Themis Yiaslas is a Psychologist in the Behavioral Medicine Clinic; Ajay Sood is Chief, Endocrine Section; Gregory Ono and Cynthia Spann are Clinical Pharmacists; Tara Rogers-Soeder,Janelle Embree, and Carrie Caputo are Dietitians, Nutrition and Food Service; June Taylor is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. Rachel Kitazono is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and Saul Schaefer is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento. Correspondence: Themis Yiaslas (themis.yiaslas@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Clinical practice guidelines for the treatment of patients with recent cardiovascular adverse events (AEs) include a referral to cardiac rehabilitation (CR).13 CR emphasizes exercise as the main intervention, along with coaching to promote multiple risk reduction. The most comprehensive CR program is intensive CR (ICR), including the Ornish ICR program.14 ICR includes 4 components: vegetarian diet, exercise, stress management (yoga, meditation), and group support. Ornish ICR has been shown to be efficacious in randomized controlled trials (RCTs).15-17 Three effectiveness studies, with 5,372 participants, demonstrated the real-world effectiveness of Ornish ICR in US hospitals.14,18,19 The program also was adapted successfully for the active-duty military and veteran population.20,21 Yet Ornish ICR is time intensive, and there are no certified VHA ICR Ornish sites. Furthermore, there is no formal strategy for targeting people with atherosclerotic CVD who no longer meet the criteria for CR or ICR. While Ornish ICR is highly effective for patients who are eligible and have access, a more effective and streamlined approach is needed for targeting many patients.
Nutrition may be the most powerful Ornish ICR component. The initial RCT conducted by Ornish and colleagues included only stress management training and a whole-food, plant-based (WFPB) diet, including grains, legumes, vegetables, fruits, nuts, and seeds. The trial found 91% of participants experienced reduced angina after only 24 days.15 The only single-component intervention study resulting in partial reversal of atherosclerosis was a WFPB diet-only study, which documented regression of atherosclerotic plaques after 5 years, using coronary angiography in 73% of participants, with arrested progression in the other 27%.22 Participants reported no cardiovascular AEs after 12 years.23 Furthermore, a number of other recent studies have demonstrated the benefits of WFPB diet-only interventions for type 2 DM (T2DM), hypertension, and obesity.24-27 The Heart Disease Reversal Program (HDRP) was developed to create an interdisciplinary lifestyle intervention that emphasized nutrition for a broad population of veterans with atherosclerotic CVD, of varying levels of functional ability, to promote comprehensive CVD risk reduction and bring heart disease reversal intervention into routine clinical practice.
Program Description
The Mental Health, Cardiology, and Nutrition and Food services all approved the launch of HDRP. We contacted veterans by mail, and 11% expressed interest (Figure). Among patients who received the initial mailed letter (prior to our accepting staff referrals), only 5% of patients who enrolled in HDRP reported previously being told about or prescribed a WFPB diet by any health care provider (HCP). Currently, patients are primarily referred to HDRP by Cardiology, Primary Care, and Mental Health services.
