March 2009

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Vol. 8, No. 3

John McDougall, MD

Urgent: Support the Proposed New Law in California Requiring Doctors to Provide Patients with Information on Diabetes and Heart Disease

Patients often receive inadequate and/or incorrect information from their doctors on diabetes and heart disease. For example, on heart disease, inadequate information is received on these three important issues:

1) They are told surgery (angioplasty and bypass) for chronic coronary artery disease is usually lifesaving, when the scientific research says otherwise.

2) They receive almost no education about the role of the rich Western diet in the cause of coronary artery disease and about the right way to eat to prevent it.

3) They are rarely told that changing to a healthy, low-fat, plant-food based diet will relieve symptoms of heart disease, including chest pain, and reverse the underlying disease.

Assembly Bill 1478 has been introduced by California state assembly member Tom Ammiano, representing the 13th District, to require that a physician obtain a patient's written acknowledgment confirming the receipt of information, as specified, regarding treatment through medical nutrition therapy prior to delivering nonemergency treatment for heart disease. My supporting letter on this matter is provided below.  Next month’s newsletter will have a similar letter from me about diabetes treatment and a request for your support.

Please send letters to members of the Business & Professions Committee (who are initially reviewing this bill) asking them for their support of AB 1478.  A sample letter is provided at the end of this article. Here are their e-mail addresses:


B&P consultants to the Assembly member:


For Hayashi:


For Emmerson:


For Conway:


For Eng:


For Hernandez:


For Nava:


For Niello:


For Perez:


For Price:


For Ruskin:


For Smyth:




My Letter of Support for AB 1492:

Requirement to Inform Patients in Writing about the Limitations of Heart Surgery (CABG and angioplasty) and the Benefits of Nutritional Therapies for Heart Disease

The Patients’ Right to Informed Consent

Informed consent is a patient right guaranteed by the bylaws of most hospitals. California law requires that a patient’s consent be obtained in writing for several specific procedures and treatments, including: sterilizations, hysterectomy, breast cancer, prostate cancer, gynecological cancers, psychosurgery, and electroconvulsive therapy, but not for heart surgery.1c California patients with heart disease need to be informed in writing about the lack of benefits and the real harms of current therapies with bypass surgery and angioplasty. They also need to be told that the cause of their heart disease is the rich Western diet, and that their condition is reversible with a change in diet, exercise, and judicious use of inexpensive medications.

Heart Surgery for Coronary Artery Disease

Disease of the arteries supplying the heart muscle (called atherosclerosis) affects the majority of the adult population of California. According to the American Heart Association 16,800,000 people alive today in the US have a history of heart attack, angina pectoris or both.1a The cause of this disease is well recognized as due to the meat- and dairy-centered Western diet.

Faced with pictures of the shadows of blockages in their coronary arteries (angiogram x-rays), nearly two million people in the US annually undergo heart surgeries, most patients believing that these procedures will prevent heart attacks and prolong their lives. Coronary revascularization by coronary artery bypass grafting (CABG) and angioplasty (percutaneous coronary intervention or PCI) are among the most common major medical procedures performed in North America and Europe. In the US in 2006 there were about 1.314 million angioplasties and 448,000 bypass operations performed.1b Many hospitals derive 80% of their income from the treatment of heart disease. The average total healthcare cost after five years is $100,522 for bypass surgery and $81,790 for angioplasty per patient.1

Heart Surgery Lacks Benefits for Survival, Heart Attack Prevention, or Quality of Life

More than 28 studies have been done to try to determine real life benefits from heart surgery for people with chronic blockages of their heart arteries.  Results of angioplasty have consistently shown no survival or heart attack prevention benefits over standard medical care. Studies, all performed before 1990, showed a small survival benefit in highly selected small subgroups for bypass surgery (approximately 3%) over medical therapy.

Two recent studies, the OAT (Occluded Artery Trial) and COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) studies have been especially revealing about the failures of angioplasty.  The conclusion of the OAT study of 2166 patients treated with angioplasty and medications or medications alone was: “PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during 4 years of follow-up in stable patients with occlusion of the infarct-related artery 3 to 28 days after myocardial infarction.”2,3 The most recent follow up of the OAT study found at 2 years medical therapy was less expensive with better survival than angioplasty.4 The conclusion of the COURAGE study of 2287 patients was, “As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.”5

A recent analysis of 28 studies comparing heart surgery with medical therapy, performed by doctors with a vested interest, cardiologists and bypass surgeons, found less than a 2% absolute improvement in survival achieved from heart surgery over no operation.6 And for the most part these major treatments continue to be performed without any questioning by the patients, their doctors, their health insurance providers, and anyone from the government of California.

Surgical Interventions Fail to Treat Killer Lesions

Doctors understand why heart surgeries do not save lives. The aim of heart surgery is to by pass around (bypass surgery) or rupture (angioplasty) hard, stable, large plaques found inside the heart arteries. However, these plaques are not the ones that cause heart attacks or death. A heart attack occurs when a small volatile plaque, better pictured as a tiny festering sore, located on the inside of an artery ruptures and causes the blood to suddenly form a clot (thrombus).5,7,8 The event is known as a coronary artery thrombosis, or a heart attack. The reason lives are not saved by bypass surgery and angioplasty is these surgeries completely ignore the dangerous part of the artery disease, the tiny volatile plaques (sores).

Inexpensive Diet-therapy and/or Medications Reverse Heart Disease

Beginning in the 1950s investigators from the University of Pennsylvania treated their heart patients with a low-fat diet and obtained excellent relief of chest pain (angina) in only a few days.9-12 In 1983 results published in the Journal of the American Medical Association showed a healthy diet and lifestyle could cause a 91.0% mean reduction in frequency of chest pain episodes in less than 3 weeks.13 Chest pain (angina) is the primary legitimate reason for recommending surgery. The next level of benefit from dietary therapy was established when a healthy diet was found to reverse the underlying disease (atherosclerosis) in 82% of patients in one year.14-16 The addition of cholesterol lowering medications and aspirin offers further advantages for heart patients.17

Cost Savings to the State of California

Actual figures for the number of heart surgeries for California are not available. However, assuming California has one-tenth the population of the United States, then extrapolated figures for heart surgery (131,400 angioplasties and 44,800 bypass surgeries) performed annually can be made using the average total healthcare cost after five years of $100,522 for bypass surgery and $81,790 for angioplasty per patient. 

This extrapolation suggests the potential for savings is nearly $11 billion for angioplasty surgeries and $5 billion for bypass surgery annually—money spent every year, over the next 5 years after the procedure.

By comparison diet-therapy can be taught with outpatient classes for a few hundred dollars. Intensive medically supervised live-in programs are also available for between $2000 and $4000. A cost-benefit analysis published in the October-December 2006 issue of the University of California’s California Agriculture journal has determined that every dollar spent on nutrition education in California saves between $3.67 and $8.34 in future medical costs.18


Sample Letter to Assembly Member

Dear Assembly Member (their name):

I am writing to ask you to vote for AB 1478.  Chronic diseases like heart disease and diabetes are epidemic in America and California.  From my personal experience I know that while drug medication can be of value in emergency situations, drugs ultimately never cure the disease – they only suppress the symptoms of the disease.  This is an expensive way to treat diseases. Our state cannot anymore afford the high cost of treating patients with drugs and surgery alone. Diet and lifestyle changes have been found to be helpful in arresting and even curing heart disease and diabetes, and is very inexpensive compared to drugs and surgery.  I feel doctors should give their patients the option to be referred out for diet or nutrition therapy for their non-emergency heart disease or diabetic condition. 

Thank you very much for your support for AB 1478.


Your name, address, and e-mail





1c) 1)

1)  Stroupe KT, Morrison DA, Hlatky MA, Barnett PG, Cao L, Lyttle C, Hynes DM, Henderson WG; Investigators of Veterans Affairs  Cooperative Studies Program #385 (AWESOME: Angina With Extremely Serious Operative Mortality Evaluation). Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients.  Circulation. 2006 Sep 19;114(12):1251-7.


3) Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, Abramsky SJ, Forman S, Ruzyllo W, Maggioni AP, White H, Sadowski Z, Carvalho AC, Rankin JM, Renkin JP, Steg PG, Mascette AM, Sopko G, Pfisterer ME, Leor J, Fridrich V, Mark DB, Knatterud GL; Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006 Dec 7;355(23):2395-407.

4) Mark DB, Pan W, Clapp-Channing NE, Anstrom KJ, Ross JR, Fox RS, Devlin GP, Martin CE, Adlbrecht C, Cowper PA, Ray LD, Cohen EA, Lamas GA, Hochman JS; Occluded Artery Trial Investigators. Quality of life after late invasive therapy for occluded arteries. N Engl J Med. 2009 Feb 19;360(8):774-83

5) Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. Engl J Med. 2007 Apr 12;356(15):1503-16.

6) Jeremias A, Kaul S, Rosengart TK, Gruberg L, Brown DL. The impact of revascularization on mortality in patients with nonacute coronary artery disease. Am J Med. 2009 Feb;122(2):152-61.

7) Fuster V, Moreno PR, Fayad ZA, Corti R, Badimon JJ. Atherothrombosis and high-risk plaque: part I: evolving concepts. J Am Coll Cardiol. 2005 Sep 20;46(6):937-54.

8)  Virmani R, Burke AP, Farb A, Kolodgie FD. Pathology of the vulnerable plaque. J Am Coll Cardiol. 2006 Apr 18;47(8 Suppl):C13-8.

9) Kuo P. Lipemia in patients with coronary heart disease. Treatment with low-fat diet.
J Am Diet Assoc. 1957 Jan;33(1):22-5.

10) Kuo P, Joyner C Jr. Angina pectoris induced by fat ingestion in patients with coronary artery disease; ballistocardiographic and electrocardiographic findings. J Am Med Assoc. 1955 Jul 23;158(12):1008-13.

11) Kuo P. The effect of lipemia upon coronary and peripheral arterial circulation in patients with essential hyperlipemia. Am J Med 26:68, 1959.

12) Williams A. Higginbotham A. Knisely M. Increased blood cell agglutination following ingestion of fat, a factor contributing to cardiac ischemia, coronary insufficiency, and anginal pain; a contribution to the biophysics of disease. Angiology. 1957 Feb;8(1):29-40.

13) Ornish D, Scherwitz LW, Doody RS, Kesten D, McLanahan SM, Brown SE, DePuey E, Sonnemaker R, Haynes C, Lester J, McAllister GK, Hall RJ, Burdine JA, Gotto AM Jr. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA. 1983 Jan 7;249(1):54-9.

14) Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ, Gould KLCan lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet. 1990 Jul 21;336(8708):129-33.

15)  Ornish D. Dean Ornish, MD: a conversation with the editor. Interview by William Clifford Roberts, MD. Am J Cardiol. 2002 Aug 1;90(3):271-98.

16) Curtiss LK. Reversing atherosclerosis? N Engl J Med. 2009 Mar 12;360(11):1144-6.

17) Sdringola S, Nakagawa K, Nakagawa Y, Yusuf SW, Boccalandro F, Mullani N, Haynie M, Hess MJ, Gould KL. Combined intense lifestyle and pharmacologic lipid treatment further reduce coronary events and myocardial perfusion abnormalities compared with usual-care cholesterol-lowering drugs in coronary artery disease. J Am Coll Cardiol. 2003 Jan 15;41(2):263-72.


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