Heart health is not about Telomeres…It’s much simpler than that

A recent study on healthy lifestyle changes got me thinking about why heart disease remains the most deadly human disease. A small study of just a few motivated men with low-risk prostate cancer garnered attention because it contained two important key words: Ornish and Telomeres.

Everyone knows Dr. Dean Ornish. And most of us know that telomeres are the caps at the end of chromosomes. Accumulating birthdays associates with telomere shortening, and some feel this has a causative role in cellular aging. Long telomeres are good; short ones are bad.

My friend, journalist Larry Husten (Forbes) has this comprehensive recap of the study, which was published here in the journal Lancet Oncology.

In short, researchers showed that patients who stuck with the Ornish plan (strict diet, exercise, stress reduction and social support) had longer telomeres. People are excited about this because telomeres are the hottest new surrogate for health and longevity. Maybe so, more studies will tell that story. The bottom line is the same: people who eat well, exercise a lot, manage stress and have social support look good, feel good and live longer. That fact is so old, it’s hard to write an interesting sentence about it.

What grabbed my attention about the study was not the cellular aspects, the specifics of the diet or the rigor of the science. What struck me were the comments from the president of the American Heart Association, Dr. Donna Arnett. Recall the AHA’s mission is to build healthier lives, free of cardiovascular diseases and stroke.

Here is a quote from Larry’s piece concerning Dr. Arnett’s comments: (The last line was the zinger.)

The study was “interesting” and “fascinating” but pointed out that it was a very small pilot study with only 10 people in the intervention group. “The fact that they could increase telomere length is impressive,” she said. Interventions that increase telomere length are worth further study, but it will be extremely difficult to prove a link between the effect on telomeres of an intervention and an improvement in outcomes. She also noted that patients in the treatment group were “clearly a very motivated group” who had good adherence to the program. For “people with time and motivation this may be feasible… for other people this might be a challenge.”

That last sentence is the problem. It encompasses everything that is wrong about how the AHA, ACC, most doctors and most people approach heart health. “For people with time and motivation, this may be feasible…”

Good health isn’t something that comes from anything else other than motivation and taking time for healthy behavior. Sure, you can wrestle about what diet plan is best, but everyone knows a bad diet from a good one. Good food is real food, and less of it. You can haggle about which exercise is best, but again, it’s not complicated. Good exercise is that which makes you sweat for more than twenty minutes each day that you eat. Stress management is simple too. Life can’t be lived without stress; it’s how we manage it that matters. In most cases, it’s our choice how much inflammation we bring onto ourselves. We can choose less inflammation; our doctor cannot. Finally, on the matter of social support, this, too, is a choice. We can choose to interact with others with compassion and kindness. Or we can choose the opposite.

That paragraph is old news as well.

The major point here is that doctors can’t gift people time and motivation. Neither can the AHA and ACC. The problem with statements like those made by the AHA president is the assumption that motivated people who do make the time for health are extraordinary. “For other people, this might be a challenge.”

That bothers me because inherent in those words is the idea that for the other people, the busy people for instance, we have a shortcut—a blood pressure pill, a cholesterol pill, a stent, an AF ablation. This sort of thinking eliminated physical education from the normal school day—we don’t have time for gym. (I bet they do in Finland.)

I always come back to the 240lb fat man with high blood pressure and adult onset diabetes. Whose job is it to treat these problems? The answer is obvious: it’s both of our jobs. The problem now is that the sick-care culture puts too much emphasis on what doctors and scientists can do, and far too little on what people can do. You don’t really think taking 5 different chemicals is the answer for a 240lb fat man, do you?

Far too many patients think there is a solution other than taking time and being motivated. Good lifestyle behaviors are not extraordinary. We have to stop saying that. The magical thinking must end. There is no ‘easy’ substitute for time and motivation.

Telomeres notwithstanding!

JMM

13 comments

  1. Calling the head of a physician corporate political organization a “healthcare leader” is a stretch.

  2. Hello Dr. M
    There are, as Larry Husten points out in his excellent overview of this study, “a number of reasons why you should be very cautious before drinking this Kool-Aid” – e.g. not a randomized trial, only 10 subjects, measuring telomere length (a surrogate endpoint) NOT a good way to assess the value of an intervention.

    I’m a big fan of your wise advice (“You only need to exercise on the days you plan to eat!”) and quote you frequently both online and when I do presentations to women about heart health. But I was a distance runner for 19 years before my heart attack (and thus the most surprised person in the CCU over that reality!) The Ornish program – particularly the diet – is so drastic and so severely restrictive that I suspect only the John Mandrolas of the world can realistically be counted on to actually stick to it for any meaningful length of time. I still manage to drag my sorry ass out the door every morning to exercise because of my significant hope that daily exercise may just help prevent another cardiac event – but please consider that the “motivation” required to do this completely wipes me out for the rest of any given day. Don’t ask me to give up birthday cake at tomorrow’s family dinner on top of that.

    My hunch is that you are speaking from the perspective of a competitive cyclist, meaning that you enjoy what Dr. Ann Becker-Schutte calls “Healthy Privilege”, and for whom the prospect of patients (never mind AHA presidents) being unwilling/unable to embrace Ornish lifestyle makeovers is hard to comprehend.

    Personally, I don’t give a flying fig what the AHA has to say about telomeres or this study. But I think Larry nailed it pretty fairly with his assessment.
    regards,
    C.

  3. John, I agree with Carolyn and I think you are attacking a straw man. I don’t think Arnett was promoting drugs and medical interventions at the expense of lifestyle changes. She was simply acknowledging the well-known fact that the vast majority of people are incapable of following for any length of time the specific Ornish program. Of course you could always try to change human nature. On the other hand, public health changes are more likely to have a broad effect (gym for every kid, soda restrictions, cheap and plentiful fruit and veg, etc).

    1. Larry,

      How soon you forget. On your bike commute to ESC in Amsterdam, how many American-looking people did you see?

      The beautiful Dutch people that I saw on my commute may or may not have been on an Ornish diet.

      I don’t care which diet you pick, the point is that motivation and taking time for health is the answer.

      I want the AHA and ACC to say that.

      We don’t need to change human nature. We need to change American nature.

  4. A healthy lifestyle isn’t such a challenge, getting people motivated is the challenge. The young mother in the grocery store says “It’s only a cookie. He’s a child, why should I worry about heart disease?” The teenager isn’t thinking about it at all if they aren’t anorexic. The college kid says “I’m young and I exercise all the time. A diet based around ramen isn’t going to hurt me.” The thirty year old says “I’m not that old yet. I’ll worry about that next year. Right now, let me enjoy the game. (and the pizza and chips and terrible food that goes with it.) I’ll make it up by cutting the grass tomorrow.” People don’t see that heart disease didn’t start with the heart attack. It started back when mom was deciding what you eat and the school board was deciding when you could go out and play. The choices you and others make over your life time is where heart disease starts. Oh yeah, and the genetics thing too. Some of us just have crappy genes. I had my first major heart event on the playground when I was 7 years old and weighed 28 pounds.

  5. The same “magical thinking” also applies to education. It is solely the responsibility of schools and teachers to raise the educational level & performance of American students & that by spending more and more we will eventually get the outcomes we want, regardless of the motivation of students & their parents.

  6. Ornish’s program is possibly stricter than it ought to be; one might actually do better by eating more healthy fat and ignoring his anti-alcohol beliefs. Those who can’t follow it ought to try following a modified version rather than just giving up and pounding pills. I can affirm that a modified version of the program (sans strict veganism) reversed my husband’s “incurable” heart problems. Although he’s slacked off considerably on the dietary restrictions, we still eat 95% home cooking based on real rather than processed foods, and I don’t think our diet is drastic, miserable, or in opposition to human nature. Home cooking and, gasp, plant foods can be utterly delicious.

    One of the cardiologists who committed malpractice on my husband told him, in attempting to push lifetime warfarin: “I tell my patients if you like steak, eat steak; if you like broccoli, eat broccoli. Just don’t eat steak one week and broccoli the next.” It turned out that this guy specialized in heart transplants. Well, I thought, if you have patients who have such severe heart problems you’re shoving them toward transplants, and they like to eat steak every night, you should tell them they need to jolly well learn to like something else! I don’t know if he is just stunningly ignorant of the benefits of dietary change, or if he holds his patients in such contempt that he presumes they “can’t” eat differently and would rather choose lifetime patienthood and early death than cut the red meat, so there’s no point in giving them the truth. Either way, it made me bitterly angry to contemplate the defeatist message he was feeding his less informed patients.

  7. Thank you! Yes it is BOTH our jobs. But the AMA called obesity a disease, so now obese people are victims of a disease that needs to be treated by doctors. Way to get a free pass.

  8. Dr. M.,

    I appreciate and agree with your perspective on this research. But I want to push back in one direction. There are people in this country who are working hard at two minimum-wage jobs to try to feed a family, who may really not have enough time to devote to their own health. And who may have sources of stress that you and I, as relatively well-off members of society, would have a hard time imagining.

    So while I agree with your push to share the responsibility for heart health between the doctor and patient (and others), for a pretty large segment of our society this is going to be really tough!

    1. That’s true, and such systemic obstacles to good health ought to be addressed (of course, one political party does not want them to be). But I think they are sometimes exaggerated. Relatively healthy staples can be cheaper than processed crud and can be cooked with little active preparation time if you know what you are doing. A small but helpful amount of fresh plant food can be grown almost anywhere for a cost of minutes and pennies per week. Too many Americans don’t even know how to cook a pan of lentils, but I refuse to believe that they are too stupid to learn, because every one of their grandmothers managed it.
      Also, steering people with financial issues toward reliance on medical interventions is a recipe for bankruptcies, as drug side effects lead not to withdrawal of drugs but to more and costlier drugs, and as patients are told that they “need” [there’s that word, Dr. M!] ever more tests and follow-ups. My family has recently suffered substantial financial repercussions from the last pointless echocardiogram my husband will ever submit to – and we were allegedly insured and had savings. A poorer person, not knowledgeable and confident enough to say no, would keep getting tested to financial destruction. I know people who are barely keeping roofs over their heads who continue to shell out for everything their doctors demand because they think if the doctor says it, “you gotta do it.”

  9. They say laughter is the best medicine.

    When I face a 60 year old who was fired because of his age, and his wife has serious medical problems, and his daughter is a drug abuser, and he has to raise two small grand children aged 2 and 4, and his house is being foreclosed, well I tell him not to stress out about stuff, go ride his bike, and shop at Whole Foods and Fresh Market. When he stops laughing, he admits that he really does feel a little better.

  10. When I see the 298 lb guy who works for corporate America, who calls 18 holes of golf three times a week exercise, is looking for his testosterone shots to somehow make his fat magically disappear and swears he doesn’t eat much, I agree with you. But when I see the single mom with two teenage daughters who works customer service for Humana, who barely gets a vacation and if she has to leave work to care for her sick child, she pays for it out of her “Allowed Time Off” (there goes the vacation) I am agreeing with Andy. While we are waiting for corporate culture to change (ROFL) my patients are not looking to extend their telomeres, they are just hoping to survive one more week. That may not be what you intended, but this is what many of my patients would hear.

Comments are closed.