“Take a few full, deep breaths, really expand your lungs,” Dr. Lee Lipsenthal tells the group seated before him at the San Francisco Bay Club. “Now think of someone you really love. Keep breathing deeply. Try to feel the feeling of love in your body.” Lipsenthal gives us a few more seconds, then asks, “How many of you were able to get there?” All hands go up. Do that every day, whenever you feel stressed, he says, and you’ll lower both your blood pressure and your cholesterol.

If it sounds too woo-woo to be true, Lipsenthal has the research to back it up. He also has a long list of corporate and healthcare clients who find that similar stress management exercises pay off in better health for their employees.

Lipsenthal, an internist with a specialty in cholesterol disorders, won’t hesitate to prescribe a cholesterol-lowering statin drug to patients at high risk for a heart attack. Even then, he recommends avoiding the dangerous side effects of statins by keeping the dose as low as possible. And for all of us, he says, there are better ways of protecting our hearts. Where statins only treat the symptoms of heart disease, stress management treats the cause.

Most cardiac rehabilitation programs include some form of meditation or stress management, along with exercise and a low-fat diet. Anger and anxiety produce the stress hormones cortisol and adrenaline, which in turn increase the liver’s production of cholesterol and triglycerides. Lower your stress hormones with meditation or yoga and—assuming you don’t sabotage yourself with a high-fat diet—you’ll also lower your LDL, or bad cholesterol, by 20 percent and cut your triglycerides by half.

“People that have hostility, anger and depression over time tend to get a lot of cortisol output,” says Lipsenthal. “Cortisol accelerates plaque growth. Anxiety increases adrenaline, which also increases plaque formation, but it has more of an increase in heart rhythm disturbances.” The stress hormones also inhibit blood flow by increasing blood viscosity and they promote clotting. The reason for that, says Lipsenthal, is the primal fight-or-flight response. “If you get bitten by a saber-toothed tiger you want to be able to clot. So when you’re under stress, you’re more likely to develop these tiny clots. But what happens is those little clots add up over time to more plaque.”

Meditation also seems to make people more likely to exercise and eat well. Lipsenthal points to one study that looked at three groups of heart patients, one of which had been trained in meditation. Five years later, that group had a 75 percent reduction in adverse cardiac “events,” compared to the other two groups. Not only were they still meditating, they were also exercising and maintaining healthier diets, even though they hadn’t been trained in either exercise or nutrition. Meditation, he says, “shifts your perspective on how you take care of yourself. You’re more able to live a healthier lifestyle if you’re more calm and clear.”

Lipsenthal makes a good poster boy for meditation. Slightly paunchy with a shiny pate and closely trimmed salt-and-pepper beard, he has a jolly glow about him, like a Happy Buddha. At 47, he’s been meditating for 25 or 30 years. He started getting serious about it as a way of reducing his stress while he was in medical school. He followed the published research on stress management techniques and their effect on heart disease over the next several years, then set up a cardiac rehab center in Philadelphia, incorporating diet, exercise, yoga and meditation. He moved his family to Marin in ’94 to become medical director for Dr. Dean Ornish’s Preventive Medicine Research Institute in Sausalito.

Ornish’s groundbreaking research, published in 1983, showed for the first time that heart disease could be reversed through a four-pronged “lifestyle” program: low-fat diet, exercise, stress management and participation in a support group. Since then, it’s become generally accepted in the medical community that “lifestyle” programs work—when they’re followed. There’s the rub. Most people have a hard time making such changes on their own, without the group support and instruction that a structured program provides. But these programs aren’t covered by insurance, so they’re not widely available. We have one here in affluent Marin—the TAM (Total Atherosclerosis Management) Program—for those who can pay for it out of pocket. Also, scattered throughout the county are yoga and tai chi classes, meditation groups, support groups, nutritional counseling and exercise training for people with the self-discipline to put together their own programs. But why aren’t comprehensive lifestyle programs insured?

Insurance executives initially told Ornish they didn’t believe people would stick to the program. Another argument was that people change insurance so often that some other company would probably reap the benefit of a program that would take years to pay off in improved health. Eventually, Ornish convinced Mutual of Omaha to fund a demonstration project with eight hospitals across the country. They found that, after three years, 80 percent of patients were able to safely avoid bypass surgery or angioplasty—at a savings of almost $30,000 a patient.

Ornish pressed Medicare officials on the issue for six years before he succeeded in persuading them to run a five-year demonstration project of their own. It was completed in 2004, and an advisory commission voted in January to work out the details of national coverage. Ornish is feeling encouraged. He expects that if Medicare covers lifestyle programs, other insurance companies will, too. And once they’re insured, more such programs will be offered. “We doctors tend to do what we get reimbursed to do, and we get trained to do what we get reimbursed to do,” he says. “So if we could change reimbursement, we could potentially change medical practice and medical education.”

• • • •

ONLY A FEW dozen comprehensive lifestyle programs exist in the U.S. today. Many more have come and gone, unable to be sustained without reimbursement. The TAM Program has been running for 15 years, but program director Vicki Chase says it operates in the red. The physicians group that sponsors it, Cardiology Associates of Marin, recently established a fund-raising arm to make up the deficit and expand the program.

Chase was brought in to develop TAM in 1992, after having started a cardiac rehabilitation program 10 years earlier in Sonoma. She brought her husband along with her, a tai chi teacher whom she’d met when they both worked at the Sonoma program. At 56, she has the wholesome look of a former athlete—she used to be a serious swimmer and dancer. She wears a white polo shirt imprinted with the words “Team Tam” and a blue-and-green logo that evokes the outline of Mount Tamalpais. The offices and the cardiac rehab gym are housed in a large, two-story medical building in Larkspur, just down the road from Marin General Hospital.
“People in Marin know all the right things to do, but they don’t necessarily do them,” says Chase. “We developed the TAM program to give them the structure, the professional support and the peer support, so they’re working on a common goal with people in a similar situation.” The eight-week program has the same basic components as the Ornish program, with some minor differences: TAM has more flexible, individually tailored diet and exercise guidelines; for stress management, Ornish offers yoga and meditation, while TAM has classes in tai chi and Feldenkrais movement, with less focus on meditation. Even so, Chase says that patients are more likely to continue meditation than either tai chi or Feldenkrais. “You can do it anywhere,” she says. “Sit in the airport and do it while you’re waiting for your plane. And the more you do it, the better you feel.”

In the Ornish program, a three-year study found that graduates were more likely to stick with stress management than with diet or exercise. “We see about 75 percent adherence to the stress management at the end of the third year,” says Lipsenthal. “People like doing it.” What’s more, the Ornish studies found that of all the components, stress management was the most effective at shrinking the size of blockages in the arteries. And the more time patients devoted to stress management, the more their blockages regressed. “We started to see more and more regression with people who did more than 45 minutes a day, with the greatest amount of regression over 60 minutes a day,” says Lipsenthal. “So personally, I think stress management is the strongest component in the program.”

• • • •

LIPSENTHAL LEFT THE staff of Ornish’s Preventive Medicine Research Institute last March to pursue a number of other projects—one of which is a study he’s running at the University of Michigan that’s looking at a particular meditative-like technique. The technique was developed by the Institute of Heartmath, which develops tools for improving job productivity, academic performance and health. Heartmath has trained clients as diverse as Hewlett-Packard, Kaiser Permanente and the California Department of Corrections. The tool Lipsenthal is studying with a group of heart attack patients at the University of Michigan is “emotional shifting.” At the lecture he delivered at the San Francisco Bay Club, he gave attendees a taste of it by asking them to focus on someone they love.

“It’s a way to help people relax and get grounded in the moment of their day,” he tells me later. “If your kids are driving you crazy, say, you take a few deep breaths and then think of them when they’re sleeping.” He pauses to let that image sink in, sees the smile on my face. “See how you go there immediately? That’s an emotional shift. Yeah, they’re losing it now, but they’ll be cute when they’re asleep. And if you can practice that moment to moment and day to day, it really starts to flavor the rest of your day. What happens is you shift the hormonal state of your body at that moment. It’s been shown that this lowers blood pressure and cholesterol and the stress hormones, which should diminish the risk of subsequent heart attacks. Meditation and yoga work to lower your overall threshold. But these techniques are very functional in the moment.”

One man who came to hear Lipsenthal at the Bay Club wanted to see if Lipsenthal knew anything about an experimental treatment he’d read about. Lipsenthal did—but didn’t give him the answer he was looking for. The man looked to be in his 70s. He’d already had an angioplasty and had been on Lipitor for the last two years. Now he was looking for another medical fix for his heart disease and Lipsenthal gave him little encouragement. No matter how effective your medication is, it won’t do you any good unless your lifestyle is healthy, Lipsenthal told him. “If you’re running around with high stress hormones, it’s almost like taking your Lipitor with a cheeseburger. It doesn’t work.”

Part of the problem is that people don’t want to give up their cheeseburgers. Maybe they do for a while, after a heart attack has confronted them with their mortality. Then denial sets in again and they’re back to their old ways. And doctors don’t have the time to educate patients about diet. “When you have an average office visit of eight-and-a-half minutes and you’re running from patient to patient and you’re trained to do angioplasty or write prescriptions, it just doesn’t happen,” says Lipsenthal. “We do three times more bypass and angioplasty here than any other country, and the rates of death from heart disease are exactly the same. So we’re not impacting death. It’s supply and demand. We have a huge supply of surgeons and cardiologists. Also, hospitals get paid very well for their cardiac centers, their bypass and angioplasty centers. They’re getting a lot of money from Medicare, so that’s what they do. So there’s a real economic drive there, unfortunately.”

Even when doctors do tell patients to alter their diet, they usually recommend minor changes that won’t lower cholesterol enough, thinking that’s all their patients will be willing to do. Ornish says that kind of thinking is fallacious. “The conventional wisdom is that small, gradual changes are easy, and big, comprehensive changes are difficult if not impossible. But in actuality, when you only make small changes, you don’t get much benefit. The American Heart Association diet, for example, doesn’t stop the progression of heart disease, it doesn’t really cause your cholesterol level to go down very much and it doesn’t make you feel much better. So you have the worst of both worlds—you have the hassle and deprivation of making some changes but not enough to experience much benefit.”

On the other hand, when people make big changes in diet, exercise and stress management, they start feeling better almost immediately. “It reframes the reason for making those changes from risk factor reduction and prevention—which most people think are really boring—to feeling better—not 30 years later, but a week or two later,” says Ornish. “We found over 90 percent reduction in the frequency of angina in the first few weeks. These are people who can’t work or have sex or take a shower or walk across the street without having angina, and within a few weeks, they’re pain-free.”

To Ornish and Lipsenthal, there’s a kind of Alice-in-Wonderland illogic to the way heart disease is treated—the inexpensive and effective treatment is dismissed in favor of the costly, traumatic, less effective one. “We’ve gotten to a point in medicine that’s so topsy-turvy,” says Ornish, “where it’s considered conservative to cut people’s chests open and bypass blocked arteries and stop the heart and put your entire blood volume through a heart-lung machine, or to blow up balloons in arteries or even put in radioactive stents—and yet it’s considered somehow radical to ask people to walk, quit smoking, eat vegetables and talk about their feelings in a group.”

Tonight, March 2, 7:30-9pm, Lee Lipsenthal, M.D., former director of the Dean Ornish Clinic and incoming president of the American Board of Holistic Medicine, will answer questions about heart health, medications and alternatives. The event is free at the Stress Management Center of Marin, 1165 Magnolia Ave., Larkspur, 415/461-2288.