It's enlistment day at cardiac boot camp.
Survivors of heart attacks, strokes or bypass surgery have trooped in from around the world to the stately old Claremont Resort and Spa in the hills above Oakland because they are dying.
And if there is one thing every decent, self-respecting heart patient knows by now it's that you have to reckon with Dr. Dean Ornish.
So 109 mostly middle-aged recruits, or in a few cases their insurers, have paid $3,600 each to learn a completely new way of living. Over five rigorous 7 a.m.-to-10 p.m. days, they will buy into a program that they and many others believe is their last best hope to prolong life.
As a speaker who routinely draws crowds of more than a thousand people in places like Ames, Iowa, and author of several landmark research papers and best-selling books, Ornish fits the description of a guru.
And the 42-year-old Sausalito internist is a credible guru. His Heart Disease Reversal Program--in which an austere diet combines with exercise, stress management and psychosocial support to reverse blockages in the coronary arteries--has proven to be scientifically valid.
"But we don't look at him as a god or anything," protests a veteran Ornish research patient, a man who has adhered to the regimen for nine years.
"No, merely a saint," chimes in another vet.
Ornish is so popular that the stalwart establishment of cardiovascular medicine has been forced to reckon with him too. And although dozens of patients attending the Residential Lifestyle Retreat here were dispatched by their cardiologists, many in the field remain skeptical about or downright hostile to the Ornish approach. Even amid wide acceptance that it can slow or reverse the progression of heart disease, naysayers began arguing as early as 1983 that the plan is too forbidding for most people.
And now, a newer criticism suggests the high-carbohydrate Ornish diet is all wrong.
But Dean Ornish is used to deflecting brickbats. And tonight, as he presides over the opening banquet of 10%-or-less-fat stuffed zucchini, steamed rice, and mushroom and spinach lasagna, he comes across as self-effacing and, despite a distant history of severe depression, greatly at peace with himself.
"It amazes me to see how this program is evolving and growing," he says in a soft, therapeutic speaking style that puts people visibly at ease. "I think I have the world's best job, because I love what I do."
As the patients sip their tomato consomme, Ornish urges them to participate in everything: two sessions per day of stress management, one hour of exercise, private counseling with a physician, lectures and a group support meeting in the evening. The special meals, prepared under the watch of Ornish's French chef, will be served at 8:15, 12:30 and 6.
"We're not going to be police," he says. "We're not going to monitor you. There are three restaurants here. There is room service. They are all available to you. But you'd be missing out on the real power of this experience to [cheat]."
After a dessert of strawberry crepes and perhaps their final cup of real coffee ever, the patients, many of them so sick that a defibrillator is kept on hand, disperse in an upbeat mood. Donna Johnson, 53, of Ben Lomond, Calif., is glowing. She has read two of Ornish's four books and followed his diet for several years. "I didn't expect for Dean Ornish to actually be here," she gushes. "He's just like I thought he would be!"
The strength of that response may be flattering, but it also fuels the critics who believe that only Ornish can inspire such success. The question now is, can the Heart Disease Reversal Program transcend its magnetic founder? Will it work without his healing touch?
After 19 years of research, Ornish wants that to happen. He hints that he's ready for a change and a chance to devote his abundant energy and 16-hour workdays elsewhere. He talks about studying the reversal of early-stage prostate cancer through a holistic approach and about getting remarried and having children. He was divorced in 1994 after a brief marriage to a physician whom he met when both were in medical school.
Back then Ornish was a brilliant and precocious student at Baylor College of Medicine in Houston. In 1977 he first proposed that lifestyle changes could reduce heart disease--a heretical idea in cardiology.
His first two studies, conducted at Baylor and during his internship at Massachusetts General Hospital, showed so much promise that the latter appeared in the Journal of the American Medical Assn. and led to "Stress, Diet & Your Heart" (Holt, Rinehart & Winston, 1981). Ornish was 27.
Recognizing that he was on a track that would challenge the tenets of cardiology, Ornish set up shop--the Preventive Medicine Research Institute--in the most unlikely place possible, laid-back Sausalito, and began a project in which he followed 48 patients for a year. Half of them were assigned to the Ornish plan, which called for classes several times a week in nutrition, exercise and stress management, as well as support group meetings.
That study, published in 1990, used cardiac PET scans to show that Ornish's patients had small but significant reductions in the blockages in their coronary arteries. Meanwhile, the other 24 patients on a traditional 30% fat diet all had more blockage. Ornish's resulting book, "Dr. Dean Ornish's Program for Reversing Heart Disease" (Ballantine Books, 1990), has sold more than 600,000 copies.
The work has made Ornish one of the few practitioners to successfully test an Eastern style of health care, which focuses on holistic healing, using traditional, Western scientific methods, notes Dr. Fred Guggenheim, an Arkansas psychiatrist, over a lunch of veggie burgers, rice salad and baked French fries at the Claremont. Guggenheim had a heart attack in September and, soon after, called Sausalito to sign up for the retreat.
"Ornish has had so much vision. He went the traditional, organizational route to give credence to the holistic approach. Internists want numbers, numbers, numbers," Guggenheim says.
But is Ornish the only one who can pull off the numbers?
So it would seem, judging by evidence presented at the annual gathering of the American Heart Assn. last fall in Anaheim.
When scientists from the Cleveland Clinic Foundation were called to present data from their attempt to replicate Ornish's landmark study, researcher Marsha F. Lowrie said hesitantly from the podium that they had none.
After nine months of intensive recruitment, the Cleveland team had managed to enroll only three patients. The many candidates who declined said they were interested only in the diet or didn't have time for such a disciplined regimen of exercise and stress-reduction classes.
Concluding her remarks with the comment that perhaps the Ornish plan wasn't very practical, Lowrie was stunned when the audience of cardiologists and cardiac nurses responded in a kind of collective amen.
"There is an assumption that Ornish's plan works for people who don't live in Sausalito," one doctor complained sarcastically.
"This study certainly validates what nurse-practitioners believe," said a nurse in the audience.
"We promise patients things we really can't deliver," added another cardiologist.
But Lowrie believes Ornish is straightforward about how tough his program is. "If you read his books, you can see what he is telling you to do. He doesn't hide it," she says. "But you have to be a very special kind of person to do the diet. No meat. No fish. No chicken. No dairy. I tried it for a week myself and I couldn't do it. I was hungry all the time. I quit at six days."
Undaunted, Ornish has set out to show that his magic has wings. Two years ago, he began establishing his protocol at eight medical centers across the country.
"The questions we're trying to answer are: Can we train other health professionals to do what we do? And can they, in turn, motivate their patients?" Ornish says. "I mean, I don't even know most of those patients. I haven't even met those patients!"
No data from the national study, which is being compiled independently by a Harvard doctor, have been published. But Ornish says that 90% of the hundreds of participants are adhering to the plan.
The results should quiet some of Ornish's critics, says Dr. Ronald Krauss, a UC Berkeley cardiologist and chairman of the American Heart Assn.'s nutrition committee.
"I think it will help in two respects: One is to show that physicians other than Dr. Ornish can motivate people to follow this rather extreme program for extended periods of time. No. 2, it would suggest that there is a larger population that could benefit than the few that he has reported on."
But, Krauss says, some doctors complain that Ornish's studies fail to identify which components--diet, exercise, stress reduction, social support--have a clinical impact.
"It would be particularly welcome if you could extrapolate his findings to the larger field," Krauss says, noting that most cardiac rehab programs are less comprehensive. "Ornish stands to benefit a lot if his program were approved [by insurers]. But it's not at all clear that one has to be as extreme as his program dictates."
Indeed, the AHA urges Americans to aim for a diet of no more than 30% fat. The typical U.S. diet is about 40% fat.
Even Ornish's longtime collaborator has decided that the program is too extreme and may even be dangerous.
Dr. K. Lance Gould, a highly regarded, crusty Houston cardiologist who conducted the PET scans for Ornish's studies, is promoting his own lifestyle modification plan that emphasizes a more flexible diet (although it's also about 10% fat) and cholesterol-lowering drugs.
Gould is among a growing number of cardiologists and nutritionists who say that a diet high in carbohydrates (Ornish's diet is about 75% carbohydrate) can--in some people--cause harmful blood fats called triglycerides to surge and levels of the protective HDL cholesterol to fall. Although he last year coauthored with Ornish a study showing dramatic improvements in patients on the Ornish plan, Gould now says, "I think it's quite clear that these people [on high carbohydrate diets] are at high risk for ongoing disease."
Given recent studies on carbohydrate response and the benefits of using cholesterol-lowering drugs, Gould says he felt compelled to distinguish himself from Ornish.
"Dean's a little mad at me right now," he says. "[Ornish's approach] was a good idea to start with. But it is part of my integrity to speak up. Because when the hype is greater than the science it burns all of us."
Sparring publicly with Gould has been unsettling for Ornish, particularly since he believes he helped convert Gould from a surgeon to a cardiologist who relies on surgery only as a last resort. Ornish argues that the increase in triglycerides occurs in diets high in simple carbohydrates, such as sugar, while his plan involves complex carbohydrates, such as whole grains and beans.
"The only thing that concerns me is that [Gould] says his diet is better than what we're doing," Ornish says. "But I think the burden of proof is on them to demonstrate that. This is not the Sermon on the Mount, either. We are always looking for ways to make our program better. And if the data come out showing there are better ways of doing it, then we'll certainly modify ours accordingly."
Ornish has the kind of unwavering self-confidence that makes for a vigorous defense. He is cautious with the media and exerts tight control over his schedule and his message.
But in his books and in conversations with patients, Ornish betrays a vulnerability wrought by a turbulent past. Raised by high-achieving parents who expected greatness from their children, Ornish was stunned to learn as a premed student in Houston that he wasn't the smartest kid around. Questioning his very worth, at 19 he devised a plan to kill himself.
Before he could carry it out, a case of mononucleosis sent him home to his parents' care Dallas. Ornish took antidepressants and entered into psychotherapy, which he continues today. But he says he regained his physical and mental health in large part through yoga and meditation with the spiritual teacher Swami Satchidananda.
"I came about as close to committing suicide as you can without actually doing it," he says. "I've been living on borrowed time since I was 19. Every day is a gift. That perspective allows me to do things that other people might not be able to do. It completely changed my life."
He practices yoga daily as a reminder that "what brings me happiness is already inside me if I'd just stop disturbing it." That outlook, in turn, helps him avoid focusing too greatly on wealth and achievement.
"I've had enough fame and fortune to know that it's fun, but it doesn't bring lasting happiness to me. What really makes me feel good is working with people who are in pain and showing them how they can use that pain as a doorway for transforming their lives in a way that can make a difference.
"I also do this work because it forces me to deal with aspects of myself that I'd like to ignore. I mean, I could make a very nice living just writing books, lecturing and practicing medicine and not have to worry about how I'm going to raise enough money to pay 23 full-time and about 70 part-time staff people."
He is trying to say that he's not such a bad guy, despite the arrows routinely shot his way out of jealousy or legitimate scientific concern.
His brush with death taught him not to obsess about the future. And it is perhaps a tribute to him that, despite his hectic, jet-setting schedule and the unrelenting challenges from critics, he appears serene.
His career, he says happily, "really has all the elements of a great adventure. There are life and death issues. You have your known allies and your known adversaries, and your unknown allies and unknown adversaries. It's remarkable to me to watch it unfold."
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
Dr. Dean Ornish
Native?: No. Grew up in Dallas; has lived in the Bay Area since 1984.
Family: Divorced from Dr. Shirley Brown in 1994. No children.
On his Heart Disease Reversal Program: "Your body has a remarkable capacity to begin healing itself, especially in heart disease, if you give it a chance. So this whole program is really based on the idea of not giving you something magical you need to get better, but in stopping you from doing the things that are causing the problem."
On his quest for intimacy: "I'm ready to be in a committed, monogamous relationship and start a family. Time will tell. I try to take the same approach to that as I do to my work--which is that the universe will provide somehow."
On his goals as a scientist: "I think we're at the same state with prostate cancer that we were 19 years ago with heart disease, when I began doing this work. In its early stages, I think it can be reversed. No one has ever shown any kind of cancer can be reversed. So there is an opportunity to do that using prostate cancer as a first step."