How is that a discredited diet developed by a man with no scientific or nutritional background and with no legitimate scientific studies supporting it has been endorsed by Medicare to be taught intensively to patients after their coronary bypass surgery or heart attack?
The explanation involves pseudoscience, evangelical nutritional fervor and a Senator who managed to get Congress to pass laws supporting “integrative” medicine
Nathan Pritikin’s Pseudoscience Longevity Legacy
Nathan Pritikin was an “inventor” who became convinced that heart disease could be treated by following an ultra-low fat diet.
After establishing his “Longevity Center” in Santa Monica for well-heeled clients, (the average price per week for one is about $4,500) he wrote a book entitled “The Pritikin Program for Diet and Exercise” in 1979.
The book sold more than 10 million copies in paperback and hardcover and was on the New York Times Bestseller Top Ten list for more than 54 weeks.
He committed suicide in 1985 at the age of 69 years
The Pritikin brand, however, lives on and continues to promote a diet that contradicts scientific findings in the last two decades that clearly indicate an ultra-low fat diet is not sustainable or effective in reducing heart disease.
There are two aspects of the Pritikin brand that make it stand out from the rest of the fad diets that clutter the book store shelves and the internet blogs: a thin veneer of scientific legitimacy and funding by the federal government.
The Pritikin Brand Has Done A Very Good Job Of Promoting Itself As Evidence-Based But It Is Not
From the very slick website promoting the Pritikin Longevity Centers:
“More than 100 studies in prestigious medical journals like the New England Journal of Medicine and Circulation have documented the Pritikin Program’s extraordinary success in helping thousands worldwide. Discover what the Pritikin Program can do for you.Whether severe restriction of dietary fat is a realistic public health approach to lowering serum cholesterol levels is uncertain.”
Although partially true, this is a totally misleading statement.
The reference from the “prestigious” New England Journal of Medicine is a letter to the editor (thus not peer-reviewed research) written by R. James Barnard, Ph.D in 1990.
Barnard has a Ph. D in exercise physiology and has worked as a consultant for the Pritikin center since 1978. As an employee of Pritikin he cannot be expected to provide unbiased scientific analyses.
He has written a book (Understanding Common Diseases and the Value of the Pritikin Eating and Exercise Program) which was published by the Pritikin organization in 2013.
In the preface to this book, he indicates “It wasn’t long after I started to work with the Pritikin participants that I realized Mr. Pritikin’s claims were correct…at this point I decided to collect data for publication in the medical literature”
Good science involves generating a hypothesis and then performing experiments to prove or disprove the hypothesis. In Barnard’s case he clearly had decided beforehand that the diet worked and he spent the rest of his career trying to gather data from the humans in the Pritikin center (60 studies) and from rodents that he fed high sugar and fat diets (40 studies) to support this claim.
Barnard does have a publication in Circulation (as opposed to a letter) but it is also an example of bad science and would not be published in a reputable journal in this day and age. His Circulation publication in 2002 looks at what happens in 11 men who are given an ultra low-fat diet and forced to exercise aerobically for 45-60 minutes daily.
They were forbidden to consume alcohol, cigarettes or caffeine.
There was no control group for comparison and we have no idea what the lifestyle of the men was before entering the study. And, of course, the investigators were not blinded and were extremely biased.
What a surprise! The men lost weight, had a lower blood pressure and a lower cholesterol level after 3 weeks of being tortured on the Pritikin diet and exercise plan.
Barnard’s other publications, which serve as the sole “evidence base” for the Pritikin program are similar to the Circulation publication: they involve short, unblinded, uncontrolled studies of what happens to various metabolic parameters when individuals are subject to the Pritikin torture program.
Interestingly, by 1990 when he wrote that letter to the editor he ended it by saying:
“Whether severe restriction of dietary fat is a realistic public health approach to lowering serum cholesterol levels is uncertain”
What’s Wrong with the Pritikin Diet?
The Pritikin diet is similar to other now discredited diets promulgated by Dean Ornish and Caldwell Esselstyn which are ultra-low fat and almost vegan. Such ultra-low fat diets are not recommended by any major scientific organization and are not supported by the scientific literature.
Pritikin’s diet recommends you never consume what they term “saturated-rich foods” such as
- butter
- tropical oils like coconut oil
- fatty meats
- dairy foods like cheese, cream and whole/low fat milk
- Processed meat such as hot dogs, bacon and bologna
- cholesterol-rich foods like egg yolks
This diet eliminates what most of us would consider a satisfying and filling meal.
The Pritikin diet recommends “caution” (less is better) for the following:
- oils
- sugar
- salt
- refined grains
The most recent scientific evidence on diet strongly contradicts a substantial number of these recommendations: for example, dietary cholesterol is not of concern: fish and vegetable oil, particularly olive oil, consumption is encouraged, dairy fat reduces atherosclerosis and obesity.
Medicare Covers Pritikin for “Intensive Cardiac Rehabilitation”
As part of the Affordable Care Act, Congress established and funded something called “intensive cardiac rehabilitation” or ICR.
The portion of the act that establishes ICR was crafted because of the influence of the legendary ultra low-fat/vegetarian evangelist Dean Ornish upon Senator Tom Harkin of Iowa.
Harkin has been waging a war on science and promoting pseudoscience and “alternative” medicine for some time. As science-based medicine wrote:
“Senator Tom Harkin (D-IA) helped set up the National Center on Complementary and Alternative Medicine (NCCAM). The whole idea of setting up such an agency is a bit quixotic—after all, the National Institutes of Health already study health science. As my colleagues and I have written many times before, the very idea of the agency seems ridiculous. Many, many studies have been funded which fail basic tests of plausibility and ethical propriety. Also, a huge percentage of the studies funded fail to ever publish their results. Still, some studies have been published, and more often than not, they find that the “alternative” modality being studied fails to behave better than placebo. That’s probably the sole redeeming quality of the agency, but not enough to keep it open, as these studies could have been done under the auspices of the NIH.”
The wording of the ICR section says that an approved ICR program is a physician-supervised program that
has shown, in peer-reviewed published research, that it accomplished—one or more of the following:
positively affected the progression of coronary heart disease; or reduced the need for coronary bypass surgery; or
reduced the need for percutaneous coronary interventions; and a statistically significant reduction in 5 or more of the following measures from their level before receipt of cardiac rehabilitation services to their level after receipt of such services: low density lipoprotein;triglycerides;body mass index;systolic blood pressurediastolic blood pressure and the need for cholesterol, blood pressure, and diabetes medications.
These criteria are clearly crafted to correspond to the weak data that Barnard had published during his time working for and promoting the Pritikin Longevity Center.
The Decision Memo that CMS delivered approving the Pritikin program is embarrassingly naive in its analysis:
The study by Barnard and colleagues (1983) showed that participation in the Pritikin Program was associated with a reduction in the need for bypass surgery. Although the sample size was small, the study provided long term follow-up. At five years, there were four deaths (6%). There was no direct comparison group but the authors reported that, at the time (1976-1977), mortality associated with coronary artery disease was “as high as 50% by the third year.” At five years 12 patients (19%) had bypass surgery. Since all patients were recommended to have bypass surgery prior to enrollment, there was a reduction in bypass surgery over the follow-up period.
The 1983 “study” by Barnard is really not even worthy of publication. He was collecting information on 60 participants in the Pritikin program who had been told by their physicians that they needed coronary bypass surgery.
We have no idea what would have happened to these highly motivated, cherry-picked individuals if they had not entered the Pritikin program. Comparison to historical controls to support the efficacy of an intervention is unacceptable in today’s scientific literature.
Intensive Cardiac Rehabilitation: Good Idea But Bad Implementation
I am a huge supporter of working with patients who have coronary artery disease or are at risk of heart attack to reduce their risk by lifestyle change and appropriate medications.
I applaud science-based government initiatives to study this and implement proven techniques.
Unfortunately, the way that ICR was foisted on Americans shows how easily good ideas can be hijacked by a few fervent hucksters who have the ears of prominent politicians who lack the background to properly understand science-based medicine.
Skeptically Yours,
-ACP
20 thoughts on “The Pritikin Diet: Discredited By Medicine But Now Endorsed By Your Federal Government!”
Thank you Dr. Pearson for providing this information about the Pritikin diet. I value your knowledge on this issue!
My relatives just went to pritikin in Miami and think it’s the greatest thing. I have high blood pressure and eat no salt. Pritikin takes you off your blood pressure meds and tried to prove it can get better by diet and exercise and less salt. One of my relatives who went there their blood pressure became too low! I don’t know what to think
Jenny, Your relatives must be well-heeled to afford the Pritikin in house program. I would say any approach that totally controls your diet and activity (high carb, high fat or otherwise diet) is going to be successful in the short term in getting weight off which will improve BP. The real difficulty is finding sustainable diet and activity plans and Pritikin is not sustainable because it is unnecessarily restrictive of fat.
Dear Doc….my husband has recently been introduced to this diet..he had a stent put in..in June …the cardiac rehab stated they only use this Pritikin diet…that set up red flags for me, I’m cautious of anything that says ONLY. Upon reviewing this DIET, I noticed it mentions a lot of eating SOY, Stevia and sucralose, starchy vegetables such as potatoes, beans and oats…hmmm..my husband is diabetic and he cannot have starchy foods as it will drive his blood sugar crazy. Let me say this..1) Soy is NOT a healthy food at all, the research I’ve done shows it to be a round up ready crop, does NOTHING for nutritional values and has recently been found to be a cancer causing product, pushed on to us by the big industries and GOVERNMENT because it can be produced in mass quantities cheaply and sold high. 2 ) Stevia although it is plant based is known to counteract with diabetic medication. 3) Sucralose (SPLENDA) has detrimental affects on the human body. 4) Starchy foods convert to sugar….so here are just four things that this DIET is over looking when being used by the general or supervised public. Most common people who are under stress from learnning they have a heart condition may not realize they may be causing other ill affects in the process. SOMETHING about the setting made me uncomfortable, too much of a controlled setting. I told my husband it was like all the puppets following one another because they are told it will HELP them. People want and need structure, but this situation gave me the creeps. Another thing about this diet is that it mentioned sweetness of real fruit, or canned fruits. Diabetics must be aware of SUGAR ALCOHOLS…which come from real sugar in certain fruits. Canned anything has nitrates, sodium…I know I’m ranting about the diabetic aspect, but this diet IS NOT in my eyes for someone with diabetes. I’ve learned a lot from the Joslin Diabetes Center in both Boston and New Hampshire, and at both places they agree certain diets are NOT made for everyone….I just wanted to voice my opinion, as I have had the time to delve into this diet enough to realize this isn’t for my husbands rehab. And finding out it has been PUSHED thru by the GOVERNMENT and MEDICARE with out any substantial trials also makes me uneasy. I will be looking into health clubs with personal trainers and I will continue to cook real food from the garden not a can for my husband…this diet is scary…. Thanks for listening.
Kathi,
Excellent observations, thanks for your comment. The Pritikin diet is very problematic for diabetics.
I feel compelled to respond further to the author of the article and the above comments:
I am in possession of the Patient Resource Binder produced by the Pritikin Intensive Cardiac Rehab program which is employed at my local hospital. The information in the binder is in direct opposition to statements made in the above comment. I.e. “mentions a lot of eating SOY, Stevia and sucralose, starchy vegetables such as potatoes, beans and oats…” I would suggest that Ms. Roach’s husband was not given the actual Pritikin ICR program, but something else if he was advised as per what she has written.
In fact, in the sections for “overweight diabetics and individuals with insulin resistance and related conditions, type II diabetes, metabolic syndrome, and abdominal obesity”, in the binder specifically discourage refined, processed and/or concentrated high-calorie-dense foods such as fruit juices, dried fruit, sugar-added fruit jams and jellies, breads, dry cereals, crackers, pretzels, bagels and popcorn. It also discourages “fat-free” snacks and sweets. Nowhere in the program are canned goods promoted or encouraged.
The Pritikin diet does not encourage “a lot of…starchy vegetables such as potatoes, beans and oats”. But, to understand what it does recommend, one has to understand what the differences are between refined vs. whole grain, and “complex” vs. “simple” carbohydrates, etc. The Pritikin material is very clear on this.
The Pritikin material does NOT push “a lot of” soy. It is mentioned as an alternative to animal proteins for which limits are recommended. There is no prescribed amount anyone should ingest of soy. Nor does it recommend or push Stevia, or sucralose–it merely mentions those are better than sugar if someone “has to have” sweeteners but the recommendations are for no such sweeteners.
I spent years as a registered nurse whose job involves teaching patients about their conditions and lifestyles. There is nothing in the Pritikin program (individualized for a diabetic individual) that is contraindicated for diabetics. Further, each person in the Intensive Cardiac Rehab is counseled concerning recommendations tailored for them, although everyone is taught the general theories regarding nutrition, and unhealthy lifestyles’ contributions to poor health and heart disease. Additionally, of course, each patient is in the program at the direction of his/her cardiologist or cardiac interventionist who are informed of the individual’s progress through regular check-ups and charted progress.
In my opinion, then, the Pritikin program is not problematic for anyone, much less diabetics. I would challenge anyone to show me a symptomatic diabetic who has diligently adhered for a reasonable time to a diet as healthy as the Pritikin diet.
This is your blog and you can enjoy free speech in it, but ethically I felt compelled to comment as I do on anything I encounter which discourages prudent health recommendations (such as the anti-vax propaganda by certain high-profile individuals without qualifications) by discrediting the originator or a proponent of it particularly when so many health professionals and esteemed organizations such as the CDC and NIH support the methods and data.
For the record, knowing very little about the man Pritikin was, I have based my comments directly and ONLY on the written material provided the persons enrolled in the ICR, and on my entire nursing education and experience. I appreciate the opportunity to voice my opinions on this passionate topic. Thank you.
Holly,
I appreciate your thoughtful comments and emailed you separately to begin further dialogue.
My interaction with you prompts me to write a new blog post on the Pritikin ICR.
Dr P
Thank you Dr. P.
I look forward to more of your thoughts as well.
H.
it seems to be easy to be sceptical of alternative, natural trials to relieve the causes rather than the symptoms. One glaring fault with this article is the fact that Pritkin was diagnosed with heart disease while in his 40’s yet his own autopsy a few decades later showed his arteries were akin to those of a young man and totally clear of any signs of heart disease.
\
This is a common deception of Pritikin supporters. Pritikin was told he had “coronary insuficiency” on the basis of no definitive testing. So we really don’t know if he had coronary disease or not. The autopsy report is not available for review. A letter to the editor of the New England Journal of Medicine signed by two Pritikin Longevity doctors claims that the coronary arteries were free of obstructive plaque but that there were fatty streaks in the arteries. These doctors clearly had a motivation to make Pritikin’s heart appear fine.
Ultimately, however, it is not important what Pritikin died of or what his heart looked like-one person does not prove or disprove the effectiveness of a diet.
” it is not important what Pritikin died of ”
Then why did you make a point of his having died by suicide, and say so in a most demeaning and disparaging manner? How does your statement about how he died have any relevance to your article?
He could have been clobbered by a Mack truck; would that de-legitimize his diet too?
Other than objecting to the restriction on the tastes YOU want in your diet, have you found anything unhealthy in the Pritikin diet comprised of low fat, low sodium, low sugar, non-fat dairy, a modicum of healthy proteins such as fish high in omega 3 fatty acids, and minimal red meat, and high in whole grains and legumes? Just wondering because you’re the only cardiologist, or MD for that matter, I’ve ever heard trashing such a diet as the one Pritikin recommends.
Holly,
Thanks for your comments on my Pritikin post. I think yours are the first reasonable comments from a Pritikin supporter I have received. Also, the first from a Pritikin ICR practitioner. As time permits I want to post them and discuss in more detail that program which many of my patients have been subjected to.
Just to respond to a couple of things you said.
I have written a companion post to this on the manner of Atkins death which has been grossly distorted by the low fat/vegan community. I make the point that we shouldn’t be choosing our diets based on how the originator of the diet lived or died.The ultra low fat /pritikin advocates went so far as to publicize Pritikin’s autopsy findings. I thought it should be pointed out that he committed suicide and that if one wants to trumpet Pritikin’s autopsy findings (and distort Atkins) one should acknowledge his depression and the possibility that his diet contributed to it.
Unhappiness with the food that one has to eat daily is a major factor to consider in choosing a diet and one major limitation of the Pritikin diet is lack of sustainability.
There is a way to make Pritikin’s diet healthy by eating high quality carbs and lots of vegetables but this diet, like the original Atkins is too difficult for most patients to continue lifelong.
And finally, ironically at our medical center which has bought into Pritikin ICR despite the objection of the majority of the cardiologists I have yet to find a fellow cardiologist who promotes it to his/her patients.
Dr. P
The previous president of the College of Cardiology advocates a diet similar to that of Esselstyn
Thanks Anthony. A very interesting and thought provoking piece.
Lately, I’ve been quite obsessed with lipidology, something that didn’t really interest me during my early years as a cardiologist. To fuel my addiction I recently bought a very fresh and beautiful book called Clinical Lipidology, a companion to Braunwald’s Heart Disease.
As expected, there is a chapter on dietary patterns for the prevention and treatment of CVD. Not many pages though because cardiologists do have limited interest in diet. Of course there is a mention of the DASH diet, the Mediterranean diet and vegetarian diets. Pridikin is not mentioned though.
But, interestingly, Ornish gets to play a role:
“Striking reductions in LDL-C, angina and stenosis have been demonstrated with a very-low-fat vegetarian diet. In the Lifestyle Heart Trial 48 patients with moderate to severe CVD were randomized to an intensive lifestyle intervention, including a vegetarian diet with only 10% fat or to a usual care control group…”
The additional lifestyle measures are mentioned of course but their impact is neglected by the authors of the chapter.
The also write: “Although the feasibility of such marked dietary changes has been questioned by some, this trial demonstrated the efficacy of this strategy in high-risk patients, and Medicare has begun covering the Ornish plan.”
And the final words: “This low-fat, vegetarian diet combined with lifestyle strategies was the first dietary pattern shown to reverse arterial stenosis.”
I must say I’m really stunned. These results have not been reproduced. In no other area of cardiology have we allowed ourselves to rely on a study with 48 patients. Obviously, the does not have the power to allow such conclusion to be drawn. It’s a hypothesis generating study or a pilot study at best.
By the way, sorry for the long text, it was driven sheer by frustration. And now I’m really thinking about the money machines you mentioned.
Axel,
No worries on the long comment. The Ornish data on those 48 patients continues to be regurgitated ad nauseam and as you pointed out is now supported by the American government. And it is stunning, as you put it, that this tiny study from one heavily biased center would have been embraced by Medicare.
Ornish is a tireless promoter his approach and manages to get the attention and ears of the rich and powerful in the US.
The Medicare intensive cardiac rehab scam was crafted to fit precisely to the “data” supporting the Pritikin and Ornish programs.
it is extremely difficult to become one of the patients in the Ornish program at UCLA that Medicare pays for– it seems one has to be close to shuffling off this mortal coil to get in on Medicare. However, you can pay 10 grand anytime. A bit pricier than Pritikin, and no lodging at Trump’s Turnberry Isle Club either.
What about the seventh day adventist studies?
https://www.ornishspectrum.com/wp-content/uploads/can-lifestyle-changes-reverse-coronary-heart-disease.pdf
You said – “discredited diets promulgated by Dean Ornish and Caldwell Esselstyn”
Are you saying these diets do not work?
http://dresselstyn.com/JFP_06307_Article1.pdf
http://doctorklaper.com/medcap-images/Esselstyn-Nutritional-Reversal-of-Cardiovascular-Disease.pdf
http://www.ornishspectrum.com/wp-content/uploads/Intensive-lifestyle-changes-for-reversal-of-coronary-heart-disease1.pdf
I’m saying there is no good evidence to support the Ornish/Pritikin/Esselstyn diet. I’ve commented on the lack of good studies supporting Esselsytyn’s claims ().
The Ornish claims are based on a study he performed between 1986 and 1992 which originally had 28 patients with coronary artery disease in an experimental arm and 20 in a control group.
The experimental patients received “intensive lifestyle changes (10% fat whole foods vegetarian diet, aerobic exercise, stress management training, smoking cessation, group psychosocial support).
The control group had none of the above.
Ornish likes to tout this as showing “reversal of heart disease” because at one year the average percent coronary artery stenosis by angiogram had dropped from 40% to 37.8% in the intensive lifestyle group and increased from 42.7% to 46.1% in the control patients.
In other words the “reversal” was minuscule.
Furthermore, dropping coronary artery blockages by 5 or 10% doesn’t really matter unless that is also helping to prevent heart attacks.
There were no significant differences between the groups at 5 years in hard events such as heart attack or death.
In fact 2 of the experimental group died versus 1 of the control group by 5 years (?suicide)
Ornish’s Lifestyle Intervention is not a trial of diet.
It is a trial of multiple different factors with frequent counseling and meetings to reinforce and guide patients.
Since investigators clearly knew who the “experimental patients” were and they were clearly interested in good outcomes in these patients there is a high possibility of bias in reporting outcomes and referring for interventions.
This study has never been reproduced at any other center.
Because of the small numbers, lack of true blinding, lack of hard outcomes and use of multiple modalities for lifestyle intervention, this study cannot be used to support the Ornish/Esselstyn/Pritikin dietary approach.
Consequently, you will not find any source of nutritional information or guideline (unless it has a vegan/vegetarian philosophy or is being funded by the Ornish/Pritikin lifestyle money-making machines) recommending these diets.