Confessions Of A Reformed Cardiologist. A Plant-Based Diet And Your Heart? - Robert Ostfeld, MD, MSc

well thank you so much for that incredibly generous introduction and it's a real honor to be with you all here uh today and to see the incredible things that you and your team are putting together to try to help people be healthier prevent disease it's really wonderful so um i i'm so grateful and thank you so much for for your work helping to help lots of people get healthier it's just wonderful so thank you thank you and we see your slides perfectly by the way okay that's good i wasn't sure if that was gonna happen but all right so well it's great to be with you all um today and so we're gonna we have a while so i'm gonna kind of talk about a few topics along the way and we're gonna start my title my talk is a plant-based diet and cardiovascular health and these are my disclosures so you know like many of the speakers here and many of the physician or medically trained people here in the audience you know i learned a lot along the way about diagnosis treatment of disease lots of real from wonderful people lots of wonderful information but i really didn't learn much about nutrition and prevention of disease and that's unfortunately a common theme and things are changing thanks to conferences like this and many of you and so there's actually an interesting study by dr debris where they asked cardiologists do you think nutrition lifestyle is important mostly as nutrition do you think nutrition is important for preventing disease and like 90 percent of them said yes and they said uh they asked you know how many of you feel comfortable counseling patients about it i forget the exact number but it was like you know something like two percent like something ridiculous so unfortunately the message isn't quite getting out there yet enough in medical training but times are changing i get to give the second year preventive cardiology annual lecture to the second year medical students at einstein and of course we've been a lot about nutrition and diet into that and i know that that's happening in many other institutions and many other platforms so things are changing but we're nowhere near where we need to be and i have a few cases i could talk about um and i think i'll talk about a couple of them later this is one i've talked about before and would love to share it's a great kind of launching point for talking about the impact of plant-based nutrition and i also want to give a shout out to the speaker just before me dr esselstyn uh who of course ever needs no introduction and everyone knows here he's an incredible teacher clinician researcher uh as a real friend and mentor uh of mine and to me i'm extremely grateful for his support information guidance and you know he without him and his his family you know our program really would be nowhere near as established as it has been today uh so um he's been and you know his work really helped to launch the kinds of work that we're doing at montefiore so thank you dr esselstyn so this patient um about 60 years old and he started to have chest pain angina and he would get it sometimes even sitting still sometimes walking a few blocks and he went to go see his primary care doc and he told his primary care doc hey you know i'm i don't want to take any medications and i don't want to do any procedures invasive procedures and you know it's the patient's the boss as long as there's an informed decision about it you know at the end of the day the patient's the boss and of course when we're preventing and trying to treat patients preventing disease and trying to treat patients we use all the above lifestyle change and medications when indicated but at the end of the day the patient's the boss this patient did not want to do either one of those which is fine and he started having chest discomfort this the primary care doctor did stress tests which was positive and it's only really in medicine that the word positive means something negative and so it showed that there was cholesterol blockages in the blood vessels that feed his heart with blood um and so his cardiologist sent or his primary care doctor sent him to us and you can see the baseline uh vitals that he had he was a little overweight his blood pressure was a little bit up his ldl cholesterol was a little bit high he could block like one or three blocks and he would stop because he got chest pain and so um at that point he wasn't interested in statins or aspirin and you know those would be certainly indicated in somebody like this but at any rate i what he did is he adopted a whole food or smartly processed minimally processed plant-based diet and what we're going to do is we're going to circle back to him a little later in the talk and see how he did and so heart and blood vessel disease is the leading cause of death in the u.s a couple heart attacks happen every minute in the u.s so i don't know we've been speaking for five minutes of ten heart attacks so far it is by far uh well it is the number one killer of adult men and adult women in the us and women are about six seven times more likely to die from heart and blood vessel disease than they are from breast cancer so clearly you do not want either one but it highlights the epidemiologic importance of heart disease in women it's a very costly disease process as well and it just keeps going up year after year and unfortunately you know as dr esselstyn describes well it is a process that starts when we're very young and there's a pathology study of kids um who died for other reasons and are not heart reasons and they looked at their coronary arteries and 65 of these kids between 12 and 14 years of age had early signs of coronary artery disease or cholesterol disease in the blood vessels that feed the heart with blood um that's a lot i'm sure most of you listening here are older than 12. um and then of course there are multiple other famous pathology studies some of our our veterans those who died in the korean and vietnam war wars they you know are soldiers uh they are in the prime of life some of them you know 20 years old uh and a very large percentage of them had overt coronary artery disease that you could just see and in a more recent study although not super recent uh in consecutive trauma victims the mean age is 26 78 of them had overt coronary artery disease it's pretty unfortunate so this is common um and as you well know atherosclerosis can start when this is a this is a blood vessel this is the heart here this is a blood vessel this is the center of the blood vessel where the blood flows and this of course this inner lining here that's the endothelial cell we want to treat that well it's like wallpaper the inner lining of the blood vessel and what can happen is these endothelial cells can become injured from smoking inflammation pollution toxic western diet and when that happens these little cholesterol particles here can burrow cross into the wall of the artery where they can become oxidized pro-inflammatory kind of like a splinter it gets all red and inflamed in your finger but the same kind of thing here except in the blood vessel the wall of blood vessels and that creates inflammation more cells come in the endothelial cells get sicker more cholesterol particles burrow across and it snowballs and then the only thing that separates the blood the blood flows from all of this cholesterol plaque with lots of pro-coagulant factors and inflammatory factors is of course the very thin fibrous cap which with all this oxidative stress and inflammation can become weaker and weaker over time and so one random tuesday afternoon that fibrous cap cracks and all this cholesterol plaque then touches the blood and the blood can clot off no more blood flow to the heart muscle so if it clots off here right there the rest of this artery no more blood flow no more blood to the heart this is a histologic picture of that and you can see here's a blood vessel and here's all that cholesterol plaque here's that really thin fibrous cap it cracks and then you can see a clot developed heart attack this person obviously died this is a picture of a heart right here this is a coronary artery one of the blood vessels that feeds the heart with blood and you can see here that there was a fibrous cap rupture and a clot developed in the coronary artery no more blood flow and this person died from their heart attack so that's bad news but there really is an incredible opportunity for all of you and all of us and frankly everyone to turn it around so there is a really wonderful study the inner heart study that was published in 2004 in lansing and that showed that about 90 percent of the risk for mi or myocardial infarction heart attack can be accounted for by the following nine risk factors and i have little asterisks by them ones that are basically diet or impacted by diet so abnormal lipids smoking high blood pressure diabetes abdominal obesity psychosocial factors and actually interesting interestingly we'll look at a little bit of data how how you eat can improve mood the consumption of fruits and vegetables alcohol although we should touch on that because the evidence supporting that is getting much weaker in fact almost gone for cardiovascular health certainly there's no benefit for cancer and regular physical activity and this is a really cool study by dr bundy and what dr bundy tried to do is kind of estimate there's there's something called american heart association simple seven or life simple seven that includes smoking body mass index physical activity a healthy diet score total cholesterol blood pressure and hemoglobin a1c and one of the goals of the american heart association was to try and optimize these risk factors nash internationally or nationally more specifically of course that has failed miserably but the what this particular study did was they classified life simple seven to people three groups and if you look here for example the healthy diet score they looked at ideal intermediate and poor healthy diet score and in order to be in this particular analysis to have an ideal diet you had to consume four or five of the following components that i'll mention in core with zero or one so those five components in this study was four and a half servings of fruits and vegetables a day at least three servings of whole grains a day at least low salt consumption fatty fish two or more times a week and low sugar sweetened beverage consumption so if you had four or five of those in this study you were considered to have an ideal dietary pattern and just of note 0.7 of the u.s in this study had an ideal dietary pattern 75 percent had a poor dietary pattern so people spend a lot of time arguing about is this you know this diet is 99 perfect this five is 98 perfect that is largely a distraction from a societal level because we are not within a mile of what is 98 perfect so um just keep that theme in mind anyway so this is a really cool study and what they found is they looked a total cardiovascular health score and you can so if you had an ideal whatever measure you got two points intermediate one poor zero and they defined a high cardiovascular health score as 12 to 14 points and low at zero to eight points about seven percent of the u.s had high cardiovascular health incorporating life's simple cell and about 59 had low we're not doing well this study is from 2021 and what another so what they also did is they tried to estimate what would happen if people modified these lifestyle factors let's look at the healthy diet score they estimated that if everybody adopted a healthy diet score after one year cardiovascular event rates would fall by a little more than 40 percent and if you just look at blood pressure if everybody got to an ideal blood pressure then lower cardiovascular event rates by about 40 like these are big numbers um and it would be wonderful if we could get even within a mile of these so gosh i can't really fully read my slide but at any rate uh this is looking i think at the impact of a plant-based diet on how do i shrink this thing oh well i don't know um but this is looking at the impact of a plant-based diet in the cardia study which is the coronary artery risk development in young adults and this is a great study they followed people prospectively for i don't even know 30 40 years in this study but in this particular analysis they started with people 18 to 30 years of age who are free of cardiovascular disease in this particular analysis they um [Music] analyze about 5000 subjects and they followed them for 32 years and they put people into quintiles of diet score the highest versus lowest of a plant-based diet and the highest quintile versus the lowest had a 52 lower hazard of developing cardiovascular disease but it's really never too early to begin and never too late to start because for the people who changed their diet from year 70 or 20 comparing quintiles even if it took them seven years to change they still had a substantial decrease in cardiovascular disease outcomes so never too early to begin never too late to start and this study is really looking at the impact of combining different risk factors here um and unfortunately i don't have the updated slide here but that's okay what this looks at is the role of physical activity diet and both on metabolic syndrome metabolic syndrome is a constellation of findings that increases your risk for cardiovascular diseases metabolic syndrome is defined as abdominal obesity insulin resistance hyperglycemia dyslipidemia and high blood pressure and in this particular analysis from the framingham heart study they looked at about 2400 subjects for eight years and in this analysis if you adhere to the physical activity guidelines for america just that you had a 34 lower hazard of developing the metabolic syndrome and if you would just adhere it in isolation to the 2015 dietary guidelines for americans which had more fruits and vegetables you had about a 32 lower hazard of developing cardiovascular disease and if you adhere to both this is the number i left out it was substantially lower still i believe even less than a 50 or more than a 50 reduction in the hazard cardiovascular and of course there's not really a heart diet eyeball diet earlobe diet they kind of all go together and what kind of dietary pattern is healthful for cardiovascular disease can be helpful for cancer and this study kind of gets at that this is there's something that we look at called the american college of cardiology 10-year cardiovascular risk estimate and it's a calculator and we plug in different numbers like age blood pressure cholesterol sex smoking and we get a 10-year estimate of cardiovascular risk it could flow it could be high and so here this you can see this blue line is a cardiovascular risk more than 20 percent all the way down red all the way down to the purple less than five okay but what they did and so this score is impacted by things that are impacted by diet cholesterol blood pressure and so what they did is they said okay let's see if you had more than a 20 percent after sporadic cardiovascular disease risk how does that impact cancer risk well incident cancer was highest and it was lowest for the lowest atherosclerotic cardiovascular disease risk so it all kind of goes together and so we're going to talk about a few things and then i'm going to bounce around to some other topics because we've got a while and so we're going to talk about the impact of a plant-based diet on cardiovascular health on cholesterol information and blood pressure on weights diabetes novel risk factors and quality of life mortality and some other things as well so how are we defining a plant-based diet here and this is what our patient beginning started so it includes minimally or smartly processed plant-based foods with vegetables fruits whole grains beans lentils tofu yams nuts and seeds and this study gets to the point that smartly processed is important um you know there's got to be a difference between cookies and kale and of course there is in this wonderful analysis by dr satisha she asked if you eat more of a plant-based diet is it helpful is it not helpful and this is an analysis i think of around 200 000 people worth 4.8 million person years of follow-up that's a lot follow me for one year in a study that's one person you're following anyway um so this little blue line here this is a plant-based diet index so the more of a plant-based diet you ate the better you did but there's got to be a difference between cookies and kale so what they did is they created an unhealthy plant-based diet index and a healthy plant-based diet index basically kale and cookies so if you ate the cookies you're plant-based well that's not healthy um and if you ate the kale you do even better than the plant-based diet so the devil's in the details and in this analysis this red line here that's animal food so the more animal food you ate the worse you did but this is the cookie group the less healthy plant foods and this analysis did even numerically worse than animals and along the lines of whole grains this is a wonderful meta-analysis by reynolds in lansing in 2019 and basically found with 135 million person years of following and basically found the more whole grain uh the less cancer the less cardiovascular disease and in this wonderful analysis by dr dew published in new england journal of medicine they asked if you eat more fresh fruit is it good is it not good well it turns out in this analysis it's good they had 3.2 million person years of follow-up so the more fresh fruit you ate the less cardiovascular disease less stroke and along those lines this is for stroke quality of a plant-based diet and risk of total ischemic and hemorrhagic or bleeding stroke and a healthy plant-based diet significantly lowered the risk of stroke about a 10 lower hazard i think this is quintiles and an unhealthy plant-based diet and this analysis was neutral this is a great study and it's a little complicated so and the reason that i bring this study up is because um our like i'll be in clinic and patients will say hey dr ashfield you know uh my mom has heart disease my dad has diabetes i'm gonna get those things it's in my gene it's in my genes and of course genes matter but lifestyle matters too and this study really gets to that and if you look kind of just as a trend stepping back you can see here these little black dot black squares get more and more to the right and what this is they what they did is they looked at a number of genes that are known to increase cardiovascular risk i believe 26 of them they put them into thirds you have low genetic risk intermediate genetic risk and high genetic risk in the high genetic risk group you can see your risk of cardiovascular disease was more than in the lower group makes sense genes matter but what is particularly interesting in this group is uh that lifestyle really impacts the outcome and findings independent of genetic risk so here in the high genetic risk group if you had an unfavorable lifestyle this was your future risk of cardiovascular events but in the high genetic risk group if you had a favorable lifestyle you lowered it by about 50 your future risk and these are people who are exercising in this favorable group at least once a week and their diet is not was not a whole food plant-based diet in the in the favorable lifestyle group so you can imagine if they're eating even more healthy and exercising more often the risk may have fallen even more so genes matter but lifestyle matters too all right so we talked a bit about the impact of a plant-based diet on cardiovascular health what about cholesterol inflammation and blood pressure very important risk factors so this study is an interesting uh called a study called looking at a portfolio diet this is a direct comparison of a dietary portfolio of cholesterol lowering foods these are high fiber uh plant-based foods and comparing them with the statin in patients or patients with high cholesterol there's a small study and they put them into three groups in random order and the control group they didn't have portfolio they didn't get statin they lowered uh their cholesterol by about eight percent the statin group and it was a low dose of the statin uh they lowered their cholesterol by about 33 and you can see the dietary portfolio arm came close at around 29 so really an impressive drop in cholesterol simply from dietary change and in this analysis about cholesterol out of korea this is the association between different types of plant-based diets and risk of of dyslipidemia or abnormal cholesterol it's a prospective cohort study and they defined this lipidemia broadly and they looked at about 4 500 koreans and had 14 years of follow-up and for quintiles of plant-based diets for a healthy plant-based diet the highest quintile had a 37 percent lower hazard of developing dyslipidemia and the unhealthy plant-based diet had about a 48 greater hazard of developing dyslipidemia um also ldl cholesterol or maybe apob containing particles can that it can get as we talked about get oxidized in the wall of the blood vessel where it could become particularly atherogenic and flat pro-inflammatory and in an interesting cross-sectional analysis looking at the ldl particles and vegetarians versus omnivores those and vegetarians were more difficult to oxidize crp is a measure of blood measure of inflammation it also can promote inflammation but it is in a really interesting study out of nyu called evade cad they randomized patients with stable coronary artery stable blockages not after a heart attack but stable coronary disease and they randomized them to the american heart association diet or a plant-based diet for eight weeks and they found that the plant-based diet significantly lowered chemo crp more than the american heart association diet blood pressure as well the cardiac study the study of youth the with in this analysis of 15 years of follow-up eating more plant-based nutrition is associated with lower blood pressure as well as in cross-sectional analyses and of course there's the dietary approach to stop hypertension diet which is largely but not completely plant-based and when compared to a control more western-style diet significantly lowers blood pressure okay so we talked a bit about the impact of a plant-based diet on cardiovascular health on cholesterol inflammation and blood pressure what about weight well so this is the seventh-day adventist um study the seventh-day adventists treat their body like a temple and even those eating a western-style diet among the seventh-day adventists tend to have a much healthier western style diet than the typical western person and they have a lot of healthy dietary patterns including non-vegetarians semi-vegetarians pescal vegetarians lacto-ovo vegetarians vegans and in this cross-sectional analysis about 60 000 people the only group with a normal body mass index is the vegans about normal is less than 25. this is a really cool randomized trial this is really hard to do by dr turner mcgreevey and colleagues and it's a comparative effectiveness of plant-based diets for weight loss a randomized control trial of five different diets it's relatively small six months and they had five arms vegan vegetarian pesky vegetarian semi-vegetarian and omnivorous and the vegan arm after six months lowered their weight by about seven and a half percent that's a lot and it was significantly less than the pesco vegetarians semi-vegetarians the omnivores but not statistically significant less significantly less than the vegetarians um all right so we touched on cardiovascular health cholesterol inflammation blood pressure weight how about diabetes well in a similar analysis from the seventh-day adventist cross-sectional analysis of about 60 000 people by different dietary patterns non-vegetarians semi-vegetarians pesco vegetarians lacto-ovo vegetarians vegans the group with the lowest percentage of diabetes was the vegans this is a very interesting analysis also by dr satija a plant-based dietary pattern and incidence of type 2 diabetes in u.s men and women results from three prospective cohort studies physicians health study nurses health study 1 or cell study 2. and they had about four million person years of follow-up and they put them into deciles and if you were in the highest decile of a healthy plant-based diet you had about a 34 lower hazard in developing diabetes incident diabetes type 2 and you had about a if you had an unhealthy plant-based diet about a 16 increased hazard of developed incident type 2 diabetes all right well along the theme of it's never too early to begin never too late to begin changes in plant-based diet indices and subsequent risk of type 2 diabetes in women and men three u.s prospective cohorts and this is about three million person years of follow-up and each 10 increase in a healthy plant-based diet over four years was associated with a nine percent lower risk of incident diabetes never too late to start and in this interesting analysis of the seventh-day adventists at least weekly intake of an animal product versus none was associated with a 74 higher odds of having diabetes this is a great randomized controlled trial along those lines i'm sure many of you are familiar with it by dr barnard and his group and they randomized 99 subjects for 22 weeks with adult onset type 2 diabetes to either a plant-based diet or the american diabetes association diet and the plant-based diet arm lost significantly more weight and their ldl cholesterol fell significantly more than the american diabetes association now in subjects who did not change their medications this is the blue is the vegan arm and the red is the american diabetes association diet arm and for of these who did not change their medications because you can imagine if your glucose is falling a lot they may have to back off on some of your high glucose medications for your own safety so for those who did not have medication changes the hemoglobin a1c a measure of diabetes fell significantly more in the vegan arm than it did in the american diabetes association army but overall not included not taking into account the medication changes uh there was a trend in the plant-based arm but not a significant one this is really cool work from dr dew we talked about his work with plant with eating more fresh fruit and cardiovascular disease and in this analysis they asked if you eat more fresh fruit is does that impact incident meaning developing diabetes and also what if you even have diabetes in the first place is eating more fruit do anything well here for incident diabetes developing diabetes this is in 480 plus thousand people the more fresh fruit you ate the less likely you were to develop diabetes okay that's not make sense what if you had diabetes at the get-go 30 000 people had diabetes at the beginning of this study you ate more fresh fruit is it good is it bad well in this analysis it was good more fresh fruit was associated with living longer associated with fewer diabetes complications like visual and kidney issues okay impact of a plant-based diet we talked a bit about cardiovascular health cholesterol inflammation blood pressure about weight about diabetes let's touch on some novel or less discussed risk factors and quality of life so novel or maybe less discussed topics genes you mentioned that study earlier where genes matter but lifestyle matters too and you know we can't change our genes although now with crispr technology that may not no longer be true but for the most part we can't change our genes um but we may be able to change which ones are expressed and what am i getting at well there's a very interesting study by dr ornish where they took people with early stage prostate cancer it's not randomized but they had them have a healthier lifestyle eating more healthy regular exercise psychosocial support and they biopsied the prostate beginning and after about three months and they found that many pro cancer genes were down regulated in their expression and many anti-cancer genes were upregulated in their expression meaning you couldn't change your genes but you could change which ones speak making the healthy ones speak more loudly and the unhealthy ones speak more softly it's pretty cool and uh so also the microbiome uh of course that's a vast area and there's gosh trillion bacteria in each one of us so you could say that we're really the parasites and it's pretty clear that eating a high-fiber plant-based diet leads to a more healthful optimal microbiome which is intimately related to our health in ways we're just beginning to scratch the surface of whereas animal-based foods may promote a healthy microbiome much less so and according for example if you eat high fiber that promotes the replication of healthy microbiome and it will digest eat the fiber turn it into a short chain fatty acid called butyrate which will seep across the intestinal wall helping the integrity of the intestinal wall it may make intestinal wall cells make less cholesterol can get absorbed into the body be anti-inflammatory help avoid insulin resistance and have a myriad of effects you really are what you eat um the uh i'm just going to jump down to endothelial progenitor cells or epcs this is very interesting as well you know our body turns itself over our our skin our heart our blood vessels turns itself over over time just like the endothelial cells and there are endothelial progenitor cells that come from the bone now that go and kind of replace the older sicker endothelial cells that we have in our blood vessels and the walls of our blood vessels and so and it turns out that if you have more endothelial progenitor cells in your blood that is associated with better cardiovascular outcomes in a small randomized trial of young women in okinawa they fed them either their regular diet or a diet enriched with green leafy vegetables and those who eat more green leafy vegetables did better meaning they had more endothelial progenitor cells how about quality of life hugely important changes in plant-based diet quality and health related quality of life in women and increases in a healthy plant-based diet index was associated with improvements in physical and mental health related quality of life in women as measured by the sf 36 score and now i'm blanking where i saw this but there's a very recent large study looking at frailty where eating more plant-based protein was associated with improvements in frailty and more animal-based proteins less so but you have to forgive me i just don't have that slide in here okay so we talked about the impact of a plant-based diet on cardiovascular health cholesterol inflammation blood pressure weight diabetes novel risk factors quality of life what about mortality well changes in plant-based diet quality and total and cause specific mortality in this analysis over 700 000 person years of follow-up they compared compared with persons whose indices remain stable among those with the highest quintile and diet score with a healthy plant-based diet you had about a 10 lower hazard and an unhealthy plant-based diet you had about a 12 percent higher hazard of mortality and this is a wonderful study fruit and vegetable intake and mortality results from two prospective cohorts of us men and women and also a meta-analysis of 26 cohorts so in the prospective cohorts of u.s men and women five servings per day of fruits and vegetables versus two servings per day of fruits and vegetables was associated with a 13 lower hazard of death and in a meta analysis with follow-up ranging from about four and a half to thirty years with one point almost 1.9 million subjects from 29 different countries five versus two servings a day of fruits and vegetables was associated with the same 13 reduction in mortality and in another separate meta-analysis each serving of fruits and vegetables a day was associated with a five percent reduction in mortality now um we'll touch on this theme again later but we do not have to have perfection be the enemy of good every little bit counts and in this analysis by dr song where they looked at 130 000 people with three and a half million person years of follow-up they asked if you replace just three percent of your calories from animal-based protein with three percent of calories from plant-based protein is it good is it not good well it turns out it's good in this analysis if you replace just three percent of your calories from animal-based protein with plant-based protein that's associated with living longer you can see they had so much data they could break it down by type of animal protein and in this analysis pro if you replace just three percent of your calories from processed red meat with three percent of calories from plant-based protein you had a 34 percent lower hazard of death unprocessed red meat 12 poultry six fish and this analysis six percent eggs 19 dairy eight percent every little bit counts um and here i want to just touch on animal the animal base i'm stressing animal-based ketogenic low-carb diet patterns and i think that the allure of that is based on a popular myth and that popular myth is that in 1980 or so they told us to eat low fat look at us now we're fat and sick that's a nice simple narrative that's not what happened they may have told us to do that but we didn't do that we ate more of everything including fat so i think it's just fake news the underpinning of that um there's no long-living society that lives in a state of chronic ketosis that suggests that living that way is not helpful chronically and the inuit population the circumpolar population that lives in greenland they actually and it's hard to you know particularly for global warming um well probably still but it was hard to live up there you know it's hard to grow an apple tree they're eating a lot of fish and it's it's easier for them to you know to have a lower carb diet because there's not a lot of carbs around and the uh they actually have a mutation that makes it harder for them to go into a state of ketosis suggesting again that it is not healthful chronically and the blue zones as you all know are five regions across the world one of them is seventh diabetes in loma linda california they have the most centenarians of any top of any group uh in the world five areas throughout the world one is a common theme their diet is well more than 50 carbs it's not sugar cookies it's not cakes it's tubers it's beans it's lentils um it's truly whole grains and interestingly the simone people from the jungles of bolivia they have the lowest rates of heart disease ever recorded in the medical literature their diet is about 72 percent carbs obviously it's multifactorial they have a they're very physically active and uh have a lot of psychosocial or impressive social networks but their diet is 74 carbs 14 fat and 14 animal uh protein and that animal protein is um uh like wild monkeys like to catch wild lemons so it's probably a slightly healthier kind of animal protein that the typical westerner is exposed to 72 carbs lowest rates of heart disease ever recorded in the medical literature and this really cool metabolic ward study by dr paul and colleagues where they put 20 people in a metabolic board and they had a completely controlled environment and they controlled everything they ate or are they and so this was an ad-lib feeding study they were either fed a low carb diet or a low fat diet they were given the food they could eat as much or as little as they wanted and one of the things about the the animal-based keto diet is to say well you know you'll eat less because ketones and stuff but at least in this randomized trial ad lib energy intake was lower throughout in the low fat arm versus the low carb arm and they looked at a number of secondary analyses the ldl cholesterol fell significantly more in the low fat triglycerides fell significantly more in the low carb diet glucose was about the same and crp fell significantly more was was i should say was significantly lower in the low fat arm is after two weeks and there are a variety of prospective cohort studies with a variety of different endpoints that demonstrate consuming more of an animal based low-carb pattern not necessarily keto but an animal-based low-carb pattern is associated with worse outcomes and this one by dr lee published in circulation showed that after a heart attack people who ate more of an animal-based ketogenic diet did worse than other types of dietary patterns and there's a variety of mechanisms of harm a couple i want to point out a new 5gc is a sciacilic acid that lives on cell membranes we humans don't have it but non-human primates have it on their cell membranes who cares well people thought you know why is it that like red meat for carnivores isn't so bad but for us seems to cause trouble and what they so what they did is they created i think it's a rat remember it's a mouse or rat model but they created a rat or mouse model that didn't have any new 5gc on their cells and they fed them red meat with a new 5gc and that new 5gc made it onto the cell membranes of these rats or mice and they the animals saw it as foreign and attacked it and had increased their uh liver cancer rates by like five times and they had more inflammation and so it's hypothesized that when we eat red we can bring these sciacilic acids onto our cell membrane and our bodies see it as farm promoting inflammation etc antioxidants berries so plant-based foods in general have 64 times more antioxidants than animal based foods and berries have about 90 times more antioxidants than do fish um and in terms of the ketogenic uh diet it really lacks hard outcomes we need there's really we need more data and there's multiple side effects of harm at least in the pediatric epilepsy literature because it is indicated for refractory epilepsy um and but in those select groups there's some trouble uh there are some indeed a number of side of it and of course when you eat a low carb or possibly animal-based ketogenic diet pattern or animal-based low-carb diet you're leaving out some of the healthiest foods in the world you're leaving out whole grains we talked about that meta-analysis by dr reynolds with 135 million person years of follow-up for eating more whole grains is associated with better outcomes leaving out beans and rentals which are associated with living longer and you're leaving out fruits there's no long-living population that's in a state of chronic ketosis there's no hard outcome to meet safety data epi and mechanistic studies epidemiology and mechanistic studies not support benefits suggest harm small randomized trial by dr hall's group does not suggest weight loss with it and you're giving up some of the healthier healthiest foods in the world and let's look at different nutrient breakdowns this is a plant-based diet versus a mediterranean-style diet versus an animal-based animal-based low-carb diet and the plant-based diet is equal parts tomato spinach lima beans peas and potatoes the mediterranean diet is about 40 percent plant-based of the plant-based diet and a half a piece of skinless chicken one teaspoon of olive oil and one cup of one percent milk and the animal-based low-carb arm is equal parts beef pork chicken and whole milk let's look at the cholesterol you don't need to eat a drop your body makes all you need how about fat much lower in plant-based protein oh my god my muscles are gonna go away uh you'll get all the protein you need meeting your caloric needs on a plant-based diet and you don't have to take my word for it you can take patrick lablumian's work for it he's quite literally the world's strongest man and he's vegan how do i know that he's the world's strongest man well i know that because he won the world's strongest man contest that's how i know and beta-carotene it's subtle dietary fiber using the microbiome it's subtle your constipation will go away calcium magnesium stacks up in a friendly way for a plant-based diet right circling back to our guy this is the guy the six-year-old person who's had a positive stress test uh and chest pain with a little bit of activity and he went plant-based and he didn't want to take medications which was his choice you can see he lost weight blood pressure fell this is after i think three months i can't see the slide on top here ldl cholesterol felt like 70 points you could walk a mile and it would stop because you could chest pain fast forward about a year blood pressure was good cholesterol is good he could jog about two miles he stopped because of discomfort and i bumped into him like four or five years ago and the guy jogs four miles now and he stops because he gets bored and the um we had a couple other cases though we just very recently published i don't have a slide of it in the international journal of disease reversal and prevention the journal that dr kim williams is the editor-in-chief of and it was a couple cases of microvascular angina previously called syndrome x and sometimes people will get angina discomfort without a major blockage in the blood vessels the three big blood vessels that feed the heart with blood but there's tons of itty-bitty teeny-weeny little streams miles and miles miles and miles of teeny itty-bitty little leaning streams that also feed all the heart all the muscles throughout the heart we don't see that on catheterization you can get a sense of it if if the blood flows slowly through the heart you can get a sense that the micro blood vessels are not doing well it flows fast they are doing well so there are ways we can get a guesstimate of how they're doing um anyway we had a couple patients who had microvascular angina no obstructive coronary disease but an engine of symptoms and you could look at the case if you're interested it's in this month's um uh edition and of the journal and dr and kathleen allen a medical student at dartmouth geisel school of medicine is the first author of our our two cases and basically a plant-based diet um resolved their symptoms and you know for the first patient had many had tried multiple other things and nothing helped and we were fortunate that a plant-based diet was able to turn her symptoms around and she went from not she used to play devil's tennis all the time and then couldn't and then went back to playing double tennis and uh is very happy so we're very pleased about that i wanted to bring that up because there's really not a lot of good therapy for microvascular angela now it's a it's a it's a increasingly understood area i mean it's been known about for a long time but it's been getting it's kind of having its moment fortunately in the sun more now because it needs a lot of work done with it and we are pleased to be able to contribute to the conversation in regard to diet change and a potential impact on microvascular angina this is a nice quote today no one can deny the possibility of adequate nutrition and the prolonged maintenance of health and vigor on a vegetarian diet that's a quote from the journal of the american medical association in 1912. of course there are other types of benefits from eating more plant-based nutrition costs and the environment um no planet no health who cares a healthy harvest no planet and animal agribusiness creates more greenhouse gases than all transportation combined which of course includes cars and at least a model out of the uk and belgium showed that a wider implementation of a plant-based plant-based eating would lead to large net economic gains for society and improved health outcomes for the population in the country the us where health care costs keep on growing as a percentage of the gdp like we got to start to bend the curve somehow and gosh if there is only some potential solution it's just a mystery obviously i'm kidding um so we talked about the impact of a plant-based diet on cardiovascular health cholesterol inflammation blood pressure weight diabetes novel risk factors and quality of life and mortality and i wanted to touch on another topic erectile dysfunction which is also potentially meaningfully impacted by diet and lifestyle and is an area that seems to get people's attention so the definition of erectile dysfunction is the inability to attain or maintain an erection for satisfactory sexual performance and there is a definition the iif international index of erectile function five scores a validated score uh for it and they ask you five questions one to five points based on the answer the first question is how do you rate your confidence that you can get and keep an erection from very low to high and a score of 22 to 25 is no erectile dysfunction and there are different levels of severe and immediate moderate i don't have those numbers up here but this is an easy google finder so how does one get an erection it's a psychological neurological and vascular event um and blood will flow into the penis through an artery and it will engorge the penis and go into uh vascular or venous venules which will expand and then hit up against fibrous tissue and that fibrous tissue the blood will hit up against it and make it more difficult for blood to exit the penis and that's how you get interaction and that there's a psychological component neurologic and vascular component to that what causes erectile dysfunction well there's really they put into three categories organic psychogenic mixed an organic kind of like a medical medical cause is the most common with vascular in the us being by far the most common but there are other causes neurogenic hormonal drug induced side effects some medications can do that psychogenic anxiety depression can do that mixed causes the vascular and the same kind of disease process that causes poor blood flow to the heart also can cause more blood flow to the penis and cause erectile dysfunction and it's common from 40 to 59 year olds happens about 15 of the time 60s 45 70 70 of time i think it's much higher than that i just think people don't want to talk about it we frequently call erectile dysfunction the canary in the coalmine for heart disease because typically erectile dysfunction happens two to three years before angina or chest pain from cholesterol blockages and about three to five years before cardiovascular events like heart attack or stroke um and why well the artery to the penis is smaller than the arteries to the heart so by the time you have a blockage in an artery in the penis causing poor blood flow to the penis you very likely have a blockage in the blood vessel in the heart um but it's just not clinically obvious yet and atherosclerosis cholesterol disease in the blood vessels it's a systemic disease it doesn't just affect one blood vessel or one little area it affects the whole vascular tree how about some epidemiology about erectile dysfunction well in a prospective cohort of almost two thousand men four to seven years a day 40 to 70 years of age erectile dysfunction was associated with a 40 percent greater hazard of death versus no erectile dysfunction so vasculogenic that's what i have here vasculogenic erectile dysfunction shares the same risk factors as heart disease so if you have diabetes in various studies you have a much higher odds of having erectile dysfunction just like with heart disease high cholesterol significantly increases the odds of having erectile dysfunction just like heart disease obesity significantly increases the odds of having erectile dysfunction just like heart disease inflammation just like heart disease smoking just like heart disease including cigars so they share same risk factors not surprisingly and when one is evaluating it oftentimes we'll incorporate you know our urologic colleagues because they are indeed experts in this area but we will look for psychological causes medications we will look for hormonal issues is there a testosterone level issue is there a thyroid issue and we will try to optimize cardiovascular risk factors including diet and exercise and stopping smoking and sometimes improving erectile function can be particularly motivating there are multiple studies that show that losing weight can help with erectile dysfunction and this is effective lifestyle changes on erectile dysfunction in obese men a randomized controlled trial this is 110 men followed for two years without a lot of vascularity or a lot of risk factors and they had detailed instruction regarding diet and exercise to lose 10 percent of weight versus general info and they lost a little over five kilograms versus a little less than one and the uh ief score that questionnaire for rectal function improved in the intervention group significantly remains stable in the control room this is the effect of intensive lifestyle changes on erectile dysfunction in men this was 209 with or at risk for erectile dysfunction the following for two years and they advised weight reduction by more than five percent increase monounsaturated fat consumption to greater than ten percent of calories less saturated fat increase fiber consumption decrease saturated fat consumption and encourage exercise versus general guidance on healthy diet and lifestyle and normal erectile function increased from 34 to 56 percent in the intervention arm versus 36 38 of the control on the significant difference can't read the title of this one but this was people with type 2 diabetes and they had 306 overweight or obvious men with erectile dysfunction the intensive lifestyle change versus general advice and at one year the intervention group lost significantly more weight and had a small but significant increase in the iies score versus control which had no significant improvement and there's multiple randomized studies of the mediterranean mediterranean-style diet diet enriched in vegetables fruits whole grains beans and lentils improving erectile function i think this is erect i can't quite read it but i think this is erectile dysfunction in men with the metabolic syndrome and which is a constellation of risk factors we mentioned earlier as part of the cardiac study or as part of the framingham cohort perspective study they looked at and 65 men with erectile dysfunction mediterranean diet versus control and two years 13 men in the mediterranean group and 12 in the control group reported normal erectile function and endothelial function inflammatory markers were improved in the intervention group but unchanging the control group which lends mechanistic reasons as to why they may have found what they've or they found what they found in a cross-sectional analysis of almost 700 men in the icaria study was recently was presented as an abstract and long-term adherence to a mediterranean diet was associated with improved sexual function as measured by iaf5 score i have not seen it yet published but hopefully it has been what about erectile function and specific foods so pistachios in this studies pistachio diet improves erectile function parameters and serum lipids in patients with erectile dysfunction this is an uncontrolled trial not super high quality uncontrolled 17 men with ev 100 grams of pistachio nuts per day to a standard diet for three weeks they saw significant improvements in erectile function pistachio but this is a more rigorous study effect of nut consumption on erectile and sexual function in healthy men a secondary outcome outcome analysis is the ferdinand's randomized controlled trial and this is a randomized control trial of 83 men within b it was a western diet with 60 grams of nuts per day versus western diet and avoidance of nuts and there is no significant change in erectile function now whether that's just the western diet overwhelm the nuts or nuts don't actually help for this hard to know exactly but this is what they've found and this i can't read before the title but 53 men with mild to moderate erectile dysfunction this is pomegranate juice pomegranate juice was associated with the trend toward improving erectile activity as assessed by the global assessment questionnaire but no such trend was seen in the iief score so really people think more that healthful dietary patterns not surprisingly are the ticket to improving erectile functioning there's related observational data this is dietary flavonoid intake and instance of rectal dysfunction and the highest quintile of fruit had 14 percent lower risk of incident a.d over 10 years um erectile dysfunction and fruit and vegetable consumption among diabetic canadian men this is across sectional analysis of 1500 men 26 reported symptoms were diagnosed as a needy each daily serving of fruit and vegetable as measured by a frequency questionnaire was associated with the 10 percent decreased odds and self-reported ed association between comorbidity and erectile dysfunction of patients with diabetes 300 iranian men with diabetes consuming fruits seldom or weekly was associated with a higher odds of erectile dysfunction 3.2 times higher odds versus daily consumption of fruits erectile dysfunction and cardiovascular risk factors in the mediterranean dietary 400 or so spanish men 42 with ed consumption of tree nuts two or more times per week and consumption of vegetables one or more times per day was associated with lower odds of erectile dysfunction respectively here as assessed by the questionnaire dietary patterns seem to be helpful dietary factors in erectile dysfunction 100 ml with ed and 100 match controls higher intakes of fruits nuts vegetables and higher monounsaturated fat saturated fat ratio more plant-based foods were associated with lower risk of bd how about supplements there's not really great data and there's no particular supplement that's formally recommended for erectile dysfunction exercise absolutely it's part of the american neurologic association guidelines the one copy that they give is cycling and the issue is if you sit on a seat that like pushes up underneath it can squish the pudendal artery and that could injure or the potential nerve and that can cause injury there so it's important to get those seats with the divots to protect the pudendal artery and the pudendal nerve smoking clearly associated with a higher incidence of erectile dysfunction um it's tough they're tough to get people to stop smoking it's a real vexing issue but if you can please do this is from our article that we published in american general medicine about lifestyle change and erectile function and saying how erectile dysfunction is the canary in the coal mine warning about increased risk of future atherosclerotic cardiovascular disease events it's common and impacted by lifestyle can be worsened by diabetes obesity hypertension inflammation and smoking data is limited regarding supplements improving erectile function with lifestyle change may also reduce the risk of future atherosclerotic cardiovascular events and i can't really read these two bubbles so erectile dysfunction is common it's probably underreported it's the canary in the coal mine of cardiovascular disease it's overlapping risk factors of cardiovascular disease lifestyle changes improve both cardiovascular disease risk and erectile function and potential improvements in erectile function may prove to be uniquely motivated this is a great quote from dr kim williams past president of the american college of cardiology i recommend plant-based diet because i know it's going to lower their blood pressure improve their insulin sensitivity and decrease their cholesterol this is where we are in the bronx uh montefiore health system bronx is arguably the least healthful inner city in the us nobody wants this title um and it is there are 62 counties in new york state and the bronx is number 62 last place in regard to health and it's not even close to 61. um so this is where we're based so it's it's it's a challenge and it's a privilege to be able to you know help people who help groups that need help frankly um and one question that i got and i talked about recently at the american college of cardiology is how in our system we many years ago got our system to offer plant-based meals for inpatients um that you could order in our electronic medical records system and now it's different you know now that there's wonderful there's a law in place at least has to be offered in california new york i don't know that if it's been done anywhere else and of course the physicians committee for responsible medicine pcrm has played an integral role in getting those laws passed and so what they asked me how do we move this mountain well there's physician interests and many of you in this audience there's righteous indignation and we're doing so poorly with dietary health in the u.s there's endless sources of righteous indignation and being a friendly pit bull with a plan and this is that study by bundy that we talked about where point seven percent of the u.s has a healthy dietary pattern an ideal dietary pattern all right lots of room for righteous intonation there so we wrote an article called creation of inpatient plant-based program published international disease international journal disease reversal prevention and we really meant it as kind of a how-to like you know to adapt to your system and we had a six step plan and the first step is to get an interdisciplinary team you need a physician lead to drive it you need to involve your director of food services that person knows about billing about intricacies of how your particular system makes food different systems make it and store it differently neither director of nutrition can be sure you're you're following uh governmental mandates for various nutritional needs etc and some hospital systems outsource to big food companies and you would need your liaison to that company if you wish to go down this path step two is you would develop recipes with nutrition and i to be frank i just sat there with nutrition and we went back to work and we made recipes we have a week's menu of breakfast lunch and dinner you want to have a multi-disciplinary meeting to refine the recipes to be sure they're ethnically and culturally relevant to be sure they're appropriate in terms of a cost perspective that's a big deal obviously for health systems and then you want to have some tastings to optimize the flavor and presentation and that's we did that we're like okay this is good it's bad i'll keep on changing it um and it's come out i think pretty good and while all this is com going on you want to work with your electronic medical record team i think for two things one is to get a name for it and some of them we our system is on the character limit so we call ours cardiac plant-based um and you want to be sure that the order is in a very easy place to find like initially ours was like three sub you'd go on die and it's like three subfolders down and six heart but um now it's on the very first line so you want it you just want to remove the friction step three patient education of course we should all be doing this every day some degree of discussion with patients regarding the importance of a healthier diet for their care we have a handout that we can give patients um and we we're very fortunate we have the documentary film forks over knives that plays on continuous loop on one of the inpatient channels with spanish subtitles um that you know they can watch whatever they want but they could all i could also walk in the patient's room and put this on it's a wonderful way to help outsource the education because when you're as you all well know when you're fielding phone calls and rounding on 25 patients and you have residents and fellows you can't spend 40 minutes speaking with each patient about diet and lifestyle there just is not enough time in the day um and this is the same slide every little bit counts i don't expect that we're going to fully change someone's life diet with a two-day hospital stay but we want to plant a seed every little bit counts we want them to know that their doctors think it's important step four staff education you want to have staff lectures and small group educational sessions on the diet um support from nurse managers on each floor is helpful outside speakers like for example when you're going to kick off your program you can have someone who could give a grand rounds or something on guide and lifestyle and also promote the program that you're doing help get the word out leverage your internal communication systems your emails newsletters this one i have an asterix required practical video i have not been able to get monthly bureau to do this um and i'd love if they did in medical systems it's like hurting cats you know residents come and go doctors nurses of team members all come and go and but they have to credential and they have to reproduce and there are lots of videos that we have to watch as part of that process and i'd love to create even just a six minute video that's required at credentialing and re-credentialing so you know everybody sees it and it's three minutes about why eating plant-based diet is healthy and three minutes about how you order it this is where you click this is what it looks like get um and you want it to be short and simple because no one likes watching these videos but at any rate i have not been able to get monetary do that but other systems are putting such things in place and tastings for staff are helpful you wanna we we when we started the program i rolled it out hospital i don't think that's a great idea our system is huge uh it gets a little unwieldy i think uh piloting it on a single floor is great so you can plan to study act and make it better like the first day we had cow's milk come up with it so you know there's just a learning curve with it um and then you want to evaluate objective and subjectively uh one thing subjectively that we found is that a plant-based diet looks a lot different than some of our patients are used to eating and that would turn people off and so what we did is we asked the pa or a nurse or resident is ordering food to go into the patient's room early on in their stay like you know as they're getting checked in or just after we're going to be giving you healthy foods to help protect your heart that's it and then at least they're they know the food's important and they're primed for something healthy so and i wouldn't use the term we never use the term vegan um you know that's not just necessarily health related you can be vegan and very unhealthy as you know and that term is you know has ethical and other things with it which are very can be very lovely but it also turns some people on so i'd recommend not using that term we've had people be very frustrated with someone inadvertently use that term um at any rate just having them say that little comment has been very helpful for us in terms of getting people to be happy to eat or willing to eat the diet so uh you want to and another idea is keep things simple there's lots of opportunities to keep it simple and one of them is leveraging your emr one thing that we do is i've quote mandated it that our cardiology fellows we have a pretty big cardiology fellowship program i think it's like 11 fellows general fellows a year that's one of the biggest in the u.s um and we i mandate it so they have to in their consult notes does the patient consume at least five servings of fruits and vegetables daily yes no deferred they have to answer and we put this right above the assessment of plan so it's good real estate and people will be more likely to see it and we do this why so the patient knows it's important a fellow knows it's important anyone reading the note knows that cardiology cares about it and you know then our trainees leave they go all over the world and hopefully this they'll take these themes with them and one other one that i just started doing is for the positions in the audience you know we often use the term gd eminence and mary gdmt that's guideline directed medical therapy for heartfelt gdmt use it all the time um and i started to do gdn and his enhancement gdnt why that stands for guideline directed nutrition therapy and i write it out so no one thinks i'm making a typo and because what it does and i'll say guideline direct gdnt you know please order a cardiac find based on because what it does is it gives it the diet the imperture the the significance the weight of guideline guideline backing which it has just like guideline directed medical favorite heart failure there are american college of cardiology guidelines about health diet nutrition and it's eating lots of vegetables and fruits so there's guidelines behind it so why don't we throw the weight of that evidence behind it in our note to you know make it anyway so i've been doing i just started doing that and playing with that so there are three key ingredients six step plan keep it simple um oh yeah we just this past year made something called the cardio nutrition podcast it's through the american college of cardiology it's about um 15 short bite size lectures 10 to 20 minutes on different dietary topics we talk about the guidelines of dr kim williams it's really great one he also touches on covid and diet um we talk about different dietary patterns mediterranean keto plant-based etc and it can be found anywhere where you get podcasts so that's it yep thank you very much and thank you very much this was so thorough and so helpful for so many of us really really appreciate this uh dr osfield and um it's okay with you we've got a few minutes for some live q a sure excellent thank you very much um so just want to make sure that everybody understands how we go about that here at the real truth about health we uh typically don't take questions directly from the chat box but we do ask people to raise their hand if nobody if you don't know how to raise your hand uh your virtual hand that is what we do is you click on one of your zoom tabs it's called your reactions tab when you click on that you'll see different functions one of them is the raise hand function raise your hand we will see your hand raised and we'll get to you as quickly as we possibly can and and we'll do that by my calling you by your first name and then i'm muting you so with that um we'll get right to it with michelle michelle welcome oh thank you very much uh and thank you so much dr osfield i have to give you just a little bit of context and my question is relating to um the myocarditis uh for young people with covid19 i'm uh i'm a registered holistic nutritionist in canada and um i i run you know i see clients um to help them with their nutrition and i that always edges them as much as possible towards a whole food plant-based diet and i've had very consistent with everything that you teach in in these programs i've seen tremendous tremendous transformations of people just simply by guiding them in that direction and helping them understand um what's good for them what's not i have a new client who was asking um so he's 20 years old who has suffered this they they have made him part of the study they that the only conclusion is that he has unfortunately suffered a vaccine injury from the copen 19 vaccine um i did a scan of the literature and i'm i'm not a doctor or a regulated health professional i'm a registered holistic nutritionist so i i can't diagnose treat but i do i do look for the literature to see where it's nudging you is there any evidence of dietary interventions i don't see anything yet about this particular condition but i have a hypothesis that we've seen so much success with other cardiovascular conditions that simply guiding him towards a whole food plant-based diet is going to be the best intervention that we know at this point to help him recover i wonder if you have any opinions or if you perhaps know something that um isn't maybe available to the to the public yet that might um that i might suggest to help this person yeah so as i understand it he had a he has myocarditis after getting the covet 19 vaccine um and i'll have opinions but i can't unequivocally give you an answer uh because i don't think we know uh there clearly is an association with um better outcomes when you get covet 19 in general not talking about the vaccine so i'm going to i'm going to circle around the point for a moment there clearly are associations of better outcomes when you have a healthier dietary pattern the incidence of myocarditis is much higher from covid19 itself the viral infection itself than it is from the vaccine so we certainly encourage people to be vaccinated for a whole host of reasons um and you know so the but you're much more likely to get a myocarditis from kova than you are from the vaccine but you know there is an association with uh uh myocardius and the vaccine i'm not aware of any specific treatment for it whether you know it's from covid or from the vaccine there can treat related symptoms the course tends to be better when it's from the vaccine probably a healthy lifestyle helps um and that's that's about all i got so i i just don't have a great therapy uh for that my hypothesis is that a plant-based diet would be helpful but i can't unequivocally prove that to you thanks very much for that and up next we have yaron welcome hi um hi hello doctor thank you very much for your great presentation so i um i did a few years ago three years ago a cardiac calcium score test was called cat cat scan because of a family history my my dad you know got a very young heart that i can die from it and uh i got a very high score although i did i did not have any symptom so i decided to switch to a full plant-based diet and and change my lifestyle and now after about three years that i made the change how would you recommend to make a follow-up to see if my situation been improved do would you recommend to uh do any other tests to do the cardiac the cat scan again or do any other test because there is i know uh some radiation with this test uh what what would you recommend thank you so i'm not able to give out specific medical advice um i think in general when someone just either pre or post knowing you have atherosclerosis by here in this case i mean knowing is um having a positive coronary calcium score um so that being more healthful is can be quite useful for you over your one's overall health oftentimes in these situations when someone has atherosclerosis in addition to lifestyle we might add a statin but in terms of follow-up testing and other other things i really need to leave that to your personal position because there are many variables that go into dietary recommendations medication recommendations so i'm really not able to go beyond that but i do think it's wonderful that you adopted a healthier lifestyle thanks for that doctor and uh up next we have ed welcome ed uh let's see am i uh not muted yup you're all set we can hear okay um i'm asking this question for someone who would not be understandable on their own this is a 70 year old hundred pound woman with crohn's disease who was diagnosed with a heart attack after the fact at the age of 67. she eats a whole food plant-based diet she comments probably too much sugar and exercises regularly ldl 39 hdl 36 triglycerides 132 she's on a baby aspirin 50 milligrams of metoprol and 20 milligrams of atervas statin calcium and she wants to know does it make any sense to be on these drugs you know we thought with the low ldl you didn't need to be taking drugs well again i'm gonna need to defer to her primary doctor about that in general um for ldl i mean if someone stops taking [Music] the statin ldl will go up a lot because they work very well well their ldl was very low to start with well so i mean i'm not able to give out specific recommendations for her care i can just tell you in general that's what happens and there is um a substantial amount of evidence that lower is better um and you know there are some guidelines that recommend even less than 55 or lower in particular high-risk situations um so i uh in general when someone has had a heart attack and and it is quite common to see them on an aspirin and a statin that's very common and often times a beta blocker as well that wouldn't be a surprise to a cardiologist to see that group of medications and we think about it as all of the above one of course lifestyle and medications and i'm sorry i just can't get more specific for an individual person because everybody's got certain things different things going on that makes perfect sense thanks very much doctor and up next we have kaylee welcome kaylee thank you hi this is kaylee covington i want to thank you so much for having seen me several times over the last years for your patience for your commitment to what you believe in and yet for allowing me to to make my own final decisions and being supportive nonetheless so i want to let you know that without statins now i've gone down to normal blood pressure and i'm so happy and i'm so grateful that you're on the planet and that you're helping people and that that you are who you are oh thank you so much well thank you for those kind words and i'm glad you're doing well that's wonderful okay thanks thanks kaley and um for everyone else um at the moment i don't see any other hands raised i've got a couple of questions for you if that's okay but i do want to remind everybody what a what a great opportunity to ask dr osfeld your questions directly we have a few more minutes left so if you'd like again just press your reactions tab and up comes a a menu and you click on your raised hand function and we'll see your hand raised so um you know for now i guess my my first question to you is and if you've covered this forgive me but are there any nutritional supplements vitamins minerals powders probiotics that you recommend for any reason for your patients there are two supplements that i routinely recommend the first one is vitamin b12 and of course b12 lives in the soil it's made by microbiome of the bacteria in the soil and now that you know when we get our vegetables and stuff it'll say like triple wash and then wash them again and so all the dirt is washed off of it so you're not getting beets well that way and animals get it because they either eat dirt or other animals that eat dirt and so if you're going plant-based you really make have a very low exposure to b12 so i encourage patients i just recommend they take 500 micrograms of b12 three times a week to start i'll check a level and kind of go from there that's just empirically how i've done it um but since you know we're using so many pesticides and things now that people who eat an animal diet very very often they're b12 deficient too because the micro microbes have been killed so it's something that i've actually been screening for much more than i had been earlier on in my career and i see low b12 levels a lot so b12 is one the other one that i recommend is an omega-3 um and that it's not for heart health but it's for brain health and although we'll have you know sometimes you know you need hemp seeds chia seeds ground flaxseed meal that can give us ala but not everybody converts ala to the omega omega the epa or dha well so i do that kind of developing suspenders so those are the only supplements that i reckon that i recommend excellent thank you very much for that and we now have a few more hands raised so i'm going to go now to uh rebecca and welcome rebecca hi thanks um can you hear me yes okay um could you talk about the impact of soy and any any impact on the thyroid any negative impact on the thyroid i'm not that i'm aware of in lower doses but to be honest i'm not an expert in that topic and i would be i'm not i wouldn't be the greatest person to ask about it i'm not aware of a negative impact at you know typical doses you know amounts that you might get from say you know if you ordered out chinese food or something so i'm sorry i wish i had better for you but that's all i've got we appreciate your candor thanks doctor and up next we have uh cynthia welcome cynthia hi cynthia hi dr oswell this is cynthia lee i'm so grateful to have you as being my uh wonderful cardiologist i i really feel much better following the whole food plan based diet that's all i wanted to say oh well thank you so much for your kind words i'm glad you're feeling better that's great yes thank you dr thanks for sharing that cynthia we all appreciate that and up next we have ulysses welcome yeah thank you doc have you given any thought to the inclusion of dog chocolate in the diets of your client yeah sure i mean i think it's a wonderful treat um i've got some like just four feet away from me um i uh yeah i mean i don't have it on my list my checklist of things i'll often give people to eat but i do think that if it's you know truly dark chocolate without the cow's milk and i've the kind of the threshold that i've used for no particularly great reason is seventy percent um or higher i'm very for patients having you know a little bit of dark chocolate as a treat and also putting cacao if they want into a smoothie it can be great there was the cosmos trial that just came out and i'm not i don't remember all the details of it and that study uh looked at a dietary supplement of cacao and i think that there was some metabolic benefit i can't may have been neurocognitive as well i don't remember exactly but if you google cosmos trial it'll give you the details it was run out of the preventive medicine group at brigham and i believe joanne manson is one of the senior authors on that study but there was some sign of benefit in a large randomized trial um so yeah i think it's great thanks very much for that and now we're going to bring in excuse me we're going to bring in wendy hi wendy hi doctor oh it's great to uh hear you again i've i've hurt you in person a number of times i have um i'm i'm still confused about eating carbs right now i actually just cooked dinner i made a lot of vegetables i made some japanese squash i i just want to know how many carbs can you really have and am i um making taking a risk in developing diabetes and having too many um whole grain carbs whether that's you know whole grain bread or brown rice it's hard to say specifically for any one person um so and it's not one size fits all of course now the simon a people that we mentioned in the jungles of bolivia they had i think only one or two of them there were many hundreds of people in the study had even minimally elevated glucose and their diet is 72 carbs the study by um reynolds where it was like 135 million person years of follow-up they had um [Music] more whole grains associated i believe with less diabetes um so the devil's in the details really and of course the studies by dr satija showed that eating a healthful plant-based diet not sugar cookies was associated with improved outcomes so it's hard to say for sure for any one person i do encourage my patients to have three servings of whole grains a day that's like you know brown rice quinoa that kind of thing um so but you know some people don't do well with that some people need to have lower carb diet and that's something to talk about with your regular doctor they can or your or your rd and they can follow various metrics like hemoglobin a1c and your weight and other things to try and help titrate a diet that's specifically helpful for you thanks very much for that doctor and up next now we have joanie welcome joey hi this is actually john gone's husband so anyway i wanted to ask you if one is borderline diabetic with a high ldl what is the danger if i didn't prescribe the statin or if one is prescribed a statin crest or specifically um well i mean when when a statin is indicated um and there's some you know various ways we can assess that but if a statin is indicated then the benefits far outweigh the risk there was i believe i believe it was a subgroup analysis of the jupiter study there is some suggestion that for people who are [Music] insulin resistant or borderline diabetic that statins may increase diabetes but in that study the subjects who were on the path toward being diabetic already i believe became diabetic 31 days earlier than they would have otherwise um but yet they still had incremental benefit on average some didn't um and on average they still did better so when it's indicated we use it in diabetics we use it in pre-diabetics all the time it can be an incredibly helpful medication if you read the internet statins are the worst thing in the history of time uh there's really a lot of the better study than aspirin there's stated millions of subjects about it and obviously there's side effects with any kind of medication but for someone who is indicated in the benefits uh far outweigh the risk and so um i can't say specifically for you uh that um you know what what to do but in general we do use it frequently with high ldl and someone who is insulin resistant separately there is a study called dpb diabetes prevention program that was published in like 2000 i think in new england journal medicine and that looked at insulin resistant patients and they randomized them to control a healthy lifestyle or metformin and metformin lowered incident diabetes more than control but the healthier lifestyle which was like extras i forgot the details of it um but included exercise lowered the incident diabetes even more so really as you know uh underpins the importance of a healthy lifestyle thanks very very much for that doctor and up next we're going to bring in max welcome max hi uh doctor you recommended omega-3 as a supplement can you please be more specific what type of omega-3 you will recommend to vegans um i really can't because i don't know of any great studies looking at it and it's kind of an empiric recommendation there are algae oil based um omega-3 supplements that some of my vegan patients will get but that's about you know that they're they're findable online but there's not a particular brand that i endorse or know know well so sorry about that thanks very much for that doctor and now we're gonna go to somebody with the initial cg welcome cg oh let me try that again there you go hi um yes doctor do you know why dr esselstyn um recommends cooking the leafy greens to get the nitric oxide i mean he says to cook them for six minutes and it seems like you're cooking them to death and all the vitamins and minerals are going to end up in the water is eating raw leafy greens not as beneficial um well i mean dr esselstyn has incredible experience with his patients they've done exceptionally well and i do think he i think there's a i think there's a little bit of data that that he has about how cooking them can help potentially and putting a little vinegar on them can augment their improvement on um endothelial function what i what i recommend patients do honestly is to try to mix it up uh because some fruits and vegetables some vegetables you cook certain nutrients come out some you don't cook other nutrients come out uh so i encourage people to mix it up and um i so i don't know beyond that i think that he has a little bit of data that it can improve nitric oxide um uh function or manufacturing within the endothelial cell that's the best i've got on that but i do like patients to mix it up and it is oftentimes very hard for people to have green leafy vegetables six times a day in that context and some people can they have wonderful improvements but that is a challenge for some of my patients thanks doctor and up next we're going to bring in steve welcome steve a lot of steve's me dad you're the one thank you hi thanks ben uh hi doctor wonderful uh schmooze thank you so much um dr kim williams just dropped a bomb on us about not supplementing with b12 if you're an ex-smoker ah help us navigate this one just stop taking the b12 and not worry about it because we get something in the stuff that's added to the food and what do we do i don't know i don't know that data um what was his issue with it that uh an ex uh sort of like the beta-carotene study way back in the day that if you're a neck smoker it's gonna you know feed the aggressive lung cancer yeah so um i know the study you're talking about i'm just not too familiar with data of b12 and ex-smokers increasing lung cancer it may very well but given that i'm not sure exactly what study he's talking about i have i'm just going to have to defer on that i'm going to have to look it up myself so sorry we really appreciate that doctor thank you and i'm going to ask lois to unmute yourself if you can lois see if that there we go hi lois hi hello um i have a question about um whether it what you recommend for your patients who can't take statins and have atherosclerosis and maybe i'm speaking for myself my cardiologist would like my numbers to be a little bit lower um do you have any recommendations for that yeah there's also i'm so sorry lois we accidentally muted you before you if you could just unmute yourself one more time let's see oh there we go hi and i forgot my second question so if you could just address the question on stat so a few things there's lots of ways that we can lower cholesterol beyond statin um now sometimes with statins there's different things we can try some people can tolerate it once a week we can change the dose we could change the type of stat and there's all sorts of little tricks we'll have up our sleeve to adjust that but assuming someone can't take satin at all or it needs the ldl needs to be lowered on top of the statin of course we recommend lifestyle change but from a medicinal standpoint there's a medication called zedia that a lot of people will use it blocks cholesterol absorption and it can lower it 15 to 20 percent more that works very well uh usually very well tolerated completely different mechanism of action as statin compared to statin and then of course there's the newer pcsk9 inhibitors the injectable one every other week which work incredibly well very well tolerated can lower ldl tremendously so that's another terrific option as well um they the issue with those is that they tend to be fairly expensive right now and it can be a bit of a hurdle to get them covered uh but those those are the lifestyle zetia pcsk9 inhibitors would be you know the three usu the three usual things we've initially worked with thanks very very much for that and now i'm going to ask somebody with the initials of v t to go ahead and unmute hi welcome hi um dr also um i have a question regarding um if your cholesterol is like over 200 but your ratio is good um is that something to worry about um well uh in just speaking generally i'm not sure which ratio you mean um i think actually because i'm asking for a friend and i know that she has like over 200 um cholesterol and i think the well whatever the ratio that um one the the i guess the good one is high i'm guessing that it's the total cholesterol over hdl cholesterol is probably what they're talking about um the devils of course in the details we're learning much more that hdl is falling off of its pedestal and maybe more of a marker than anything else and mendelian randomization trials are showing that which is kind of a genetic randomized trial showing that higher hdl levels may not be helpful um so the devil is in the details and her her cardiologist could calculate her 10-year risk score um that [Music] to assess or turn your risk of having a cardiovascular event and that would include a variety of lipid metrics and can help guide decisions on whether to start a statin in a guideline-based way so it doesn't mean she's off the hook doesn't mean she's on the hook but it means that a little bit more assessment needs to be done okay thank you thanks doctor and um let me go ahead and bring in nancy uh anthony go right ahead oh hi thank you thank you um dr oswell i just have two questions would you suggest or recommend a patient that's on a statin to take the q10 as well because there have been some debates whether to take a cutin or not and the second one is since mount you mentioned mount fury offers the wellness nutrition program i mean how does one get enrolled in it it needs to be so thank you in terms of the coenzyme q10 i do not recommend that patients routinely take it the only time that i'll use it is when someone is having a lot of muscle aches on a statin there's some evidence that it might be helpful some evidence that it's not there's actually interesting n of one randomized trials that suggest some of the muscle aches may not may not actually be real but be that as it may i don't use use it routinely if someone wants to use it i don't think it's a big deal but i will sometimes try it when someone has muscle aches on a statin to see if we can get them to tolerate the statin in terms of the program we did used to have periodic saturday morning sessions modeled after dr esselstyn's where i was speaking rd would speak lauren graf we would serve lunch um we weren't in charge we didn't charge patients for it i funded it all through donations uh we were doing those maybe every other month sometimes more for like 10 years but then covet hit and i've been forced to or well i have to stop those i can't do them now so what our program currently is and from an outpatient perspective is patients come and see me uh you know they'll have some sort of cardiovascular diagnosis because i'm a cardiologist um and they'll come and see me in the office and we'll leave plant-based nutrition into their care and we'll follow up with them along those lines that hand out some things that i'll give patients and if someone is interested they can call 718-920-5 and they can get set up with a new patient appointment to see me thanks very much for that we have rebecca back hi rebecca hi do you have an opinion on mammography screenings for a woman who's in her 40s whole food plant-based generally healthy and no family history of breast cancer i do not it's not my area i would follow that my recommendation would be to follow the guidelines um but it is not as a cardiologist i i do not do i do not order a mammography got it thank you very much for that as well and um i have a feeling that lois remembered her second question lois i'm going to ask you to unmute hi lois hi i did remember it thank you i was wondering what you consider a low fat whole foods plant diet doctors always talk about low fat is that 10 15 20 what what's the range that you usually recommend and i'm asking because i'm small so my calorie intake isn't huge so if i eat any extra flaxseed chia seeds nuts the fat or soy the fat goes way up well i think for a low fat typically falls in the 10 to 15 range um but you know there it's uh people don't necessarily have to go solo fat there are there are healthy fats that people can have as part of nuts and avocados and other things um so but that would be you know a more specific conversation with one's physician but typically a low truly low fat would be 10 15 when they call them low fat in studies they'll say less than 30 but that's not really low thank you very very much for that doctor and uh in fact you spent a few extra minutes with us and we really do appreciate that uh folks i'm sorry we couldn't get to every last question it is time for us to move on to our evening session um dr osfield my goodness how thorough a presentation and you were very gracious with all of your time here with our questions and answers so thank you so much for being here um i know i'm not the only one that wants to thank you i'm going to have my tech team on mute our entire audience what does everybody want to say to dr hospital [Music] you

Channel: The Real Truth About Health

Views: 32,566

Keywords: The Real Truth About Health, Robert Ostfeld, prevent diseases, heart disease, vegan diet, vegetarian, weight loss tips, dietary health, how to lose weight fast, whole food plant based, preventative medicine, Cardiovascular Disease, nutrition, heart attack, coronary artery disease, healthy lifestyle, healthy eating, how to prevent disease, whole foods, nutrition facts, weight loss, healthy nutrition, plant based news, veganism, vegan food, forks over knives, heart, yt:cc=on

Id: cum-aEKxZts

Length: 114min 59sec (6899 seconds)

Published: Tue Sep 20 2022