However, I have some concerns about his new book, " The South Beach Heart Program ," which claims to “detect, prevent and even reverse heart disease.” It’s based on the only published research study he authored on his program which, surprisingly, showed that LDL (“bad”) cholesterol levels did not come down significantly at all on this diet. Also, the South Beach Diet has never been shown to reverse the progression of coronary heart disease and may be too high in saturated fat and cholesterol to prevent heart attacks for many people unless a lifetime of cholesterol-lowering drugs are added.
These drugs can be useful, but they are expensive and, like all drugs, have side effects, both known and unknown. Although statins are of proven benefit in those with coronary heart disease, an article in the current issue of The Lancet raises questions about how effective statins are in preventing coronary heart disease in those who do not yet have it.
I recently interviewed Dr. Agatston and asked him to respond to these concerns. Excerpts:
Dean Ornish: Let me start by saying how much I admire your commitment to preventive cardiology, especially the pioneering and visionary work you’ve done with heart CT scans for early diagnosis of heart disease.
Arthur Agatston: It’s clear that the presence of plaque is a much better predictor of future heart attack and stroke than any risk factors. A really natural cholesterol is a super-low one—150 mg/dl or less—the way pre-industrialized societies are. If you start with diet and exercise at an early enough age, you can achieve these levels and nobody has [cardiac] events. But the later you start, after years of a typical Western diet, the harder it is to achieve this with diet and exercise alone, so I take Lipitor.
Ornish: We agree about the benefits of lowering cholesterol levels below 150 mg/dl—but not that drugs are usually necessary to accomplish this. Patients in our research (abstracted here and here who made more intensive changes in diet and lifestyle had a 40 percent average reduction in their LDL-cholesterol in one year, and none of these patients was taking cholesterol-lowering drugs. These reductions in LDL are comparable to what can be achieved with Lipitor, but without the costs and potential side effects.
Most of these patients reversed the progression of even severe coronary heart disease. Older patients improved as much as younger ones. Studies by other researchers with nutrition much lower in fat and cholesterol than the South Beach Diet have also shown similar results.
In contrast, there are no studies showing that the South Beach Diet can reverse or prevent heart disease. You’ve only published one research study looking at the effects of the South Beach Diet . You reported that LDL-cholesterol levels did not come down significantly on the South Beach Diet. Yet this is the diet you recommend for heart patients.
You also reported that patients on the South Beach Diet lost more weight after 12 weeks than those on the National Cholesterol Education Program (NCEP) diet. Did you follow these patients for a longer period of time to see if they kept the weight off?
Agatston: No. We only did the short-term study.
Ornish: As you know, it’s easy to lose weight on almost any diet; keeping it off is the problem. Studies of the Atkins diet showed that they lost more weight after 12 weeks, but these differences were not significant after one year.
I don’t think everybody needs to be on a very low-fat, whole-foods diet, which is the most common misconception about my work. If you have high cholesterol levels, you can start by making moderate changes, such as a South Beach Diet or NCEP diet. If that’s enough to bring your LDL-cholesterol down sufficiently, great, but for most people, it isn’t.
At that point, I give patients a choice, as I wrote about in one of my other NEWSWEEK columns. Instead of telling them, “Diet didn’t work, now we have to put you on cholesterol-lowering drugs the rest of your life,” I say, “You have options. It’s your choice. I can prescribe medications, or you can make bigger changes in diet and lifestyle.” We go over the risks, the benefits, the costs and the side effects of drugs versus more intensive changes in diet and lifestyle, and I support whatever the patient chooses.
Agatston: Some people will respond to a more restrictive diet, and certainly some people will dramatically bring down their LDL with restriction of saturated fat. But others don’t. And once people are at high risk or have coronary disease, and we have medications that will decrease LDL dramatically, I feel like I have to use those. There’s so much evidence for the benefit of medication, it would be unethical for me not to offer a high-risk patient the medication.
Ornish: I often prescribe statin drugs for patients who are not willing to make bigger changes in diet and lifestyle or to the relatively few patients who don’t respond to these changes. But I think they should be given the option to make more intensive changes in diet. You wouldn’t put someone on Lipitor whose LDL was already very low.
Agatston: No.
Ornish: I doubt that most readers of “The South Beach Heart Program” realize that the South Beach Diet won’t significantly lower their LDL-cholesterol. If you give Lipitor on just about any diet, the LDL is going to come down; but the question is: what is the healthiest way of eating for those with heart disease? Wouldn’t it make more sense for people who have diagnosed heart disease or whose cholesterol levels don’t respond to the South Beach Diet to make bigger changes in diet than those you recommend? You don’t offer more intensive diets as an option in your book.
Agatston: I guess that’s my experience in just my rates of success—that I just feel more successful making the moderate changes. Maybe I haven’t spent the time that you have in the belief that I can be as successful with it as with our approach. There’s a concern that I would lose too many patients who maybe can’t do it as well.
Ornish: I never tell people that they have to change their diet. Whether or not someone wants to make more intensive changes in diet and lifestyle is a personal decision. However, if doctors tell their patients, “In my experience, most people are not likely to make bigger changes in diet and lifestyle, so here’s a cholesterol-lowering drug that will lower your LDL,” then it becomes self-fulfilling.
We have data from more than 3,000 patients that we’ve trained at 40 hospitals across the country as part of three demonstration projects with Mutual of Omaha, Highmark Blue Cross Blue Shield and Medicare. We found that many patients were able to make and maintain comprehensive lifestyle changes—not only in San Francisco and New York but also in Omaha, W.Va., and Columbia, S.C., where they told me, “Gravy is a beverage.”
Studies have shown that two thirds of the people prescribed Lipitor are not taking it just four months later. So, the idea that taking a pill is easy and everybody will do it, but making bigger changes in diet and lifestyle is difficult, if not impossible—the evidence doesn’t really support that.
I think we need to distinguish between what’s easy and what’s optimal. Quitting smoking is hard, but we don’t tell people just to smoke less because it’s too hard.
Agatston: I understand. I guess it is an orientation of both my experience and what I believe is achievable in most of my patients and even losing the patient to follow-up.
Ornish: In your new book, you mentioned that President Bill Clinton had been on the South Beach Diet at the time he was diagnosed with severe coronary heart disease—what happened?
Agatston: He read my first book, but he wasn’t my patient. On the diet, he went to his high-school weight. This was an important step in the right direction, but not enough to undo the past damage. He also continued to take the statin drug Zocor for many months, but, like many people, he unfortunately stopped taking it as soon as his cholesterol dropped to an acceptable level due to the combination of weight loss and medication.
[On another note], I’m also impressed with things like the Lyon heart trial [which showed a] dramatic decrease in [coronary] events with essentially [adding] a canola oil spread [to one’s diet].
Ornish: I agree that the Lyon Heart Study showed that omega-3 fatty acids in canola or fish oil can dramatically decrease cardiac events and reduce inflammation. That’s why I’ve been recommending for many years that most people take 3 grams per day of fish oil or equivalent, which provides all of the omega-3 fatty acids that you need.
Agatston: I’m not at all opposed to what you’re doing with high-risk people in severely restricting saturated fats, and we do talk about it with individuals. It’s also partly because the way my diet evolved is oriented to the general population and what’s achievable.
Ornish: Yes, but people with heart disease may need to do more. We agree that too many refined carbohydrates are not healthful. But phase 1 of the South Beach Diet in your new heart book, as well as many of your frozen Kraft South Beach Diet entrees, includes significant amounts of ground beef, sirloin, pastrami, London broil, sirloin steak, T-bone, pork loin, boiled ham, Canadian bacon, veal, lamb, and lunch meats—for the general population it’s one thing, but are these the most heart-healthy foods for those with heart disease?
Agatston: To me, the idea is we need more omega-3 in our diet, but we were born to consume meat as well. So it’s to have meat as lean as possible and to make up the deficit that you’re getting more omega-6 than you want with making sure you get the good oil. Have lean sources of protein in general—fish, chicken without the skin and lean cuts of meat. Not that having meat—even lean cuts—every night is good for you. We prefer chicken and as lean meat as possible. I feel we evolved as hunter/gatherers where game meat is healthy. If you’re having relatively fatty cuts of meat with a lot of saturated fats—that I am against.
To me, the whole epidemic of obesity is mainly the refined carbohydrates and trans fats.
Ornish: We agree that too many refined carbohydrates are a significant factor in the obesity epidemic. But fat also plays a role, because it’s so dense in calories—9 calories per gram, versus only 4 for protein and carbohydrates.
Those without heart disease have a spectrum of choices that may include all foods depending on their goals and needs, but those with heart disease usually need to be more careful.
To conclude, can we say that we agree that an optimal diet for those with heart disease is lower in both refined carbohydrates and fat—especially saturated fat and trans fatty acids—and higher in “good carbs” such as fruits, vegetables, whole grains, legumes, soy products and other low-glycemic/high-fiber foods, with 3 grams a day of fish oil or equivalent?
Agatston: Yes. Absolutely. And again, that’s something we do recommend for patients who have high LDL’s who don’t want to take the drugs or can’t take the drugs. We do talk about more restricted saturated fat in those people. In future books, putting that in would be very reasonable. I have great respect for what you’ve done. You started when it was tougher than for me to buck the establishment. I will look at our patients and see which ones are willing to do it. But I’m quick with the statins.
