Dr. Sandeep Mehta weighs in on various diets and how they can help prevent and treat cardiovascular disease.
Next up we have DR. Sandy Meta who is another expert general cardiologist with another preventive cardiology focus. He's fellowship training cardiovascular disease as well as integrative medicine. And he is really the go to guy right around scripts clinic. If you're in a pinch you call DR meta. If you have an advanced heart failure patients you need help with managing really sick patients on the service. He's called. If you have a complex question about this lymphedema, you often call him. So he's really an outstanding colleague who's got a breath of experience um and energy and he's not afraid to help to help you out and help take care of a sick patient. Um We've asked him to cover um kind of another important topic to help us really counsel our patients regarding the specific dietary patterns that patients with cardiovascular disease would benefit from. Really looking forward to hearing about the data. Doctor meta. Thank you dr Corey thanks so much for the introduction. Um Thank you everyone for coming on a Saturday night also for a conference as well too. And so I will try to cover you know, in the next 30 minutes, you know, optimizing dietary patterns in cardiovascular disease. Um, as far as my disclosures go, I have none. You know, we all know that the the standard american diet is quite poor in terms of its nutrient components. So there's been a lot of different diets that have kind of come to fruit fish and for people trying to find ways to stay healthy. You know, more recently, some of the fat diets include things like keto diet or paleo, very focusing on high, high fats, low carb type diets. But if you actually look at it, there's actually not that much data for these kind of eating patterns. Um you know, South Beach diet Atkins diet were mostly generated in terms of helping with people with weight loss. But if you look at it from a cardiovascular disease standpoint, we'll focus on kind of the three main patterns that have a good amount of data and evidence for benefit. And so the first group is going to be, you know, plant based diets, you know, pesky terrian vegan vegetarian, another, very commonly, you know, use diet in terms of cardiovascular risk prevention is gonna be the mediterranean diet. And what kind of talk about the main studies kind of involved in that and that focuses on an eating pattern from like italy Greece spain and the mediterranean basin. Um next diet that kind of talk about from a cardiovascular disease standpoint is gonna be the dash diet. And now this was developed by the National Institute of Health trying to look for ways from a dietary standpoint to affect blood pressure that was kind of their primary goal. Um They also found that, you know, this type of diet which focused on fruits and vegetables, minimally processed foods also have beneficial effects on cardiovascular outcomes as well. Um on the bottom in the middle of two more extreme versions of kind of a plant based diet um that I kind of mentioned that have been kind of proposed to help with cardiovascular risk. And one of them is the Dean Ornish diet, which kind of focuses on very, very low fat, very, very minimal animal products and dairy plant based. And then next to that is the SSD and diet, which is essentially going to be zero fat, no animal products and 100% like plant based. Um and these are kind of, you know, utilized and and to help minimizing cardio cardiovascular risk and plaque formation. Um there's not as much stronger data is there for some of the other ones that we're gonna talk about? So if you look at it, so this is the standard american diet as we all kind of know. The acronym for this is sad. Um It actually is quite pitiful. If you actually look at the focus of this diet, it is going to be the opposite of all the other diets that are on the slide before. So if you actually look at this, you know, they're going to be people who are very strong components of all of these. But if you actually look at the core aspect of a lot of these diets, there's actually a lot of similarities. You know, one they're trying to focus on minimally processed foods to some degree. They all incorporate some degree of having a decent amount of fruits, vegetables and nuts. Um And then the other thing is they're trying to avoid things that are highly refined, refined carbohydrates, really highly processed foods. It actually ends up, even though, you know, you know, there are key opinion leaders are very passionate about this is the right approach and this is the wrong approach. There actually are a lot of similarities to a lot of these different ways of eating. Um compared to, you know, this this is kind of what we often see in our clinical practice, which tends to be uber processed, very high in salt, very high in processed fats, very high in refined sugars and pretty much low and everything that's not processed, rejected the statistics and doctors who are covered some of this actually quite well. Um 60 to 80% of cardiovascular disease. It's got to be at least in some part related towards lifestyle, some of the bad lifestyle changes that have occurred over time in the US with the lack of activity and processed foods. Half of all the deaths from cardiovascular standpoint and counting heart attacks, strokes, heart failure. Um I thought to actually be preventable if we can kind of adhere to our lifestyle goals in terms of weight activity and food. Um About 100 20 million people have chronic disease that is in part related to lifestyle and dietary choices. We all know that, you know, the obesity epidemic is kind of increasing over the years. Um And so two thirds of people are overweight in the U. S. One third of people would have what you would qualify as a healthy diet only one third. And if you actually look at, you know, four healthy behaviours, smoking activity, Wait and reasonable food. Only less than 5% of people can actually say that they can actually do all of those things. Um so you know the standard American diet and lifestyle actually leaves a lot to be desired. And so if you actually look at it, you know, this is actually at the table um looking at the amount of fast food that is consumed on a given day In the US um so they actually look at it. 1/3 of people will eat fast food on any given day. This number actually is highest in patients in their twenties and thirties. Um Kind of decreases with age. But that's that's actually a pretty large amount if you look at it from our adolescence, you know, and you know, we're trying to raise our kids to have like you know better eating patterns. But 15% of calories from kids less than 18 comes from fast food which is actually a pretty significant amount. Um about one third of people can say that they eat fast food less than two times in a week. And if you actually look at the money made in fast food in the 1970s, the fast food industry was about $6 billion $200 billion. Um and the average person will spend $70,000 per year. I mean $70,000 throughout their lifetime on fast food. This is just fast food. We're not even talking about other processed foods. If you look at as a whole, you know, the average american diet, you know, 60% of calories come from processed foods. So if you take, if you take that on an average diet is roughly around 1800 to 2000 calories. Well, that means 1200 of your calories are coming from things that really actually aren't, you know, natural or whole foods, you know, they're coming in things that are already highly refined and processed and about like a third of your calories are coming from what we would actually consider something to be like healthy, which is actually pretty shocking. And so over the next few slides, I'm going to look at some of the current guidelines and evidence for some of our current dietary recommendations. We're gonna understand that there are gaps in our knowledge. If you look at all the data and the trials looking at specific diets and eating patterns, you'll see that a lot of it isn't going to be randomized controlled trials. Actually, the vast majority of it's going to be cohort studies or observational studies and we know that, you know, assessing someone's long term diet is actually really hard to do. A lot of, it is going to be prone to recall bias. Um And other kind of confounding variables. But I think this is actually is a very important topic to go over. Um And you know we'll kind of go over some you know controversies that are kind of out there with some of some of the fat diet and some of the specific food items that you know we commonly get asked about. And if you look at the american heart association the A. C. C. Current recommendations from a dietary standpoint are that the number one most important thing that we can do to prevent coronary heart disease, atrial fibrillation and heart failure are gonna be lifestyle modifications. That was their level of one evidence recommendation. When it looks at the specific foods they actually little bit vague you know and this is coming from the prevention kind of guidelines but they emphasized you know highly their diet emphasizing vegetables, fruits, nuts, whole grains and fish was recommended. Um They recommended replacing saturated fats with mono and polyunsaturated fats to help reduce risk. So if you reduce if you switch out like the same caloric amount of saturated fat with a mono or polyunsaturated fats between be found in nuts and fish and seeds. Um There has been data suggesting a significant cardiovascular benefit and obviously you know, they recommended reducing amounts of dietary cholesterol on sodium. This is actually pretty controversial as well because the data behind you dietary cholesterol and cardiovascular risk is not the most robust. Um and obviously they recommended as part of a healthy diet minimizing the intake of processed foods. I think this is actually a key point that we have to stress with their patients. You know, everyone has these preconceived notions of what they think is, you know, the best, from an ethnic standpoint from their own research and what they've done, but I think there's a lot of common ground in a lot of these different ways of eating. And I think, you know, the biggest part is is you know that a lot of fault with our current eating styles, it's related to the fact that we eat a lot of processed meats, processed carbohydrates. Now, whether you're saying that, you know, more fat is better, or more carbs are better. Um I think the bigger key point is the quality of what we're eating makes a difference. It's not so much you adhere strictly to a plan. You know, I've had patients who were vegetarian, like, yeah, I'm the healthiest person, you know, they're like, you can't touch me, I'm a vegetarian, I eat very clean and when you ask them what they're eating um There were other eating like cake. They're eating things that bagels you know things with a lot of refined carbohydrates. And I don't think anybody would actually consider that to be you know a reasonable you know way of eating. If you actually look at you know across the pond in europe they kind of have very very similar kind of prevention guidelines as well. And recommendations from an eating standpoint. They favor a mediterranean style diet um as opposed to like a dash diet because that's what they're most familiar with. Very similar recommendations in terms of increasing consumption of fruits, non starchy vegetables, nuts, fish um Using plant based oils, yogurt and humble grains. And similar to the U. S. Recommendations. Um They want to limit the amount of processed foods and meats and refined carbohydrates. And so we actually start with you know let's start with the three diets which I think have the best data and evidence from a cardiovascular standpoint. So we'll start with the mediterranean diet until this is kind of popularized In the US in the 1960s and the seven country study done by Ancel keys. So he's a physiologist who studied like, you know, the effective diet and lifestyle on cardiovascular disease. Um and then he found like a few associations that patients who adhere to a certain kind of eating program would have, you know, less cardiovascular disease and a lot of cholesterol intake, saturated fat intake. Um and a lot of you know in activity was for risk factors. This was actually relatively well known at that time reigning diet at home. You know what's cool is it is a moderately higher fat diet, but the fats are mostly focused on olive oil and plant based oil nuts, which are just great sources of polyunsaturated and monounsaturated fats compared to saturated fats, poly and mono unsaturated fats and to have a more of an anti inflammatory fact. They also tend to have better, better effects on lipid profiles and inflammation in general. The other focus is going to be whole grains, fruits and vegetables, but also minimizing red meats and processed foods. And so the big trial that kind of showed that hey, we should all be kind of recommending a mediterranean diet was the pediment trial and this was a prospective parallel group, multi center trial in spain. It was funded by the spanish Ministry of Health and their primary outpoint endpoint with this trial was to look at myocardial infarction stroke or death from cardiovascular costs. And so they included men, you know, 55-80 women, 60-80, so around like 8000 patients. And they had about 4.8 year follow up. These are patients who did not have coronary heart disease, but they had higher risk that they were diabetic or they had like multiple risk factors, like an abnormal lipid profile, abnormal way, high blood pressure and those kind of things. And they were randomized to three groups. The first group was going to be the standard of low fat diet. You know, the second group was mediterranean diet plus nuts. So around 30 g, like mixed nuts per day. And these are mostly walnuts and hazelnuts and a sort of tree nuts of roughly around 30 g per day. Um and then the mediterranean diet plus the extra virgin olive oil group. So in this group, their goal was to drink a leader of olive oil a week, You know, or like four tablespoons per day. So when you actually look at it, you know, how did they ensure that there was compliance? And I actually think that, you know, this tool that they used in their trial was actually pretty helpful if if you if you have patients who are interested in a Mediterranean diet, you know, they had a 14 items score sheet that would look for compliance and they would assess this quarterly. And I think that's also an important point with a lot of these dietary trials. that show that show improve cardiovascular outcomes. It is something that requires like close follow up, you know, seeing if people are here and, you know, something that, you know, if you're trying to enact lifestyle changes that we really have to work at, it's not kind of like a one and done type deal if we can just like recommend this. But it's something that we have to follow up on. But if you have patients who are interested in like a mediterranean diet, I think the score sheet from the pediment trial was actually pretty helpful. I mean, it kind of, you make sure that you're utilizing olive oil is the main source of culinary fat, you're pretty high in plant material intake, low on processed foods and you get a score that comes out of it and the kind of contest your adherence. Actually, you know, one of the, one of the interesting things that comes out of my discussion with patients regarding the mediterranean diet is alcohol intake and they're like, oh, you know, part of the mediterranean diet is, you know, drinking a lot of wine and you know, our modern amount of wine and that's good for you, right? Actually, if you looked at in the predominant trial, only about a third of people have maintained the recommendation of drinking a moderate wine. Actually, most people in the trial did not have significant alcohol intake, was only about a third of people who were drinking a glass or two on average per day. So this study actually didn't really look at the alcohol, you know, as it wasn't that many people utilizing alcohol as part of that, their dietary plan. So if you actually look at their, their main outcomes, this is kind of a trial that we've all kind of seen, as you know, in our training for the pediment trial. There was some controversy with the trial. If you, if you actually followed it, you know, it was initially retracted because there was an error in rent. There was some inconsistencies and randomization for about 400 people, but once they recalculated the data and reanalyze it, outcomes are still pretty much the same. And if you look at it, the controlled group had a significantly higher increase in the primary endpoint of myocardial infarction stroke or death. Um It's about a relative risk reduction of 30% and you know the extra virgin olive oil and the nuts group were very similar. Um So if you look at it from an absolute risk reduction, It's about 1.5-2.1%. But if you look at all of our primary prevention things that we do like aspirin stand, almost none of them have that much of an absolute risk reduction. So it's actually quite powerful in terms of a lifestyle change that we can make to affect. Um not to risk and absolute risk of vascular disease. Um and actually adherence was pretty good in this trial. About 10%, less than 10% of all the groups, you know, dropped out. So they actually had a pretty good follow up. There are some kind of older trials that looked at, you know, mediterranean diet and mediterranean diet type of eating patterns and cardiovascular events. Um The first two trials aren't really mediterranean dart and the cardio protective diet study. But they looked at, you know, that kind of a pattern where if you're having higher fish intake in patients who've had an m I if you're increasing fruit, if you're increasing nuts, if you're decreasing processed foods. And both of them show that in post myocardial infarction patients, there was a pretty large statistical benefit, Probably the one that had the huge, the largest benefit was the Lionheart, the Lion Diet heart study. Which actually looked at about 600 patients, you know, post M. I. And they actually recommended a mediterranean style diet. Um And they followed them over the course of like seven years and they showed that there was from a secondary prevention standpoint the rate of re infarction was about 50-70% less. And the patients who adhered to the mediterranean diet. Now there is a little bit of controversy about this study because a lot of the patients who participated did not report their diet data, but they just said that they adhered to a mediterranean type diet. Um And they didn't really explain like how much counseling they were given. So it seems like they just kind of got like one or two counseling sessions. It would be pretty shocking if you can give someone like one or two counseling sessions and enact that kind of a change as we know that a lot of these changes require a lot of long term follow up. So that's kind of, you know, one of the diets from a cardiovascular standpoint where there's kind of a lot of benefit. The next one that actually does have a reasonable amount of data behind is going to be the dash diet. And again, this was initially developed by the National Institute of Health. Its main focus was to treat like hypertension without medications. Um, and if you look at the diet, it seems like things that we would all say to all of our patients, you know, eat a diet that's rich written fruit and vegetables and low fat dairy, modern amounts of beans and the games really high in fiber. And I think one of the other salient points about the study was as high in calcium, magnesium and potassium and relatively low in salt from a blood pressure standpoint. And it tended to be lower in total fats and unsaturated fat. And if you look at it from a blood pressure standpoint, as far as like the other dietary and lifestyle modifications, they don't have a decent effect on blood pressure, dropping systolic blood pressure by about five points and diastolic blood pressure by about three. And it had pretty minimal effects but did lower LDL a little bit in total cholesterol a little bit. But if you actually looked at outcomes and this is actually looking at cardiovascular outcomes is a meta analysis of all the trials that look at that type of eating pattern and looking at their incidents and the reduction in cardiovascular risk. The patients that were able to adhere to a dash style of diet With the highest adherence rates in the highest quintiles actually did have about a 21% reduction in coronary heart disease and about a 19% relative risk reduction in stroke. So another another another form of eating another eating plan if your patients are interested, especially the ones who have higher blood pressure. That does have some pretty robust data in terms of reducing vascular risk. The next form of the next territory plan, I think has the best data behind it is also going to be, you know, the plant based diet. And if you actually look at it, this can be, you know, a lot of different things that can be vegetarian. It can be vegan, it can be pest it terry in. It can be like ovo vegetarian eggs and vegetarian. I mean, all of these were kind of including this study that looked at the effect of this type of a diet. Those four different patterns vegetarian begin secretary in and people who are over vegetarian and versus you know, people eat more animal products or non vegetarian and looking at their cardiovascular risk over time. And there are a lot of mostly studies are actually done in europe. There are few that were done in the US. And if you actually summed all the data, there was really no difference in all cause mortality. But if you look at cardiac specific mortality, which is the bottom panel, uh, there was actually a pretty statistically significant difference in coronary heart disease, mortality and outcomes. Um, If you look at it as a whole, about 20 to 25% relative risk reduction um in Coronary heart disease. And probably one that had the biggest change was the epic Oxford study, which showed that if you adhere to a vegetarian diet for roughly around 11 years, um there was a 32 Percent decrease, a relative decrease in incidence of coronary heart disease. And again, you know, these were talking about relative risk reduction and absolute risk reduction and you know, even though we're talking about absolute risk reduction of 1% or 2%, if you actually look at it from a population-based standpoint, these are actually huge. I mean these are actually more powerful then a lot of the medications that we use um in terms of number needed to treat in terms of efficacy if we can get people to kind of adhere to these kind of eating patterns. Um the challenging part is that this requires a lot of patient intensive work of counseling, a follow up in order to kind of enact some of these changes, you know, and I found this to actually be a really interesting study. This kind of alludes to the point that I made kind of earlier on. So does food quality matter. If people just say I'm vegetarian, I'm mediterranean doesn't make a difference. And the answer to that is going to be yeah. So this is a study that was done at Harvard and then incorporated, you know, three big cohort studies that are all very well known. It's going to be the nurses, health studies, number one and two and the health professional study. And it was actually looking at, you know, page based eating through all the questionnaires that they kind of filled out. Um, and they were free of, these are patients who are free of disease at baseline. Um, and they created like a plant based dietary index, you know, kind of like a questionnaire and a form that would say like, hey, you know how much, how and here you are to a plant based diet. And then they kind of separated into other questionnaires. Are you a healthy plant based diet or a unhealthy plant based diet? Um And so if you actually look at the data for this, you know, patients who pretty much panel be right over here. This is looking at patients who had animal foods, the non vegetarians versus people who had a less healthy plant based diet versus a more healthy plant based diet. And pretty much the patients who had a less healthy plant based diet, which means sweet refined carbohydrates, juice and sugar. They were pretty much done the same curve in terms of increase in cardiovascular risk patients who ate like animal, animal products and saturated fat. It was only the group that adhere to like a healthy plant based diet that had the beneficial outcomes in terms of cardiovascular risk, healthy plant based being or grains more natural, minimally processed nuts, legumes, you know, and those kind of things. Um and the same thing kind of follows, you know, you're just looking with people who just ate a plant based diet based on penalty. The unhealthy plant based diet actually did worse from a cardiovascular standpoint than people who adhere to like the healthier plant based diet. So the big takeaway I got from this is that well, actually, you know, quality actually matters. It's more, it's more than just saying that, you know, you're adhering to a mediterranean diet, you're hearing between a vegetarian diet. I think we also have to ask our patients, you know, exactly, what are they eating, What's the quality of the food that they're eating? How much process are they eating? You know, another thing, you know, we want to spend a few slides about talking about something that's been a little bit more popular recently and so this is the ketogenic diet, you know and it's kind of these kind of concepts of high fat diet have been around for some time and a lot of it stems from a lot of the metabolic disease that we see in the US that we think in part is due to very very highly refined carbohydrate intake. You know, a lot of diabetes, a lot of obesity and a lot of weight gain. And so the premise of this diet is that if you focus on very very high fat including you know sometimes very high saturated fats, very very low carbohydrates and moderate amounts of protein is that you can stimulate the state of ketosis where essentially you know, the liver is producing ketone bodies and it typically does that when you're fasting um if you have no insulin like type one diabetics or you do extreme exercise and the benefits of this is that your body will shift towards using ketones as the main energy source as opposed to glucose. And the thought is that this will lead to better glycemic control, better weight management, less metabolic syndrome. The higher fat diet may raise cholesterol, but some of its proponents will say that, you know, this will be because the LDL size is improving its bigger LDL and not more smaller, you know, pathogenic LDL and it might have a beneficial effect. And triglycerides. And the ketogenic diet has been used and has a role in some childhood epilepsy syndromes. But again, there's not a lot of data behind this. There's no good like cohort studies directorate, prospective randomized, controlled trials about this. Um and oftentimes when people do start this kind of a diet, they often get, you know what's quote unquote, you know, the keto flu um, where as their body shift towards the toes, it's kind of just feel crummy there a lot of gastrointestinal side effects as well. So it's not like oftentimes the easiest for someone who hasn't been exposed to it, but this is something that's very popular and the big frustrating thing with the ketogenic diet is that, well, you know, I think of keto, I think of, you know, there are ways you can do it right. You know, like the picture on the right that you're having stamen, you're having asparagus, you're having vegetables. Um, more often than not when I have patients who are doing the ketogenic diet, they're more like the patient on the left, so they use it as a kind of an excuse to eat a lot of processed foods, tons of big and tons of lard, tons of butter. Um, and pretty much use it as an excuse to say, hey, you know, I can eat these unhealthy foods and I can be okay, you know, it's healthy. Um, and I think that's kind of where a lot of the problem with the ketogenic diet is. You know, I think if you look at it from a core standpoint, yeah, you can do things such as like a healthy version of keto with an emphasis on non starchy vegetables, high in fiber. You can have maybe a little bit more lean protein intake, fish, fatty fish, chicken, turkey and even some plant based sources that are higher in protein. Yeah, You can kind of have a higher fat diet, but keep it rich in polyunsaturated fats and monounsaturated fats as opposed to just saturated fats like nuts, seeds, olive oil. And you can still use minimal minimize processed food, but often times most of the patients that have come in kind of randomly saying, hey, I try to keep a diet to lose weight, but often telling me that they're eating, you know, tons of bacon, tons of, you know, pretty much fried processed meats and tons of butter and they think that that's going to be healthy for them. Um and so that's, I think one of the biggest frustrations with the ketogenic diet is kind of, it's very popularized, but people will take it as an excuse to say, I can eat these things and it's okay. Well no, I think, you know, food quality and food choices still matter. And then, you know, from, from overarching standpoint, you know, this is stuff that, you know, we all kind of tell our patients and some of those previous three diets kind of incorporate look at some of the data for some of these things specifically. Um But you know, from an overall arching standpoint, I think the focus should be a, you know, a diet should be minimally processed and high end plant material rich in dietary fiber and phyto sterols, whole grain intake, beans, lentils, legumes have been shown to decrease cardiovascular outcomes, moderate amounts of nuts, seeds and oils like olive oil and plant based oils, lean protein sources, you know, low fat dairy is reasonable and the focus should be on high amounts of you know, monounsaturated and polyunsaturated fats as opposed to saturated fats. If you actually look at the evidence for nut intake and cardiovascular risk, they're actually this is a really interesting, better analysis that was done among look at look at the same cohorts the nurse's health study, the health professional study looking at, you know, tree nuts, which includes almonds, walnuts, peanuts, which I actually learned that peanuts are not technically enough there legume um Looking at the intake of those three different groups of nuts and then also peanut butter. Um and looking at the incidence of cardiovascular disease and she looked at it. You know what, it's tended to have the evidence and data for the most benefit. Peanut butter, there's pretty much no difference in cardiovascular risk. So, you know, pretty much peanut butter isn't isn't considered the same as eating the peanuts having peanuts. And tree nuts also had trends towards, you know, a reduction in cardiovascular risk. And if you actually looked at the study, you know, For every .5 half a serving of nuts that someone had in a day per week for every one more serving per week, That would reduce cardiovascular risk by about 10%. If someone can have about half a serving of nuts per day. So pretty small amounts of, you know, the common, you know, palm form of nuts or a few almonds are a few walnuts um if they can have about a half a serving a day and it reduces risk of heart attack stroke and coronary heart death, You know, by around 20-30%. Actually pretty significant. Yeah, if you actually look at and think why walnuts are kind of um more favorite and have a better level of evidence. If you look at walnuts actually tend to be the highest in poly unsaturated fatty acids, we tend to have a more beneficial effect from a cardiovascular standpoint that even mono unsaturated fatty acids. Um so they want to tend to be high in polyunsaturated fatty acids and pretty low in saturated fast compared to some of the other nuts. The other kind of thing that's been associated with good cardiovascular outcomes is going to be, you know, fish intake. So if you actually look at the seven country study, this is going to be looking at patients from the 19 sixties. Um looking at their incidence of coronary heart disease related, efficient take. There was kind of a linear dose related relationship between fish intake and incidence of coronary heart disease. Um this is actually very similar to the data. We see more contemporary. You know, the top left um slide looks very similar to the bottom line, which is looking at a meta analysis of files that currently look at the amount of fish consumption on a daily basis and looking at cardiovascular outcomes. And again, the same kind of dose relationship between intake of predominantly fatty fish like salmon, mackerel anchovies, you know, things that tend to be very high in anti inflammatory omega three fatty acids and also a pretty good lean protein source on the dose relationship between fish intake and mortality and cardiovascular outcomes. And I think a lot of the data from looking at populations of where people blue zones where people live very long and very healthy. You do see a lot of fish intake and minimally processed food intake in those populations. The other kind of general recommendation made by the H. A. N. D. A. C. Is looking at the whole grain intake and whole grain being the entire grain. You know have to learn a little bit about brain anatomy. Grain has an endo sperm a germ a brand. And apparently in the milling process you get rid of the brand of the german kind of left this process tendo sperm and it just tends to be more carbohydrate rich and it gets rid of actually some of the, the phyto nutrients the fiber aspect of and some of the minerals that are in the grain but actually eating the whole grain. So things like bulger oats, kenya, buck, wild rice, brown rice, actually very nutrient and fiber dense the complex carbohydrate and actually again a dose related association between consumption of whole grains on a daily basis. Um and reduction in all cause mortality and cardiovascular mortality as well. So I think again, with fish intake, with nut intake, with grain intake, they think there is a very strong body of evidence that these things actually do reduce cardiovascular outcomes and they actually are beneficial in terms of incorporating into a healthy diet. Yeah, so this is kind of a little bit more controversial because of all of the fat diets right now are recommending high saturated fats and really high fat intake diets. And so again, you know, they do, we haven't reviewed the data and they kind of look and say, hey, you know, there's an association between saturated and pro inflammatory fats and from feeding trials from data that we have before that, you know, this will this will raise inflammation, this will raise LDL and total cholesterol and overall these lead to a more malignant pattern of risk from a cardiovascular disease standpoint, if you actually look at a prior studies have showed that if you Isil calorically, so the same caloric value, replace 1% of your of your saturated fat intake with either a complex carbohydrate or a mono or polyunsaturated fat. You get about 21% relative risk reduction for every 1% exchange. I mean, the table on the right kind of illustrates, you know, the association between obviously Trans fat which is no longer allowed in foods. Um having the highest association between cardiovascular risk, saturated fast, not as much, but still association between increased saturated fat intake, especially when it reaches about 5% of our total caloric intake and the beneficial effects of mono and polyunsaturated facts. And so if you actually look at this, the knee hole sand study, which is actually quite interesting and looked at patients who are japanese who migrated from japan to hawaii to California. And they're changing their dietary and lifestyle pattern over time and their association with cardiovascular risk. Um and so they adopted pretty much, you know, a traditional japanese diet which was, you know, lowering fat, you know, reasonably high in carbohydrates but not processed foods. And they kind of adopted the more Western diet which was going to be higher in fat higher and I mean lower in carbohydrates. And hiring processed foods, their serum cholesterol went up about 25%. Um They're saturated, fantastic. Obviously was much higher. Um Their alcohol intake was actually a little bit less, but their their cardiovascular mortality rate was about three times as much just by adopting kind of this Western lifestyle following these people over time and again, kind of adopting that highly processed, high saturated fat type diet. So actually, there is a pretty interesting paper that was put in, you know, the Journal of The Deck Journal recently looking at um should be really be caring about saturated fat intake. And my answer, this is gonna be, yeah, we actually should. I think there's enough data suggest that, you know, reducing saturated fat intake and replacing it with healthier sources of calories such as like mono and polyunsaturated fats and or complex carbohydrates. Actually, there is a significant risk benefit. Um But there was some this, they published a study that looked at, you know, maybe if you're eating healthy sources of saturated fats, um you know, it can account for some of the negative aspects of some of the healthy aspects of it um in terms of protein and other nutritive benefits and that there was really no association between cardiovascular or diabetes risk. Um I would say the biggest limitation for this study was that it was funded a lot by long term funding came from the meat industry, the cattle industry and the dairy industry. So there is the, you know, there is the potential for bias and I do think that there is enough data and evidence that there is going to harm, you know, towards high saturated fat intake. But I think the real thing is, you know, it's what you're replacing, it goes back to the quality of the food. If you're replacing, you know, uh stay wanna saturated fat, refined capital hydrate, you probably really helping your patients that much. Um if you are replacing that with healthier fats, mono and polyunsaturated fat or you're replacing it with the complex carbohydrates, but when you actually are making a, you know, a beneficial change, I'm gonna kind of ties back to the quality of it. Yeah, I think we're kind of running short on time so I kind of briefly blow over some of these slides. Another thing I got commonly asked about is going to be coconut oil. And so if you actually look at it, you know, coconut oil is thought to be healthy because it's a medium chain fatty acids which seems to have, you know, anti inflammatory and may be beneficial effects on metabolic disease. Um I will say though that coconut oil tends to have the type of medium chain fatty acid is Lorik acid. It behaves more like a long chain fatty acid which tends to be the ones that are more inflammatory saturated fats. And so in short, you know I don't really recommend you know people using high amounts of coconut oil because it has the same kind of effect on L. D. L. Cholesterol and pathogenic risk. If you actually look at you know, again, coming back to the quality of food processed food intake Average in the us about 7.5 servings per day. Each additional serving is about 9% of cardiovascular risk. Again kind of going back to those studies looking at like saturated fats are okay or not okay. I think a lot of it kind of comes down to quality again if you're replacing saturated fats and things that are high in in saturated types of fatty acids with things that are, it could be monounsaturated or polyunsaturated or or gold grains. You're gonna have a beneficial effect in terms of cardiovascular mortality and morbidity. Another common thing that I get asked about our eggs and I think this is actually probably the best data that I found for that. And this is looking at a meta analysis of all the trials and this is kind of forest plot. And you look at most of the trial showed that there was no significant difference in terms of consumption for patients who are in the moderate range of consumption, which is gonna be about less than seven eggs a day. And there are some smaller studies that will show that if you have a higher amount of consumption and dietary cholesterol check has about your daily amount of dietary cholesterol, that there is going to be an association between that and cardiovascular risk. But these are kind of smaller studies and they don't adjust for a lot of the confound ear's. Um and so I think, you know, for mild amounts of that consumption like less than you know, seven per week. You know, usually I'm okay with that any more than that. I tell them to get egg substitutes or use half of the yoke was kind of my general recommendation. And this is kind of similar data looking at eggs from the harm stamped in a very small trial and stroke in 2015 showing that there was an association between eggs and and cardiovascular risk, but again, very small, didn't account for a lot of the variables. And so I think if you're eating moderate amounts of eggs like less than seven a week, I think you're okay unless your goal is from a lipid standpoint, these are patients who are higher risk and you might kind of force their dietary cholesterol down. But for the general population, if you're having less than seven day, it's usually okay data kind of supports that any more than that, they tend to kind of maybe you run the risk of some of these effects of higher cholesterol and you might kind of advise to maybe use like half egg whites in half yellows or next substitute. It would kind of jumped to the end because we're running out of time. I think this is where I should have spent most of my time um is going to be, how do we improve patient outcomes Now? We all know kind of the gist of a lot of the basics of nutrition stand and what we should be recommending to our patients. Um But on average, you know, we're not we're not really well trained to as well, You know, on average were about 19 hours of education Um in medical school over four years I think is, you know, pretty lacking in our average PCP. And specialist visits are in the order of like 20 minutes. And usually that's going to be about seven minutes of talking from the primary care and seven minutes of talking from the patient's standpoint. And so that doesn't give us a lot of time to kind of dial velvet to dietary changes and dietary counseling. And if you actually look at it, most of these trials that showed the significant impact of diet interventions and cardiovascular risk was intense to follow up. It was counseling on a regular basis. So how do we incorporate some of these things into our kind of constrained visits And so, you know, I'm actually lucky enough to work in a place where I actually have, you know, a lot of my time is spent towards lifestyle counseling, but if you don't have that, usually my initial goals are to pick low hanging fruit, you know, it's very hard to change multiple different things, but if you can pick one or two things to kind of work at and usually the simple ones are going to be, you know, the amount of processed food or eating out and what we're drinking, you know, we shouldn't be drinking a lot of sugary drinks, you know, things like, you know, so does juice, um wine, beer, all those things are just refined carbohydrates and so usually work with some of these simple things like trying to get people at home more. Um I try to be specific set with them, certain goals, like they're eating out four times a week, we'll try to do it one or two and I ask them those questions. Follow up visits. I think it's helpful tool that we often underutilized. It's utilizing dieticians and nutritionists. You know, these these people are there to spend time with our patients and kind of go over this in more detailed and often times we have the time to. Um And so I think it's important as a team based approach to improving outcomes that we kind of utilize this because again, if you look at the data um to implement these dietary changes takes a lot of visits, it takes a lot of time. There will be times that I will actually have patients only have counseling only visits. Um and so I will bring people back just for that. I know we're about to wrap up but I will be done in about a second. And so the other thing is there are a lot of lifestyle intervention programs and courses as well that you can refer patients students. So I advise people to do a little bit of research that if you're a physician or even if you're patient there are some of these programs that can be a little more intensive and give the patients to help they need. And with that I think I will end dr meta. Thank you so much. Super comprehensive review. Just kind of what we're hoping for. I certainly learned a lot and I think we can apply a lot of this because these are common questions that come up and how to really counsel our patients appropriately. Um Your talk um you gave about two talks there, so thank you so much. We got a lot of questions because you they have a great comprehensive talks. We've got some specific questions for you, but I want to give you a breather breather, you're already getting hoarse from all your discussion. So take a break. I want to ask Dr Sahar a couple of questions that came up. We'll do a quick Q and a um and then we'll try to wrap things up in the next 10 minutes to get back on track and get our break before the 12 15 talk.
