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to Menu Page(McIntosh et al., 1988; Blair et al., 1989; Okawa, 1992) and that magnesium treatments offer the potential for minimizing such brain damage (McIntosh et al., 1989; Vink, 1991-1992; Smith et al., 1983).
Clinicians in Japan have shown in a small pilot study that intravenous magnesium infusions improved the cerebral flow of stroke victims (who before treatment had low magnesium levels in their cerebrospinal fluid) (Iwasaki et al., 1989). Indeed, 10 patients who received magnesium therapy had a better return of normal cerebral functioning than did ten control patients who did not receive magnesium after a stroke. Whether prompt magnesium treatment after a stroke and/or after brain trauma will improve the prognosis of such patient deserves further investigation.
Selenium. In certain regions of the world, including Great Britain and parts of the United States and Canada, selenium levels in food are so low that the possibility of subclinical deficiency (and a possibly related adverse effect on mood) exists. Benton and Cook (1991) conducted a double-blind, crossover trial of 50 subjects in ostensibly good health. They ~were randomly assigned to receive a 100-microgram selenium tablet or placebo each day for 5 weeks. After a 6-month washout, they received the alternate treatment for 5 weeks. Benton and Cook concluded that the intake of selenium tablets was associated with an elevation of mood, particularly in subjects whose diets were relatively deficient in the trace element.
Amino acids. A double-blind, randomized study showed S-adenosylmethionine--the physiologically active form of the amino acid methionine--to be a more rapidly acting antidepressant than the pharmaceutical drug imipramine in treating major depression (Bell et al., 1988). At the end of this 2-week study, 66 percent of the S-adenosylmethionine patients had a clinically significant improvement in depressive symptoms versus 22 percent of the imipramine patients. If S-adenosylmethionine does turn out to be a more rapidly acting drug--taking days rather than weeks to achieve results--this characteristic may offer a considerable advantage in light of the known risk of suicide during the early nonresponding phase of treatment with most, if not all, other antidepressants.
~Clinical trials of the amino acid glycine given orally to schizophrenic patients have yielded conflicting results. However, in the most recent double-blind study, Javitt and colleagues (1994) showed a statistically significant improvement in negative symptoms of schizophrenia when glycine was added to conventional antipsychotic drug regimens. This suggests that glycine may serve as a distinctive and valuable adjunctive treatment for schizophrenia.
Essential fatty acids. Vaddadi and colleagues (1989) reported the results of a double-blind crossover trial of essential fatty acid supplementation in 48 predominantly schizophrenic psychiatric patients. Active treatment produced highly significant improvements in total psychopathology scores and a significant improvement in memory.
Food and Macronutrient Modification Diets as a Method for Controlling and Treating Chronic Illnesses
This section is an overview of the theoretical basis and available research on a variety of diets that are advocated for the treatment of chronic conditions such as cancer, ~cardiovascular disease, and food allergies. Virtually all of these dietary interventions emphasize the intake of much more produce (fresh and freshly prepared vegetables, fruits, whole grains, and legumes), providing high nutrient density while at the same time restricting such "empty" calories as those provided by sweets, fats, and overprocessed foods. In these diets, moreover, overall caloric intake tends to be lower than that of the general U.S. population.
Nutrient modification for the treatment of cancer. Cancer accounts for one of every five deaths in the United States (American Cancer Society, 1990). More than 1 million cases of new cancers are diagnosed every year, and about 75 million, or one in three Americans now living, will eventually have cancer (Public Health Service, 1990). Cancer is not one disease but a constellation of more than 100 different diseases, each characterized by the uncontrolled growth and spread of abnormal cells. Cancer may strike at any age, though it does so more frequently with advancing age. Although corroborative intervention data are not yet available, it is estimated that 35 percent of cancer deaths may be related to diet (Eddy, 1986).~The rationale behind most dietary regimens for the treatment of cancer--and for vegetarian, low-fat, high-fiber dietary regimens in particular--is that if dietary excesses can lead to the development of certain cancers, then such cancers may be susceptible to dietary manipulation as well. These diets, for the most part, share certain characteristics with the kinds of foods currently recommended by mainstream groups, such as the American Cancer Society (ACS), for lowering the risk of developing cancer and heart disease. Recent ACS guidelines for cancer prevention suggest reducing the intake of fat, alcohol, and salt-cured and smoked foods while increasing the intake of fruits, vegetables, and whole grains (Nixon, 1990). One way these alternative dietary regimens for cancer differ, however, from mainstream preventive recommendations is that they may emphasize a few particular foods and limit or totally eliminate others.
In September 1990 the U.S. Congress Office of Technology Assessment (OTA) completed a study of a number of unconventional cancer treatments. Among these was a variety of dietary regimens developed for the treatment of cancer and/or the support of patients undergoing conventional cancer therapy. This report, Unconventional Cancer Treatments, ~focused on three of the most well-known dietary interventions for cancer: the Gerson therapy, the Kelley regimen, and the macrobiotic diet. These three regimens and a few others are reviewed below. Findings from the OTA report as well as studies done since that report was released are covered.
Gerson therapy. The Gerson therapy was developed by physician Max Gerson in the early part of this century. Gerson was born in Germany in 1881 and immigrated to the United States in 1936. He received his New York medical license in 1938 and his U.S. citizenship in 1944. He opened a private medical practice in New York City and in 1946 also began treating patients at nearby Gotham Hospital.
He gained renown in Germany through his success in treating tuberculosis of the skin through low-salt dietary management (Gerson, 1929). He then began testing modifications of this regimen in other conditions, including pulmonary tuberculosis (Gerson, 1934). He first used his diet for cancer in 1928, reportedly after a woman with a bile duct cancer that had spread to her liver insisted that he put her on his diet despite his reluctance to do so (Lerner, 1994). ~Much to his surprise, Gerson wrote, the woman recovered (Gerson, 1958). Afterward, Gerson tried variations and combinations of foods and other agents on his patients, noted the ones who reacted favorably, and adjusted subsequent patients' regimens accordingly (Gerson, 1978). By the time he came to America, he was focusing on treating cancer patients.
In 1946 Gerson testified before a subcommittee of the Senate Committee on Foreign Relations, which was holding a hearing on a proposed bill to authorize increased Federal spending for cancer research. Gerson reported to the Senate committee that he had developed a dietary regimen that was effective for the treatment of advanced cancer. According to the historian Patricia Spain Ward, Gerson's testimony was supported by the director of the Gotham Hospital, with which Gerson was affiliated, as well as others in attendance (Ward, 1988). Gerson described five patients in clinical detail and submitted written case histories of those and five more patients who had been treated with his regimen, in whom he had observed improvements in "general body health" and, in some cases, tumor reduction. In a later publication, Gerson noted that in six additional patients his treatment ~appeared to reduce inflammation around the tumors, relieve pain, improve psychological condition, and provide at least temporary tumor regression (Gerson, 1949). In the mid-1950s, Gerson first published explanations of the components of his regimen and the rationale for their use, along with some of the clinical outcomes he observed.
Gerson believed that his treatment regimen reversed the conditions he thought necessary to sustain the growth of malignant cells. He attached great importance to the elimination of "toxins" from the body and the role of a healthy liver in recovery from cancer. Gerson noted that if the liver was damaged (e.g., by cancer or cirrhosis) the patient had little chance of recovery on his or her treatment regimen (Gerson, 1949, 1986). He observed that cancer patients who died during treatment showed a marked degeneration of the liver, which he presumed was due to the release of unspecified toxic factors into the bloodstream by the process of tumor regression. He believed that these toxic tumor-breakdown products poisoned the liver and other vital organs (Cope, 1978).
Another central point of Gerson's approach concerned the balance of potassium and sodium ~in the body. He believed that an imbalance in the concentration of these substances contributes to cancer-induced edema, a condition in which cellular damage leads to infiltration by excess sodium and water, failure of cellular transport mechanisms, subsequent failure of cellular energy production, and, finally, loss of resistance to cancer. Therefore, he sought to eliminate sodium in patients' diets, supplement it with potassium, and thereby alter the internal environment supporting the tumor (Gerson, 1954a, 1954b, 1954c).
At present, the Gerson therapy is an integrated set of treatments that include the restriction of salt in combination with potassium supplementation of the diet. Thyroid supplements also are given to stimulate metabolism and cell energy production. Hourly feedings of fresh, raw juices of vegetables and fruits are given in addition to a basically vegetarian diet. Fat intake is restricted (to lower intake of potential tumor promotors), and protein is temporarily restricted (to promote nonspecific, cell-mediated immunities). Coffee enemas are provided to manage pain and to stimulate bowel and liver enzymes that may increase the release of toxins (Gerson Institute, undated-a). Other treatments beyond the ones specified by Gerson have been added to the current protocol in recent years. Gerson gave patients raw liver juice ~several times daily, but the practice has been abandoned by current practitioners because of bacteria in the liver juice that caused major infections in some patients (Office of Technology Assessment, 1990).
Critics of the Gerson therapy point to the fact that it is based on the beliefs of a physician who practiced many years ago and whose knowledge of the cause of cancer was rudimentary (Green, 1992). Proponents of the therapy argue, rather, that Gerson was far ahead of his time; however, they also note that many of Gerson's original assumptions and therapies have been updated to take into account the latest scientific evidence (Hildenbrand, 1986).
Because of such misconceptions about Gerson and how his therapy is currently administered, proponents contend that it has never been given a fair evaluation by mainstream science. Furthermore, they argue that such myths and misconceptions about the Gerson therapy are perpetuated by major medical journals that routinely publish articles attacking the basic tenets of the therapy while refusing to publish rebuttals to such attacks ~(Lechner and Hildenbrand, 1994).
Research base. There have been several attempts by a number of groups and individuals to assess the clinical effects of the Gerson regimen. However, none have yet offered any definitive results (Office of Technology Assessment, 1990). The following is an overview of early and more recent cases.
In 1959, NCI reviewed 50 case histories presented in Gerson's book, A Cancer Therapy: Results of Fifty Cases. NCI concluded that in the majority of cases a number of basic criteria were not met. NCI also concluded overall that Gerson's data provided no demonstration of benefit (Avery, 1982; U.S. Department of Health and Human Services, 1987). The Gerson Institute, however, disputed NCI's findings and charged that NCI had dismissed legitimate evidence on the basis of technicalities. In addition, the Gerson Institute claimed that even though NCI had indicated six cases were acceptable for further review and another 20 needed further documentation, NCI's own records indicate that such reviews were never done (Gerson Institute, undated-b).~More recently, an exploratory study of the clinical effects of some components of the Gerson regimen was conducted by Peter Lechner, M.D., at the University Hospital of Graz, Austria. This study used a modified Gerson therapy (i.e., liver juice and thyroid supplements were omitted, the number of coffee enemas was limited, and a high-calorie beverage was added to double energy consumption) as an adjunctive treatment. Lechner reported that patients following the modified Gerson regimen showed no side effects attributable to the treatment and did not become malnourished. One of the patients with inoperable liver metastases who followed the Gerson treatment showed a temporary regression. In Lechner's opinion, there were subjective benefits from the modified Gerson regimen: patients needed less pain medication, were in better psychological condition, and experienced less severe side effects from chemotherapy than did control patients (Lechner and Kronberger, 1990).
Lechner's study also suggested that a modified Gerson regimen might be effective in lowering rates of postsurgical complications and secondary infections, increasing tolerance of conventional radiotherapy and chemotherapy, reducing reliance on analgesics, providing for ~an improved overall psychological profile, retarding progress of liver metastases, and improving the state of malignant effusions (Lechner and Kronberger, 1990).
A research team from the University of London that visited the Mexican clinic offering the Gerson therapy (see below) in 1989 on behalf of a British insurance company studied 27 cases in detail. Of those cases, 20 were considered not assessible. Of the 7 assessible cases, 3 showed progressive disease, 1 showed stable disease, and 3 (43 percent of the accessible cases) were in regression. Moreover, the therapy clearly provided a subjective benefit for the patients and their families. In light of the poor prognosis of most of the patients they observed at the clinic, the British team concluded that the example of the Gerson therapy demonstrated a "way forward" for the treatment of cancer (Sikora et al., 1990).
The Gerson Research Organization of San Diego is currently conducting large retrospective reviews of treatment outcomes of more than 5,400 patient charts, including 5-year survival rates by stage (Hildenbrand et al., 1993), for patients treated by the Mexican medical group Centro Hospitalario Internacional del Pacifico, S.A. This facility, a semi-intensive care ~hospital, has offered Gerson's treatment since 1976. The review will include patients who either had no previous treatment or failed previous treatment as well as patients who received complementary conventional treatments.
Kelley regimen for cancer. In the 1960s, William Donald Kelley, an orthodontist by training, developed and publicized a nutritional program for cancer after reportedly being told by his doctor that he had metastatic pancreatic cancer and had only 2 months to live (Office of Technology Assessment, 1990). By trial and error, he self-administered doses of enzymes, vitamins, and minerals to treat his cancer. After his recovery, he applied his dietary program to his family; he also believed that his wife and two of his three children had developed cancer (Kelley, 1969). The Kelley regimen clearly derives from Gerson's. Common elements include carrot juice, a basically vegetarian diet, coffee enemas, and pancreatic enzymes, although pancreatic enzymes play a more emphatic role in the Kelley treatment. The Kelley regimen for cancer became one of the most widely known unconventional cancer treatments. Although Kelley is no longer practicing his treatment, the regimen has been continued in a variety of forms by his followers.~One of the people who adopted the Kelley regimen for the treatment of cancer patients was New York physician Nicholas Gonzalez, M.D. Gonzalez has examined the Kelley regimen and provided his own analysis of Kelley's individual metabolic profiles. According to Gonzalez, Kelley believed that human beings are of three genetically based types: sympathetic dominants, parasympathetic dominants, and balanced types. Sympathetic dominants, who have highly efficient and developed sympathetic nervous systems but inefficient parasympathetic nervous systems, evolved in tropical and subtropical ecosystems, eating plant-based diets. Parasympathetic dominants, in which the opposite is the case, evolved in colder regions, eating meat-based diets. Balanced types, whose nervous systems are equally developed, evolved in intermediate regions, eating mixed diets (Office of Technology Assessment, 1990).
Kelley developed a diet for each type according to the type's hypothesized historical origins. He had also traced a characteristic path of "metabolic decline" for each group when it consumed the wrong diet. He associated "hard tumors" with severely compromised sympathetic dominants, and "soft tumors" (cancers of the white blood cells and lymph ~system) with severely compromised parasympathetic dominants (Office of Technology Assessment, 1990).
As offered by Gonzalez, the Kelley program stresses biodiversity, tailoring diets to individual needs and ranging from purely vegetarian to diets requiring fatty red meat several times daily. Patients consume many supplements--vitamins, minerals, and trace elements--in 130 to 160 capsules daily.
Research base. In his 1987 manuscript One Man Alone: An Investigation of Nutrition, Cancer, and William Donald Kelley, Gonzalez presented case histories of 50 patients he selected from his files (Gonzalez, 1987). This case series has been singled out by proponents as one of the most convincing in support of an unconventional cancer treatment (Office of Technology Assessment, 1990).
In 1990, OTA attempted to find out whether the information presented in these cases would be convincing to the medical community by asking six physicians on its advisory panel to ~review the cases; three of the physicians supported some unconventional treatments, though none was associated with Kelley or Gonzalez, and the other three were mainstream oncologists. Fifteen cases were judged by the reviewers generally supportive of some unconventional medicine as definitely showing a positive effect from the Kelley program; in contrast, the mainstream oncologists found that 13 of these 15 were unconvincing and that 2 were unusual (Office of Technology Assessment, 1990).
Another nine cases were judged unusual or suggestive by the supportive group, and unconvincing by the mainstream group. Another 14 cases were judged by the supportive physicians as having been helped by a combination of the Kelley regimen and mainstream cancer therapy; the mainstream group found 12 of these cases unconvincing and 2 unusual. Finally, 12 cases were considered unconvincing by both groups of physicians. The different interpretations of these cases by physicians who are open to unconventional medicine and those who are not illustrates the difficulty in evaluating therapies that fall outside the bounds of conventional medical wisdom.
~Gonzalez recently submitted to NCI a meticulously documented best case series (Friedman, 1993). At least 6 of the 24 cases reportedly document complete remissions of cancers, 5 of them metastatic to various sites including liver, pleura, brain, and bone. Two additional cases reportedly document partial remissions.
Macrobiotic diet for cancer. The philosophy and general components of the "standard macrobiotic diet" are described below in the "Alternative Dietary Lifestyles and Cultural Diets" section of this chapter. In the area of cancer management and treatment, the macrobiotic philosophy holds that the development of cancer is determined by dietary, environmental, social, and personal factors; by extension, existing cancers may be influenced by the same factors. The development of cancer is described as a long-term, multistep process that begins well in advance of actual tumor formation (Kushi and Jack, 1983).
According to macrobiotic teachings, accumulated toxins result from overconsumption of milk, cheese, meat, eggs, and other fatty, oily, or greasy foods. Also included in this list are foods with a cooling or freezing effect, such as ice cream, soft drinks, and orange juice ~(Kushi and Jack, 1983). Macrobiotics uses the traditional oriental concepts of yin (expansive) and yang (contractive) to devise a framework for explaining and formulating a set of dietary recommendations to treat each type of cancer.
A macrobiotic approach to treating cancer would first classify each patient's illness as predominantly yin or yang, or sometimes a combination of both, partly on the basis of the location of the primary tumor in the body and the location of the tumor in the particular organ. In general, tumors in peripheral or upper parts of the body or in hollow, expanded organs are considered yin; examples include lymphoma, leukemia, Hodgkin's disease, and tumors of the mouth (except tongue), esophagus, upper stomach, breast, skin, and outer regions of the brain. Tumors in lower or deeper parts of the body or in more compact organs are considered yang; examples include cancers of the colon, rectum, prostate, ovaries, bone, pancreas, and inner regions of the brain. Cancers thought to result from a combination of yin and yang forces include melanoma (skin cancer) and cancers of the lung, bladder, kidney, lower stomach, uterus, spleen, liver, and tongue (Kushi and Jack, 1983).
~For cancers classified as predominantly yang, the standard macrobiotic diet is recommended, with slight emphasis on yin foods. The same diet is recommended for yin-classified cancers, with a slight emphasis on yang foods. Patients with cancers resulting from both yin and yang imbalances are advised to follow "a central way of eating," as suggested in the standard macrobiotic diet. Different cooking styles also are recommended on the basis of this disease classification (Kushi and Jack, 1983).
Research base. The available information on the effectiveness of the macrobiotic diet for treating cancer comes from retrospective case reviews and anecdotal reports, some of which come from the popular literature, and two unpublished retrospective studies (Office of Technology Assessment, 1990). A number of individual accounts of patients who attributed their recovery from cancer to their adherence to a macrobiotic diet have been written in recent years.
In one unpublished retrospective study, Carter and colleagues (1990) compared survival times between 23 pancreatic cancer patients maintained on a macrobiotic diet and similar ~patients who received conventional cancer therapy. The authors reported that the mean survival (the average) and the median survival (the point in time after diagnosis by which half the group died) was significantly longer for the macrobiotically maintained patients. A followup study by Carter also showed improved survival time for 11 patients with prostate cancer on a macrobiotic diet. However, OTA pointed out that the studies had design flaws that may have overstated the effect (Office of Technology Assessment, 1990).
In another unpublished manuscript, Newbold (undated) presented six case histories of patients with advanced cancer who adopted a macrobiotic diet in addition to using mainstream treatment. These cases were well described medically, including references to appropriate diagnostic tests (all but one case was definitely biopsy proven) and followup scans and tests (Office of Technology Assessment, 1990).
As in the review of the Kelley regimen, when OTA asked its independent advisory panel of six physicians to review Newbold's cases the three mainstream reviewers did not find any of the cases compelling, while two physicians who were open to unconventional therapies were ~more positive about the outcomes. One concluded that five of the six cases (all except the one without the biopsy-proven diagnosis) showed positive effects from the macrobiotic diet. The remaining physician found two cases that seemed "legitimate," two "highly suggestive," one "suggestive," and one not convincing (Office of Technology Assessment, 1990).
The retrospective studies presented by Carter and Newbold's case histories were later combined and published in the Journal of the American College of Nutrition (Carter et al., 1993). Although the design flaws noted by OTA were still extant in the study, an accompanying editorial suggested that these findings may provide clues to a new approach to the dietary management of cancer (Weisburger, 1993). The editorial stated that the macrobiotic diet has "been construed by classical nutritionists as inadequate. . . . Yet, the application to control the growth of cancer may actually be based on the fact that it is an inadequate diet." The editorial continued by stating that "Perhaps the time has come to teach nutritionists that, in some instances, a nutritional regimen clearly deficient in growth promoting substances might actually be helpful in controlling otherwise untreatable diseases."
~Additional cancer diets. Additional cancer diets reviewed by the Office of Technology Assessment included the Livingston/Wheeler regimen and the Wigmore treatment.
Livingston/Wheeler regimen. This regimen is mentioned here because its practitioners advocate diet as a means of potentiating antitumor immunity. Based on Dr. Virginia Livingston's observation of a putative cancer-causing microorganism, the treatment combines vaccines, bacterial reagents, a patented retinoic acid, intravenously administered vitamins, long-term use of antibiotics, and a modified Gerson diet with coffee enemas. Her San Diego-based clinic has continued, after her death, to offer her treatment.
Wigmore treatment. This treatment is an empirically developed dietary regimen (Wigmore, 1985) that uses seed sprouts, wheat grass juice, and uncooked vegetables and fruits. The available literature contains accounts of positive outcomes in cancer, but they are presented without conventional documentation, making it impossible to confirm or deny them. Although advocates have gone to considerable lengths to present supportive literature for their practices (Wigmore, 1993), formal clinical testing has been limited to studies of the ~reversible, short-term effects of the diet on serum lipids, lipoprotein, and apolipoprotein (W. Ling et al., 1992), which findings are consistent with, if less extensive than, those of similar fat-restricted, basically vegetarian diets (Walford et al., 1992).
Fat-modified diets for treatment of cardiovascular disease and diabetes. Coronary artery disease is the leading cause of death and disability in the United States. Seven million people, nearly 3 percent of the U.S. population, have clinical coronary heart disease. Every year, 1.5 million Americans have acute heart attacks, which kill approximately 520,000 persons, 247,000 of whom are women (American Heart Association, 1991). In fact, cardiovascular diseases--primarily coronary heart disease and stroke--kill nearly as many Americans each year as all other diseases combined (National Center for Health Statistics, 1990). Furthermore, more than 60 million Americans, or 30 percent of the adult population, currently have high blood pressure (National Heart, Lung, and Blood Institute, 1985), which makes them prime candidates for stroke and heart or kidney disease.
Balloon angioplasty (inserting a tiny balloon into the circulatory system and inflating it to open up a plaque-blocked artery) is performed approximately 300,000 times a year in the United States. Although angioplasty provides immediate and possibly lifesaving relief for many patients, it is not a long-term solution. There is no evidence that angioplasty does anything to prevent future angina (severe chest pain) or heart attacks, and about 30 to 40 percent of all angioplasty-treated vessels block up again within 6 months, meaning another angioplasty must be performed (Becker, 1991). Each angioplasty procedure costs about $20,000.
For the most severe cases of heart disease, surgeons remove veins (usually from the legs) and use them to "detour," or bypass, around the clogged arteries of the heart. Even though people who undergo bypass operations experience a reduction in chest pain, the benefits of this surgery, which costs approximately $30,000, often wear off (Myrmel, 1993).
Researchers have known for several decades that a proper diet may prevent the onset of cardiovascular disease. However, once an individual develops this chronic condition, surgery and drugs have been considered the only available methods in mainstream medicine for trying to reverse its effects (Califf et al., 1989). Only recently has diet been considered an ~alternative to drugs and surgery for treating cardiovascular disease. In the mid-1970s, Nathan Pritikin began using an extremely low-fat, high-fiber diet along with exercise to treat heart disease patients and showed that he could lessen their clinical symptoms. Then in the late 1980s, San Francisco physician Dean Ornish set out to do the same. However, Ornish was armed with a powerful new tool: the angiogram, which is an interior picture of patients' blood vessels. Using "before" and "after" angiograms, Ornish was able to see how changes in diet and lifestyle affected the status of the blockage, or plaque, in the artery. The Pritikin and Ornish diets are described below.
Pritikin diet. The diet is named after the man who developed it, Nathan Pritikin, who had been told by his cardiologist that he was at great risk of death from myocardial infarction. Therefore, he patterned for himself a diet modeled after a vegetarian diet followed by the people of Uganda, who were shown to be essentially free from death by heart attacks (Martin, 1991). In the late 1960s, after a few years on this diet, Pritikin decided that it had saved his life and founded his clinic in Santa Monica to treat cardiac patents.
~The Pritikin diet is basically vegetarian, high in complex carbohydrates and fiber, low in cholesterol, and extremely low in fat (less than 10 percent of daily calories). The Pritikin diet also requires 45 minutes of walking daily. Although this diet and exercise program can be followed completely on an outpatient basis, the Pritikin Longevity Center in Santa Monica recommends that patients attend a 26-day program to learn how to prepare their new type of meals and practice new daily exercise and living habits.
Ornish diet. This diet was developed by Dean Ornish, M.D., an assistant clinical professor of medicine at the University of California, San Francisco. The Ornish diet is basically vegetarian, allowing no meat, poultry, or fish, and permitting only the white of eggs. Also, no nuts, caffeine, or dairy products, except a cup a day of nonfat milk or yogurt, are allowed, and no oil or fat is permitted--not even for cooking. Two ounces of alcohol a day are allowed. Providing an average of about 1,800 calories a day, the diet provides 75 percent of its calories from carbohydrates and less than 10 percent from fat (Ornish, 1990). The American Heart Association's recommended adult "prudent diet" calls for total fat of less than 30 percent, which Ornish feels is not really low enough, even for healthy adults, but ~especially not for people trying to reverse atherosclerosis (Ornish, 1990). Ornish provides his patients all their lunch and dinner meals, precooked, packed in Tupperware, and handed out a week's worth at a time.
In many ways, the Ornish diet is similar to the Pritikin diet. Both are basically vegetarian (although Pritikin does allow 85 grams of chicken or fish per week), high in complex carbohydrates, high in fiber, low in cholesterol, and extremely low in fat (less than 10 percent of daily calories). However, Ornish's program--run on an outpatient basis--calls for stress reduction practices in addition to the diet and emphasizes emotional social support systems, particularly between members of the group. It also requires daily stretching and an hour's walk three times a week.
Research base. The following is an overview of the available research on these two ultra-low-fat dietary regimens.
Pritikin diet. In a study of men taking the Pritikin 26-day course, all 21 participants reduced ~their cholesterol level, 19 reduced their triglyceride level, and 16 had a reduction in their estradiol level (Rosenthal et al., 1985).
In another study assessing the effectiveness of the Pritikin diet and exercise program on cardiovascular hemodynamics, 20 subjects were divided in two groups (active/treatment and control). These data were compared to a group of 10 healthy individuals not involved in the program. Hemodynamic parameters were collected at admission and at the end of the 26-day program. In obese and hypertensive subjects not on medication who followed the Pritikin program, the cardiac index increased by 10 percent, mean arterial pressure decreased by 5 percent, and the systemic vascular resistance index decreased by 18 percent. Little change was seen in controls. There also was an improvement in ventricular performance (Mattar et al., 1990).
The Pritikin diet has also been studied in connection with adult-onset diabetes mellitus and peripheral vascular disease. Studies suggest that it may show promise in controlling newly diagnosed cases of adult-onset diabetes without drugs. One study (Barnard et al., 1982) ~evaluated 60 patients who had completed the Pritikin 26-day program. Of the 23 who were taking oral hypoglycemic agents upon entry, all but 2 were off medication by the end of the program. Of the 17 patients who were taking insulin, all but 4 were off medication at discharge. Two of those 4 had their insulin reduced by 50 percent, while the remaining 2 had no major change in their insulin dosage. Fasting blood glucose levels were significantly reduced in all patients; serum cholesterol levels were similarly reduced, as were triglyceride levels. The group as a whole lost an average of 4.3 kg of body weight and achieved 40.5 percent of their desired weight loss. Maximum work capacity increased significantly, while daily walking increased from approximately 11.7 minutes a day to approximately 103 minutes.
In another study, University of California, Los Angeles (UCLA) investigator Dr. James R. Barnard put 650 diabetic patients on the Pritikin diet. After 3 weeks, some 76 percent of the newly diagnosed diabetics, along with 70 percent of those on oral agents, had normal glucose levels (Barnard et al., 1992). However, only 40 percent of those already receiving insulin responded to the diet. According to Barnard, muscles, which may become severely ~insulin resistant during drug treatment, respond to exercise and a low-fat diet. In contrast, drugs may eventually weaken the pancreas while failing to reduce physically and financially devastating vascular complications (e.g., deterioration of eyes and kidneys).
Ornish diet. In what is now known as the Lifestyle Heart Trial, in the late 1970s and early 1980s Ornish conducted a series of trials in which patients with confirmed heart disease were placed on a diet and lifestyle modification program. In the first study, after 30 days people reported a substantial reduction in frequency of angina (heart pain), and many were pain free. Cholesterol levels were down about 20 percent, and high blood pressure was reduced (Ornish et al., 1979). In a followup study in the early 1980s, Ornish reported that 30 days of his regimen were enough to improve blood flow to the heart in some patients and that patients could exercise almost 50 percent more, on average, than they could before beginning the treatment (Ornish et al., 1983).
Finally, in a prospective, randomized, controlled trial to determine the effectiveness of his program over a longer time, Ornish and his colleagues put 28 men and women whose ~arteries were partially blocked on his program for a full year. Twenty other patients were assigned to a "usual care" group. After 1 year, without the use of lipid-lowering drugs, patients in the experimental group (i.e., receiving the Ornish treatment) reported a 91-percent reduction in the frequency of angina, a 42-percent reduction in the duration of angina, and a 28-percent reduction in the severity of angina. In contrast, control group patients reported a 165-percent rise in frequency, a 95-percent rise in duration, and a 39-percent rise in severity of angina (Ornish et al., 1990).
Patients in the experimental group also showed a significant overall regression, or reduction, of coronary atherosclerosis (blocked arteries) as measured by angiograms. In contrast, patients in the usual care group had a significant overall progression, or worsening, of their coronary atherosclerosis. This finding led Ornish to conclude that the conventional recommendations for patients with heart disease, such as a 30-percent fat diet, are not sufficient to bring about an improvement in many patients.
Ornish has never tested separately each component of his multifaceted program, so it is ~impossible to be sure which component contributed most to the improvements. If it was the dietary regimen that led to the improvements, it is a regimen that most Americans would have a hard time following, admits Ornish (Schardt, 1993). However, some researchers believe that it does not take such a radically restricted diet to start reversing the effects of heart disease. In a study in Germany, 56 men suffering from angina caused by partially blocked arteries were placed on a reduced-fat diet (less than 20 percent of calories from fat, 7 percent of calories from saturated fat, and 200 mg of cholesterol a day). As in the Ornish program, they also participated in an exercise program. After a year, angiograms showed that the blockages in 32 percent of the men on the low-fat diet had improved, compared with just 17 percent in the control group (Schuler et al., 1992).
In addition, in the late 1980s, researchers in Britain placed 26 men with partially blocked arteries and elevated blood cholesterol on carefully monitored diets and reduced their fat intake to 27 percent of calories--about three-fourths of what the average American eats. The diet's saturated fat and cholesterol amounts also were substantially less than most Americans eat, while its fiber content was slightly higher. Over the next 3 years, the men on ~the fat-restricted diet suffered only one-third as many deaths, heart attacks, and strokes as men in the control group--who were not told what to eat, and whose diets were not monitored (Watts et al., 1992). Furthermore, angiograms showed that the openings in the arteries of 38 percent of the men who changed their diets became slightly larger.
Food elimination diets for treatment of food allergies. Allergies to food, or food intolerance, have become a major area of research in recent years. Many of the researchers involved in this research specialize in environmental medicine (see the "Alternative Systems of Medical Practice" chapter), which is the science of assessing the impact of such environmental factors as chemicals, foods, and inhalants on health. It provides an understanding of the interface between the external environment and the biological function of the individual.
Dietary management of food allergies is based on avoidance of food antigens and the 4-day rotary diversified diet. With the rotary diet and avoidance of repetitive food exposures, it is possible to reduce sensitivity to foods and hasten recovery from food allergies. Nutritional supplements are prescribed as indicated by objective nutritional testing and the symptoms of ~the patient.
Research base. Miller (1977) studied eight chronically ill food-sensitive patients who were tested with provocation-neutralization techniques. The patients were treated with injections of allergy extracts and compared to those treated with placebos. In a rigidly controlled study, King (1988) showed a correlation between oral food challenge and provocation-neutralization testing. Treatment using results from this testing showed significant symptom relief. Using neutralization therapy, Rea and colleagues (1984) found significant improvement in 20 patients with known food sensitivity in signs and symptoms of allergy reactions to certain foods.
Food intolerance is also being studied as a causal or contributing factor in rheumatoid arthritis. In a clinical trial in Norway, Kjeldsen-Kragh and colleagues (1991) found that fasting followed by dietary restriction could relieve the symptoms of rheumatoid arthritis on a long-term basis. They subjected 27 rheumatoid arthritis patients to a 7-to 10-day fast (except for herbal teas, garlic, vegetable broth, a decoction of potatoes and parsley, and ~extracts from carrots, beets, and celery) followed by 1 year of an individually adjusted vegetarian diet. The diet-restricted patients stayed on a Norwegian health farm the first 4 weeks of the study. A control group of 26 patients stayed in a convalescent home for 4 weeks but ate an ordinary diet throughout the trial.
After 4 weeks, the diet group showed a decrease in pain score; a significant decrease in pain, morning stiffness, and the number of tender and swollen joints; and improved grip strength and ability to articulate the joints. There was also a significant improvement in a number of biochemical markers associated with inflammation. These improvements were maintained throughout the year. In contrast, the control group showed a decrease in pain score after its stay in the convalescent home, but none of the other indices improved. At the end of the study the conditions of the control patients had deteriorated.
This study suggests that there is a food allergy component to rheumatoid arthritis and that food restriction appears to be a useful supplement to the conventional medical treatment of rheumatoid arthritis. Darlington and colleagues (1986) and Beri and colleagues (1988) ~obtained similar results, but their studies lasted only 3 months.
There is also evidence that food elimination diets may benefit many children with hyperactivity (Kanofsky, 1986). Several research teams have used double-blind designs to demonstrate this point. The Institute of Child Health and Hospital for Sick Children in London undertook a randomized, crossover, placebo-controlled trial to evaluate the effect of diet on the development of hyperactivity (Egger et al., 1985). The first phase of the study consisted of placing 76 hyperactive children on a food elimination diet. The presupposition was that individuals can be sensitive to a food or food additive in their diet and that improvement occurs when the offending foods or food additives are removed from the diet. At the end of the first phase of the study, 62 of the 76 children (82 percent) improved on the diet, and a normal range of behavior was achieved in 21 (29 percent) of them. In addition to overactivity, other symptoms such as headaches, abdominal pain, antisocial behavior, and fits were also often alleviated.
In all, 48 foods were implicated as contributing to hyperactivity in the young patients. ~However, 34 of the 50 children for whom full data are available reacted to fewer than 7 foods. Two reacted to 30 foods. Five patients were also noted with symptoms from such inhalants as pollen, perfume, and house dust. Foods that frequently caused problems included cow's milk (64 percent of subjects tested), chocolate (59 percent), wheat (49 percent), and oranges (45 percent).
The second phase of the study included 28 children from the original group, who entered into a double-blind, crossover, placebo-controlled trial that reintroduced one incriminated food. Symptoms returned or were exacerbated much more often when patients were on active material than on placebo. One of the most interesting findings of the study is that the artificial food coloring tartrazine and the preservative benzoic acid were the commonest food items causing a reaction. The behavior of 79 percent of the 34 children tested deteriorated when tartrazine or benzoic acid was reintroduced into their diet. These findings are compatible with the work of Dr. Benjamin Feingold, the San Francisco allergist who implicated tartrazine and other artificial food additives in children's diets as contributors to hyperactivity. It is worth noting that the same London group also published a study stating ~that 93 percent of 88 children with severe, frequent migraines recovered on a diet that eliminated foods and food additives that had been shown to cause symptoms (Egger et al., 1983).
Some confirmation for the food elimination treatment for hyperkinesis was provided by Kaplan and colleagues (1989). In their study, 10 of 24 hyperactive children exhibited approximately a 50-percent improvement in behavior when placed on an elimination diet that was not as restrictive as the London diet.
Alternative Dietary Lifestyles in Prevention and Treatment of Chronic Illness
A number of alternative dietary lifestyles throughout the United States and the world are believed to increase resistance to illness. Although some diets, such as macrobiotics, have been intentionally developed in the past half-century, others have evolved more naturally over the centuries.
~An "alternative lifestyle" diet can be described as any diet that differs from the mainstream American diet. Such diets include various forms of vegetarianism and diets with emphasis on "natural," "organic," "unrefined," "unprocessed," and/or other health foods in varying degrees. Others are drawn from other societies around the world, such as the "Mediterranean" diet.
Historically, there has been much skepticism among some health professionals about such diets. For example, when the vegetarian movement started in the United States about 50 years ago, people questioned whether adults subsisting on such diets could even do a full day's work and still survive (Krey, 1982). However, generations of people around the world have now grown up on these diets, helping to dispel such myths. Furthermore, many individuals and population groups have practiced vegetarianism on a long-term basis and have demonstrated excellent health (American Academy of Pediatrics, 1977). Indeed, the case against such diets has been largely cultural and economic (see the section "Barriers and Key Issues Related to Diet and Nutrition" in this chapter).
Vegetarian diets. Vegetarian diets are among the most common of alternative diets in the ~United States today. The degree of vegetarianism can vary widely, ranging from those who eat red meat infrequently to those who totally exclude any animal-derived foods, such as dairy products or eggs, from their diet. Vegetarianism is often categorized according to the extent of these restrictions. For example, people who consume dairy products and eggs but not other animal foods are referred to as lacto-ovo-vegetarians, while people who avoid all animal products are referred to as vegans. Studies of vegetarians in the United States and other industrialized nations probably provide the most extensive support for the idea that alternative dietary habits can favorably influence the incidence and pathology of disease.
This section focuses on the nutritional aspects of the two most widely studied variations on the vegetarian diet: the one followed by adherents of the Seventh-Day Adventist Church, and the macrobiotic diet. The health-related data from people eating these diets are compared with data taken from individuals in the general U.S. population.
Seventh-Day Adventists. The Seventh-Day Adventists are a Protestant sect that among other things preaches a clean, wholesome lifestyle and admonishes against eating animal flesh ~(i.e., red meat, poultry, fish). Thus, Seventh-Day Adventists are for the most part lacto-ovo-vegetarians. They also abstain from alcohol, tobacco, and caffeine-containing beverages, such as coffee and tea. Even though they avoid meat, Seventh-Day Adventists' diets are not substantially lower in fat intake than the typical American diet. For example, in one survey of lacto-ovo-vegetarian Seventh-Day Adventists, total fat intake averaged 36 percent of energy versus 37 percent for the average American (Phillips et al., 1983).
Macrobiotic diet. Along with Seventh-Day Adventists, people who consume a macrobiotic diet have been studied extensively to examine associations with disease risk factors. In addition, macrobiotic diets are among the most popular alternative dietary therapies for cancer and other chronic diseases (Cassileth et al., 1984).
The earliest version of the macrobiotic diet, termed the "zen macrobiotic diet," originated with the lecturer-philosopher Georges Ohsawa (1893-1966), the pen name for Yukikaza Sakurazawa, a Japanese teacher who studied the writings of Japanese physician Sagen Ishikuzuka (1850-1910). Ohsawa is said to have cured himself of serious illness by changing ~from the modern refined diet then sweeping Japan to a simple diet of brown rice, miso soup, sea vegetables, and other traditional foods. He initiated the development of macrobiotic philosophy, reportedly integrating elements of Eastern and Western perspectives with "holistic" perspectives on science and medicine. Ohsawa made his first of several visits to the United States in 1959.
Ohsawa outlined 10 stages of diet (designated by numbers -3 to +7). Diet -3 consists of 10 percent cereal grains, 30 percent vegetables, 10 percent soups, 30 percent animal products, 15 percent salads and fruits, 5 percent desserts, and beverages "as little as possible." With each higher number diet, Ohsawa reduced the percentages of foods from some categories or eliminated the category entirely and increased others, so that in the +3 diet, for example, 60 percent was cereals, 30 percent was vegetables, and 10 percent was soups.
Since the early 1970s, the macrobiotic movement in the United States has been under the leadership of Michio Kushi. Kushi, who studied with Ohsawa and came to the United States from Japan in 1949, preserved elements of Ohsawa's philosophy while incorporating a ~variety of broader and more complex components into macrobiotic philosophy and practice. Most notably, Ohsawa's 10-phase dietary levels were replaced with the general "standard macrobiotic diet," which Kushi described in detail in his 1983 book, The Cancer Prevention Diet (Kushi and Jack, 1983).
Unlike Seventh-Day Adventists, whose vegetarian diets usually include dairy products and eggs, the standard macrobiotic diet as practiced today tends to minimize consumption of all animal products except fish (M. Kushi, 1977, 1983). Thus the macrobiotic diet is predominantly vegan, with an emphasis on whole cereal grains and vegetables, preferably organically grown. As a result, it tends to be relatively high in complex carbohydrates and low in fat content (and, therefore, calories) in comparison with the standard American diet. One survey of 50 adults consuming a macrobiotic diet demonstrated that fat intake averaged 23 percent of energy, saturated fat intake averaged 9 percent of energy, and carbohydrate intake averaged 65 percent of energy (L. Kushi et al., 1988).
Research base. The following is an overview of the available research on the ~health-promoting and disease-preventing effects of the Seventh-Day Adventist and macrobiotic diets.
Seventh-Day Adventist diet. Despite their relatively high fat intake, Seventh-Day Adventists have less heart disease and incidence of some cancers than occurs in the general U.S. population. For example, Seventh-Day Adventists who eat little or no red meat have a lower death rate from heart disease than the general U.S. population (Phillips et al., 1978; Snowdon et al., 1984a). Indeed, studies on Seventh-Day Adventist males have shown that their serum cholesterol levels were lower and that the first heart attack occurred almost a decade later than average. The incidence of heart disease was only 60 percent as high as that of a control group in California (Register and Sonnenberg, 1973). Abstinence from tobacco and alcohol also may have contributed to this effect.
Studies comparing Seventh-Day Adventists with non-Adventists demonstrate that the former tend to have lower blood pressure levels as well. For example, in one study in which age, sex, and body size were taken into account, blood pressure levels for vegetarian ~Seventh-Day Adventists averaged 128.7 mm Hg systolic and 76.2 mm Hg diastolic versus nonvegetarians' average levels of 139.3 mm Hg systolic and 84.5 mm Hg diastolic (Armstrong et al., 1977). Similar findings were seen in other studies comparing vegetarian and nonvegetarian Seventh-Day Adventists (Melby et al., 1989).
Another study comparing blood pressure levels of vegetarian Seventh-Day Adventists with nonvegetarian Mormons, who similarly avoid tobacco and alcohol, demonstrated that the Seventh-Day Adventists still had lower blood pressure levels (Rouse et al., 1982). Comparisons of California Seventh-Day Adventists with their non-Adventist neighbors also demonstrated that the Adventists had lower LDL cholesterol levels (Fraser, 1988).
The overall cancer death rate of male Seventh-Day Adventists is only about half that of the overall cancer death rate of the U.S. general population, and the overall cancer death rate of female Seventh-Day Adventists is about 70 percent of that of the general population (Phillips et al., 1980). The lower death rates apply not only to those cancer sites known to be associated with cigarette smoking (e.g., lungs), but also to other sites such as the breast. In ~fact, Adventists have 80 to 90 percent of the general population's breast cancer death rate and only 50 to 60 percent of the colon and rectal cancer death rate (Phillips et al., 1980). These observations suggest that smoking habits alone cannot explain the difference between cancer death rates of Seventh-Day Adventists and those of the general population.
The results of other prospective dietary studies among Seventh-Day Adventists are mixed when vegetarians are compared with nonvegetarians. For instance, there appears to be little relationship between such dietary variables as total fat or animal fat intake with risk of breast cancer (Mills et al., 1988, 1989a). However, in two prospective cohort studies, Seventh-Day Adventists who rarely consumed meat, poultry, or fish appeared to have a lower risk of breast cancer than those who consumed these foods at least once a week (Mills et al., 1989a; Phillips and Snowdon, 1983). In neither of these studies was this association statistically significant.
However, a study of 35,000 California Seventh-Day Adventists, covering a followup period from 1976 to 1982, did indicate an increased risk of colon cancer with increasing animal fat ~intake (Morgan et al., 1988). Indeed, those individuals in the highest third of animal fat intake rates had a risk of developing colon cancer that was 1.8 times that of individuals in the lowest third of animal fat intake rates; people with intermediate animal fat intakes were intermediate in their risk (Morgan et al., 1988).
In another study of cancer among 25,000 California Seventh-Day Adventists covering 20 years (1960-80), men who consumed meat at least four times a week experienced a prostate cancer death rate of 41.9 deaths per 100,000 person-years versus 29.7 deaths per 100,000 person-years for men who did not consume meat (Phillips and Snowdon, 1983). In the study begun in 1976, daily consumption of meat was associated with a risk of developing prostate cancer 1.41 times greater than that of men who never ate meat (Mills et al., 1989b). In the earlier study, meat intake was also associated with increased risk of prostate cancer (Snowdon et al., 1984b).
On the other hand, increased consumption of beans and lentils appeared to decrease the risk of colon cancer in the Seventh-Day Adventist population (Morgan et al., 1988). In fact,