Best Heart Health Diet? Ornish, Esselstyn, CHIP

Heather Bedard, C.H.E.

This article will seek to compare the heart health 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 should be found in their natural, plant-based 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 aligns with a study conducted in April 2014, which shows a strong association between the consumption 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 in moderation, up to 2 servings per day. The primary benefit of consuming non-fat dairy over full-fat dairy is presumably to minimize fat intake (below 10%), thereby reducing the risk of elevating serum cholesterol levels.

While some studies are mixed on the validation of restricting various types of fats, the preponderance of evidence suggests that diets 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 nonfat milk contains 4 mg of cholesterol, and the fat content is often replaced with 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 of 774 Finnish men, which showed an 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, it 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 consume a significantly higher amount of fiber than is found in the standard American diet and feel full much faster while consuming fewer calories. There are also no restrictions on the types of fruits, vegetables, grains, and legumes that can be consumed.

One small limitation is the high-fat content of nuts and seeds, such as almonds, pistachios, and flax seeds. These are kept to a minimum due to their high fat content. The program recommends two servings of less than 3 grams of fat per day. This would be the equivalent of 4 cashews or 5 almonds per serving.

These high-fat items are allowed primarily due to their other cardio-protective properties.[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 aims to promote a more restful and peaceful way of life, and for this reason, it restricts the consumption of 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 limiting alcohol to one serving, which, according to their guidelines, is 1.5 ounces of liquor, 4 ounces of wine, or 12 ounces of 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 emphasizes stress management as a crucial aspect of achieving 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 have shown that stress affects the cardiovascular system, increasing inflammation and coagulability, as demonstrated in a 2007 study involving 108 healthy men and women.[xi] For a person struggling with weight, stress may show up as isolation, overeating, or exhaustion.

A meta-analysis of studies up until 2011 shows a 1.5-fold increase in the risk of CHD in adults who experience social isolation[xii], while another meta-analysis of 148 studies shows 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 have proven the veracity of managing stress through meditation, according to a systematic review and meta-analysis of randomized controlled trials conducted in March 2021.[xiv] Additionally, a growing body of randomized controlled trials supports the use of yoga in managing cardiac function.[xv]

Another very important element in achieving health outcomes is incorporating exercise. The frequency and type of activity are determined by the participant's health goals, but on average, the Ornish Program recommends 3-5 hours of aerobic activity per week in addition to strength training 2-3 times a week.

A Turkish study on physically active young men found 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 that resistance training reduced 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 individuals who live in a community together tend to 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 its participants succeed in their relationships. This, combined with other therapeutic counseling efforts, can give people the edge they need to succeed in their overall health.

Despite strong evidence of the success of this diet, several limitations can be identified. 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 also applies to the use of egg whites.

With a plant-based diet, participants would benefit from eliminating animal products entirely and obtaining 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 multivitamin. 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. Flaxseed and Canola oil have the lowest levels of saturated fat, but still contain 120 calories in just 1 tablespoon, and should be consumed with caution. Eating even a very small amount of oil and then consuming some nuts would easily put you over the recommended threshold for fat intake.

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, the CHIP (Complete Health Improvement Program) is a lifestyle change program designed to prevent, treat, and reverse chronic diseases. The diet portion of this program is best described as a whole-food, plant-based diet that allows some meat but recommends restricting it.

However, one can eat as many fruits, grains, legumes, and vegetables as they want, as long as they are mindful to keep fat to below 20% of their daily caloric intake. The high fiber content of plant foods, along with their low calorie count, helps participants lose weight without feeling as restricted as they would on many other diets.

A systematic review of the effect of fiber on satiety and food intake found that 22% of participants reduced their food intake, and 39% reported a 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 recommended to drink at least 84 oz of water daily on the program and to eliminate substances 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 the 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, which may explain why 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 reduce total sleep time and sleep efficiency, and worsen perceived sleep quality in individuals who consume it, as reported in a 2017 systematic review of epidemiological studies and randomized controlled trials.[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 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 of this diet is its restriction on 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 controlled 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 was found to slightly raise blood pressure for 3 hours 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 their cardiovascular health should be aware of the types of fats they are consuming (animal vs. plant) and how these fats affect their 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 aged 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 appears to be the most restrictive of the three diets being compared. This program differs from the other programs in that it focuses exclusively on diet.

There are varying degrees of intensity in this program. If you have heart disease, you will eat exclusively plant-based - no meat, no oil, and no nuts. If you are looking to improve your current health status, you can still eat exclusively plant-based (vegan) foods, but you can also incorporate a small amount of nuts or avocado into your diet, while still keeping your daily fat intake below 10%. 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 risk of cancer due to its ability to increase 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 further research is needed. However, some studies suggest that liquid versus solid meal replacements may affect postprandial appetite and food intake in older adults[xl], and that mastication has an impact 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 or minerals. A clinical study examining the postprandial effects of Mediterranean diet components found 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 of this diet is the level of adherence required to succeed. If someone is at a low risk of disease, they may find it challenging to adhere to this diet long-term.

Comparisons

Overall, these three heart health diets share a similar emphasis on consuming plants, avoiding calorie restriction, and trusting the body to heal itself.

At first glance, 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, and 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 sizes, or are performed by the program itself.

Keeping this in mind, each program compares as follows:

In a prospective, randomized, controlled trial involving 28 participants in the Ornish Program, 82% of patients demonstrated 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 whom dropped out by 5.5 years. Of the 11 that remained, all experienced a reduction in cholesterol levels, and no new infarctions occurred.[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 involving 337 participants aged 43-81 years, researchers demonstrated clinical improvements 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 rates after 5 years, ranging from 50-71%, while CHIP has the lowest of the three programs, with a 37% retention rate after 4 years. Although this is the lowest retention percentage, the number of participants in the study is 30-40% higher than in the studies of the Ornish Program or Dr. Esselstyn.

All three show improvements in heart health 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 takeaways from these comparisons are that sustaining an optimal diet, apart from lifestyle changes, can and will reverse disease progression, and that, based on average retention rates (sustainability), the most likely success would predominantly be found in Dr. Esselstyn’s or Dr. Ornish’s group.

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Sources:

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