Do or diet: treating disease with food.

A million and a half Americans will suffer heart attacks this year. Half a million of them will die, most before they reach the hospital.

More than 60 million Americans have high blood pressure. That makes them prime candidates for strokes and heart or kidney disease.

Diet can help prevent heart disease and hypertension. But can eating healthier help you lower your high blood pressure? Or unclog your arteries?

While the most severe cases still need drugs or surgery, growing evidence suggests that many people can control heart disease and hypertension by changing what they eat. Welcome to the world of angioplasty.

More than 300,000 times last year, U.S. cardiologists threaded tiny balloons into the arteries that fed the heart muscles of their patients. When they inflated the balloons, the cholesterol build-ups (plaques) that were blocking those arteries were plastered back against the walls, opening up the blood vessels.

According to Nicod and Scherrer, the "fun" of doing angioplasties, not to mention cardiologists' typical $20,000+ fees, help explain why so many are performed, and why they cost Americans more than $8 billion last year.

But while angioplasty provides immediate--possibly life-saving--relief for many people, it's not a long-term solution.

"There is no evidence that angioplasty does anything to prevent future angina or heart attacks," says John C. LaRosa, Dean for Research at the George Washington University Medical Center in Washington, D.C.

What's more, adds Peter Kwiterovich of Johns Hopkins Hospital in Baltimore, "about 30 to 40 percent of all angioplasties block up again within six months or so." In most cases, that means another angioplasty.

What's more, a recent nationwide analysis of angioplasties showed that more than half are being done without the proper diagnostic tests to see if the patients really need them.[1]

The case for coronary bypass surgery isn't open and shut, either.

In patients with severe heart disease, particularly when the arteries that nourish the heart are too clogged for angioplasty, surgeons remove veins (usually from the legs) and use them to detour around the plaque-filled arteries.

Yet while people who have undergone bypasses do experience a reduction in severe chest pain (angina), the benefits of surgery eventually wear off. In one of the best studies of its kind, 11 years after more than 650 heart disease patients at VA hospitals were randomly assigned to receive either a bypass or drugs, the bypass patients suffered no less angina than the drug-takers.[2]

And they didn't live any longer, either.

"Only in a select few with serious main coronary artery or multiple-vessel heart disease does the bypass prevent death," says LaRosa.

Ya Gotta Have Heart. What about diet? It can help prevent heart disease. So why not use it instead of angioplasty or bypass surgery to treat heart disease?

After all, that's just what diet-pioneer Nathan Pritikin had been doing since the mid-1970s, when he had heart disease patients throwing away their medication after following his program, which included a very-low-fat, high-fiber diet and exercise.

In the late 1980s, San Francisco physician Dean Ornish set out to do the same. But Ornish was armed with a powerful tool--the angiogram, which is a picture of the insides of patients' blood vessels.

Using before-and-after angiograms, Ornish was able to see how changes in diet affected the buildup of plaque.

He put 22 men and women whose arteries were partially blocked on a program consisting of a Pritikin-like vegetarian diet, at least three hours of moderate exercise a week, meditation (for stress management), and twice weekly group meeting to help reinforce the changes they were being asked to make.[3]

After only a year, angiograms showed that the arteries of 18 of the 22 had actually begun to clear. Less than half the people in the control group (who were not put on the program) showed any improvement. The 22 patients also had significantly less angina.

As Ornish points out, it's not clear which combination of the three treatments--diet, exercise, or meditation--was responsible for his patients' slightly widened arteries. It probably didn't hurt that they lost an average of 22 pounds, either.

If diet was responsible, it was one that most Americans would have a hard time following. It consisted mostly of vegetables, grains, beans, and fruit (see "Regression Analysis"). No meat or poultry. No fish. No animal products at all except the occasional egg white and a daily cup of skim milk or non-fat yogurt.

"The point of our study was to determine what is true, not what is practicable," says Ornish. He concedes that adherence to the program would have to be "very good" for improvement to occur.

Doubting Thomas. Some researchers believe that it doesn't take such a radical diet to start to unclog arteries.

In Heidelberg, Germany, 56 men who were suffering from angina caused by partially blocked arteries were placed on a reduced-fat diet (less than 20 percent of calories from fat, seven percent of calories from saturated fat, and 200 mg of cholesterol a day). As in Ornish's program, they also participated in a daily exercise routine.

After a year, angiograms showed that the blockages in the arteries of 32 percent of the men had lessened slightly, compared to just 17 percent of those in the control group.[4]

And in the late 1980s, researchers at London's St. Thomas' Hospital placed 26 men with clogged arteries and elevated blood cholesterol on carefully monitored diets that reduced their fat intake to 27 percent of calories. (That's about three-quarters of what an average American gets.)

The diet's cholesterol (200 mg a day) and saturated fat (8 to 10 percent of calories) were substantially less than most Americans eat. Its fiber was slightly more.

Over the next three years, the men suffered only one-third the number of deaths, heart attacks, and strokes as men in the control group, who weren't told what to eat and whose diets weren't monitored.

What's more, angiograms showed that the openings in the arteries of 38 percent of the men who changed their diets had become slightly larger. Only four percent of the control group showed any improvement.[5]

But some researchers are skeptical of the London study.

"I would like to see more data before I would feel confident that a diet of 27 percent of calories as fat would cause [an improvement in the arteries]," says Johns Hopkins' Peter Kwiterovich.

Plaque to Basics. While all of these studies showed only tiny increases in the arteries' openings, that translates into major health benefits.

"What appears to happen is that you stabilize the plaque," says George Washington University's John LaRosa.

"So, even though the opening hasn't changed all that much, the plaque is no longer susceptible to clot, spasm, and hemorrhaging, which are probably the things that cause the final [closing off] of the vessel."

Despite diet's promise as a treatment for atherosclerosis, it's not yet time to bury the scalpel.

"If someone needs their coronary artery blood flow or exercise tolerance improved right now," says LaRosa, "then you have to do something to open up their blood vessels right now with angioplasty or bypass surgery.

"But if you want to prevent a coronary or sudden death down the road," he adds, "you have to get the cholesterol down. That's where diet and drugs come in."

Runs Silent, Runs Deep. It's called the "silent killer."

More than 50 million of us have it, but almost half of us don't know it.

If your systolic blood pressure (the larger number) is 140 or more, or if your diastolic blood pressure (the smaller number) is 90 or more, you have it, too. Ditto if you're taking medication to keep your pressure below those numbers.

And if your numbers are slightly below that (130 to 139 or 85 to 89), you're in danger of developing it.

Having hypertension is no picnic. While the disease itself is unlikely to cause pain, it makes you much more susceptible to stroke, heart failure, atherosclerosis, and kidney disease. That's why at least half of all people who know they have high blood pressure are taking medication to lower it.

Unfortunately, only about four out of every ten people on hypertension medication are able to keep their pressure under control, according to new, unpublished data from the National Center for Health Statistics.

And then there's the expense and side effects of drugs.

All Hypertension's a Stage. "You can make the argument across the whole [range] of hypertension for the importance of diet and exercise in its treatment," says Norman Kaplan of the University of Texas Southwestern Medical Center at Dallas.

Kaplan chairs the subcommittee on "lifestyle modification" of the Joint National Committee for the Detection, Evaluation, and Treatment of Hypertension (JNC).

In more than half of all people with "high normal" blood pressure (see "Gauging Pressure"), Kaplan says, diet and exercise can stop it from becoming worse.

"Even people with Stage 1 hypertension can avoid drugs if they lose excess weight through diet and exercise and reduce their sodium intake to about 2,000 mg a day," he adds.

In fact, the JNC recommends that patients newly diagnosed with Stage 1 hypertension try three to six months of lifestyle modification before drugs are considered.

And even if that fails, taking weight off and keeping sodium under control can help lower the medication dosage. What's more, if blood pressure returns to near normal, exercise and a careful diet could--with medical supervision--allow a person to get off drugs.

For example, says Rose Stamler of the Northwestern University Medical School in Chicago, "a nutritional intervention program permitted 39 percent of our hypertensive patients who were previously well controlled by drug therapy to [keep their blood pressure normal] without drugs for four years" (the length of the study).[6]

How? By following a diet that reduced their weight an average of just five pounds, their sodium consumption to 2,400 mg a day, and their alcohol to one drink a day.

For people with Stage 2 or Stage 3 hypertension, "diet is much less likely to have enough of an impact on its own," says Kaplan. Still, it can help minimize drug doses.

And sodium isn't the only nutrient that people with hypertension should limit.

"Everything we recommend about weight control and dietary fat is even more important for hypertensives," he adds, "because they are at a greater risk of developing all the [blood vessel] problems."

[1] Circulation 87: 1489, 1993.

[2] Circulation 86: 121, 1992.

[3] The Lancet 336: 129, 1990.

[4] Circulation 86: 1, 1992.

[5] The Lancet 339: 563, 1992.

[6] Journal of the American Medical Association 257: 1484, 1987.