Most of the stress we generate ourselves...

by Professor Thomas Schmidt from the medical college in Hanover

There is a worldwide interest in the treatment results from "the San Francisco Lifestyle Heart Trial" - especially regarding the long term results in the treaty "Lifestyle Changes and coronary heart diseases". Professor Thomas Schmidt from the medical college in Hanover and Professor Larry Scherwitz, director of the Institute of preventive medicine in Sausalito, California, discuss this at a seminar at the AHG-clinic at Schweriner See in Germany.

Professor Larry Scherwitz relates that the use of yoga, relaxation and meditation is effective in the rehabilitation of heart patients.

Schmidt: What reactions have you had on the results you've achieved?

Scherwitz: More than 350 hospitals have contacted our institute and shown an interest. The press has been enthusiastic with articles in the newspapers and editorials in journals. Patients have come from all over the USA to participate in our programmes, so we have been full up with more than 400 patients a year. We have also trained the staff at 12 hospitals in the use of this programme - so now, heart patients are being treated all across the USA.

Has there been an interest from other countries than the USA?

Yes, we have conducted eight research studies, four in the USA, two in Germany, one in Holland, and one in India.

Why such an international interest?

Well, the interest is there because the programme works. When patients follow this they lose weight, their blood pressure can come down, their chest pain diminishes in a short time, usually within two weeks, their exercise capacity increases, their hostility is reduced, their depression seems to abate, and, as our results in the San Fransisco trial indicate: the arteries tend to open up with intense practice of this programme.

Additionally, in the States, and perhaps in Europe as well, there is a movement to find new methods that fit in with conventional treatment. What is new in this context, is that it empowers the patients to do something for themselves.

The capacity of the heart to pump blood increased by more than 6% in the trial group after one months intensive work with the Lifestyle Heart Trial programme (dark grey column).

During the same period of time the control group became 2% worse (light grey column).

This is a pretty comprehensive change in life style, how have you managed to get the patients to continue even after five years?

We developed some routines that turned out to be an appropriate way to treat heart disease.

Our staff was also following the programme with the diet, yoga exercises and the meditation. They were enthusiastic about it.

We co-operated with physicians who referred patients to us.

When we asked the patients: "How can you follow this?", they'd answer: "We help each other. We make a close bond together". Sharing experiences and opening up to one another on an emotional level, it seemed to help them to feel like a team following a programme. By practising the programme, they helped their fellow patients to do the same. We think this opening of the emotional heart helped open the vessels. It seems that the patients who were most affectionate to one another had the greatest opening of the vessels.

Do you think that the method of rehabilitation used in San Francisco can be successfully adapted to the conditions in Germany?

Theoretically, Germany has a better potential for doing this programme than any country in the world. You have the infrastructure for the rehabilitation programme, you have an insurance network that can pay for it, you have an abundance of heart patients, so theoretically it can work better here than anywhere. The challenges are the resistance to it. The idea that patients can't do this, or the ignorance about what this is. The fact that many of the doctors and nurses don't have any training themselves in this means that they don't really understand it. So, there is some resistance that we need to overcome.

I think that if we had a good demonstration study here, and good publicity for the results, then more people would be open to this approach.

At the cardiac rehabilitation clinic AHG in Wölitzsee in Berlin, preventive methods as you describe, such as stress management, antidotal treatment for smokers, physical exercise and a diet programme are given as components in a three-week rehabilitation programme. Which intensity should these preventive measures have to achieve a lasting effect on the patients?

Stress management is very important.

We find that stress management with the use of yoga is one of the most powerful components to achieve a reversal of the blockages in the coronary arteries.

If patients just exercise a little, follow a low fat diet and take their medication, they still get a progression of the disease over a five year period.

But if they do all of these things, and also do an hour of yoga daily, they can stop the disease from progressing. And if they do more, if they do an hour and a half of yoga, and follow the diet and exercise and come to the groups, they can actually reverse the blockages so that the arteries open up. But the programme must be intensive for them to get a reversal of the heart disease.

In your study, stress management means traditional yoga programmes. Is that right?

There are five components: There is stretching ...

That is yoga asanas?

Yes, yoga asanas. There's breathing techniques, there's deep relaxation, there's meditation and visualization. And all five together make a hand that can grab the stress and reduce it. We have shown in study after study that the more they practise the yoga exercises, the lower the cholesterol goes, independent of diet. The hostility diminishes too, and the exercise tolerance increases, even when the exercise level is kept the same, but with more yoga. So there's both psychological and physical benefits from the yoga - plus the opening of the arteries.

How much yoga do your patients do every day?

Out of the eight studies we've done, the German patients have done the most yoga. They did 110 minutes of yoga a day. Even three months after they were ready at the clinic they were still doing this much yoga every day.

So they liked yoga?

They liked it very much, and they followed it very well. And these people were working. They were driving to work and so forth. They had managed to work this in to their life style, they made a change.

So yoga training should be the main component in a rehabilitation programme for cardiac patients?

We've never seen a patient get a reversal of disease who didn't do yoga. So our results suggest that it's a critical component to getting reversal. It is not easy to reverse this disease. It's like a freight train that just keeps going, and when a truck comes across the intersection it has to stop and it's very hard to stop it. And then to back the train up is even harder. So the yoga is a very important thing for stopping the train, and for getting it to back up.

Which of the various components is the most important one, if you cannot do everything?

I've very seldom done a presentation when I wasn't asked this question, and I usually answer with another question: "How many legs does a dog have?" Normally four: There are four components: Diet, exercise, stress management [yoga, breathing exercises, relaxation and meditation] and group support. Which of these legs is most important for a dog to be able to run? They're all necessary, they all work together.

The stress management helps the group support become deeper. When things are a little tense in the group we sit back and do a little breathing. So the stress management helps the group, the diet helps the exercise. All the legs need to run together to stop this train.

Yoga has an age old tradition, but today it is often used in a superficial way, and sometimes people call themselves yoga teachers who have not had a proper and thorough training. Do you think that it is important that people that teach these yoga and meditation techniques really know what they are doing?

The training of the yoga teacher is very important. We have found in teaching the 12 hospital groups that it doesn't work so well to take a nurse and teach her yoga for six weeks, and then have her to be the yoga teacher. It's better to take a yoga teacher who has been practising for 20 years and teach him or her some medicine - about the heart and how to take care of patients.

So it's not simply a little training that's important. The transformation of who one is, that one knows oneself, is something one achieves through many years of work with oneself - that one has peace and confidence and inner enthusiasm motivates the patients to use yoga too. So it's very critical.

I wouldn't want a yoga teacher to have less training than a physician, or a surgeon. Our experience is that we need dedicated yoga teachers who've been doing this for a long time.

Is the programme cheaper than the traditional way of treating heart patients?

I think this has to be answered in the long term. We've done a short-term study of three years with 477 patients in eight treatment centres in the United States. We found that if a patient is facing a bypass surgery or an angioplasty and chooses to do our programme instead, 90% of the patients appear to be able to avoid having the operation, in that short period. We don't know yet what would happen after another five years. So it saves money for those patients who are about to incur a major expense. We don't know yet if patients are stable, or whether it will save money in the long run.

So the answer is a partial answer. We have had patients who were on the transplant list to get a new heart, which is an extremely expensive procedure. They have gotten off that list and have become so much better that they do not need a new heart, and that's very cost effective.

Here is a group of patients doing yoga, shown on a slide during one of Professor Larry Scherwitzes lectures. As one can see, it is yoga based on the classical yoga asanas. The pose on this picture is shoulderstand.

How could the best possible treatment for these patients be developed in the future?

I think that science needs to go hand in hand with the health policy as well as with publicity. In terms of the science, we have shown that the vessel appears to open, but we do not know what has happened to the actual structure of the blockage, and the consistency of the scar tissue. For example, the intercellular cholesterol, is it leached out? What happens to the calcium deposit? What happens to the fibrous cap? We need to know what's happening when people get reversal.

We need to do further research where we get patients to do the programme intensively, and to have examinations before and after on the vessel structure. This is also a part of the scientific work.

In terms of public policy, it is important that patients can choose what approach they want to take. There should be a well-trained staff available that can recommend the programme through their own practice as well as through other patients'.

The cause of heart disease should be considered. It's not simply a list of risk factors. It appears to have something to do with fulfillment and with love and connectedness, and therefore the spirit must be taken more into consideration. I would like to hear the word spirituality used more in this context. We don't use that word anymore, but that sense of being connected, and that we're all part of the living process is, I think, important to engender in the healing of heart disease.

One has to consider very carefully where the source of stress comes from. I think that the perception that stress is on the outside, that it comes from work, and that if you stop work, the stress will go away. But there's another way to look at it. Most of the stress we generate ourselves. I mean, in this country and in the United States and in other Western European countries we have enough to eat, we have shelter, but we generate our own stress from the inside.

So advice about this needs to come from a deep understanding of the person you are dealing with, and how that person interacts in the world - and from where this person gets a sense of being needed and of fulfillment.

Among many publications written by Larry Scherwitz and his colleagues, e.g. Dean Ornish, we have chosen to refer to one which this discussion is based on: “Can Intensive Lifestyle Changes Reverse Coronary Heart Disease Without Lipid-Lowering Drugs? Five Year Followup of the Lifestyle Heart Trial”, Journal of the American Medical Association 280, No. 23, 1998. Authors: Ornish D, Scherwitz L, Billing J, Gould L, Merritt T, Sparler S, Armstrong W, Ports T, Kirkeeide R, Hogeboom C, Brand R.

The somewhat poor quality of the pictures in this article is due to the fact that the seminar was documented on videotape.

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