Book review by Anne Macaulay, Ph.D.
UnDo It!, written by Dean Ornish, M.D. and Anne Ornish, outlines the lifestyle medicine program that the Ornishes have developed and tested through a number of randomized controlled clinical trials and demonstration projects. Their program for reversing heart disease is covered by Medicare and is the first time a lifestyle medicine intervention has been covered for heart disease.
In addition to being medically effective, this program is cost-effective. In a demonstration project, Mutual of Omaha found that almost 80% of people who were eligible for bypass surgery or a stent placement were able to safely avoid these medical interventions by following the Ornishes’ lifestyle medicine program instead – saving almost $30,000 per patient in the first year.
The Ornish's research, and that of others, shows that many of the most common chronic diseases can be slowed, stopped, or reversed by their lifestyle medicine program, including:
- Reversing even severe coronary heart disease
- Reversing type II diabetes
- Reversing, slowing, or stopping the progression of early-stage, non-aggressive prostate cancer
- Reversing high blood pressure
- Reversing elevated cholesterol levels
- Reversing obesity
- Reversing some types of early-stage dementia
- Reversing some autoimmune conditions
- Reversing emotional depression and anxiety
In randomized controlled trials performed by Dr. Ornish and colleagues, within a month of following the lifestyle medicine program, participants showed significant improvement in blood flow to the heart and in the ability of the heart to pump blood during exercise. There was a 91% reduction in the frequency of angina in the first few weeks, and most patients became free of chest pain during that time. Within one year, even severely clogged arteries often became less clogged.
The Ornishes’ lifestyle medicine program consists of 72 hours of training time per patient, as opposed to the average 10 minutes of a typical office visit. This training is broken down into two 4 hours sessions per week for nine weeks.
Each session includes:
- One hour of supervised exercise
- One hour of stress management
- One hour of a support group
- One hour of group meal and lecture
Their lifestyle program emphasizes making big changes all at once so that participants quickly feel improvement and are motivated to continue. When participants make only moderate changes, they may be frustrated by lifestyle restrictions and yet not feeling the effects or finding symptoms improvement.
The Ornishes emphasize a new unified theory of chronic disease. Rather than viewing chronic diseases as being fundamentally different from each other, they should be viewed as diverse manifestations and expressions of similar underlying mechanisms such as:
- Chronic inflammation and immune system dysfunction
- Chronic emotional stress, depression, overstimulation of the sympathetic nervous system, stress hormones, and lack of sleep
- Gene expression
- The microbiome
- Oxidative stress, cellular metabolism and apoptosis
This unified theory of chronic disease – that is, the same mechanisms affecting a wide variety of chronic illnesses – also provides additional scientific evidence to explain why people often have several chronic diseases (which are called co-morbidities) at the same time, and why they share so many common risk factors. For example, many people with heart disease also have high blood pressure, type two diabetes, elevated cholesterol levels, obesity, and other chronic illnesses.
This theory also makes clear why the same lifestyle changes can help prevent and improve all of these co-morbidities simultaneously since they interrelate.
Personalized medicine is in the headlines daily with many food and healthcare companies promising to tailor a diet and lifestyle program based on your genome, blood test results, and clinical status. The Ornishes claim that this is largely a myth. In their research, there wasn't one set of lifestyle recommendations for reversing heart disease and a different one for reversing prostate cancer, diabetes, and other chronic illnesses. It was the same lifestyle medicine program for reversing all of these. This shouldn’t be surprising.
Most people know that exercise is helpful for a wide range of health conditions, but the Ornishes say "practitioners don’t prescribe running for heart disease and weight lifting to prevent diabetes." Similarly, the Ornishes propose that we don’t need different diets—a healthier diet is likely healthier for everyone and will help prevent a wide range of illnesses.
This recommendation differs from the Suppers’ approach of personalizing diet through trial and error. However, it’s clear that the Ornishes want people to avoid obsessing over just the right diet and instead get busy implementing the major lifestyle changes that everyone agrees work. There are no controversies on three quarters of their program: move more, stress less and love more. And there is no controversy on the major diet recommendations of the Ornishes and other experts on health: avoid all sugar and refined grains (white flour, white rice, corn syrup etc.) while dramatically increasing vegetable intake. The only controversies are whether animal protein versus vegetable protein is better for you and how high the fat content of your diet should be. However, the debate on these issues shouldn’t stop people from going ahead with what we know is true: eat real food including lots of vegetables, move more, stress less, and love more!
After this useful introduction, the book moves on to cover each recommendation in detail: Eat Well, Move More, Stress Less, and Love More. The second half of the book includes an extensive collection of vegan recipes that avoid refined grains and sugar followed by appendices of recommended foods.
The Ornishes recommend a low-fat, vegan diet for treating heart disease and other chronic ailments. Here are the Ornishes’ dietary recommendations in a nutshell:
- Consume mostly plants: vegetables, fruits, whole grains, legumes, soy products and small amounts of nuts and seeds in a form as close as possible to their natural, unprocessed state.
- What you include in your diet is as important as what you exclude. There are thousands of protective factors in plant-based foods that have anti-cancer, anti-heart disease and anti-aging properties.
- Minimize or eliminate animal protein and replace it with plant-based protein.
- Avoid sugar, white flour, white rice, and other processed, grain-based carbs.
- Consume 3 grams per day of omega-3 fatty acids.
- Reduce intake of total fat, especially trans fats, saturated fats, and partially hydrogenated fats.
- Organic is optimal as organic food both tastes better and avoids pesticide residues which can disrupt hormones.
- Recommended supplements while on a vegan diet: omega-3 fatty acids, vitamin C, a multivitamin without iron, vitamin D3, turmeric, calcium citrate, CoQ10, and a probiotic.
The Ornishes stress that low-fat versus low-carb is a false choice. Most health care providers and nutritionists agree that Americans do eat too many refined bad carbohydrates such as sugar, white flour and white rice. What the experts disagree on is where to go from there.
Atkins and some interpretations of Paleo would recommend replacing the bad carbs with more animal products. The Ornishes recommend going the other direction and replacing bad carbs with good carbs such as fruits, vegetables, whole grains, legumes, and soy products (in their natural state). They recommend a diet that is low in both fat and refined carbohydrates and that eliminates animal products.
The diet they recommend to undo chronic disease is much lower fat than most people typically eat--closer to 10 to 15% fat rather than the 40% in a typical American diet. This is the percentage of fat found until recently in the diet of countries such as China, where the prevalence of heart disease and other chronic diseases was quite low. In practical terms there's no need to track the amount of fat you consume if you only eat plant-based foods as they exist in nature (while limiting intake of high fat foods such as oils, nuts and avocados).
They then go on to address a number of myths about a low-fat vegan diet:
- Myth: "It’s hard to get enough protein."
- Plants contain all essential amino acids in different proportions and they do not need to be combined at the same time, as used to be believed. As long as you're eating a variety of foods including legumes and eating enough calories to maintain your weight, you'll get enough protein.
- Myth: "You can lose more weight by going low carb ketogenic."
- This may be true, but you can also lose weight by smoking or taking chemotherapy. This doesn’t mean that it’s healthy!
- Myth: "Americans have gotten fatter while eating less fat."
- It’s true that Americans have gotten fatter since the recommendations came out to eat less fat and the low-fat craze took over. However, Americans haven’t actually been eating less fat. It turns out that in every decade since 1950 people have been eating more fat, more sugar, more meat and more total calories. We are eating an average of 67% more fat, 37% more sugar, 57 pounds more meat, and 800 more calories per person. It’s not surprising that we’re getting fatter—it’s not because we’re eating too little fat; it’s because we're consuming too much of everything.
- Myth: "A Mediterranean diet is optimal for reversing heart disease."
- A Mediterranean diet is better than the diet that most people consume, especially with its emphasis on fruits and vegetables and less red meat. However, it doesn't go far enough to reverse heart disease. It does reduce strokes due to the increase in omega-3 fatty acids which is why they recommend that everyone take fish oil or flaxseed oil.
The Ornishes reference a number of studies showing that higher amounts of animal protein yield higher rates of mortality from cancer, diabetes, heart disease, etc. As is always the case, these retrospective diet questionnaire studies are hard to evaluate as people who follow dietary recommendations are also more likely to follow exercise recommendations. For example, there are also compelling studies in mice showing that a vegan diet leads to clean arteries whereas a standard American diet leads to partially clogged arteries and a ketogenic/Atkins diet leads to severely clogged arteries. However, these studies have not been done in people. The Ornishes have published multiple research studies on their whole lifestyle intervention plan which is impressively effective, but it is hard to tease out how much the vegan diet is responsible for these results.
Supper’s members are familiar with the adage that “How You Feel Is Data” and are encouraged to discover what diet works best for their bodies. Also familiar to Suppers members may be the Ornish's message regarding mindful eating. They encourage: before eating, close your eyes, take a couple of deep breaths, and ask yourself how you are feeling right now. If you are craving food, ask yourself whether what you really need right now is a cookie or a walk or a hug? Take some time to reflect on your eating patterns to see if you can recognize what typically prompts you to eat. How often do you find you eat because it's time--lunch break or a family dinner or because you looked at the clock? Do you find yourself eating simply out of boredom or just to be with family and friends? It's advantageous to knows the difference between your physical hunger and your emotional hunger. Emotional hunger can get triggered when your emotions get out of balance, like when you haven't eaten or you're feeling stressed or tired. At best, eating temporarily numbs your feelings and give you a quick food high. Just remember that this pleasure is only momentary. Be sure to enjoy your food more by being mindful and present when you eat. When people eat in front of a TV, they eat 40% more, but enjoy the food less.
The chapter ends with suggestions for maintaining this diet when eating out and with friends. There are also a number of affirmations such as “I know I feel better when I eat healthier.”
Most people already know that exercise is "good for you." It helps you lose weight, stay healthy, look younger, and feel better.
Exercise also helps you live longer:
- Going from being sedentary to walking 20 to 30 minutes a day can cut premature death rates by 20 to 30%.
- Just 25 minutes of brisk walking a day can add as much as seven years to your life.
- In the women's health study of tens of thousands of women, those who walk briskly for just 15 minutes a day on average cut the risk of death from heart attack and stroke in half.
Just a little bit of exercise makes a huge difference! If you are short on time, you can achieve most of the longevity benefits of exercising in only five minutes a day if you run instead of walking. That said, walking provides most of the same benefits as high intensity exercise without the risks of musculoskeletal injury or sudden cardiac death. If you have a chronic disease, check with your doctor before starting any high intensity exercise.
The exercises the Ornishes recommend are: walking for aerobic exercise, strength training to maintain muscle mass, and stretching because it also helps reduce stress. However, most importantly, chose exercise that you like and that you’ll do! Try to find one in each of those three categories. In short, do what you enjoy, make it fun, and do it regularly. Try exercising with a friend, with your dog, or with your favorite music or podcast.
Some other benefits of exercise:
- As little as ten minutes a week of exercise makes you happier.
- Exercise is as good or better than anti-depressants in treating and preventing depression.
- Exercise leads to brain growth and an improvement in memory.
- Chronic stress can lead to chronic muscle tension, often leading to back pain, neck pain and more stress in a vicious cycle. So when you stretch chronically tense muscles slowly and gently, you allow both your body and mind to relax.
- Your lean muscle mass naturally decreases as you get older and so does your bone density. Resistance training helps prevent these and increases both the strength and size of your muscles.
The remainder of the Move More chapter consists of two sets of resistance band exercises for the strength training component of the program. Stretching is covered in the Stress Less chapter.
Chronic stress underlies many chronic diseases and stress is linked to the six leading causes of death – heart disease, cancer, lung ailments, accidents, cirrhosis of liver, and suicide. This effect is mediated by the sympathetic nervous system.
Chronic stress can:
- Increase inflammation in your brain, which can lead to or exacerbate depression
- Have a harmful effect on the balance of the of your microbiome
- Cause blockages to build up faster in your arteries, independent of diet
The good news is that stress comes primarily not just from what happens to us, but more importantly, how we react to what happens to us. How you adapt is a function your lifestyle and your beliefs. Even though we can't change what's going on in our lives, we have a lot more choice about how we react to it than we might have believed. Managing stress more effectively can beneficially affect your health. Just as chronic stress can suppress your immune function, love, altruism, and compassion can enhance it.
One study found that it isn't the objective measure of stress that determines its effect on telomeres. It's how people reacted to stress. Perceptions of stress were more important than what was objectively occurring in their lives. So if you feel stressed, you are stressed. This is empowering because the lifestyle medicine program in UnDo It! can teach you how to buffer the stress so it doesn't affect your telomeres or your health and you'll become more resilient.
How to reduce stress:
UnDo It! outlines five different stress reduction techniques followed by step-by-step instructions. Do what works best for you and your lifestyle and find a way to make your practice a regular part of your life. The techniques they describe and teach are:
- Gentle stretching
- Breathing techniques
- Guided imagery
- Deep relaxation
Other techniques for reducing stress:
- Visualize stress as enhancing your performance—good butterflies.
- To reverse chronic disease, commit to an hour a day of stress reduction. That’s a lot, but the average person spends 5 hours per day on their mobile device or watching TV. Consistency is even more important than duration, and more time spent on stress reduction is needed to reverse disease than to prevent it.
- Spend less time on social media. This is a side benefit of spending more time on stress management—you’ll spend less time on social media!
- Sharing authentic feelings in a safe and intimate environment with friends, a support group, a minister or a therapist can be a powerful tool for reducing stress.
- Taking care of a pet reduces stress.
- Digital detox.
You'll probably find endless excuses not to manage your stress; it can be all too easy to talk yourself out of doing what's good for you. “I'm too busy.” “I'm too tired.” “It doesn't work.” “I don't enjoy it.” “I have an injury.” “I have to calm down before I start.” “I fear feelings coming up.” “I get bored.” For each of these excuses, the authors provide answers to help you make stress reduction a habit in your life.
The need for authentic connection and community is primal--as fundamental to our health and well-being as the need for air, water and food. Love and intimacy are healing; loneliness and isolation are deadly. Intimacy can come from the romantic love of a partner or the platonic intimacy of a friend, child, parent, sibling, teacher or a pet, which can provide a healing experience of unconditional love.
There are tens of thousands of studies showing that people who feel lonely, depressed, and isolated are 3 to 10 times more likely to get sick and die prematurely from virtually all causes when compared to those who have strong feelings of love, connection, and community.
Forty percent of adults in United States report feeling lonely. There has been a radical shift in our culture in the past 50 years with the breakdown of social networks which used to provide a strong sense of connection and community. Instead, we have social media networks where people only share the best part of their lives. Real-world social networks are positively associated with well-being, but the use of Facebook was actually negatively associated with well-being. The more people used Facebook, the worse they felt.
Loneliness causes chronic emotional stress and over-activation of the sympathetic nervous system. Also, inflammation is persistently increased in people who are lonely or depressed. This is mediated by changes in C-reactive protein, interleukins, and other mechanisms.
The initial purpose of the group support session in the Ornishes’ lifestyle medicine program was to help people stay committed to the other aspects of the diet and lifestyle program. Dean Ornish assumed that people would be sharing recipes, shopping tips, information about running shoes etc. Instead, he learned that bringing people together in a supportive environment allows them to let down their emotional defenses and to talk openly and authentically about what is really going on in their lives – about their families, their marriages, their kids, their work, their school, and so on. That's what they needed and wanted most. A safe support community is a powerful antidote to loneliness and isolation. It's so meaningful that after the earlier studies ended, the subjects continued to meet regularly in their support groups for decades thereafter. This is a significant reason they are achieving such high levels of adherence to the program.
The support groups create a place that feels safe enough to express your authentic feelings without being judged, abandoned, or criticized. Once you experience this, then you'll be more likely to have the courage to open up in significant ways to your friends, family, and loved ones – because you now you know how good it feels to experience this level of community and connection with each other. Although this is the part of our program that many people think they will have difficulty with and believe is least important, they usually find the most meaningful and transformative for them. It's amazing how quickly people can bond in this context.
- Join a support group or create one of your own. There are resources for finding Ornish support groups and for how to create one of your own where everyone feels safe, supported, and trusts in confidentiality.
- Pay attention to your feelings. Many of us learn to bottle up our feelings. Too often we've learned how to please others by not expressing how we're really feeling, and gradually we become unable to recognize our true feelings.
- Get in the habit of checking in with your feelings. Get comfortable and centered in a safe place. Close your eyes. And focus inward. Bring your attention to rest on your heart and simply notice the emotions that are present. Gently ask it “heart, how are you feeling?” Give yourself permission to attend to whatever you're honestly feeling at this moment. Sense what resonates with you: frustrated, discouraged, energized, anxious, calm, lonely, hopeful etc.
- Our feelings connect us, where as our thoughts are often perceived as judgments that isolate us. Therefore, learn to differentiate your thoughts from your feelings.
- Putting feelings into words makes sadness, anger, and pain less intense. When you put feelings into words you seem to be hitting the brakes on your emotional responses.
- Learn to listen with empathy and compassion. Not judging and not giving advice, but instead reflecting back what the other person is feeling “It sounds like you are really frustrated,” for example. And then respond with your own feelings “My heart goes out to you that you are going through this.”
- Learn to care for yourself with kindness, patience, and perseverance when things don't go as you planned, or you fall off the wagon in your heart healthy lifestyle practice. Be sure you don't lose your way because you lost compassion for yourself.
- Smile and laugh freely. Figure out what makes you laugh and do more of it!
- Express gratitude daily.
- Support and serve others, whether it be family, neighbors, or through volunteer work.
- Frame your choices so they're meaningful for you. Instead of focusing on thoughts such as “I can't eat everything I want” which leaves you feeling chronically stressed and deprived, you might reframe your experience as “I'm choosing not to eat certain foods because when I replace them with healthier options. I feel so much better.”
- Let go of blame, shame, grudges, and other invisible weight that you are carrying.
The authors emphasize that this is a love program! When you feel good – both physically and emotionally – the upgrade to your life is so gratifying that it becomes a much more sustainable motivator than your fear of dying.
RECIPES AND APPENDICES
The Ornish Kitchen and True Love Recipes are low fat, whole food, vegan recipes for breakfast, lunch and dinner as well as condiments and soups.
Appendix A is a two week meal program to jumpstart the program. It can seem overwhelming to make such big changes in your way of eating, so this is a plan using commercially available food that fit their guidelines and which you can use to stock your pantry and freezer. Eat these foods for just a week or two because you'll start feeling so much better so quickly that you'll be more motivated to learn how to shop and cook meals on your own. Then you can use these prepared meals are less frequent basis.
A sample menu would be: Oatmeal with blueberries for breakfast, gluten-free beans and rice burrito with leafy greens and shredded carrots for lunch, sweet-and-sour Asian noodle bowl with broccoli slaw, leafy greens, and salad dressing for dinner and snacks of an apple, baby carrots, black bean dip, whole-grain crackers and dry roasted edamame.
Appendix B: Stocking your kitchen for success. This appendix contains lists of recommended staples for preparing your heart-healthy own food.