A four week residential program for primary health care ... - Nature

European Journal of Clinical Nutrition (1999) 53, Suppl 2, S72±S77 ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00 http://www.stockton-press.co.uk/ejcn

A four week residential program for primary health care patients to control obesity and related heart risk factors: effective application of principles of learning and lifestyle change M SjoÈstroÈm1,2,3*, AB Karlsson1,2, G Kaati1, A Yngve2, LW Green4 and LO Bygren1 1

Department of Social Medicine, University of UmeaÊ, Sweden; 2Unit for Preventive Nutrition, Department of Medical Nutrition, È rebro, Sweden; and Karolinska Institutet, Stockholm, Sweden; 3Department for Physical Education and Health, University of O 4 Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada

Objective: To test the short and long-term effectiveness of a four week residential program for primary health care patients to control obesity and related risk factors for cardio-vascular disease (CVD), especially blood pressure (BP). Design: Prospective clinical study, with follow up after 1 and 5 y. Setting: Vindeln Patient Education Centre, Vindeln, and Department of Social Medicine, University of UmeaÊ , Sweden. Subjects: Approximately 2500 individuals, with two or more of the traditional risk factors for CVD, participated in the program. This report describes a subsample of 100 consecutive patients, 52 9 y, 53 men, with obesity and=or high BP. Intervention: Four week residential program with lectures and group discussions as well as practical sessions in smaller groups (meal preparations, physical exercise, etc). The patients were followed-up medically in their home area. Outcome measures: Weight and blood pressure. Results: Dramatic reductions of weight and, especially, of blood pressure (BP) occurred during the residential weeks, and the reductions were pronounced also after 1 y. After 5 y, the total mean weight among men with initial BMI 30 kg=m2 was still 5 kg lower, and diastolic and systolic BP among those with hypertension was 15 and 20 mm Hg lower, respectively, than before the program. Conclusions: The full-time participation in the residential program and the enrollment and commitment of the patients may explain the clinical outcome. A level of predisposition greater than that required of most weightand BP-control programs was con®rmed and a great preventive or therapeutic potential was indicated. The study illustrates an effective application of the Precede-Proceed model of health promotion planning. Sponsorships: The County Council of VaÈsterbotten, and The Swedish Council for Planning and Coordination of Research (FRN), (grant no 880704:2 A14-5=11) Sweden. Descriptors: primary health care; health promotion; patient education; prevention; obesity; hypertension; nutrition; food habits; physical activity

Introduction Individuals at risk for cardiovascular disease (CVD) can be in¯uenced through learning and training of skills to enable the behavioural and lifestyle changes required for control of weight and blood pressure. Several multifactorial, lifestyle risk-reduction trials, in which counseling has been central regarding a healthful diet and regular physical exercise, have clearly demonstrated that the atherosclerotic processes, with or without medical therapy, can be slowed, arrested, and even reversed (Ornish et al, 1990, 1998; Schuler et al, 1992; Watts GF et al, 1992; Haskell et al, 1994; Esselstyn et al, 1995; Niebauer et al, 1995, 1997). In one of these trials (Esselstyn et al, 1995), 18 heart disease patients followed a very-low-fat plant-based diet and, where needed, received hypolipidemic medication. Eleven of the patients had follow-up angiograms at 5 y, and among these patients 11 of 25 atherosclerotic lesions had regressed and 14 had been arrested. No patient had any *Correspondence: M SjoÈstroÈm, Unit for Preventive Nutrition, CNT, Novum, S-141 57 Huddinge, Sweden. Guarantor: M SjoÈstroÈm

evidence of new infarctions or of clinical progression. In contrast, patients treated conventionally had experienced 49 cardiovascular events during the preceeding 8 y. This illustrates the potential of a non-pharmacological approach to prevention and treatment of cardiovascular disease in the primary health care physician's practice. In the north of Sweden there is a relatively high incidence of CVD (Stegmayr et al, 1997). The occurrence of the traditional risk factors for CVD among the population in this region has been carefully analyzed in the WHO MONICA Project, and the trends in the development of the risk factors have been followed (Peltonen et al, 1998). A residential centre for individuals at special risk for cardiovascular disease, Vindeln Patient Education Centre, was built and started up in 1984. It was run by the local primary health care organisation. The general practitioners and hospital physicians could refer, without any cost, their patients to the Centre. A model of residential health education was developed. Here we report the short- and long-term results from a study in which this model has been used. A consecutive series of 100 patients, with hypertension or who were overweight, participated in a 4 week

A four week residential program M SjoÈstroÈm et al

full-time residential program to enable the control of weight and blood pressure. The clinical outcome after 1 and 5 y respectively was encouraging. The social support throughout the residential learning process and the feedback on progress during that period seems to have provided the reinforcement necessary for long-term maintenance of the initial improvements. The results are discussed in view of known principles of learning, and behavioural and lifestyle changes. Methods In Sweden most general practitioners and district nurses work in primary health care (PHC) centres run by the county councils. They are responsible for promoting health and for the care of geographically de®ned populations. Vindeln Health Centre Vindeln is located in the North of Sweden, 55 km west of UmeaÊ, in the County of VaÈsterbotten (approx 250 000 inhabitants). Vindeln Patient Education Centre is run by the local PHC Organisation. Recruitment of patients During a 10 y period, 1984 ± 95, the primary health care physicians in VaÈsterbotten had the opportunity to refer individuals at special risk for CVD to Vindeln Patient Education Centre. During this period about 2500 patients were referred, all of whom had at least one risk factor for CVD, besides overweight, such as hypertension, and diabetes. The reason for referral was that traditional counseling and pharmacological treatment had failed to give the results expected. Each month a new cohort of 30 individuals was admitted. They all arrived the same day (Monday, 1st week) to the Centre and stayed for nearly 4 weeks (Thursday ± Friday, 4th week), i.e. for 24 days. The patients were permitted to visit their families during the second and third weekend of the period. Family members were also encouraged to visit the Education Centre, especially during the weekends. Food during the residential period The meals were fat- and salt-reduced and mainly based on vegetable components but lean ham, chicken or ®sh were sometimes served. Breakfast, at 07.00, was low-fat and ®bre-rich. Lunch opened with a salad buffet, and 10 ± 15 min later a main course, often prepared by the participants themselves, was served. Supper, usually a low-caloric soup, was served at 17.00. Fruit and vegetables, such as sticks of carrots and Swedish turnip were served between meals. Afternoon coffee was available, but coffee was not served otherwise during the day. Smoking and use of alcohol were not permitted. Activities The 30 patients were divided into four smaller workinggroups, 7 ± 8 individuals in each. Each day was ®lled with problem-oriented activities, often carried out in the working-groups. Some of the activities were scheduled while some were based on the participants' own suggestions. Lectures, demonstrations and group discussions, with or without a supervisor, took place daily. Most of the time, however, was ®lled with practical sessions, such as meal

preparations and physical exercise. The lunches were often prepared in the working-groups by the group members themselves after an introduction and demonstration by a dietician. The group could also, eventually together with the dietician, go for a study tour in the local food store. Freedom of choice and commitment were emphasised throughout the whole course. Towards the end of the residential period each patient wrote his or her own plan of action, or a contract, about how to maintain the improvements in their health behaviour. This was done with support, if needed, from the members of the staff. The staff included, except for the dietician, a physician, two nurses, three physiotherapists, a housekeeper, cleaners and kitchen staff, all of whom were available for consultations and guidance during the whole period. The members of staff were all trained to create a positive atmosphere and friendly environment. Medical follow-ups The individuals visited their own primary health care centre for the usual medical-care follow-ups. They also returned to the Vindeln Patient Education Centre after 12 months and 5 y, each time for 3 ± 4 d, for reinforcement, revision of the home program and measurements. Measurements Body weight and blood pressure were measured using a standardized protocol, at the beginning of the residential period, and during follow-ups at 12 months and 5 y. One and the same scale was used throughout the study. Blood pressure was determined using a semi-automatic machine, operated by the same nurse throughout the study period. The patients in this report A consecutive series of 100 patients, 53 males, 47 females, with hypertension, i.e. diastolic blood pressure (DBP) 90 mm, or taking antihypertensive medication, and=or overweight (Body Mass Index (BMI) 30) were followed during the residential period and also measured at the repetition weeks after 12 months and 5 years. Referral main diagnoses were in 83 cases of hypertension, in 24 obesity, 16 diabetes, 12 angina pectoris or previous myocardial infarction, and 10 hyperlipidemia. Table 1 gives mean values of physical and social variables at the beginning of the residential period. The following days and weeks were ®lled with learning and training of skills, including cooking and physical exercise, as well as social activities. The members in the different working groups supported each other, as is usually the case in this model, and gave feed-back to one another. The patients expressed that they experienced a positive, constructive and safe atmosphere. Results Dramatic reductions in weight and both diastolic and systolic blood pressure occurred during the residential weeks, amongst both men and women (Table 2 and Table 3). Symptoms, such as headache, allergic manifestations and joint pains, improved markedly, whilst blood lipids and blood sugar showed more favourable values.

S73


S74

Table 1 Physical and social characteristics of 100 individuals referred to the four week residential program to control obesity and related heart risk factors

Age (y) Weight (kg) BMI (kg/m2) < 25 25 ± 30 > 30 Diastolic BP (mmHg) < 90 90, or medication Smokers Cohabiting Children Educational level Primary Secondary University

Male n 53

Female n 47

Total n 100

51.8 8.6 93.0 17 29.4 4.5 5 31 17 93.2 11 3 50 15 44 45

52.3 9.2 82.4 14 30.5 5.3 6 22 19 89.3 11 7 40 8 34 38

51.6 8.9 88.1 17 29.9 4.9 11 53 36 91.4 11 10 90 23 78 83

22 20 9

21 21 2

43 41 11

Figures are number of individuals, otherwise mean s.d.

Weight The reduction in mean weight among the obese male patients was about 7 kg (BMI reduced by 2.1 kg=m2, P < 0.000, paired t-test), and for females 4.2 kg (BMI reduced by 1.35 kg=m2, P < 0.000) after the three residential weeks (Table 2). After 12 months the weight remained at the same low level. After the ®ve years the overall decrease in weight was still signi®cantly lower (P < 0.05), however the values for males were not fully signi®cant (4.7 kg, P 0.084) compared with those at the beginning of the residential period. Corresponding values for females were 73.6 kg (P < 0.005) after 12 months and 71.84 kg (P 0.33) after ®ve years. Blood pressure There were dramatic and throughout statistically signi®cant changes already after the ®rst residential weeks in both systolic and diastolic blood pressure, both among the men and women with hypertension (total mean DBP values decreased from about 100 mm Hg down to 85 mm Hg

Table 3 Number of patients with diastolic blood pressure DBP < 90 or 90 mm Hg with or without medication before the residential period and one and ®ve years later Anti-hypertensive medication DBP Before < 90 90 Total 12 months < 90 90 Total 5 years < 90 90 Total

Yes

No

Total

36 33 69

10 21 31

46 54 100

42 11 53

39 8 47

81 19 100

54 10 64

32 4 36

86 14 100

or lower) (Table 2). The reduction became even more pronounced towards the end of the residential period (DBP down to 81 mm Hg). Mean reduction was 19 and 27 mm Hg for DBP and SBP, respectively, for both men and women. After 12 months and ®ve years, the blood pressures still remained at a low level. Mean DBP after 12 months was 85 mm Hg for males and females, respectively, and SBP about 143 mm Hg for both sexes. DBP after ®ve years was 87 mm Hg and 82 mm Hg, for males and females, respectively, and SBP 146 mm Hg and 141 mm Hg. Medication Of the 90 patients, de®ned as having hypertension at the beginning of the residential period, 33 had both a high DBP ( 90 mm Hg) and were taking anti-hypertensive medication, whilst 36 with medication showed a diastolic blood pressure lower than 90 mm Hg (Table 3). Twenty-one individuals had a high DBP but were without medication. Thus, 54 patients (33 21) had a DBP 90 mm Hg (cf Table 2). After 12 months only 19 patients remained at that level, and after ®ve years 14 patients (Table 3). At the ®ve year follow up, ®ve patients who had been taking medication at the onset of the study, no longer needed it. The dose

Table 2 Changes in BMI, diastolic and systolic blood pressures (DBP, SBP) (mean s.d.) at arrival (2nd or 3rd day) and changes in BMI and BP during the residential period and 12 months and 5 y follow-up, respectively. The data have been obtained among obese patients, with BMI > 30, or patients with arterial hypertension, i.e. with DBP 90, with or without anti-hypertensive medication

2

BMI at arrival (kg/m )(n) Changes in BMI after 1 week 2 weeks 3 weeks 12 months 5 years DBP at arrival (mm Hg) (n) Changes in DBP after 1 week 2 weeks 3 weeks 12 months 5 years SDP at arrival (mm Hg) (n) Changes in SDP after 1 week 2 weeks 3 weeks 12 months 5 years *33 of 54 had anti-hypertensive medication.

Males

Females

Total

34.2 4.4 (17) 7 0.93 7 1.42 7 2.10 7 2.10 7 1.42 100 9 (32) 7 16 7 19 7 19 7 15 7 13 164 16 (32) 7 23 7 28 7 27 7 21 7 18

35.6 4.1 (19) 7 0.70 7 1.17 7 1.57 7 1.35 7 0.70 99 6 (22) 7 13 7 17 7 19 7 15 7 17 164 14 (22) 7 21 7 24 7 27 7 22 7 22

34.9 4.3 (36) 7 0.81 7 1.29 7 1.82 7 1.70 7 1.04 100 8 (54)* 7 15 7 18 7 19 7 15 7 15 164 15 (54)* 7 23 7 26 7 27 7 21 7 20


(daily de®ned doses, DDD) of antihypertensive medicine was also reduced, if initial DBP was 90 mm Hg 37% and 46% after 12 months and ®ve years, respectively, and if < 90 mm Hg 31% and 17%. Discussion Blood pressure The most striking result was the widespread short- and long-term decrease in blood pressure to normal levels, amongst both males and females. About 75% of the patients (40 out of 54), with a diastolic blood pressure of more than 90 mm Hg at the beginning of the program, remained at a level below 90 mm Hg ®ve years later. There is such a thing as a spontaneous reduction in blood pressure among patients with hypertension, but the reduction is not, according to our own clinical experience, of such a magnitude as in the present study. Neither do we believe that the high diastolic blood pressure measured in the beginning of the residential period is an artefact, for example expresses a habituation to the measurements, which sometimes may be the case in multiple risk factor interventions (Ebrahim & Smith, 1997). More than four out of ®ve (83%) of our individuals were referred to the program due to hypertension, usually resistent to any of the traditional therapeutic efforts, and they had all been subjected to several blood pressure measurements before they came to the Health Centre. The measurements were always made in the morning of the 2nd or 3rd day of the stay by a trained person according to a standard protocol. Others have also found a rapid reduction of blood pressure under conditions similar to those in our study. McDougall et al (1995) conducted a study to demonstrate the effectiveness of a strictly vegetarian very low-fat diet on cardiac risk factor modi®cation. Five hundred men and women participated in an intensive 12-day live-in program at a hospital-based health-centre. The program focused on dietary modi®cation, moderate exercise and stress management. During this short period, cardiac risk factors improved. There was, above all, a reduction of blood pressure of 6% and a weight loss of 2.5 kg for men and 1 kg for women. These ®ndings are similar to those in our study. However, no report of the long-term effects of the program of McDougall et al (1995), seems to have been published. A substantial reduction in blood pressure can be explained by the diet rich in fruit, vegetables, and low-fat dairy food with reduced saturated and total fat (Appel et al, 1997). Among 133 subjects with hypertension, such a diet reduced systolic and diastolic blood pressure by 11.4 and 5.5 mm Hg more than a control diet, within one or two weeks. Weight loss is also accompanied by a reduction in blood pressure; a large number of controlled trials have reported that weight loss reduces blood pressure or the need for medication in hypertensive patients (NIH=NHLB Clinical Guidelines, 1998). We made no systematic attempts to reduce the antihypertensive medication during the residential period, although the patients themselves sometimes initiated a reduction, or a complete withdrawal, of their medicine. The usual follow-ups in the primary health care centres in the home-area of the patients resulted in a general reduction by 30 to 45% of the daily de®ned doses (DDD). A more marked reduction in medication might have been possible in many cases, but the physicians, due to the theraputic

tradition in this ®eld, did not even seem to consider a reduction or withdrawal of the anti-hypertensive treatment. Weight The reduced body weights, for males of 5 to 7 kg, was albeit not of any extreme size, a most appreciated outcome. The real reduction of body fat was probably more pronounced, as some of the fat tissue might have been replaced by muscle tissue. The daily physical activities of many different kinds during the residential period (endurance exercise as well as strength training) and the improved activity habits thereafter, above all veri®ed by measurements of VO2max (to be reported elsewhere), support that suggestion, not to mention the patients, own assurances that the body shape had been much improved. Furthermore, the maintained reduction in body weight of about 5 kg after ®ve years should be considered in the light of the fact that people in these age groups in general, at least in Sweden (Kuskowska-Wolk & BergstroÈm, 1993a, b), increase their body weight by 500 to 700 g per year, that is an increase by 2.5 to 3 kg in a ®ve year period. If this were true also for our patients the relative weight reduction should be considered to be 7 to 8 kg, or, to say it in an-other way, the initial reduction in weight was maintained for at least ®ve years. CHIP experiences In an intensive hospital-based educational program (Diehl, 1998), participants were encouraged to exercise 30 min per day and to embrace a largely unre®ned plant-food-centered diet that is high in complex carbohydrates and ®ber, and very low in fat, animal protein, sugar, and salt, and virtually free of cholesterol. A total of 304 enrollees in the ®rst program were at elevated risk of coronary artery and related diseases. Of these enrollees, 288 graduated from the program. At four weeks, overall improvements in the participants blood pressures (DBP 76 mm Hg for males, 75.5 for females), weights and body mass indexes (BMI 71.0 and 70.9) were highly signi®cant. In this 4-week program, the patients met daily for 2.5 h from Monday to Thursday, that is 40 h of intense education. In addition, they attended two half-day applied nutirtion work-shops on consecutive Sundays with sit-down banquet meals. The amount of education in the program of Diehl (1998) is less than half of our full-time residential program. The outcome (blood pressure, BMI) also seems to be only half of ours. So far, their results after 12 months have not been published. The lifestyle heart trial This randomized clinical trial investigated whether ambulatory patients could be motivated to make and sustain comprehensive lifestyle changes and, if so, whether the progression of coronary atherosclerosis could be stopped or reversed without using lipid-lowering drugs as measured by computer-assisted quantitative coronary arteriography (Ornish et al, 1990, Ornish, 1998). Experimental group patients were prescribed an intensive lifestyle program that included a 10%-fat vegetarian diet, moderate aerobic exercise, stress management training, smoking cessation and group psychosocial support. Patients were encouraged to avoid simple sugars and to emphasize the intake of complex carbohydrates and their whole foods. The majority of experimental group participants (20 of 28 patients) were able to make and maintain the intensive

S75


S76

lifestyle changes not only for one year but also for an additional four years (Ornish et al, 1998). The adherence to all aspects of the program was excellent during the ®rst year and good after ®ve years, although these patients initially volunteered to participate for only one year when they entered the study. The patients lost 10.9 kg at one year (baseline mean weight 91.4 kg) and sustained a weight loss of 5.8 kg at ®ve years (corresponding data on our overweight patients at Vindeln Patient Education Centre were 6.8 kg and 4.7 kg, respectively). The control group had increased weight by 1.4 kg after ®ve years. Blood pressures were slightly lowered, but SBP and DBP were low already at baseline. There were more than twice as many cardiac events in the control group. The Precede-Proceed model Our study illustrates the effective application of theory and evidence-based principles of learning and behavioural or lifestyle change. These principles are synthesized and re¯ected in the Precede-Proceed model of health promotion planning (Green & Kreuter, 1991, 1999). The model suggests that the forces in¯uencing lifestyle can be organized broadly into three categories of determinants; predisposing, enabling, and reinforcing factors for behavioral change. The predisposing factors for lifestyle change involve the cognitive motivational forces such as knowledge, attitudes, beliefs, values, perceptions, and selfcon®dence. The enabling factors include skills and resources necessary to carry out the recommended behaviour. Reinforcing factors include the rewards and satisfactions received or felt in response to the changing behaviour. The Precede-Proceed model emphasises the importance of assessment and planning to match interventions directed at each of these sets of factors according to the characteristics of the behavioural changes and the population. Our program of intervention for hypertension and obesity reduction incorporates attention to each of these three sets of factors. The enrollment and commitment of people to the several weeks of full-time participation in the residential program presupposed and con®rmed a level of predisposition greater than that required of most blood pressure and weight control programs. The training and participation in, for example, meal preparation provided for the development of skills and the management of food resources that should enable the behaviours required for effective weight reduction. The social support throughout the residential learning process and the feedback on progress with blood pressure and weight reduction during that period, as well as in scheduled follow-up medical visits in their home areas, provide for reinforcement necessary for maintenance of the weight control behaviour. The reduction of symptoms such as headache, allergic reactions, joint pains and medication side-effects would also have reinforced the behaviours leading to these felt improvements in quality life and the visible reductions in weight and blood pressure. Conclusion The four week residential program for primary health care patients to control obesity and related risk factors for CVD, especially blood pressure, was found to be effective, both in short-term (4 weeks or 12 months) and long-term (5 y). Nearly four of ®ve patients (40 of 54) reduced initial DBP 90 mm Hg to a level below 90 mm Hg. The participation

in the full-time residential program and the enrollment and commitment of the patients may explain the encouraging clinical outcome. Our data on weight and blood pressure development con®rm a level of predisposition greater than that required for most life-style intervention programs. They indicate an interesting preventive or therapeutic potential of supervised residential programs. References Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH & Karanja N (1997): A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N. Engl. J. Med. 336, 1117 ± 1124. Diehl HA (1998): Coronary risk reduction through intensive communitybased lifestyle intervention; the Coronary Health Improvement Project (CHIP) experience. Am. J. Cardiol. 26, 83T ± 87T. Ebrahim S & Smith GD (1997): Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease. Br. Med. J. 314, 1666 ± 1674. Esselstyn CB, Ellis SG, Medendorp SV and Crowe TD (1995): A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician's practice. J. Fam. Pract. 41, 560 ± 568. Green LW & Kreuter MW (1991): Health Promotion Planning: An Educational and Environmental Approach, 2nd ed. Mountain View, CA: May®eld Publishing Co. Green LW & Kreuter MW (1999): Health Promotion Planning: An Educational and Ecological Approach, 3rd ed. Mountain View, CA: May®eld Publishing Co. Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, Williams PT, Johnstone IM, Champagne MA, Krauss RM, Farquhar JW (1994): Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation 89, 975 ± 990. Kuskowska-Wolk A & BergstroÈm R (1993): Trends in body mass index and prevalence of obestiy in Swedish men 1980 ± 1989. J. Epidemiol. Community Health 47, 103 ± 108. Kuskowska-Wolk A & BergstroÈm R (1993): Trends in body mass index and prevalence of obestiy in Swedish women 1980 ± 1989. J. Epidemiol. Community Health 47, 195 ± 199. McDougall J, Litzau K, Haver E, Saunders V & Spiller GA (1995): Rapid reduction of serum cholesterol and blood pressure by twelve-day, very low fat, strictly vegetarian diet. J. Am. Coll. Nutr. 14, 491 ± 496. Niebauer J, Hambrecht R, Schlierf G, Marburger C, Kalberer B, Kubler W & Schuler G (1995): Five years of physical exercise and low fat diet: effects on progression of coronary artery disease. J. Cardiopulm. Rehabil. 15, 47 ± 64. Niebauer J, Hambrecht R, Velich T, Hauer K, Marburger C, Kalberer B, Weiss C, von Hodenberg E, Schlierf G, Schuler G, Zimmerman R & Kubler W (1997): Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical exercise. Circulation 21, 2534 ± 2541. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ & Gould KL (1990): Can lifestyle changes reverse coronary heart disease? The lifestyle heart trial. Lancet 336, 129 ± 133. Ornish D (1998): Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. Am. J. Cardiol. 26, 72T ± 76T. National Institutes of Health, National Heart, Lung, and Blood Institute (1998): Clinical guidelines on the identi®cation, evaluation, and treatment of overweight and obesity in adults. The evidence report. Ornish D, Scherwitz LW, Billings JH, Gould L, Merritt T, Sparler S, Armstrong W, Ports T, Kirkeeide RL, Hogeboom C & Brand RJ (1998): Intensive lifestyle changes for reversal of coronary heart disease. JAMA 280, 2001 ± 2007. Peltonen M, Huhtasaari F, Stegmayr B, Lundberg V & Asplund K (1998): Secular trends in social patterning of cardiovascular risk factor levels in Sweden. The Northern Sweden MONICA Study 1986 ± 1994. Multinational Monitoring of Trends and Determinants in Cardiovascular Disease. J. Intern. Med. 244, 1 ± 9. Schuler G, Hambrecht R, Schlierf G, Niebauer J, Hauer K, Neumann J, Hoberg E, Drinkmann A, Bacher F, Grunze M & Kubler W (1992): Regular physical exercise and low-fat diet; effects on progression on coronary artery disease. Circulation 86, 1 ± 11.


Stegmayr B, Asplund K, Kuulasmaa K, Rajakangas AM, Thorvaldsen P & Tuomilehto J (1997): Stroke incidence and mortality correlated to stroke risk factors in the WHO MONICA Project. Stroke 28, 1367 ± 1374.

Watts GF, Lewis B, Brunt JNH, Lewis ES, Coltart DJ, Smith LDR, Mann JL & Swan AV (1992): Effects on coronary artery disease of lipidlowering diet, or diet plus cholestyramine, in the St. Thomas Atherosclerosis Regression Study (STARS). Lancet 339, 563 ± 569.

S77