History: How It All Began

by Ethel Nelson, MD

  “We’re sorry, but there’s nothing more we can do for you.”
At age 59, Connie Thebarge had just been given what essentially was a death sentence from her doctors. What could she do? Where could she go? If the prestigious Ottawa Heart Institute couldn’t help her, then who could?
The prognosis had not been entirely unexpected. Connie knew that things were not going well with her. Considering her longstanding

    • history of hypertension;
    • two heart attacks followed by triple coronary bypass surgery;
    • diagnosed with diabetes in 1985;
    • unsuccessful angioplasty in 1988;
    • diabetic neuropathy in her legs making walking excruciatingly painful;
    • her pill count up to 27 a day.

  What sort of good news could she expect? No wonder she was depressed!
And yet, 12 years later, Connie is walking three miles a day, swimming twice a week, dancing and taking trips to Florida and Europe. The depression and angina are gone, and so are most of her pills—all thanks to a complete lifestyle change.

CHIP Project
   Amazing, you say. Not at all. How was this accomplished? By following the principles and practices promoted by the Coronary Health Improvement Project (CHIP) a community-based lifestyle intervention program designed to drastically reduce coronary risk and improve health.
   Is community-based lifestyle change possible? Critics have argued that lasting lifestyle change is not possible and that the only real solution is through drug or surgical therapy. During the past three decades, hospital-based and resort-style lifestyle centers, however, have proven otherwise. But can such programs be successfully extended to communities? And can these educational programs make a significant dent in solving the runaway epidemic of coronary heart disease, diabetes, hypertension and obesity that especially plagues the affluent nations of the world?

Lifestyle Medicine Institute
   Part of the answer may be found in the amazing growth of the small but ambitious Loma Linda-based Lifestyle Medicine Institute in Southern California, directed by cardiovascular epidemiologist, Hans Diehl. Dr. Diehl’s CHIP programs have been conducted successfully in more than 150 cities in North America as well as in Bangalore, India, Australia, and in Switzerland.
   Perhaps the success of the Lifestyle Medicine Institute (LMI) has more to do with its mission rather than its uniqueness. Many institutes for lifestyle change exist, but few have LMI’s ambitious drive to reach the public with the “good news” that being healthy is a personal right.
   Who then is Hans Diehl? Is his CHIP program the model for realistic health change, or is it just another profit-making venture preying on the fears of people in trouble?
   To answer that question we need to go back to the beginning and follow the activities and events, which led to the formation of the Lifestyle Medicine Institute and to the concept of community-based health promotion as embodied in CHIP.
Coming to Montreal from Germany in 1965 as a young executive trained by the Krups Corporation, 19-year-old Diehl was amazed at the possibilities North America held out to young people. Before too long, he returned to college and enrolled in premed. After graduation from Loma Linda University’s School of Public Health with a doctorate in Health Science and a Master’s in Public Health Nutrition, he took post-doctorate training in epidemiology at the University of California at Los Angeles.

Nathan Pritikin
   Meanwhile, Nathan Pritikin, a non-medical visionary was causing ripples in the medical community with his claim that simple lifestyle changes in diet, smoking and exercise could dramatically improve the clinical course of coronary heart disease, diabetes, hypertension, gout, arthritis and obesity—”diseases of dietary abundance,” he called them. Intrigued by progress reports from the Santa Barbara-based, four-week, residential intervention program, Diehl visited Pritikin and asked him about his success rates with essential hypertension.
   “About 80%,” Pritikin replied. “It’s an estimate, since I’ve not yet analyzed my medical records.”
   Incredulous at this high percentage, Diehl offered to do the statistical analysis to examine the claim. “If these figures are correct,” he thought to himself, “then Pritikin may be on to something very significant and important.”
Pritikin took on Diehl, and Diehl proved Pritikin wrong: within four weeks, not 80%, but 83% of the 225 hypertensive patients on medication were drug-free and normotensive. They no longer required pills to lower their blood pressure. That was enough to entice Diehl to join the Pritikin Longevity Center as its first director of research and education.
   Diehl observed that Pritikin not only emphasized a diet drastically lower in fat, sugar, salt and cholesterol, but he also promoted progressive exercise for the patients flocking to his physician-monitored center. On his advisory board were two British physicians, Drs. Denis Burkitt and Hugh Trowell. Internationally known for their advocacy of a high-fiber diet, they reinforced Pritikin’s commitment to a fiber-rich diet centered around unrefined grains, fruits, vegetables and legumes.
   Observing the rapid, consistent and nearly miraculous improvement of patients under close staff physician supervision, Diehl began to wonder to what extent such a lifestyle medicine approach could be used on a community-wide basis. Instead of spending $8,000 to $13,000 with institutional supervision, perhaps the same results could be accomplished for a fraction of this cost thus reaching a much larger segment of the population.
   For the next several years Diehl kept this idea in the back of his mind, waiting for the right opportunity. In the meantime, he spent two years as a National Institutes of Health-supported research fellow in cardiovascular epidemiology at Loma Linda University where he analyzed Pritikin’s data in more detail. At the same time, he began to lecture about the potential of reversing many of the so-called “Western killer diseases.” It wasn’t long before a following developed.
   Among them was a middle-aged, discouraged woman from Wisconsin who later described herself as a “Fat droopy worm who’d heard a two-hour lecture on ‘How to Eat More and Weigh Less.’” Maybe there was a way to avoid the diseases that had claimed her parents and grand­ parents. Having hit bottom, she decided to give it a try and began to follow the principles.
   A year later, Grace Jones reported, “The worm has become a butterfly. Every facet of my life has changed. My aches have disappeared. I’ve lost 40 pounds, and I’m still losing. My blood pressure is down to 120/70 and my cholesterol at the lowest ever—139 mg%. I walk regularly and I have as much energy and endurance as I had at age 21. “And,” she added, “my depression is gone.”

Creston CHIP
   Finally, in 1988, a breakthrough came when Sidney Kettner, MD, then chief-of-staff of the Creston Valley Hospital, invited Diehl to conduct a four-week CHIP in this British Columbia community of 3,000 adults. Diehl carefully planned 40 hours of instructive motivational lectures. After meager advertising, to the organizer’s amazement, some 400 responded to the Creston experiment conducted in mid-winter.
   Before the lectures began, a coronary risk assessment — called HeartScreen — was made, including a brief medical and medication history, blood chemistry (testing for cholesterol, LDL, HDL, triglycerides, glucose), blood pressures, overweight determination, smoking history, stress level, casual heart rate, and level of exercise. A food frequency was also included.
   The four-week educational program conducted Monday through Thursday covered the areas of physiology, clinical management and lifestyle interventions for coronary heart disease (CHD), hypertension, diabetes and obesity. Cooperation came not only from physicians and dietitians, but also from merchants who were encouraged to provide “healthier” foods at special discounts. Supermarkets had “specials” for fresh produce; local bakeries promoted multi-grain breads at 30% discount, and local health food stores provided “specials” for low-sodium condiments, multi-grain breakfast cereals and scores of crock pots.
   Individualized HeartScreen evaluations were made by Dr. Diehl and participating physicians following an established protocol. All clinical parameters were re-tested four weeks later, after three months and then again after one year
Fred MacKay, a 70-year-old hypertensive farmer who had suffered heart attacks in 1984 and 1987, was told by his doctor to change his diet. He substituted chicken for beef and reduced his dairy intake. But after hearing Diehl’s lectures, he decided he had to become much stricter with his diet and to increase his daily 30-minute walk to two hours a day. After only two weeks, Fred’s cholesterol had dropped 13%, he’d lost four pounds, and his blood pressure was near normal. Eight years, 26 pairs of hiking boots, and 20,000 miles later, his weight had dropped from 185 to an ideal 160 pounds, his cholesterol had fallen from 202 to 120 mg%, and his blood pressure was normal.
   During the same CHIP campaign, an initially skeptical reporter dropped 40 pounds and became a believer.
Quick to see the advantages of such a program in reducing the cost of governmental health care, provincial health officials approached Dr. Diehl to see if he would conduct a CHIP research project in Vancouver, British Columbia. Diehl declined, however, feeling he was not yet ready for the big city. Much more had to be learned. He set a five-year goal for himself, hoping at the end of that time to enter a major city with a proven health program.

Vernon, Kelowna CHIP
    After Creston, Diehl was invited to the town of Vernon with a population of 25,000. Some 1,500 attended. Then came Kelowna, only 30 minutes from Vernon. Of the 50,000 adult population, more than 2,500 attended the CHIP program in four programs, six months apart.
    Diehl soon learned that greater numbers of people would join the program if certain advanced preparations were made in the community. So, six months prior to the Vernon CHIP project, he laid the groundwork by contacting the “gate-keepers of the community”—the local medical society, the clergy, the media, the city council, the mayor and the merchants. It was soon evident that greater supplies of recommended fruits and vegetables must be stocked to accommodate the participants’ demands. When he suggested, for instance, in the Cornwall project, that instead of a candy bar the CHIP attendants eat a mango—the rush was on.
Convincing the grocers, however, was another thing. “Mangoes?” they laughed. “The people here don’t even know what a mango is!”
    “They soon will—I guarantee it. Order 500 mangoes,” Diehl insisted.
During the campaign, 7,000 mangoes were sold. And not for the usual dollar apiece. “We need CHIP-cheap produce!” Diehl argued. Result: Mangoes 3/$1.00. Both grocers and customers were exuberant!
    The local bakeries, given Diehl’s 100% whole-wheat bread recipe, cooperated with record sales and again, everyone was happy.
    Long-term results were encouraging. Periodic testing of CHIP participants showed that average blood cholesterol levels after one year were still down 10%. Diehl reminded participants that blood cholesterol reduction is the most important factor in lowering the coronary risk. “For every 1% drop in cholesterol, heart attack risk drops 3%.” The most improvement was shown by those in the highest cholesterol group (greater than 240 mg%) who showed a 17% reduction, cutting their coronary risk in half.
    During the four-week intervention period, “overweight” and “obese” CHIP participants lost an average of six and eight pounds respectively. Yet, they claimed, “We’ve never eaten so much food in our lives.” This was exactly what Diehl had promised would happen.
   At the end of one year only 7% of the participants were unable to keep their weight down, an astounding success rate when compared to the usual 90% “relapse” that most weight control programs suffer during their first year. Instead, 93% of the obese participants lost an average of 16 lbs. The proof was in: People had not just changed their diets—they had changed their lifestyles!
    Reverend Albert Baldeo, a well-known Kelowna clergyman, added his testimony, “I was standing at an open grave one day conducting a funeral when I became dizzy and almost fell in. I gasped to myself, “Lord, not yet!” and determined to do something about my high blood pressure and excessive weight. I joined the very next CHIP program. My blood pressure plummeted and in time I lost 50 pounds. Of course, it cost the church, because they had to buy me new vestments! But the congregation was elated to have a pastor with a new silhouette!”
   Lifestyle changes, however, were not limited to diet. While about 5% said they engaged in “vigorous exercise” at the beginning of the program, the percentage jumped to 23% by the end of the four-week series. Some 52% reported having moved to more strenuous levels of exercise.
   At the same time, systolic and diastolic blood pressure levels decreased significantly in spite of marked reductions in the amount of medication. The same happened with diabetic patients: many with high blood sugar levels or on diabetic pills or insulin, found their blood sugar levels coming down so much that physicians often had to reduce or discontinue the medications. In addition, elevated triglycerides dropped 15% in four weeks.
   These early demonstration projects proved not only that people were interested in improving their health but also that coronary health risk factors could be significantly decreased through a community-based health education program. In addition, CHIP proved that positive clinical changes could be sustained over time and that these improvements could be delivered in a cost-effective manner largely funded by the participants themselves.

Alumni Chapters
   At the end of each four-week CHIP program, on graduation night, Diehl encourages graduates to form local CHIP alumni organizations. They would choose officers, charge annual membership fees, and set up monthly educational meetings featuring well-known health/medical lecturers, vegetarian cooking classes, seminars dealing with stress management, stop smoking classes, and “CHIP-nics.” In addition, members are kept informed through regular CHIP newsletters.
   But the story doesn’t end here. News of these small successes would soon spread to unexpected new places.