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Abstract

Overestimates of the efficacy of surgical and pharmacological interventions for the prevention and treatment of chronic disease and underestimates of the associated risks may bias physicians and patients against lifestyle medicine interventions that can be cheaper, safer, and more effective by treating the underlying cause of disease. The leading causes of both death and disability in the United States are diet, followed by smoking. The food and tobacco industries share similar tactics to downplay and obfuscate the risks associated with their products, but physicians can educate themselves about the role lifestyle interventions can play in the prevention and treatment of chronic disease. For example, a diet centered around whole plant foods can be used to successfully treat angina and painful diabetic neuropathy and may help prevent low-back pain and Alzheimer’s disease, all perhaps because of a common underlying vascular component. The delay between recognizing the risks of smoking and effective public health measures may have cost millions of lives. Similar delays in stopping dietary diseases may cost millions more.

Keywords

plant-based diet angina low-back pain diabetic neuropathy Alzheimer’s disease

Whereas most patients may wish to be informed about the likelihood of benefit, if they knew the truth, few would apparently comply with physician recommendations to initiate these drug regimens.

In 1903, Thomas Edison predicted that “the doctor of the future will give no medicine, but will instruct his patient in the care of [the] human frame in diet and in the cause and prevention of diseases.”¹ Overestimates of the efficacy of more conventional medical interventions for the prevention and treatment of chronic disease and underestimates of the associated risks may be forestalling Edison’s vision of lifestyle medicine. For example, patients may vastly overrate the effectiveness of breast and bowel cancer screening to prevent cancer death, bisphosphonates to prevent hip fractures, and preventive medications to avert cardiovascular disease mortality.² Patients believe that statin drugs are as much as 100 times more effective than they actually are in preventing cardiac events.³

For the average individual, the chance of benefit is normally less than 1 in 20 over 5 years for pharmacological interventions such as statins, antihypertensives, and blood thinners.⁴ Whereas most patients may wish to be informed about the likelihood of benefit, if they knew the truth, few would apparently comply with physician recommendations to initiate these drug regimens.⁴

For high-risk patients (post–myocardial infarction or unstable angina), the absolute risk reduction achieved with pravastatin over 6.1 years for myocardial infarction or death is ≈3%.⁵ If this were explained to patients, few may choose the solely pharmacological route when lifestyle adjuncts, such as dietary interventions, may be up to 20 times more effective in preventing cardiovascular events.⁶ Lifestyle medicine can not only be cheaper and safer, but can work better.

Informed consent involves laying out the risks as well as the chance of benefit. Adverse effects from prescription drugs alone kill an estimated 106 000 Americans every year.⁷ Adding in those who died from unnecessary surgery, hospital-acquired infections, and medical errors, the iatrogenic death toll effectively makes medical care the third leading cause of death in the United States.⁸ But only those on medications are killed by medication errors or side effects. One has to be in the hospital to be killed by a hospital error or nosocomial infection. The best way to avoid the adverse effects of medical care is to not become ill in the first place.

Simple diet and lifestyle changes may reduce the risk of developing major chronic diseases by nearly 80%.⁹ At least 70% of strokes and colon cancer, more than 80% of coronary heart disease, and more than 90% of type 2 diabetes may be avoidable.¹⁰ According to the largest systematic effort to study the global risk factors for disease, the leading causes of both death and disability in the United States are diet, followed by tobacco.¹¹ Most Americans are killed and disabled by what they put in their mouth: food and cigarettes.

Angina

Heart disease is our leading cause of death and disability.¹² In a randomized controlled trial, Ornish et al¹³ showed that cardiac patients placed on a plant-based diet and lifestyle program for a year reported a 91% reduction in angina attacks. In contrast, control group patients who were instead told to listen to the advice of their physicians, had a 186% increase in reported attack frequency. The marked reduction in chest pain frequency, duration, and severity was sustained 5 years later, a long-term reduction in angina comparable to that of coronary artery bypass surgery or angioplasty but without the associated risks.

The lifestyle intervention included moderate aerobic exercise, but the same 91% mean reduction in frequency of angina episodes was also achieved without the exercise component.¹⁴ Subsequent work by Esselstyn demonstrated heart disease reversal using a whole food plant-based diet as the only lifestyle intervention,^15,16 suggesting that dietary change is the most active ingredient.

Ornish and Esselstyn were not the first to report remarkable clinical reversal of coronary artery disease symptoms. For example, a case series titled “Angina and Vegan Diet” was published in the American Heart Journal in 1977. Cases like Mr F. W. were described, a 65-year-old with such severe angina that he had to stop every 9 or 10 paces. Within months of excluding meat, dairy, and eggs from his diet, he “climbed mountains, no angina pain.”¹⁷

Objective reversals of coronary artery stenosis with diet and lifestyle changes have been documented using angiography¹⁸ and single-photon-emission computed tomography imaging.¹⁹ The rapid relief of angina before one would expect changes in atherosclerotic occlusion may be a result of an improvement in endothelial function. As demonstrated by ultrasound during brachial-flow-mediated dilation, the arteries of those eating vegetarian diets may vasodilate 4 times better than those eating nonvegetarian diets.²⁰ However, the cardiovascular benefits of plant-based eating may be undermined by hyperhomocysteinemia if patients do not ensure a regular reliable source of vitamin B12 through fortified foods or supplements.²¹

An executive at the drug company that developed the antianginal ranolazine derided the primacy of lifestyle change, noting that “many patients may not be able to comply with the substantial dietary changes required to achieve a vegan diet.”²² Ranolazine can cost up to $6000 a year,²³ but has been considered safe and efficacious.²⁴ At the highest dose, ranolazine may prolong exercise duration by as long as 33.5 s.²⁵ It does not appear as though those relying on the pharmaceutical route will be climbing mountains anytime soon.

Low-Back Pain

Chronic low-back pain now affects about 1 in 5, disabling more than 30 million Americans. Low-back pain has become one of the largest problems for public health systems in the Western world during the latter half of the 20th century.²⁶ Are we just lifting more heavy stuff? Mechanical factors, such as lifting and carrying probably do not play a major role.²⁶ The answer may lie in diminished blood flow.

Magnetic resonance (MR) aortography shows that atherosclerosis can obstruct the branching arteries of the abdominal aorta that feed the lumbar spine,²⁷ and these occlusions are associated with disc degeneration. Intervertebral disks represent the largest avascular tissue in the body.²⁸ Oxygen and nutrition must diffuse in from the margins, making them especially vulnerable to deprivation.²⁹

Postmortem angiographic studies have found that those with stenotic arteries supplying the lumbar spine were 8.5 times more likely to suffer from chronic low-back pain.³⁰ This may explain why back pain may predict fatal myocardial infarction,³¹ similar to the link between erectile dysfunction and cardiovascular events.³² Atherosclerosis is a systemic disease that can affect the entire vascular tree.

By the age of 49 years, nearly all the disks of those eating the standard American diet may show at least a grade II degradation.³³ This deterioration can start as young as age 11 years.³⁴ Atherosclerosis starts in childhood. By age 10 years, nearly all children appear to have aortic fatty streaks.³⁵ This may explain why low-back pain is now common even in children and adolescents.³⁶

The regression of coronary and peripheral atherosclerosis with the aid of dietary interventions has been demonstrated for decades.³⁷ An interventional trial for low-back pain with an atherosclerosis-reversal diet, with both clinical and MR angiographic correlates, would be a welcome addition to the literature.

Painful Diabetic Neuropathy

Diabetes mellitus is the seventh leading cause of lost life in the United States³⁸ and the eighth leading cause of lost health.³⁹ Up to 50% of people with diabetes eventually develop neuropathy,⁴⁰ which can manifest as chronic neuropathic pain that is often resistant to conventional treatments.⁴¹ However, the rapid regression of neuropathic pain within days of instituting lifestyle changes was first reported in 1994.⁴²

A total of 21 people with diabetes suffering with moderate or worse painful neuropathy for up to 10 years were placed on a diet of unrefined plant foods, with daily conditioning exercise (brisk walking). Complete relief of the pain was reported in 17 out of the 21 patients within 4 to 16 days.⁴²

The intervention took place in a residential live-in program where patient meals were provided. What happened after they were sent back into the community? The 17 responders were followed for a period of 1 to 4 years, and in all except 1, the relief from the painful neuropathy continued or improved even further. The efficacy likely explains the level of continued dietary compliance.⁴²

Diabetic neuropathy can be one of the most painful and frustrating conditions to treat. After years of painful suffering, how could complete and lasting relief of pain be achieved in three-quarters of patients within a matter of days? It did not appear to be the improvement in blood sugar control, because it took approximately 10 days for the diet to control the diabetes, whereas the pain was gone in as few as 4. One proposed mechanism was the inflammatory effect of trans fats naturally found in meat and dairy,⁴² but it appears to take 9 months or more of animal product and processed food avoidance to remove trans fats from one’s tissues.⁴³ A more likely mechanism given the rapidity of response is an improvement in blood flow.⁴⁴

Nerve biopsies taken from diabetics with severe progressive neuropathy show small-vessel disease within the nerve.⁴⁵ The resulting endoneurial hypoxia may play an etiological role in neuropathic pain.⁴⁶ Diet and exercise-induced improvements in hemorheology—decreased blood viscosity—may explain the rapid pain relief by ensuring sufficient neural tissue perfusion.⁴⁶

Plant-based diets may also help prevent^47,48 and treat diabetic retinopathy. Kempner et al⁴⁹ were the first to document the reversal of diabetic retinopathy with diet. They found that 30% of participants (13 of 44) on a plant-based diet of mostly rice and fruit showed a marked fundal regression of diabetic hemorrhages, exudates, aneurysms, and retinitis proliferans.

Alzheimer’s Disease

Alzheimer’s dementia perhaps best captures the difference between life span and health span. Few would choose longevity if it meant no longer recognizing oneself in the mirror.

In 1901 “Auguste” was taken to an insane asylum by her husband. She was described as a delusional, forgetful, disoriented woman who could no longer carry out her homemaking duties. She was seen by Dr Alois Alzheimer and was to become the case that made his a household name. On autopsy, he described the plaques and tangles in her brain that would go on to characterize the condition; but lost in the excitement of discovering a new disease entity, a clue may have been overlooked. The postmortem findings suggested vascular involvement: “Die größeren Hirngefäße sind arteriosklerotisch verändert [The larger vascular tissues show arteriosclerotic change].”⁵⁰

The link between coronary artery disease, degenerative brain disease, and dementia is considered one of the most poignant examples of the systemic nature of atherosclerosis.⁵¹ There is a substantial body of evidence that strongly associates atherosclerotic vascular disease with Alzheimer’s disease (AD). Postmortem studies, for example, have shown that those with AD had significantly more atherosclerotic stenosis in their intracranial arteries.⁵² The resulting chronic brain hypoperfusion may play a pivotal role in the pathophysiology of AD.⁵³

The correlation between cerebrovascular atherosclerosis and Alzheimer pathology suggests that interventions shown to prevent and treat atherosclerosis may be useful for the prevention and treatment of AD as well.⁵⁴ Zhu et al⁵⁵ followed 423 individuals with mild cognitive impairment for 4 years to assess the impact of intracranial artery stenosis on the progression to AD. The cognition and ability to carry out activities of daily living of those with a greater intracranial atherosclerotic burden declined significantly faster, coupled with a doubling of incident progression to AD.

Once AD is diagnosed, Deschaintre et al⁵⁶ showed that treatment of vascular risk factors such as hypertension and hypercholesterolemia is associated with significantly slowed progression of the disease. It has been said, “The goal of medicine is to provide patients with hope, and when there is no hope to offer understanding.” For the first time in the history of the disorder, we may now have the chance to provide Alzheimer patients with hope.⁵⁷

Dietary guidelines for the prevention of AD include minimizing intake of saturated and trans fats found in meat, dairy, and processed foods and instead centering one’s diet around vegetables, legumes (beans, split peas, chickpeas, and lentils), fruits, and whole grains.⁵⁸ This is consistent with epidemiological data from Asia, associating rising Alzheimer’s rates with increased animal fat consumption,⁵⁹ and North America, where matched individuals who ate meat (including poultry and fish) in the Adventist Health Study were 2 to 3 times more likely to develop dementia than their vegetarian counterparts.⁶⁰

What about the role of metals in AD? A systematic review found that copper and iron intake may just aggravate the detrimental effects of a high-cholesterol and saturated fat diet on the risk of developing AD.⁶¹

What about the so-called Alzheimer’s gene, ApoE4? Diet appears to trump genes. The highest observed frequency of the ApoE4 allele is in native Nigerians, but they also have among the lowest Alzheimer’s rates.⁶² This apparent paradox may be explained by the role of ApoE as the principal cholesterol carrier in the brain.⁶³ Low cholesterol levels associated with eating the traditional plant-based West African diet⁶⁴ may lead to changes in brain ApoE expression.⁶⁵ Just because we may have been dealt some bad genetic cards, does not mean that we cannot try to reshuffle the deck with diet.

Best-Kept Secret in Medicine

The same type of diet that has been shown to improve angina—a diet centered around whole plant foods—is the same diet that may help prevent and/or treat low-back pain, diabetic complications, and dementia, perhaps because of a common underlying vascular component. This is the same type of diet eaten by populations that were largely free of many of our deadliest and most debilitating diseases.⁶⁶

Heart disease was so rare among those eating these traditional plant-based diets that there were papers published with titles such as “A Case of Coronary Heart Disease in an African.” After 26 years of continuous medical practice in East Africa, Singh and Trowell⁶⁷ recorded their first case of coronary heart disease among a population of 15 million—a judge who had started consuming a partially Westernized diet containing meat, dairy, and eggs.

The protection from Western chronic diseases enjoyed by plant-based populations in rural Africa and Asia⁶⁸ may have derived from a combination of the preponderance of whole plant-based foods and the avoidance of animal-based and processed foods,⁶⁸ but interventional trials were required to substantiate the role of diet.

Lifestyle medicine pioneers such as Pritikin,⁶⁹ Ornish et al,⁷⁰ and Esselstyn et al⁷¹ placed patients with coronary heart disease on the kind of diet consumed by populations in which coronary heart disease was practically nonexistent⁷² in hopes that the progression of the disease could be stopped. Instead, the disease often started to reverse. As soon as patients stopped eating an artery-clogging diet, their bodies were often able to start dissolving some of the plaque away. Even in some cases of severe triple-vessel heart disease, arteries opened up without drugs or surgery,⁷³ suggesting that their bodies wanted to heal all along but were just never given the chance.

The best-kept secret in medicine may be that given the right conditions, the body can sometimes heal itself.⁷⁴ If one of our patients strikes their shin on a coffee table, the pain and swelling will resolve naturally unless they keep hitting it in the same place day after day. Scripts for analgesics might help mediate the pain, but if they continued hitting it 3 times a day—at breakfast, lunch, and dinner—it may never heal. Like prescribing nitroglycerine for chest pain, one can offer relief but one may not be doing anything to treat the underlying cause.

Within 15 to 20 years after smoking cessation, lung cancer risk approaches that of a lifelong nonsmoker.⁷⁵ In many cases, our lungs can clear out the tar, and eventually, it is almost as if we never started smoking at all. Every morning of our smoking life that healing process presumably started until that first cigarette, reinjuring our lungs with every puff, just like we can potentially reinjure our arteries with every meal.⁷⁶ All we had to do all along was treat the cause by removing the offending agent and allow our bodies’ natural healing processes to bring us back toward health.

Nutritional Equivalent of Smoking Cessation?

There is only one diet that has ever been shown to reverse coronary artery disease in the majority of patients. If that is all a plant-based diet could do—reverse our number 1 killer—should not that be the default diet until proven otherwise? The fact that such diets may also be effective in preventing and arresting other leading causes of death and disability such as type II diabetes⁷⁷ would seem to make the case for plant-based eating overwhelming. So why do not more doctors prescribe it?

Available time is a reason frequently cited by physicians for failing to offer nutrition counseling, but the perception that patients “fear privations related to dietary advice” may be an even stronger factor.⁷⁸ It is hard to imagine a physician refraining from encouraging smoking cessation out of a concern for how much patients enjoy their habit.

In a compelling editorial in the American Medical Association’s journal of ethics titled, “The Physician’s Role in Nutrition-Related Disorders,” Neal Barnard shared his own story of tobacco addiction,⁷⁹ which ended in the 1980s as the lung cancer death rate was peaking in the United States. Smoking mortality has since dropped with dropping smoking rates.⁸⁰ No longer were there ads featuring doctors beseeching patients to “Give your throat a vacation. . . . Smoke a fresh cigarette.”⁸¹

Physicians realized that they were more effective at counseling smoking cessation when they no longer had tobacco stains on their own fingers. The medical profession went from being a bystander or even enabler to leading the fight against tobacco. Barnard argues that today “plant-based diets are the nutritional equivalent of quitting smoking.”⁸²

It took half a century after the initial studies linking smoking and cancer for the enactment of effective public health policies to be put into place,⁸³ a delay that cost millions of lives.⁸⁴ Must we wait another 50 years to respond to the epidemics of dietary disease?

The tobacco and food industries share similar tactics: manufacturing doubt over safety, manipulating research, and unduly influencing regulatory agencies. In contrast, powerful and cheap health-promoting activities such as healthy eating may be too cheap, cannot be patented, and so may not be profitable enough to have a large corporate budget driving their promotion.⁸⁵

For example, the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) promotes a series of Nutrition Fact Sheets. Industry sources pay $20 000 per fact sheet and explicitly take part in writing the documents. So the public can learn about eggs from the egg industry or the benefits of chewing gum from the “Wrigley Science Institute.”⁸⁶

When the American Academy of Family Physicians (AAFP) was called out on their proud new corporate relationship with Coke to support patient education on healthy eating, an executive vice president of the Academy tried to quell protest by explaining that this alliance was not without precedent. They had relationships with Pepsi and McDonald’s for some time.⁸⁷

When this did not placate critics, the AAFP executive assured them that the American Dietetic Association had made a policy statement that “there are no good or bad foods.”⁸⁷ This is a position that the food industry has exploited. In its early years, the tobacco industry used a similar argument: smoking per se was not bad, only “excess” smoking.⁸⁸ Everything in moderation.

Phillip Morris is still fighting into the 21st century. One of their latest covert campaigns, dubbed ‘‘Project Sunrise,” is an explicit divide and conquer strategy against the tobacco control movement.⁸⁹ Leaked internal planning documents list as a key project objective, “Create schisms—force them to fight among themselves.”⁹⁰ Their hope is that the success of the antitobacco movement “may blind organizations to carefully orchestrated efforts by the tobacco industry and its allies to accelerate turf wars and exacerbate philosophical schisms.” This is how the industries of death and disease fight the public health community. This is why it is critical that the lifestyle medicine movement remains unified.

The New Normal

Thankfully, there is a corporate sector that benefits from keeping people healthy, the insurance industry. In 2013, a “Nutritional Update for Physicians” was published in the journal of Kaiser Permanente, the largest managed care organization in the country, covering 9 million people with approximately 15 000 physicians who were told “Healthy eating may be best achieved with a plant-based diet, defined as a regimen that encourages whole, plant-based foods and discourages meats, dairy, and eggs as well as all refined and processed foods.”^91(pp61)

“Too often, physicians ignore the potential benefits of good nutrition and quickly prescribe medications instead of giving patients a chance to correct their disease through healthy eating and active living. Physicians should therefore consider recommending a plant-based diet to all their patients, especially those with high blood pressure, diabetes, cardiovascular disease, or obesity page 61.”⁹¹

The Permanente Journal update stressed the importance of using plant-based diets as a first-line treatment for chronic illnesses. The major described downside is that plant-based eating may work too well, potentially dropping blood pressures or sugars too low in those on antihypertensive or antidiabetic drugs, requiring an adjustment or elimination of medications.⁹¹ The side effects, then, may be having to wean off of drugs.

The nutritional update ends with a familiar refrain, “Further research is needed.” In this case, though, “Further research is needed to find ways to make plant-based diets the new normal.”⁹¹

Footnotes

Acknowledgements

This work was presented at Lifestyle Medicine 2014; October 19-22, 2014; San Diego, CA.

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Plant-Based Diets for the Prevention and Treatment of Disabling Diseases

Abstract

Keywords

Angina

Low-Back Pain

Painful Diabetic Neuropathy

Alzheimer’s Disease

Best-Kept Secret in Medicine

Nutritional Equivalent of Smoking Cessation?

The New Normal

Footnotes

Acknowledgements

References