The Pritikin Diet: Discredited By Medicine But Now Endorsed By Your Federal Government!

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 CMS 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 has managed to get Congress to pass laws supporting “integrative” medicine

Nathan Pritikin’s Pseudoscience Longevity Legacy

Nathan Pritikin is an “inventor” who became convinced that heart disease could be treated by following an ultra-low fat diet.

Screen Shot 2015-11-29 at 9.22.28 AMAfter establishing his “Longevity Center” in Santa Monica for well-healed clients, (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 died at the age of 69 after slashing his wrists with a razor blade.

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The reference  from the “prestigious”  New England Journal of Medicine is a letter to the editor (thus not peer-reviewed research) written by R. James Barnard, Ph.D in 1990.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.

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.

It’s a wonder they didn’t slit their wrists while trapped in the Pritikin center undergoing this program.

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 vegetarian. 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 most of what makes for a tasty 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.

 

 

 

10 thoughts on “The Pritikin Diet: Discredited By Medicine But Now Endorsed By Your Federal Government!”

    1. 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.

  1. 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.

    1. 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.

      1. 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.

  2. 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.
    \

    1. 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.

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