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===== Why Almost Everything Dean Ornish Says about Nutrition Is Wrong.=====  
===== UPDATED: With Dean Ornish's Response=====

A critique of the diet guru's views on high-protein diets, followed by a 
response from Ornish and a reply from the author\\

{{::2024-01-22_093713.jpg|}}\\

//Editor's Note: Our April 22 article elicited a lengthy response from Dean 
Ornish, which we publish here, along with a rebuttal from Melinda Wenner Moyer.//

Last month, an op–ed in The New York Times argued that high-protein and high-fat 
diets are to blame for America’s ever-growing waistline and incidence of chronic 
disease. The author, Dean Ornish, founder of the nonprofit Preventive Medicine 
Research Institute, is no newcomer to these nutrition debates. For 37 years he 
has been touting the benefits of very low-fat, high-carbohydrate, vegetarian 
diets for preventing and reversing heart disease. But the research he cites to 
back up his op–ed claims is tenuous at best. Nutrition is complex but there is 
little evidence our country’s worsening metabolic ills are the fault of protein 
or fat. If anything, our attempts to eat less fat in recent decades have made 
things worse.\\

Ornish begins his piece with a misleading statistic. Despite being told to eat 
less fat, he says, Americans have been doing the opposite: They have “actually 
consumed 67 percent more added fat, 39 percent more sugar and 41 percent more 
meat in 2000 than they had in 1950 and 24.5 percent more calories than they had 
in 1970.” Yes, Americans have been eating more fat, sugar and meat, but we have 
also been eating more vegetables and fruits (pdf)—because we have been eating 
more of everything.\\

What’s more relevant to the discussion is this fact: During the time in which 
the prevalence of obesity in the U.S. nearly tripled, the percentage of calories 
Americans consumed from protein and fat actually dropped whereas the percentage 
of calories Americans ingested from carbohydrates—one of the nutrient groups 
Ornish says we should eat more of—increased. Could it be that our attempts to 
reduce fat have in fact been part of the problem? Some scientists think so. “I 
believe the low-fat message promoted the obesity epidemic,” says Lyn Steffen, a 
nutritional epidemiologist at the University of Minnesota School of Public 
Health. That’s in part because when we cut out fat, we began eating foods that 
were worse for us.\\

Ornish goes to argue that protein and saturated fat increase the risk of 
mortality and chronic disease. As evidence for these causal claims, he cites a 
handful of observational studies. He should know better. These types of 
studies—which might report that people who eat a lot of animal protein tend to 
develop higher rates of disease—“only look at association, not causation,” 
explains Christopher Gardner, a nutrition scientist at the Stanford Prevention 
Research Center. They should not be used to make claims about cause and effect; 
doing so is considered by nutrition scientists to be “inappropriate” and 
“misleading.” The reason: People who eat a lot of animal protein often make 
other lifestyle choices that increase their disease risk, and although 
researchers try to make statistical adjustments to control for these 
“confounding variables,” as they’re called, it’s a very imperfect science. Other 
large observational studies have found that diets high in fat and protein are 
not associated with disease and may even protect against it. The point is, it’s 
possible to cherry-pick observational studies to support almost any nutritional 
argument.\\

Randomized controlled clinical trials, although certainly not perfect, are 
better tools for chipping away at causality, and they suggest that protein and 
fat don’t deserve to be demonized. In a 2007 clinical trial led by Gardner 
researchers randomly assigned 311 individuals to four groups: One group was 
assigned the high-fat, high-protein and low-carbohydrate Atkins diet; the second 
was assigned Ornish’s very low-fat vegetarian diet, which requires consuming 
fewer than 10 percent of calories from fat; the third was assigned the Zone 
diet, which aims for a 40/30/30 percent distribution of carbohydrate, protein 
and fat; and the fourth was assigned the high-carbohydrate, low–saturated fat 
LEARN (for: lifestyle, exercise, attitudes, relationships, nutrition) diet. The 
participants all had trouble adhering to their regimens, but all lost about the 
same statistically significant amounts of weight, and when compared head to 
head, the Atkins dieters saw greater improvements in blood pressure and HDL 
cholesterol than the Ornish dieters did.\\

The recent multicenter PREDIMED trial also supports the notion that fat can be 
good rather than bad. It found that individuals assigned to eat high-fat (41 
percent calories from fat), Mediterranean-style diets for nearly five years were 
about 30 percent less likely to experience serious heart-related problems 
compared with individuals who were told to avoid fat. (All groups consumed about 
the same amount of protein.) Protein, too, doesn’t look so evil when one 
considers the 2010 trial published in The New England Journal of Medicine that 
found individuals who had recently lost weight were more likely to keep it off 
if they ate more protein, along with the 2005 OmniHeart trial that reported 
individuals who substituted either protein or monounsaturated fat for some of 
their carbohydrates reduced their cardiovascular risk factors compared with 
individuals who did not.\\

The other problem with Ornish’s antiprotein stance is that he lumps all animal 
proteins together. For instance, he wrote that animal proteins have been 
associated with higher disease and mortality risks in observational studies. But 
“Ornish is conflating hot dogs and pepperoni with fresh, unprocessed meats,” 
says Lydia Bazzano, professor of nutrition and epidemiology at Tulane University 
School of Public Health and Tropical Medicine, “and there’s a big difference 
between them.” A 2010 systematic review and meta-analysis of 20 studies found 
consumption of processed meat was associated with an increased risk of diabetes 
and heart disease but eating unprocessed red meat was not. A 2014 meta-analysis 
similarly reported much higher mortality risks associated with processed meat 
compared with red meat consumption and found no problems associated with white 
meat. The March 2014 study that Ornish cites as finding “a 75 percent increase 
in premature deaths from all causes and a 400 percent increase in deaths from 
cancer and type 2 diabetes among heavy consumers of animal protein under the age 
of 65,” also did not distinguish between types of animal protein. And it is 
worth noting that among people in the study over 65, heavy consumption of animal 
protein actually protected against cancer and mortality. (Also: the heavy 
protein consumers in the study were consuming nearly 30 percent more protein 
than the average American does.) “Whole foods—such as whole grain products and 
fruits and veggies—are healthy, but I think that dairy products, fish and lean 
cuts of meat or poultry can also be part of a healthy diet,” Steffen says.\\

So there’s little evidence to suggest that we need to avoid protein and fat. But 
what about the claims Ornish makes about the success of his own diet—do they 
hold up to scrutiny? Not exactly. His famous 1990 Lifestyle Heart trial involved 
a total of 48 patients with heart disease. Twenty-eight were assigned to his 
low-fat, plant-based diet and 20 were given usual cardiac care. After one year 
those following his diet were more likely to see a regression in their 
atherosclerosis.\\

But here’s the thing: The patients who followed his diet also quit smoking, 
started exercising and attended stress management training. The people in the 
control group were told to do none of these things. It’s hardly surprising that 
quitting smoking, exercising, reducing stress and dieting—when done 
together—improves heart health. But fact that the participants were making all 
of these lifestyle changes means that we cannot make any inferences about the 
effect of the diet alone.\\

So when Ornish wrote in his op–ed that “for reversing disease, a whole-foods, 
plant-based diet seems to be necessary,” he is incorrect. It’s possible that 
quitting smoking, exercising and stress management, without the dieting, would 
have had the same effect—but we don’t know; it’s also possible that his diet 
alone would not reverse heart disease symptoms. Again, we don’t know because his 
studies have not been designed in a way that can tell us anything about the 
effect of his diet alone. There’s also another issue to consider: Although 
Ornish emphasizes that his diet is low in fat and animal protein, it also 
eliminates refined carbohydrates. If his diet works—and again, we don’t know for 
sure that it does—is that because it reduces protein or fat or refined 
carbohydrates?\\

The point here is not that Ornish’s diet—a low-fat, whole food, plant-based 
approach—is necessarily bad. It’s almost certainly healthier than the highly 
processed, refined-carbohydrate-rich diet most Americans consume today. But 
Ornish’s arguments against protein and fat are weak, simplistic and, in a way, 
irrelevant. A food or nutrient can be healthy without requiring that all other 
foods or nutrients be unhealthy. And categorizing entire nutrient groups as 
“good” or “bad” is facile. “It’s hard to move the science forward when there are 
so many stakeholders who say ‘this is the right diet and no other one could 
possibly be right,’” Bazzano says. Plus, discouraging the intake of entire 
macronutrient groups can backfire. When people dutifully cut down on fat in the 
1980s and 1990s, they replaced much of it with high-sugar and high-calorie 
processed foods (think: Snackwell’s). If we start fearing protein, too, what 
will we fill our plates with instead? History tells us it’s not going to be 
spinach.\\

----

**Dean Ornish Responds**\\

I don’t usually respond to ad hominem attacks, but when I read Melinda Wenner 
Moyer’s article “Why Almost Everything Dean Ornish Says about Nutrition Is 
Wrong,” I felt a need to set the record straight. The title is confusing and 
potentially harmful to many readers.\\

For the past 37 years my colleagues and I at the nonprofit Preventive Medicine 
Research Institute, in collaboration with leading scientists and medical 
institutions, have published a series of randomized controlled trials and 
demonstration projects showing that comprehensive lifestyle changes may slow, 
stop and often reverse the progression of many chronic diseases. These include a 
whole foods, plant-based diet low in refined carbohydrates, moderate exercise, 
stress management techniques and social support.\\

These studies have been conducted with well-respected collaborators, published 
in the leading peer-reviewed journals, and presented at the most credible 
scientific meetings. These include JAMA The Journal of the American Medical 
Association, The Lancet, Proceedings of the National Academy of Sciences, The 
Lancet Oncology, The New England Journal of Medicine, The American Journal of 
Cardiology and others.\\

I have presented these research findings on several occasions at the annual 
scientific meetings of the American Heart Association, American College of 
Cardiology, American Dietetic Association (now the Academy of Nutrition and 
Dietetics), the Institute of Medicine of the National Academies and many others.\\

On August 12, 2010, after 16 years of review, the Centers for Medicare & 
Medicaid Services began providing Medicare coverage for my intensive lifestyle 
program for reversing heart disease under a new benefit category, “intensive 
cardiac rehabilitation.” Many insurance companies are also providing coverage. 
My colleagues and I have been training and certifying teams of health care 
professionals at leading hospitals, clinics and health systems in this lifestyle 
program for reversing heart disease.

Earlier this year a panel of experts from U.S. News & World Report rated the 
“Ornish Diet” as the number-one diet for heart health for the fifth year in a 
row (that is, all five years they have been doing rankings).\\

When Moyer accuses me of having inadequate scientific evidence to support my 
statements, I must respectfully and strongly disagree. Let’s check the facts:\\

Headline: //Why Almost Everything Dean Ornish Says about Nutrition Is Wrong//\\

Provocative but incorrect.\\

Subhead: //When it comes to good eating habits, protein and fat are not your 
dietary enemies//\\

Her article begins with a gross distortion of what I believe. It's the type of 
protein, fat and carbohydrates that matters. The diet I recommend is low in 
refined carbohydrates and low in harmful fats (including trans fats, 
hydrogenated fats and some saturated fats) and low in animal protein 
(particularly red meat) but includes beneficial fats (including omega-3 fatty 
acids), good carbs (including fruits, vegetables, whole grains, legumes and soy 
in their natural, unrefined forms) and good proteins (predominantly plant-
based). This was clearly stated in my New York Times op–ed:\\

//“An optimal diet for preventing disease is a whole-foods, plant-based diet that 
is naturally low in animal protein, harmful fats and refined carbohydrates. What 
that means in practice is little or no red meat; mostly vegetables, fruits, 
whole grains, legumes and soy products in their natural forms; very few simple 
and refined carbohydrates such as sugar and white flour; and sufficient “good 
fats” such as fish oil or flax oil, seeds and nuts. A healthful diet should be 
low in “bad fats,” meaning trans fats, saturated fats and hydrogenated fats. 
Finally, we need more quality and less quantity.”//

Moyer wrote: //Nutrition is 
complex but there is little evidence our country’s worsening metabolic ills are 
the fault of protein or fat. If anything, our attempts to eat less fat in recent 
decades have made things worse. Ornish begins his piece with a misleading 
statistic. Despite being told to eat less fat, he says, Americans have been 
doing the opposite: They have “actually consumed 67 percent more added fat, 39 
percent more sugar and 41 percent more meat in 2000 than they had in 1950 and 
24.5 percent more calories than they had in 1970.” Yes, Americans have been 
eating more fat, sugar and meat, but we have also been eating more vegetables 
and fruits—because we have been eating more of everything.//\\

Well, that’s the point—we’re not fat because we’re eating too little fat; we’re 
fat because we’re eating too much of everything.\\

Other nonscientist, nonphysician writers have also been saying that Americans 
have been told to eat less fat—“We’re eating less fat, we’re fatter than ever, 
so we’ve been given bad advice. Eat more meat, butter and eggs, they’re good for 
you (prominently pictured on the cover of their books), all those experts have 
been wrong.” This has been repeated so often in the echo chamber of modern media 
that it’s become a meme.\\

But it’s not true. As I wrote about in my op–ed, according to the U.S. 
Department of Agriculture (pdf), every decade since 1950 Americans actually have 
been eating more fat, more sweeteners, more meat and more calories.\\

//What’s more relevant to the discussion is this fact: During the time in which 
the prevalence of obesity in the U.S. nearly tripled, the percentage of calories 
Americans consumed from protein and fat actually dropped whereas the percentage 
of calories Americans ingested from carbohydrates—one of the nutrient groups 
Ornish says we should eat more of—increased. Could it be that our attempts to 
reduce fat have in fact been part of the problem? Some scientists think so. “I 
believe the low-fat message promoted the obesity epidemic,” says Lyn Steffen, a 
nutritional epidemiologist at the University of Minnesota School of Public 
Health. That’s in part because when we cut out fat, we began eating foods that 
were worse for us.//\\

First, she’s again perpetuating the myth that “…when we cut out fat, we began 
eating foods that were worse for us.” As the USDA data show, we’re eating more 
fat, not less.\\

Second, as I made clear in the op–ed as well as in my books and journal 
articles, the diet I recommend is low in refined carbohydrates and high in “good 
carbs” such as fruits, vegetables, whole grains, legumes and soy products in 
their natural, unrefined forms (which tend to have low glycemic loads). She 
completely misrepresents my recommendations: “…carbohydrates—one of the nutrient 
groups Ornish says we should eat more of—increased.” I’ve always recommended 
that people limit their consumption of sugar and other refined carbohydrates.\\

Third, she’s confusing the USDA data (which I cited in my op–ed) and the 
National Health and Nutrition Examination Survey (NHANES) data (which looked at 
the percentage of calories). The USDA tracks changes in consumption of the 
entire food supply. In contrast, the NHANES data is from surveying only a small 
sample of people nationwide, so it’s less reliable. Sample sizes ranged from 
1,730 men and 2,003 women in NHANES 1999 to 2000 to 6,630 men and 7,537 women in 
NHANES III. Since the U.S. population last year was 322 million people, this 
represents only 0.000044% of the population, and different people are surveyed 
each year. This is why I use the USDA data (which tracks consumption of the 
entire food supply, not just a tiny sample).\\

But even if the NHANES data are accurate, they show Americans are eating more 
fat than ever and even more refined carbohydrates than ever. That only supports 
my thesis, because I recommend that people eat less harmful fats and fewer 
refined carbohydrates. The decrease in the percentage of calories from fat 
during the period 1971 to 1991 is attributed to an increase in total calories 
consumed; absolute fat intake in grams actually increased.\\

Fourth, the patients in our randomized controlled trial (JAMA. 1998) showed an 
average reduction of 24 pounds in the first year. In a larger study of almost 
3,000 patients who went through my lifestyle program in 24 hospitals and 
clinics, BMI (body mass index) decreased by 6.6 percent. In other words, the 
diet I recommend causes weight loss, not weight gain. Pres. Bill Clinton is one 
of the more public examples of this, having lost and kept off more than 20 
pounds since following the whole foods, plant-based diet I recommended for him 
five years ago (including salmon once a week).\\

//Ornish goes to argue that protein and saturated fat increase the risk of 
mortality and chronic disease. As evidence for these causal claims, he cites a 
handful of observational studies. He should know better. These types of 
studies—which might report that people who eat a lot of animal protein tend to 
develop higher rates of disease—“only look at association, not causation,” 
explains Christopher Gardner, a nutrition scientist at the Stanford Prevention 
Research Center. They should not be used to make claims about cause and effect; 
doing so is considered by nutrition scientists to be “inappropriate” and 
“misleading.” The reason: People who eat a lot of animal protein often make 
other lifestyle choices that increase their disease risk, and although 
researchers try to make statistical adjustments to control for these 
“confounding variables,” as they’re called, it’s a very imperfect science. Other 
large observational studies have found that diets high in fat and protein are 
not associated with disease and may even protect against it. The point is, it’s 
possible to cherry-pick observational studies to support almost any nutritional 
argument.//\\

First, I cited several large-scale studies from many different investigators, 
all of which showed that a diet high in red meat increases the risk of premature 
death from virtually all causes, even when adjusting for confounding variables. 
I’m not cherry-picking data; I’m looking at the preponderance of evidence from 
many studies by leading investigators such as those at Harvard School of Public 
Health.\\

Second, another “big fat lie” that has been repeated so often it’s becoming a 
meme is that there is not enough good science to inform us about an optimal way 
of eating. Believing this, many people are throwing up their hands, exasperated, 
saying, “These damn doctors can’t make up their minds—to hell with them, I’ll 
eat whatever I want,” when there is actually an emerging consensus among 
scientists and physicians who do research in nutrition about what constitutes an 
optimal way of eating. Although we always need more research, there is enough 
science now to guide us. Moyer’s article only adds to that confusion.\\

//Randomized controlled clinical trials, although certainly not perfect, are 
better tools for chipping away at causality, and they suggest that protein and 
fat don’t deserve to be demonized. In a 2007 clinical trial led by Gardner 
researchers randomly assigned 311 individuals to four groups: One group was 
assigned the high-fat, high-protein and low-carbohydrate Atkins diet; the second 
was assigned Ornish’s very low-fat vegetarian diet, which requires consuming 
fewer than 10 percent of calories from fat; the third was assigned the Zone 
diet, which aims for a 40/30/30 percent distribution of carbohydrate, protein 
and fat; and the fourth was assigned the high-carbohydrate, low–saturated fat 
LEARN (for: lifestyle, exercise, attitudes, relationships, nutrition) diet. The 
participants all had trouble adhering to their regimens, but all lost about the 
same statistically significant amounts of weight, and when compared head to 
head, the Atkins dieters saw greater improvements in blood pressure and HDL 
cholesterol than the Ornish dieters did.//\\

First, in this study, JAMA published a retraction of one of the main conclusions 
of this study by led by Christopher Gardner, which initially claimed that people 
lost more weight on the Atkins diet than on the diet I recommend, which turned 
out to be false (JAMA. 2007 Jul 11;298(2):178).This says something important 
about the quality of that research.\\

Second, there was no statistically significant difference in either systolic 
blood pressure or diastolic blood pressure after one year in comparing the 
groups. In contrast, there was a statistically significant reduction in LDL-
cholesterol in the Ornish group but not in the Atkins group after one year.\\

Third, it is a common misconception that anything that raises HDL is beneficial 
and anything that lowers it is not. This is not true, as I wrote about years ago 
in my Newsweek column. In our randomized controlled Lifestyle Heart Trial, HDL 
cholesterol did not increase but patients showed regression of coronary 
atherosclerosis after one year, even more improvement after five years, and a 
300 percent improvement in myocardial perfusion (blood flow to the heart) as 
measured by cardiac PET scans. HDL is important only to the extent that it 
affects atherosclerosis and myocardial perfusion, it is not a disease.\\

Fourth, the Gardner study did not really test very much of anything, other than 
it’s hard for many people to change their diets—any diet—from just reading a 
book. Adherence in his study to each of the diets was only 20 to 30 percent 
after one year, so it’s hard to make any conclusions at all.\\

Part of the problem in this and other studies that compare weight loss in low-
fat versus low-carb diets (which is the wrong question anyway, because it’s the 
type of fats and carbs) is that adherence to different diets is often 
suboptimal, so it’s hard to make meaningful comparisons.\\

To address this issue, a recent National Institutes of Health study that I cited 
in my op–ed put people in a metabolic ward where they could actually control 
what people were eating and then measured the effects. According to the lead 
author, "Calorie for calorie, reducing dietary fat results in more body fat loss 
than reducing dietary carbohydrate when men and women with obesity have their 
food intake strictly controlled. Compared to the reduced carbohydrate diet, the 
reduced fat diet led to a roughly 67 percent greater body fat loss."\\

//The recent multicenter PREDIMED trial also supports the notion that fat can be 
good rather than bad. It found that individuals assigned to eat high-fat (41 
percent calories from fat), Mediterranean-style diets for nearly five years were 
about 30 percent less likely to experience serious heart-related problems 
compared with individuals who were told to avoid fat. (All groups consumed about 
the same amount of protein.)//\\

Below is my letter to the editor of The New England Journal of Medicine that 
they published about this study:\\

//“The PREDIMED study is highly flawed. The control group did not follow a low-fat 
diet. This is not surprising, since researchers gave the control group little 
support in following this diet during much of the study. In the “low-fat” 
control group, total fat consumption decreased insignificantly from 39 to 37 
percent (Table S7 in the Supplementary Appendix, available with the full text of 
the article by Estruch et al. at NEJM.org). This level of consumption is much 
higher than the level recommended in American Heart Association guidelines for a 
low-fat diet (<30 percent fat) or a diet that can reverse coronary heart disease 
(<10 percent fat). There was no significant reduction in the rates of heart 
attack, death from cardiovascular causes or death from any cause. The only 
significant reduction was in the rate of death from stroke (see Table 3 of the 
article).//\\

//“The conclusion of the study should be, ‘We found a significant reduction in the 
rate of stroke among those consuming a Mediterranean diet as compared with those 
who were not making any substantial changes in their diet.’ A Mediterranean diet 
is better than what most people are consuming; even better is a diet based on 
whole foods and plants that is low in fat (especially saturated and trans fat) 
and in refined carbohydrates while allowing for sufficient consumption of n–3 
fatty acids.”//\\

Protein, too, doesn’t look so evil when one considers the 2010 
trial published in The New England Journal of Medicine that found individuals 
who had recently lost weight were more likely to keep it off if they ate more 
protein, along with the 2005 OmniHeart trial that reported individuals who 
substituted either protein or monounsaturated fat for some of their 
carbohydrates reduced their cardiovascular risk factors compared with 
individuals who did not.\\

I’ve never said that protein is “evil.” In my op–ed, I clearly stated that it’s 
better to consume plant-based proteins than animal-based proteins, especially 
red meat. I wrote:\\
//
“The debate is not as simple as low-fat versus low-carb. Research shows that 
animal protein may significantly increase the risk of premature mortality from 
all causes, among them cardiovascular disease, cancer and type 2 diabetes. Heavy 
consumption of saturated fat and trans fats may double the risk of developing 
Alzheimer’s disease.”//\\

For example, in the OmniHeart trial she cited, the group 
that was asked to consume 10 percent more protein emphasized plant proteins, not 
animal protein. And the 10 percent reduction in carbohydrate in the higher 
protein diet and the higher unsaturated fat diet was achieved by replacing some 
fruits with vegetables, reducing sweets and using smaller portions of refined 
grain products. All three diets reduced blood pressure, total and low-density 
lipoprotein cholesterol levels, and estimated coronary heart disease risk.\\

But the real issue is what happens to actual measures of heart disease, not just 
risk factors, which I will describe further on.\\

//The other problem with Ornish’s antiprotein stance is that he lumps all animal 
proteins together. For instance, he wrote that animal proteins have been 
associated with higher disease and mortality risks in observational studies. But 
“Ornish is conflating hot dogs and pepperoni with fresh, unprocessed meats,” 
says Lydia Bazzano, professor of nutrition and epidemiology at Tulane University 
School of Public Health and Tropical Medicine, “and there’s a big difference 
between them.” A 2010 systematic review and meta-analysis of 20 studies found 
consumption of processed meat was associated with an increased risk of diabetes 
and heart disease but eating unprocessed red meat was not. A 2014 meta-analysis 
similarly reported much higher mortality risks associated with processed meat 
compared with red meat consumption and found no problems associated with white 
meat.//\\

As Moyer indicates here, the 2014 meta-analysis showed higher mortality risks 
associated with both processed meat and unprocessed meats. The fact that 
processed meat is even worse for you than unprocessed meats does not change the 
fact that the risk of premature death from all causes is higher in those eating 
red meat than those who do not.\\

The fact that not all studies have shown this risk does not mean that it is not 
true. In doing large-scale studies in which people complete dietary surveys, 
there is often so much noise—especially in combining data in meta-analyses—that 
a type 2 error often occurs (that is, the noise obscures the ability to detect 
statistically significant differences).\\

In a study from Harvard School of Public Health they prospectively observed 
37,698 men from the Health Professionals Follow-Up Study (1986–2008) and 83,644 
women from the Nurses' Health Study (1980–2008) who were free of cardiovascular 
disease (CVD) and cancer at baseline. Diet was assessed by validated food 
frequency questionnaires and updated every four years.\\

They documented 23,926 deaths (including 5,910 CVD and 9,464 cancer deaths) 
during 2.96 million person-years of follow-up. After multivariate adjustment for 
major lifestyle and dietary risk factors, the pooled hazard ratio (HR) (95 
percent CI) of total mortality for a one-serving-per-day increase was 1.13 
(1.07–1.20) for unprocessed red meat and 1.20 (1.15–1.24) for processed red 
meat. The corresponding HRs (95 percent CIs) were 1.18 (1.13–1.23) and 1.21 
(1.13–1.31) for CVD mortality and 1.10 (1.06–1.14) and 1.16 (1.09–1.23) for 
cancer mortality. The editor of JAMA Internal Medicine invited me to write an 
accompanying editorial for this study.\\

A related study by this group looked at 85,168 women and 44,548 men without 
heart disease, cancer or diabetes from the Nurses’ Health Study and the Health 
Professionals’ Follow-Up Study. They concluded, “A low-carbohydrate diet based 
on animal sources was associated with higher all-cause mortality in both men and 
women whereas a vegetable-based low-carbohydrate diet was associated with lower 
all-cause and cardiovascular disease mortality rates.” Another major research 
article studied 43,396 Swedish women over 15 years. It concluded that “low-
carbohydrate/high-protein diets are associated with increased risk of 
cardiovascular diseases.”\\

I am not against all forms of animal protein. It may be worth noting that my 
most recent book, The Spectrum, featured a piece of salmon on the cover.\\

In assessing the health effects of different diets it’s important to measure the 
disease process itself, not just risk factors such as blood pressure and 
cholesterol levels. For example, an important article, published in The New 
England Journal of Medicine, reviewed data showing that high-protein, low-
carbohydrate diets promote coronary artery disease independent of their effects 
on traditional risk factors such as blood pressure and cholesterol levels. The 
arterial damage was caused by animal-protein induced elevations in free fatty 
acids and insulin levels and decreased production of endothelial progenitor 
cells (which help keep arteries clean). The Atkins diet caused the most coronary 
artery blockages whereas a diet low in fat and high in unrefined carbohydrates 
caused the least amount of blockages.\\

Although this was shown in animals, it is likely true in humans as well. I'm not 
aware of a single study showing that a diet high in red meat can reverse the 
progression of coronary heart disease. All evidence is to the contrary.\\

//The March 2014 study that Ornish cites as finding “a 75 percent increase in 
premature deaths from all causes and a 400 percent increase in deaths from 
cancer and type 2 diabetes among heavy consumers of animal protein under the age 
of 65,” also did not distinguish between types of animal protein. And it is 
worth noting that among people in the study over 65, heavy consumption of animal 
protein actually protected against cancer and mortality. (Also: the heavy 
protein consumers in the study were consuming nearly 30 percent more protein 
than the average American does.) “Whole foods—such as whole grain products and 
fruits and veggies—are healthy, but I think that dairy products, fish and lean 
cuts of meat or poultry can also be part of a healthy diet,” Steffen says.//\\

The March 2014 study in Cell Metabolism did distinguish between animal protein 
and plant-based proteins. The abstract clearly states, “Respondents aged 50–65 
reporting high protein intake had a 75 percent increase in overall mortality and 
a fourfold increase in cancer death risk during the following 18 years. These 
associations were either abolished or attenuated if the proteins were plant 
derived.”\\

The authors also reported that among those without type 2 diabetes at baseline, 
those in the high animal protein group had a 73-fold increased risk of 
developing diabetes during the study. The authors wrote:\\

//“Notably, our results showed that the amount of proteins derived from animal 
sources accounted for a significant proportion of the association between 
overall protein intake and all-cause and cancer mortality. These results are in 
agreement with recent findings on the association between red meat consumption 
and death from all-cause and cancer (Fung et al, 2010; Pan et al, 2012). 
Previous studies in the U.S. have found that a low-carbohydrate diet is 
associated with an increase in overall mortality and showed that when such a 
diet is from animal-based products, the risk of overall as well as cancer 
mortality is increased even further (Fung et al, 2010; Lagiou et al, 2007). Our 
study indicates that high levels of animal proteins, promoting increases in IGF-
1 and possibly insulin, is one of the major promoters of mortality for people 
age 50–65 in the 18 years following the survey assessing protein intake.”//\\

The 
beneficial effects of lower protein intake were not seen in those over 65. In 
people over 65 the authors observed that older people may benefit from more 
protein because they tend to be malnourished (living alone, poorer GI 
absorption, etcetera). They wrote:\\

//“The switch from the protective to the detrimental effect of the low-protein 
diet coincides with a time at which weight begins to decline. Based on previous 
longitudinal studies, weight tends to increase up until age 50–60 at which point 
it becomes stable before beginning to decline steadily by an average of 0.5 
percent per year for those over age 65 (Villareal et al, 2005; Wallace et al, 
1995). We speculate that frail subjects who have lost a significant percentage 
of their body weight and have a low BMI may be more susceptible to protein 
malnourishment.”//\\

In any event, I wasn’t “wrong” about this; in my op–ed I was 
clear that these benefits were seen in those under age 65.\\

//So there’s little evidence to suggest that we need to avoid protein and fat. But 
what about the claims Ornish makes about the success of his own diet—do they 
hold up to scrutiny? Not exactly. His famous 1990 Lifestyle Heart trial involved 
a total of 48 patients with heart disease. Twenty-eight were assigned to his 
low-fat, plant-based diet and 20 were given usual cardiac care. After one year 
those following his diet were more likely to see a regression in their 
atherosclerosis.//\\

//But here’s the thing: The patients who followed his diet also quit smoking, 
started exercising and attended stress management training. The people in the 
control group were told to do none of these things. It’s hardly surprising that 
quitting smoking, exercising, reducing stress and dieting—when done 
together—improves heart health. But fact that the participants were making all 
of these lifestyle changes means that we cannot make any inferences about the 
effect of the diet alone.//\\

//So when Ornish wrote in his op–ed that “for reversing disease, a whole-foods, 
plant-based diet seems to be necessary,” he is incorrect. It’s possible that 
quitting smoking, exercising and stress management, without the dieting, would 
have had the same effect—but we don’t know; it’s also possible that his diet 
alone would not reverse heart disease symptoms. Again, we don’t know because his 
studies have not been designed in a way that can tell us anything about the 
effect of his diet alone. There’s also another issue to consider: Although 
Ornish emphasizes that his diet is low in fat and animal protein, it also 
eliminates refined carbohydrates. If his diet works—and again, we don’t know for 
sure that it does—is that because it reduces protein or fat or refined 
carbohydrates?//\\

Only one person in the experimental group of the Lifestyle Heart Trial was 
smoking at baseline, so it’s unlikely that made a significant difference. And 
I’m not aware of any studies showing that walking and stress management 
techniques alone can reverse heart disease.\\

We also published an analysis showing that improvements in dietary fat intake, 
exercise and stress management were individually, additively and interactively 
related to coronary risk.\\

Judging the quality of a study by the number of patients is like judging the 
quality of a book by the number of pages. There are so many other factors. 
Here's a blog in which I addressed this issue:\\

<code>
“Although the sample sizes of these studies were small, there were statistically 
significant differences in all of the above measures. It is a common belief that 
the larger the number of patients, the more valid a study is. However, the 
number of patients is only one of many factors that determine the quality of a 
study.

In our studies we ask smaller groups of people to make much bigger changes in 
lifestyle and provide them enough support to enable them to do so. And because 
the degree of these lifestyle changes is much higher than a control group is 
likely to make on their own, and the intervention is potent, it becomes easier 
to show statistically significant differences even though the number of patients 
is smaller.” 
</code>

As Attilio Maseri, MD, an internationally known and respected 
cardiologist, wrote:\\

//"Very large trials with broad inclusion criteria raise grounds for concern for 
practicing physicians and for the economics of health care. The first is the 
fact that the larger the number of patients that have to be included in a trial 
in order to prove a statistically significant benefit, the greater the 
uncertainty about the reason why the beneficial effects of the treatment cannot 
be detected in a smaller trial."//\\

My colleagues and I conducted a demonstration 
project of 333 patients from four academic medical centers and four community 
hospitals. These patients were eligible for revascularization and chose to make 
these comprehensive lifestyle changes instead. We found that almost 80 percent 
were able to avoid surgery by making these comprehensive lifestyle changes.\\

It’s not just 48 patients. As I mentioned above, we found significant 
improvements in virtually all risk factors in almost 3,000 patients who went 
through my lifestyle program in 24 hospitals and clinics in West Virginia, 
Nebraska, and Pennsylvania.\\

Also, as I wrote in my op–ed in The New York Times, my colleagues and I have 
conducted randomized controlled trials that these same diet and lifestyle 
changes reverse the progression of other common chronic diseases. What happens 
to changes in blood pressure, cholesterol and weight are important only to the 
extent that they affect the underlying disease process (for example, degree of 
atherosclerosis, blood flow to the heart, cardiac events, changes in prostate 
cancer), which is what we documented. As I wrote:\\
<code>
“We showed in randomized, controlled trials that these diet and lifestyle 
changes can reverse the progression of even severe coronary heart disease. 
Episodes of chest pain decreased by 91 percent after only a few weeks. After 
five years there were 2.5 times fewer cardiac events. Blood flow to the heart 
improved by over 300 percent.

Other physicians, including Dr. Kim A. Williams, the president of the American 
College of Cardiology, are also finding that these diet and lifestyle changes 
can reduce the need for a lifetime of medications and transform people’s lives. 
These changes may also slow, stop or even reverse the progression of early-stage 
prostate cancer, judging from results in a randomized controlled trial.

These changes may also alter your genes, turning on genes that keep you healthy 
and turning off genes that promote disease. They may even lengthen telomeres, 
the ends of our chromosomes that control aging.

The more people adhered to these recommendations (including reducing the amount 
of fat and cholesterol they consumed), the more improvement we measured—at any 
age. But for reversing disease, a whole-foods, plant-based diet seems to be 
necessary.” 
</code>

//The point here is not that Ornish’s diet—a low-fat, whole food, 
plant-based approach—is necessarily bad. It’s almost certainly healthier than 
the highly processed, refined-carbohydrate-rich diet most Americans consume 
today. But Ornish’s arguments against protein and fat are weak, simplistic and, 
in a way, irrelevant. A food or nutrient can be healthy without requiring that 
all other foods or nutrients be unhealthy. And categorizing entire nutrient 
groups as “good” or “bad” is facile. “It’s hard to move the science forward when 
there are so many stakeholders who say ‘this is the right diet and no other one 
could possibly be right,’” Bazzano says. Plus, discouraging the intake of entire 
macronutrient groups can backfire. When people dutifully cut down on fat in the 
1980s and 1990s, they replaced much of it with high-sugar and high-calorie 
processed foods (think: Snackwell’s). If we start fearing protein, too, what 
will we fill our plates with instead? History tells us it’s not going to be 
spinach.//\\

I agree that replacing fat with sugar is not healthful, as I’ve written about 
for decades. But replacing animal protein with well-balanced plant proteins is 
beneficial, and this is in the mainstream of what most scientists who do 
nutrition research believe.\\

For example, the then–American Dietetic Association published a position paper 
on plant-based diets in which they wrote, “It is the position of the American 
Dietetic Association that appropriately planned vegetarian diets, including 
total vegetarian or vegan diets, are healthful, nutritionally adequate and may 
provide health benefits in the prevention and treatment of certain diseases.”\\

What is missing in Moyer’s article is the clinical experience that comes from 
helping people change their diet and lifestyle. I feel passionately about doing 
this work because it helps transform people’s lives for the better. These are 
not theoretical discussions; they are real people who have shown substantial 
improvements in their health and well-being—not just in risk factors but also in 
the underlying disease process. Over and over, I’ve seen patients with coronary 
heart disease so severe that they can’t walk across the street or work or play 
with their kids or make love or do much of anything without getting severe chest 
pain become pain-free after only a few weeks of making these diet and lifestyle 
changes. You can hear some of their stories here. We documented significant 
improvements in the heart’s function after only 24 days compared with a 
randomized control group.\\

And although no one likes to be falsely accused that almost everything they say 
is wrong, the bigger concern I have is that people who otherwise might have been 
motivated to make these highly beneficial diet and lifestyle changes may be 
discouraged from doing so by reading this essay by Ms. Moyer in which, 
unfortunately, almost everything she writes about my work is wrong.\\

Dean Ornish, MD Founder and president, Preventive Medicine Research Institute 
Clinical professor of medicine, University of California, San Francisco 
Telephone: (415) 332-2525 x222\\

----

**
Melinda Wenner Moyer Responds**\\

In his lengthy reply to my article Dean Ornish says I distort his beliefs, cite 
questionable studies and don’t have the clinical experience to assess 
nutritional evidence. If ones looks at the right data, he says, it’s clear that 
our country’s metabolic ills can be blamed on our increasing consumption of red 
meat and “bad” fats—both of which, he says, are proved to be unhealthy.\\

Ornish first takes issue with the data I cite on food consumption patterns from 
the National Health and Nutrition Examination Survey (NHANES). All consumption 
estimates are imperfect, of course, including the U.S. Department of Agriculture 
(USDA) data he cites. But looking more closely at the report (pdf) he 
discusses—as others already have—one finds that it, too, shows that in the 
decades from 1970 to 2000, when obesity and chronic disease rates skyrocketed, 
U.S. consumption of red meat and eggs dropped 12 percent. USDA data also show 
(pdf) that between 1970 and 2005 U.S. consumption of saturated fat–rich butter 
and lard as well as hydrogenated shortening decreased 17 percent. Indeed, the 
USDA explicitly states that most of our increase in consumption of added fats 
has been due to the growing use of vegetable oils and related products. So even 
when we look at the data Ornish likes, we still don’t see reason to blame 
America’s ill health on unprocessed red meat and saturated fats.\\

Ornish then cites a barrage of individual studies to back his claim that red 
meat and saturated fats are dangerous, including one that has not even been 
published in the peer-reviewed literature. He says that dietary meta-analyses 
and systematic reviews involving humans—such as the one I cited from 2010 that 
found no association between red meat consumption and heart disease or 
diabetes—can be misleading because the “noise obscures the ability to detect 
statistically significant differences.” Meta-analyses and systematic reviews 
have their limitations, of course, and they must be conducted carefully. But 
they don’t mask the truth; compared with individual studies, they get closer to 
it. As for Ornish’s contention that “the risk of premature death from all causes 
is higher in those eating red meat than those who do not,” I disagree, because 
the 2014 meta-analysis of 13 studies that I discussed did not find this to be 
true. (This lack of association is notable because this analysis probably 
overestimates risks associated with red meat consumption; all but two of the 
studies it assessed lumped processed meats into the “red meat” category.) 
Another meta-analysis of 21 studies found no association between saturated fat 
intake and heart disease. Again, meta-analyses of observational studies are 
certainly not perfect, but because they analyze all relevant data, they 
circumvent the problem of cherry-picking.\\

Ornish also dismisses the randomized controlled trials I cited in large part 
because the subjects in these trials did not adhere to the diets and reduce 
their fat intake enough. This argument raises two interesting points: First, it 
contradicts Ornish’s claim that he’s not really against fat, just certain types 
of fat. The fact is, individuals on his diet are supposed to consume (pdf) no 
more than 10 percent of calories from fat, and that’s very, very low compared to 
the average American’s adult’s intake of 33 percent of calories from fat. (An 
adult who consumes two tablespoons of olive oil in, say, a portion of salad 
dressing has already exceeded getting 10 percent of his day’s calories from fat 
if he’s eating 2,000 calories daily.)\\

Second, if subjects in dietary clinical trials—who are attending dietician-led 
classes and being monitored regularly—are unable to reduce their fat intake to 
anywhere close to Ornish’s recommendations, then how could his approach possibly 
be a sustainable solution for the entire country?\\

Ornish’s diet would probably be an improvement on the current American diet—if 
people could actually follow it long-term. But his claims about the dangers of 
saturated fat and red meat go beyond the science and in some cases contradict 
it. And although Ornish is right that I lack clinical experience, when analyzing 
evidence, distance can be useful. I have no horse in this race.\\

**Tom G observation:**\\

I am on the side of Dr Ornish here.  The author made some attention grabbing "click bait"
statements.  Ornish is not against protein or carbs as she states.  He is against High Fat
in the diet and against Red Meat. The High Fat typically comes from Animal Protein.  He also embraces carbs but only if they come from unprocessed whole food 
sources such as legumes, fruits and vegetables. I  agree that the 10% Fat number is nearly impossible to achieve but the Heart Association recommendation of 30% does not have a track record of reversing Heart Disease.\\

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