A Prospective Evaluation of Health Services Outcomes and Emerging Cardiovascular Disease Biomarkers

The primary aim of the proposed research is to examine the relationship of lifestyle changes to new dietary, biomedical, and cellular parameters among new enrollees entering the "Dr. Dean Ornish Program for Reversing Heart Disease program" at 5 selected sites. Specifically, the investigators will add assessments of emerging cardiac risk factors (e.g., high sensitivity C-reactive protein \[hsCRP\], fibrinogen, lipoprotein(a) \[Lp(a)\], small, dense LDL, apolipoprotein B \[apoB\], apolipoprotein A-I \[apo A1\], the apoB/apoA1 ratio, homocysteine \[Hcy\], B-type natriuretic peptide \[BNP\], oxidized LDL, fasting insulin and waist-to-hip ratio \[WHR\]), protective and pathogenic dietary markers (e.g., folate, carotenoids, trans fatty acids), and measures of social support and cognitive functioning to the already existing assessment variables in the Multisite Cardiac Lifestyle Intervention Program (MCLIP).

Hypothesis 1: Participation in the lifestyle program will not only be associated with favorable changes in standard coronary risk factors and quality of life, but also with improvements in emerging cardiac risk factors \[hsCRP, Hcy, BNP, fibrinogen, Lp(a), small, dense LDL, apoB, apoA1, oxidized LDL, fasting insulin, and abdominal obesity\] and psychosocial well-being (i.e., social support, and cognitive functioning).

Hypothesis 2: High intake of emerging protective dietary factors and low intake of emerging pathogenic dietary factors will be associated with improvements in both standard and emerging cardiac risk factors (e.g. Hcy, oxidized LDL).

Hypothesis 3: Degree of adherence to the lifestyle change program will be associated with differential improvement in standard coronary risk factors, emerging risk factors, cellular aging, and psychosocial variables.


Eligibility Criteria:
Inclusion Criteria:

* Eligible patients included those who had a diagnosis of coronary heart disease (CHD) from their physician or health plan, a diagnosis of diabetes, or at least 3 additional cardiac risk factors.
* A diagnosis of CHD included:

  * having diagnosed CHD based on non-invasive testing such as exercise testing, nuclear imaging, echocardiogram or other test that clearly demonstrates ischemia
  * cardiac catheterization demonstrating CHD
  * eligibility for bypass surgery/PTCA and seeking a clinical alternative
  * coronary bypass surgery
  * PTCA/stent
  * myocardial infarction.
* Type I or Type II diabetics were eligible for the program.
* For a participant to be included as a high-risk factor participant, the participant must have either a family history of premature CHD (1st-degree relative (male\<55; female \<65) with MI or sudden cardiac death) or be a male aged \> 45 or a female aged \> 55.
* In addition, there must be at least two additional cardiovascular risk factors, including:

  * current cigarette smoking (within the past 5 years)
  * hypertension: BP \> 140/90 mm Hg or on antihypertensive medication,
  * low HDL-C: \<35 mg/dl or on medications for lipid therapy
  * elevated apolipoprotein(a): \>30 mg/dl or on medications for elevated lipids
  * high total cholesterol: \> 240 or on medications for elevated lipids
  * high LDL-C: \>160 or on medications for elevated lipids
  * high sensitivity C-Reactive Protein: \> 3 mg/dl and \< 10 mg/dl
  * obesity: BMI \> 30
  * Insulin Resistant State (Metabolic Syndrome X

Exclusion Criteria:

* Exclusion criteria included:

  * ischemic left main CHD, with an obstruction greater than 50%
  * significant (\>70%) proximal left anterior descending artery disease and proximal left circumflex artery disease and an ejection fraction less than 50%, \*unstable angina
  * hypotensive response to exercise (\> 20mm Hg drop in systolic BP)
  * history of exercise induced ventricular tachycardia or 3rd degree heart block without evidence of current stability
  * CABG surgery within 4 weeks, unless approved by medical director
  * MI within one month, unless approved by medical director\\
  * HF, with functional limitation and unresponsive to medications
  * current tobacco user not concurrently enrolled in a smoking cessation program with 2-month history of smoking cessation
  * uncontrolled malignant ventricular arrhythmia despite medications and/or implantable cardiac defibrillator (ICD), unless approved by medical director, resides beyond a one-hour commute to the Program site, unless approved by Team, \*history of substance abuse disorder (inc. ETOH) without documentation of a minimum one year of abstinence
  * history of a significant psychiatric disorder without documentation of minimum one-year stability
  * impaired cognitive function, such as dementia or delirium
  * English language literacy unless Program site can accommodate
  * non-ambulatory
  * uncooperative spouse or life partner, defined as obstructive in attitude or behavior
  * the patient is deemed to be potentially disruptive to group setting by the screening team.