is a recent study showing that women with a high waist to hip measurement ratio had a much higher incidence of M.I. Is this related to hyperinsulinemia or separate risk factors.

LEE: Yes it is. There's insulin resistant states which are: hyperinsulinemia is one way of describing it, Syndrome X is another term that's used and then diabetes also falls into that realm. In all of those situations, your body is not as responsive to your own insulin that you produce. You tend to produce more insulin. So if you actually take an insulin measure of the blood, you'll find the insulin level to be high. In that situation more of the fats in the body are deposited centrally, meaning in the abdomen and chest. So generally, another term is central obesity. You can have kind of normal arms and legs but higher or larger waist areas or large chest areas. That association with coronary disease holds true for both men and women so it's not particularly gender oriented..?.. indicate is insulin resistant. The best way to manage that is to achieve as lean a body mass as possible. Do lots of aerobic exercise: running, swimming, bike riding that sort of thing... walking and also to make sure that you are not consuming a lot of the simple sugars, starches, alcohol...the things that will have your triglycerides go up. The best indicator for your success, besides your physical weight, are your triglycerides. If you're insulin resistant than the triglycerides are above 180, that's not good. If you manage to keep them below 180 than you're O.K. there.

BOB: Thank you. That'll be our last question. I'm going to turn it over to Ed so he can wrap it up with you.

JIM/LEE: OK, thanks a lot.

ED: Boy, this was absolutely terrific. I saw a lot of the audience was writing notes prodigiously. I think we all got a lot out of it. I know how busy, not only Dean is, but all you folks are. To take the time for us, we genuinely appreciate it and I thank you. I'd like to encourage the audience to give you folks a nice round of applause.

AUDIENCE: Applause.

ED: And as Dean says the applause machine worked again to fool you that there are people here.

GLENN: If we could, Ed. This is Glenn. In a sense, we should really be applauding you and we don't have the applause machine available on this end, but. Lee and I travel the country, as the rest of the team travels the country, we talk an awful lot about what you have done. You and the community there have done in terms of creating a support group in Rochester. And we've learned a whole lot about that as being a very important aspect of our Program. That's how we came to add, what we call, the self-directed community to the programs that we are currently operating and creating. And so we really, really do appreciate what you've done and what you continue to do.

JIM/LEE: Ed, I think that part of the purpose of this call, Ed was to tell you a very specific and personal thank you for everything that you've done. What you all are doing there makes our job a lot easier. Because when people start to doubt that it's possible, we just point to your group. We say, look what these guys have done on their own, without us, we've not necessary for this process. So we just really appreciate being able to say that and just hold you guys up as an example.

ED: That's nice to hear. For myself and our community and all of the people here, we appreciate those nice kind words. Thanks again.

JIM/LEE: I'm sure we'll spend some more time together in the future.

ED: We would love to do this again. Perhaps in another year if you guys are willing.

JIM/LEE: Absolutely, I'd love it Ed.

ED: Terrific.

JIM/LEE: O.K. Take care everybody. Have a nice evening. Thanks very much.

ED: Bye now.

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