va Hebenstreit remembers a trip to Israel in January 1986, when her 71-year-old husband, Werner, could not get across the street before the light changed.
"He was a cripple," said Mrs. Hebenstreit. "A permanent coronary cripple."
At his doctor's recommendation, Mr. Hebenstreit, who had had two heart attacks, joined a program run by Dr. Dean Ornish, who for more than 20 years has studied whether changes in diet and daily activities can reverse coronary heart disease. It was a radical program combining an extremely low-fat, vegetarian diet with exercise, meditation and smoking cessation.
Susan Spann for The New York Times
Eva and Werner Hebenstreit, under
their rigid dietary regimen, substitute a grain mixture for
coffee. Mostly, they eat complex carbohydrates, fruits and
"At 71, I was convinced I would die very soon," said Mr. Hebenstreit, who lives in San Francisco. "I feel healthier now than when I was 40 years younger."
Now, in a first-ever experiment on critically ill elderly people, Medicare will examine whether what worked for Mr. Hebenstreit will work on a large scale and bring down medical costs. Enrollment of volunteers started on Monday. The nutrition and exercise experiment is designed to determine whether drastic changes in lifestyle and eating habits can prevent the need for angioplasty and heart bypass surgery.
"The challenge for us is how to modernize Medicare from a medical, acute care model to a comprehensive, health care model emphasizing successful and healthy aging through health promotion and risk factor reduction," said Jeffrey Kang, chief clinical officer with the Health Care Financing Administration, which oversees Medicare.
Officials with the Health Care Financing Administration defended the choice of Dr. Ornish's program, saying that studies had been sufficient to warrant a pilot project. The program has been criticized by some health experts as too restrictive, and, they say, the studies that point to the program's success have been too small to draw such conclusions.
Dr. Michael Hash, deputy administrator of the Health Care Financing Administration, said the Ornish program was selected after Dr. Ornish made a proposal to the agency, which wanted to see if the results could be replicated. The agency is advertising for another similar program to test.
Over the next three years, about 1,800 elderly heart patients, at a cost of $7,200 each, will follow the program, run out of at least 15 centers whose staffs are trained by Dr. Ornish, for one year. While the demonstration project, financed by Medicare, tests a form of treatment, it exemplifies a broad shift toward preventive medicine being examined by Medicare. In 1997, Medicare took major steps in this direction when coverage was expanded to include colorectal cancer screening, bone mass measurement for osteoporosis and expanded benefits for screenings like mammograms and pelvic exams.
In December, a panel of experts from the Institute of Medicine, part of the National Academy of Sciences, recommended that Medicare pay for outpatient nutrition counseling. According to the report, 86 percent of the estimated 34 million Americans over 65 have at least one chronic condition like high blood pressure or diabetes that might be helped by nutrition counseling.
Many see the moves as long overdue. While Medicare has traditionally covered nutrition therapy for hospitalized patients, some health experts said that with the current emphasis on cost cutting, such services were often lost and in any case had rarely been offered to outpatients.
"Hospital stays are shorter and shorter so work that used to be done in the hospital isn't being done very much," said Dr. Virginia A. Stallings, chairwoman of the institute's panel of experts and the chief of the nutrition section at Children's Hospital of Philadelphia.
At the same time, she said, growing evidence indicates that nutrition therapy can be a cost-effective way to deal with outpatients with chronic disease.
"The science supports nutrition in the management of a number of important diseases," Dr. Stallings said. "There really is a place for this."
Some critics, however, while praising the concept, questioned whether large number numbers of people would be able to stick to the highly regimented Ornish program. For instance, Dr. Ornish recommends that fat intake be no more than 10 percent daily, while the United States Department of Agriculture's guidelines recommend no more than 30 percent.
Officials from the American Heart Association said many of the studies showing results with the Ornish program had been small and that more information was needed on which parts of the program had the most effect. They also said that such a restrictive program might have negative effects on the day-to-day quality of life of patients and their families.
"We don't feel the situation is at all clear as to whether this approach is going to be applicable to the general population," said Dr. Ronald M. Krauss, past chairman of the nutrition committee of the heart association. "They should have looked into potentially less expensive ways of doing that."
But Dr. Hash said: "We wouldn't be proceeding to demonstrate this with the Medicare population if we didn't have confidence that it had produced evidence of effectiveness in reducing heart disease. We have determined it is promising as a possible alternative to bypass surgery." Coronary heart disease, he added, is the leading cause of death among people receiving Medicare.
Medicare's test of the Ornish program is not a clinical trial, but will instead follow the progress of volunteers who enroll at the centers. Rather than testing the effectiveness of the program as a health measure per se, the Medicare is intended to show whether people who stick with it end up costing the program less. It is the first time Medicare has run a payment demonstration on a lifestyle-modification program.
Johanna Dwyer, director of the nutrition clinic at New England Medical Center Hospital, said that many elderly patients did not get nutrition counseling and that such steps could help. She recalled the case of an elderly woman with emphysema who was taking a large amount of medicine that affected her appetite.
Nutrition counselors were able to find foods she could eat and get her back on track. "Nutrition isn't a cure all, but it's part of the solution," Ms. Dwyer said.
Dr. Ornish said he began looking for a new approach to heart surgery 23 years ago when he was a medical student learning to do bypass surgery. Patients would come in for surgery, go home to the same food and stresses and soon be back for another bypass.
"For me that became a metaphor," Dr. Ornish said. "Like mopping up the floor without turning off the faucet."
The Ornish diet is vegetarian relying on combinations of complex carbohydrates to replace proteins found in meat, fish and poultry. The only animal products allowed on the diet are egg whites and nonfat dairy products. No oils can be added to food, but moderate amounts of sugar, alcohol and salt (unless otherwise restricted for health reasons) can be used. No caffeine is allowed. The bulk of the diet is made up of a large variety of whole grains, vegetables, fruits and legumes.
Mr. Hebenstreit, while no longer part of an official Ornish program, still maintains the strict regimen.
The Hebenstreits start each day with whole grain cereal, sweetened only with fruit juice. They each eat a whole orange as opposed to drinking orange juice, which is more concentrated and has a higher sugar content. Mr. Hebenstreit also has a piece of toast, spread with ripe banana and orange marmalade. Rather than coffee, the Hebenstreits have a substitute made from grain.
Lunch is typically a sandwich on whole grain bread with soy cheese, bean paste, tomato, onion and some type of green like spinach or baby lettuce, followed by fruit.
Or they make soup with a variety of beans and grains. For dinner, they have pasta or polenta with steamed vegetables and grapefruit or fat-free fig bars.
Don Vaupel, 61, a retired professor from Oakland, Calif., and an Ornish patient of 11 years, said he decided to try the program as an alternative to bypass surgery.
Looking back to his early days on the diet, he said, "all I can remember is that lots of things were dark green and brown and not very tasty." In the early days, he said lunch might have been a sweet potato and salad with nothing on it. Dinner consisted of steamed vegetables and steamed rice. Now, with all the new low-fat foods, things have gotten more interesting.
As he arrived home from the store recently, Mr. Vaupel was carrying the ingredients for a frittata he would make with an egg substitute for dinner: portobello mushrooms, fat-free parmesan and ricotta and spinach.
He generally starts his day with green tea and a soy-powder protein shake, which he pours over a whole grain cereal like grapenuts. For lunch he might have a grilled low-fat cheese sandwich on whole wheat bread.
"I just walked three miles," he said. "I don't mean walk like, oh look at the pretty flower. I walk, break a sweat and then slow down."
He meditates for an hour each morning and night although he prefers to call it "my appointment with me." He lost 110 pounds in the first nine months of the program, 85 of which have stayed off permanently and there has been reversal in the blockages of his heart, his doctors tell him.
Still, for all his accomplishments, he said he still needed nutritional counseling. Three years ago he received a diagnosis of adult diabetes, which he also works to control through diet.
"I didn't go on a diet," Mr. Vaupel said. "This was a lifestyle change. I had to change everything."