Heather Bedard, C.H.E.
This article will seek to compare the diets, programs, and results of three doctors: Dr. Dean Ornish, Dr. Esselstyn, and Dr. Hans Diehl with CHIP (Complete Health Improvement Program). We will discuss the design of the diets, the research that supports those recommendations and then determine long-term health benefits.
Dr. Dean Ornish
The Ornish Lifestyle Medicine Program is an integrated health program created by Dr. Dean Ornish. This program focuses on four main areas of health - nutrition, stress management, exercise, and love/support. The main intention of the program is to help people reverse and prevent diseases such as heart disease, diabetes, and prostate cancer.
The Ornish diet is a vegetarian diet with some restrictions. The diet is extremely low in fat (10%), low in protein (20%) and higher in carbohydrates (70%). Dr. Ornish insists that these carbohydrates be found in plant form and should not be consumed as processed grains or refined sugars. While sugar is not eliminated, it is not advised. On this program, one should keep added sugars and refined carbohydrates, to no more than 2 servings a day. This advice coincides with a study done in April 2014 that shows a strong association between the intake of added sugar and cardiovascular disease.[i] The reasoning behind this may be that sugar has an effect on blood pressure and lipid levels which can cause cardiovascular damage.[ii]
While non-dairy items are preferred, non-fat dairy is allowed at up to 2 servings a day. The point of consuming non-fat dairy as opposed to full fat is presumably to keep fat intake at a minimum (below 10%) reducing the chance of elevating serum cholesterol levels.
While some studies are mixed on the validation of restricting various types of fats, the preponderance of evidence shows that diets that are high in saturated fats contribute to cardiovascular disease.[iii] According to Dr. Ornish, dietary cholesterol should be limited to 10mg a day. Unfortunately for participants, just one cup of non-fat milk contains 4 mg of cholesterol and the fat content is usually substituted for high amounts of added sugar. Which, as stated above, can contribute to cardiovascular damage as well as the risk factors associated with weight gain. The added danger of weight gain is exemplified in a study on 774 Finnish men who showed acceleration of pre-clinical atherosclerosis with weight gain.[iv]
Meat is eliminated on this diet because it is highly associated with multiple cardiovascular issues as shown in a study on the impact of chronic dietary red meat, white meat, or non-meat protein on trimethylamine N-oxide metabolism and renal excretion in healthy men and women.[v] In concert with its extremely low allotment of animal products, the Ornish diet also allows egg whites and not eggs in their whole form. In view of the understanding that this diet is recommended for people seeking to reverse heart disease, the whole egg wouldn’t be advised due to the fact that the cholesterol found in eggs is sourced from the yolk.
There are no caloric restrictions on this diet, however, this diet is highly successful for people looking to lose weight as demonstrated in a study of participants using the Ornish program (Multi-center Lifestyle Demonstration Project).[vi] Because foods are eaten in their whole, natural form, participants eat a lot more fiber than what is found in the standard American diet and feel full much faster while eating less calories. There are also no restrictions on the types of fruits, vegetables, grains and legumes that can be consumed. One small limitation would be high fat nuts and seeds such as almonds, pistachios and flax seeds. These are kept to a minimum because of their concentrated fat levels. The program recommends two servings of less than 3 grams of fat. This would be the equivalent of 4 cashews or 5 almonds per serving. These high fat items are allowed primarily because of their other cardio-protective elements.[vii],[viii] Studies on this, however, are inherently difficult to do and have limitations such as study design and confounding factors. On this diet, your 10% daily intake of fat will come from naturally occurring fats in vegetables and grains.
The Ornish Program seeks to promote a more restful and peaceful way of life and for this reason it limits caffeinated beverages. For example, coffee is limited to 1 cup per day and caffeinated teas to 2 cups per day. Caffeine can raise blood pressure for a short period so if you are hypertensive, intake should be considered carefully with a doctor according to a systematic review and meta-analysis of hypertensive subjects.[ix] The Ornish Program also recommends that alcohol be limited to one serving, which according to their guidelines is 1.5 ounces liquor, 4 ounces wine or 12 ounces beer. According to one randomized controlled study, alcohol was associated with higher blood pressure in normotensive men.[x]
In addition to the diet component of these programs, the Ornish Program also promotes stress management as a critical part of success in long-term health outcomes. We’ve already touched on caffeine and promoting a more restful lifestyle, but Dr Ornish goes even further and delves deeper into the health risks associated with lifestyle stresses. He suggests that sudden life changes and chronic stress can exhibit themselves with different symptoms depending on the health status of the individual. For instance, chronic stress for someone with heart disease might express itself in chest pain, chronic headaches, and irritability. Many studies show that stress does affect the cardiovascular system and it can increase inflammation and coagulability as demonstrated in a study on 108 healthy men and women in 2007.[xi] For a person struggling with weight, stress may show up as isolation, overeating, or exhaustion. A meta-analysis of studies up until 2011 show a 1.5-fold increase of risk of CHD in adults who experience social isolation[xii] while another meta-analysis of 148 studies show that the quality of social relationships is inversely related to mortality[xiii]. On the Ornish Program, reducing or managing stress is accomplished through meditation, deep breathing, and yoga. Thirty years of research proves the veracity of managing stress through meditation according to a systematic review and meta-analysis of randomized control trials done in March 2021.[xiv] Additionally, a growing body of randomized control trials support the use of yoga in managing cardiac function.[xv]
Another very important element in health outcomes would be to incorporate exercise. The frequency and type of activity is determined by the health goals of the participant, but on average, the Ornish Program recommends 3-5 hrs. of anaerobic activity per week in addition to strength training 2-3 times a week. A Turkish study on physically active young men showed that anaerobic activity increased the secretion of CNP (C-type natriuretic peptide), which is protective for the endothelium, and in turn, benefits the cardiovascular system.[xvi] Likewise, a secondary analysis of a 12-week randomized clinical trial showed resistance training to reduce pericardial adipose tissue mass by 32%.[xvii]
Lastly, love and support are another foundational pillar to achieving optimal health success on this diet. Studies have shown that people who are in community together live longer than those who do not. One study on 430 patients with Coronary Artery Disease showed that they had an elevated risk of mortality when isolated.[xviii] Consequently, the Ornish Program promotes fluent listening and communication skills to help their participants to be successful in their relationships. This, combined with other therapeutic counseling efforts, can give people the edge they need to succeed in their health across the board.
Despite strong evidence for the success of this diet, there are a few limitations that can be found. Dairy and eggs are still allowed in moderation. Although the dairy in question should be non-fat, another factor that should be taken into consideration is the protein level. This pertains to the use of egg whites as well. With a plant-based diet such as this one, participants would benefit from removing the animal products completely and consuming this protein from plant sources.[xix] This level of intensity would likely be determined by their current health status and the diseases they are looking to reverse. A cohort with 16 years of observation of 237,036 men and 179,068 women, found that an increase in plant protein was significantly associated with lower overall and cardiovascular disease mortality.[xx] Moreover, the Ornish Program also recommends a multi-vitamin, which may not be necessary on a plant-based diet. A study on the effects of Carnosine and Anserine on the Destruction of Vitamin B12 with Vitamin C in the Presence of Copper, showed that any benefit of vitamin B12 was destroyed when combined with these elements.[xxi] Unfortunately, these elements are traditionally part of a multi-vitamin. Most vegetarians or vegans would benefit from supplementation with a B12 vitamin alone.[xxii] Fish oil and calcium supplements are recommended as needed; however, studies show that these are not necessarily health promoting. For example, a systematic review and meta-analysis of 20 studies including 68,680 people showed that supplementation with Omega 3 offered no reduction of risk of mortality from all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke.[xxiii] Calcium is no better as shown in 15 randomized placebo-controlled studies of participants taking calcium supplements. These studies showed an increased risk of myocardial infarction with supplementation.[xxiv] Participants in the Ornish program can easily get their RDA of calcium from plants. While fats are limited, some other oils such as flaxseed, olive, and canola are allowed. Flax seed and Canola oil have the lowest levels of saturated fat but still contain 120 calories in just 1 tablespoon and should be eaten with caution. Eating even a very small amount of oil and then having some nuts would easily put you over the recommended threshold for fats. Understanding that this diet is used extensively for patients with heart disease, allowing for added fats could prevent some people from seeing the amount of benefit they would like.
CHIP
Developed by Dr. Hans Diehl, CHIP (Complete Health Improvement Program) is a lifestyle change program created to prevent, treat, and reverse chronic disease. The diet portion of this program is best described as a whole food, plant-based diet that does allow some meat but recommends restricting it. However, one can eat as many fruits, grains, legumes, and vegetables they want, as long as they are mindful to keep fat to below 20% of their daily caloric intake. The high fiber of the plant foods along with their low calorie make up helps participants to lose weight while not feeling as restricted as they would on many other diets. A systematic review of the effect of fiber on satiety and food intake showed that 22% of the participants reduced their food intake and 39% reported lowered appetite with the consumption of different types of fiber.[xxv] Additionally, fiber is also associated with reduced risk of many different diseases including diabetes and cancer; primarily when it’s consumed as a part of a whole food.[xxvi]
It is suggested to drink at least 84oz of water daily on the program and to eliminate what are described as “risky substances”. These risky substances would include alcohol, smoking, drugs and caffeine. The research seems to support this. A combined analysis of participant data for 599,912 current drinkers in 83 prospective studies showed no threshold at which low alcohol consumption mitigated risk of cardiovascular issues.[xxvii] Furthermore, a prospective cohort study on one million women in the UK showed that women who stopped smoking before age 40 could reduce their excess mortality by 90%.[xxviii] No specific amount of caffeine is allowed so it is assumed that both coffee and caffeinated teas are eliminated together. One of the pillars of this program is sleep, perhaps explaining why caffeine is eliminated. While many mechanisms of action are acknowledged, caffeine has been shown to reduced total sleep time and sleep efficiency and worsened perceived sleep quality in those who consume it as shown in a systematic review of epidemiological studies and randomized controlled trials in 2017.[xxix] Added sugar should be reduced to 10 teaspoons and cholesterol limited to 50g per day. Although 10 teaspoons of added sugar a day is less than half of what the average American eats daily, studies still show that added sugar increases the risk of cardiovascular disease.[xxx]
There are 6 different components of this program, including diet. The others are activity, sleep, social connection, risky substances, and stress management. The program advocates that all of these components together will produce the greatest health results. For instance, a large-scale 3-year cohort study shows an association between weight gain, obesity, and sleep duration.[xxxi] Although stress management studies can be subjective, the greater preponderance of data shows that stress management can reduce cholesterol. One such association is found in a study on job stress and dyslipidemia. That study found that occupational stress was associated with high LDL and low HDL levels.[xxxii] Social connection can be highly influential on long-term health physically as well as mentally. Participants in the longitudinal study, “Social Relationships and Physiological Determinants of Longevity across the Human Life Span” showed that social isolation increased the risk of inflammation just as much as physical inactivity and that the effect of social isolation on high blood pressure was even greater than that of the risk of diabetes in old age.[xxxiii]
One of the limitations on this diet would be its restriction of sodium. Although no specification of what constitutes a “low” amount is given, studies have shown that low salt can be just as detrimental to blood pressure and cardiovascular events as is high salt intake.[xxxiv] One such study is a Cochrane review of a meta-analysis of randomized control trials on the reduction of dietary salt for the prevention of cardiovascular disease.[xxxv] The studies actually showed no certain effect of salt reduction on CVD in people with normal blood pressure. Another limitation is that depending on the reasons for participating in this program, caffeine restriction could be considered more or less useless. In a systematic review and meta-analysis on the effect of caffeine on blood pressure and cardiovascular disease in hypertensive individuals, caffeine slightly raised blood pressure for 3 hrs. following consumption.[xxxvi] The effect thereafter was significantly lessened. Lastly, the daily allowance for fat is still pretty high allowing for 20% (or 44g) on a 2,000-calorie diet. Participants who are concerned about cardiovascular health should be aware of what fats they are ingesting (animal vs plant) and how these fats are affecting cholesterol levels. Cholesterol is not found in plants so any added cholesterol in the diet (up to 50g on this diet) would have to come from animal foods. Increasing dietary cholesterol increases serum cholesterol as shown in a study of 6 men ages 41-52.[xxxvii] This in turn raises the risk of cardiovascular disease as shown in a review of the relationship of baseline serum cholesterol levels in 3 large cohorts of younger men.[xxxviii] Some of these recommendations could prove confusing for some participants.
Dr Esselstyn
Dr. Esselstyn’s diet seems to be the most restrictive of the three diets we are comparing. This program differs from the other programs in that it focuses exclusively on diet. There are varying degrees of intensity on this program. If you have heart disease you will eat exclusively plant based - no meat, no oil, and no nuts. If you are just looking to increase your current health status, you will still eat exclusively plants (vegan) but you can have a small amount of nuts or avocado added to your diet still staying below 10% of fat in your daily caloric intake. There are no calorie restrictions.
In contrast to the other programs we have looked at, animal products are completely eliminated. In addition to the variety of limits outlined in previous programs on animal consumption, one important reason for eliminating animal products is that animal protein has been associated with an increased cancer risk due to the way it increases IGF-1 levels.[xxxix]
What’s more, Dr. Esselstyn goes further and asserts that plants must be chewed and not drunk in smoothie form. His reasoning lies in the effects of chewing on bacteria levels in the mouth, digestion, and the separation of fiber from fructose. Most studies on this type of dietary claim are subjective and more research needs to be done. However, some studies do point to the idea that liquid vs solid meal replacements effect postprandial appetite and food intake in older adults[xl] and that mastication has an effect on food intake, satiety, and body weight.[xli]
Unlike his colleagues, Dr. Esselstyn does not allow for oils at all because they are high in calories and contain no fiber and no minerals. A clinical study done on the postprandial effects of components of the Mediterranean diet showed that olive oil reduced flow mediated vasodilation (FMD) by 31%.[xlii] Likewise, a randomized control trial on the effect of olive, soybean and palm oils on endothelial function in healthy, young subjects further shows that regardless of the type of oil, oil reduces FMD by at least 30%.[xliii]
No recommendations are made regarding adding supplements and instead Dr. Esselstyn advocates for eliminating fish oil and calcium supplements from the diet.
One of the greatest limitations on this diet is the level of adherence that one must keep to succeed. If someone was at a low risk for disease, they may find it difficult to stick to this diet long-term.
Comparisons
Overall, these three diets are very similar in their emphasis on eating plants, not restricting calories and confidence in the body to heal itself. On the outset there are minor differences in the percentages of fat on the Ornish (10%), CHIP (20%), and Esselstyn (none) diets as well as allowances of added cholesterol (10mg, 50mg, none – respectively). Esselstyn allows no meat or animal products while the others restrict but don’t eliminate meat and other animal products. Both the Ornish Program and the CHIP diet allow for supplementation but Dr. Esselstyn does not recommend any supplements with the exception of testing for vitamin D levels.
While each program claims efficacy and the importance of strict adherence, many of the studies they cite include self-reported data, small sample size, or are performed by the program itself. Keeping this in mind, each program compares as the following:
In a prospective, randomized, controlled trial on 28 participants in the Ornish Program, 82% of patients showed a regression of coronary atherosclerosis after 1 year.[xliv] Additionally, after 5 years a randomized controlled trial of 48 patients with coronary heart disease had a 71% completion rate and reduction of coronary atherosclerosis in the intervention group; showing that the program also has long-term effectiveness.[xlv]
Dr. Esselstyn’s program includes a study of 22 participants, 11 of which dropped out by 5.5 years. Of the 11 that remained, all saw reduction of cholesterol and no new infarctions.[xlvi] This shows that although the program is extremely difficult to adhere to, patients will see results and regression of heart disease long-term.
In a randomized clinical trial of the CHIP diet with 337 participants age 43-81 years, researchers showed clinical improvement in cholesterol, blood pressure, and glucose levels.[xlvii] Additionally, in a cohort study of 284 individuals on the CHIP program, 37% participated in a follow up health assessment after 4 years.[xlviii] All participants were able to show a reduction in BMI and blood pressure showing that this program too can offer long term health results for a variety of different health measurements.
Dr. Ornish and Dr. Esselstyn have the highest retention rate after 5 years of 50-71% while CHIP is the lowest of the three programs with a 37% retention rate after 4 years. Although this is the lowest retention percentage, the amount of people participating in the study is 30-40% more than the studies of the Ornish Program or Dr. Esselstyn. All three show improvements of biomarkers for cholesterol, heart disease, and blood pressure. Both the Dr. Esselstyn and Dr. Ornish studies state that the participants who went back to their original diet plan or tried a more conventional lifestyle and diet change program had some type of coronary event or progression of disease. Specific percentages are not mentioned. Two main take-aways from these comparisons would be that sustaining an optimal diet apart from lifestyle changes can and will reverse disease progression and that if one had to choose based on average retention rate (sustainability), the most likelihood of success would predominantly be found in Dr. Esselstyn’s or Dr. Ornish’s group.
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