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July 14, 1999

Effect of Lifestyle Changes on Coronary Heart Disease

JAMA. 1999;282(2):130-132. doi:10-1001/pubs.JAMA-ISSN-0098-7484-282-2-jbk0714

To the Editor: The enthusiastic results reported in the Lifestyle Heart Trial1 should be interpreted with caution. One surprising finding was that among control subjects, percent luminal diameter progressed despite reductions in fat intake (25% of energy) and low-density lipoprotein (LDL) cholesterol (19.3%). This contrasts with numerous clinical trials that have demonstrated that lowering LDL cholesterol and mild to moderate fat restriction impede coronary artery disease (CAD) progression.2 Therefore, it would be useful to document the prevalence of other variables (eg, cigarette smoking, fasting blood glucose level >6.9 mmol/L [125 mg/dL]) contributing to arteriographic progression and CAD events in this group. It is also noteworthy that despite the absence of cigarette smoking, 25 cardiac events occurred among the 28 patients assigned to the intention-to-treat experimental group. This suggests that despite intensive lifestyle changes, other factors may have contributed to subsequent ischemic events, revascularization, and cardiac death. Among the most obvious were elevated triglyceride levels (mean triglyceride=2.91 mmol/L [258.1 mg/dL]), an independent risk factor for CAD, even at the desirable range.3 Fatty fish, which provide a rich source of omega-3 fatty acids and lower triglycerides, were excluded in the Ornish diet. Exclusion of fish (associated with reduced CAD events4) and nuts, which contain cardioprotective antioxidants,5 may have been a disservice.