Penn Presbyterian Medical Center’s Grand Rounds program welcomed Dr. Monica Aggarwal, MD, an associate professor of medicine in the University of Florida’s Division of Cardiovascular Medicine. She discussed nutrition and the risk factors that lead to cardiovascular disease.
Alright. I know we've got a lot to cover. So um Let me start with introductions and then um we'll we'll take it from there. So welcome everyone to pen cardiology grand rounds today. CMI code for those on the phone are seven is 70,680. Again 70,680. And we'll make sure that that's in the chat box as well. But I'm really excited about today's speaker and topic. I'm honored to introduce dr Monica Aggarwal as today's speaker, Monica graduated from Uva. She then went to VCU for her medical school. She completed her residency at Tufts and her cardiology training at the University of Maryland. She is currently an associate professor of medicine at the University of florida and has really done an impressive job over her career of being a clinician or a researcher and uh and even an author of several books, nutrition and its role in heart disease is such an important topic. And Monica and I were just chatting how most of us received very little training at all and yet it impacts each of us and our patients. And I know it's so many offices that patients ask about nutrition about activity or exercise and we're kind of left with a couple of seconds to answer them but really not able to often answer all of their questions. You know, for years we were taught just to avoid fatty foods but I think there's much more to it. We're just scratching the surface of our understanding of nutrition, its role in heart disease, vascular inflammation and other chronic diseases. So, Monica has really done some amazing work in this and and I know I'm super excited to hear her speak about this. Um Similar to other grand round events. Please feel free to leave any questions or comments in the chat box or the Q. And A box harvey and I will will moderate at the end and we'll hopefully have 5 10 minutes at the end to ask some questions here to Monica. So with that I know you've got a lot to cover, Monica. I'll turn it over to you and I'm gonna spotlight your video and then we'll chat some more at the end. Great! Thank you so much. Samir for having me and to the whole staff. I really appreciate it. It really makes me happy to hear um nutrition become a more important topic um in hospital systems. Um my disclosures as we all know heart disease, some of this stuff is all new. Not new to any of us knowing that heart disease is the number one killer of men and women. But I like this slide in particular because it reminds us that most of the top 10 causes of death are largely vascular conditions and are largely preventable. We all know that with the new guideline to change in 2017, almost 50% of the us population has hypertension. 10.5% of the population has diabetes where 35% are prediabetic and 12% of the population has high cholesterol, 70% of the United States now is either overweight or obese. We now have Children that look less like the person on the left, but more like the patient or the person on the left on the right. There's a lot of conversation in the in the community in the in the world about whether patients should all be considered overweight based on the same guidelines. A lot of conversation to suggest that maybe there should be an asian B. M. I. Because asian patients are known to have heart disease at a younger age and or higher risk factors, sorry, the younger a lower B. M. I. So if you look at his p if he is B. M. I. Not sure what just happened there. Part of me, mm hmm. You can see from this slide here that this is asians here on the bold headline versus the dotted line is the non hispanic white. And if you look at hyper triglyceride, anemia, LDL, high blood pressure and diabetes, you can see that at a lower B. M. I. We're seeing higher rates of all of these, all of these conditions, uh, in the asian population suggesting that even maybe the B. M. I. That we use is not nearly adequate enough in terms of aggressive risk stratification, we all know that in primary prevention, there is we know this all know this cartoon very well in terms of aggressive lipid statins. But we have to remember that part of the in the first part of the primary prevention guidelines is to emphasize adherence to a healthy lifestyle. In fact in the prevention guidelines from 2019 we have a class one indication to emphasize the diet in high in vegetables and fruits, legumes, nuts, whole grains, fish to decrease a CVD. But how many of us are actually telling our patients this and actually telling them how this is data that we collected from the ACC showing that over 62% of the cardiologists they spend less than three minutes of their cardiology clinic visit on nutrition counseling. But that's no surprise because we also looked at how much nutrition education we're actually getting And you can see that when we pulled the American College of Cardiology that 1% of the population of doctors felt that they had received a high level of nutrition education that gave them excellent skills for counseling patients. We weren't doing much better Because if you also look at our fellows you can see that 0% felt that they were getting a high level of nutrition education. And we can certainly do better If you look at the state of US health, this is published in Jama looking at the risk of risk factors and related deaths and this is here now amplified. You can see that the number one cause or related to increase mortality and risk factors and death is dietary risk. You'll see here tobacco. And if you look at this here, this blue line here, is that association between dietary risk and cardiovascular disease. So what's wrong with our foods? What's wrong with the standard american diet with some people popularly called the sad diet? Well, the diet here in general is high in red meat. It's often high in refined grain grains, processed foods, high fat dairy desserts with non nutritious calories from that. We get from neutral, high sugar drinks. Currently .9% of adolescents And only 2-3% of adults obtain their daily recommended fruit and vegetable intake. About 75% of packaged foods in the us now contain added sugars and much of that comes from consuming sugar, sweetened beverages. This is always a fun slide to just look at because so many people love this naked drink, which is something that we all love and say, Oh, it's super healthy. And if you look at 100% juice, smoothie naked drink, there's 60 g of sugar inside a naked drink. Similarly, the, the ice coffee from Starbucks, just 31 g of sugar. Um We also are seeing a trend where in 1950s we were seeing food that was much smaller and now we really everything is supersized and now you're seeing food that just looks like a lot more like a food on the right where the average soda size is now almost 42oz. But does it really matter? Like, who cares? So what if people eat poorly? Yes, we know that in concept. But does it actually matter? And does it actually affect your risk? Isn't it all about genes? Right. Isn't that what our patients always say? If I'm doomed to already have a heart attack because my dad did, then what's the big deal? Well, I really liked this study by Kara at all and it was published in the new England Journal. And if you look at the X axis here, this is genetic risk and this is calcium score on the why and what you can see that and here is blue for favorable lifestyle and red for unfavorable lifestyle. And what you can see that even if you have if you have a low genetic risk and you have a favorable lifestyle, you can see you're you're here at about 15 for calcium scoring. But when you all, when you have a poor, unfavorable lifestyle, you have almost a double the amount of calcium score calcium similarly, if you look at the high genetic risk, which is always more impactful. You can see that you can almost double your calcium score risk by having an unfavorable lifestyle. So what you do with your lifestyle matters, your jeans definitely play a role, but doesn't your lifestyle as well. So considering that the general rule is that we have a genetic predisposition predisposition, maybe a poor, we have a poor lifestyle that triggers inflammation and illness. Typically our model is that we treat here at the inflammation and illness. But wouldn't it be nice if we started treating people more in the area of the lifestyle? One of the areas that I'm most fascinated and I do my research on is the role of the diet and how the diet impacts the gut in that triggers inflammation and illness. Now as cardiologists were not used to looking at images unless you have small kids who are obsessed with the poop emoji. Um you're not used to seeing and discussion about poo but I think that this is an important conversation and I won't overburden you with conversation about stool. I just want to go over a couple of concepts which are the concept of the microbiota and the microbiome. Just to remember that all of our surface of our body that's exposed to the air is it has bacteria, viruses, fungus and 90% of the cells that are found in our body are actually these bacteria and these viruses. So if you could argue that really only 10% of our body is human and the rest is all bacteria. I realized that simplistic but it's kind of fun and try to remember that all of those bacteria that all have their own genetic material. So a lot of people describe that the bugs that you have in your gut have their own second genome and second brain, some people call that gut your your your second brain. So those gut bugs also have an impact on how you feel. They make they make hormones like serotonin, your happiness hormone histamine at dopamine. And it changes immediately from when you're born. So if you're born by a vaginal delivery, the gut bio of the child is the same as the mother's vagina. But if you're born by cesarean section and the bugs of the mom of the child or the same as the mom's skin, the bugs in your gut changed by whether you're fed breast milk. If you have a fever, if you're given antibiotics, all of these things impact the gut bugs. But they also change based on your diet. You don't need to remember concepts like pre vitello and firma cuties which are very simplistic classes of gut bugs. But there are millions and millions of gut bugs and there's so many classes. But this is just a simplistic cartoon to kind of make us understand that the changes that can happen in your gut flora. So in early animal studies, if we look at putting people on a high fat diet, we change the amount of private tele and we increase the amount of firma cuties here me out for the rest of this, if you reduce the fat and carbohydrates in your diet. You increase the private L. A. And you decrease firma cuties. Similarly if you increase the fiber and eat more of a plant based agrarian style diet, you increase that private tele. So by reducing fat and carbs and increasing fiber and eating more of a plant farmer diet, you increase the private L. A. And you decrease the pharma cuties. We also know that people who eat these kinds of diets that are higher in fiber have more short chain fatty acids in their in their body, which have been shown to decrease gut inflammation, systemic inflammation and have been associated with reduced amounts of cancer and obesity. We also know that if you get a gastric bypass, you will also have an increase of that same private tele that you see with the increased fiber and reducing fat. Unlike the people who are on our animals that are on a high fat western diet. Here's an example of a study that was done on Africans versus african americans Africans eating the native Africans eating a primarily plant based farmer agrarian diet. Whereas the african americans were eating more of a standard american diet. These are three of the most common uh short chain fatty acids which are again high when you have higher amounts of them, you reduce inflammation and you can see that the native Africans are the significantly higher amount of short chain fatty acids than their counterpart african americans. This is a study that we did where we put patients on a we put patients on a a plant based diet for six days. And what we did was we also gave them a lifestyle intervention. And no surprise we were able to show that there was an improvement in their clinical markers after six days in terms of blood pressure and cholesterol. But most importantly to me is that they should we show that they had a significant change in their microbiota composition. Now this was important to me that this was done without weight loss because so much of the time the connection people feel that dietary change makes your weight go down. Which is why you get better in terms of your clinical parameters. But in our study we were able to show that without a change in weight you actually still improve your clinical parameters um which suggests a different mechanism. And then we were able to show that there was a significant change of the microbiota Um within only a six day period. One of the cases that is important to remember is this work that came out of stan hazen's group in in the Cleveland clinic. And he did a lot of work on a metabolite in the intestine called TMJ or tri methyl amine and oxide. And the reason this is important is because TM AO is something that's produced in our gut and it actually has been implicated in cholesterol metabolism, vascular information, inflammation and plaque formation in the arterial walls. So what happens well when you eat foods that are high in in Killeen and l carnitine foods like cheese, eggs and red meat. So what stan Hazan did was he in radio injected foods like these? And he gave them to patients and he gave them to patients and it went into it goes into their gut and it goes into your gut and making tri methyl amine and then it goes basically to your liver and makes tri methyl amine and oxide. And what he was able to show was that patients who had a higher um amount of T. M. A. O. S. The X. Axis, myocardial infarction, stroke and death on the Y. Axis. He was able to show that patients who have higher amounts of TM Ao in their body habits of my stroke and death. Now it's important to realize that this isn't positive if you have high tea Emma you are at risk that's not clear and probably isn't as more of a marker. But I think that it's important to see that when you eat different foods it changes the metabolites in your intestine which then is associated with a higher amount of m my stroke and death. This is one of my favorite slides from the stand Hazan group as well because what it does is it looks at different types of gut flora or and it looks at different amounts of production of tri methyl amine oxide. And what you can see here is time on the X. Axis and T. M. A. O. On the Y. And what you can see here is that over time an Omnivore who eats multiple different types of foods. Um and then when they had the injection or they ate the food that was high in phosphate title choline, they had an instant within 12 hours. They had an increase of their tri methyl amino an oxide in their body. What's interesting though is the vegan vegetarian did not have any change or minimal change in their T. M. AO levels after injecting the red meat. I always wonder how they got a vegan to eat that red meat. But just shows that note that the vegan doesn't have the capacity to produce T. M. AO. Which again brings back the question of whether the microbes in the microbiota are different in a vegan than in a Omnivore. So just to recap the gut flora which people often get sort of like oh God, cardiologists don't like to hear about God, I realize. But just remembering that we are heart disease, risk factors are increasing and the american diet is not optimal and it's not in line with the 2019 prevention guidelines, the dietary changes not impact risk. In addition it does affect dietary change effects uh risk in terms in addition and outside of weight loss. And that mechanism may be in part due to changes in the gut flora. Now we want to switch over topics slightly into a segue into diets to consider, which is I think what most people are interested in understanding. There's so many dietary patterns out there that people are confused about. There are many cardiologists in the community that are offering this diet or that diet. Um, and it's important for that. We all stay on the same line and remember that the 2019 guidelines recommend a primarily plant slash mediterranean style diet and let's talk, talk a little bit about that and where that all comes from. So I'm gonna go through basically some of the um and brief some of these diets. So plant based diets primarily can be broken down into the dash, which is the dietary approaches to stop hypertension diet. This is the dash. The dash diet is primarily a plant based diet. Uh, it includes more fruits, vegetables, it has low fat dairy nuts, legumes, fish and fiber and it suggests and recommends much less red meat, processed meat, sweets and saturated fat. So really focuses on low fat, um, but doesn't necessarily say you can't eat animal products in that diet and eating loads of fruits and vegetables, a vegetarian diet and that can be broken down. Some people say lacto ovo vegetarian and that really means that somebody who eats fruits and vegetables, grains, beans, but also will eat eggs, milk and cheese, a vegan. I think that these definitions are important because I think they're interchanged so often and a vegan is somebody who eats no animal products in the diet, even honey. This is often an ethical decision, an ethical decision not to harm or eat animals but can also include an unhealthy vegan. Remember Oreos in coca cola are vegan unlike a whole food plant based diet. So this is a vegan diet, but sort of the healthy vegan is what some people call it, where it emphasizes whole grains, fruits and vegetables, beans and no animal products. All of these diets have an abundance of carbohydrates and ideally those are complex carbohydrates. All of a sudden I said the carbohydrate word and people start panicking. They think, oh God, I said carbs, are we allowed to be eating carbs? Why are we advocating this? What is she talking about? So let's go a little bit over some of the diet, what we know about these diets. So unfortunately with a lot of dietary studies, their sub optimal and this is what a lot of criticism of nutrition studies in general, there's no funding for nutrition in general and a lot of the diets are lumped together. For instance, vegetarian, vegan, whole food plant based all because under one umbrella, they're often studies are observational and then not randomized. They're based on food frequency questionnaires, so they're not, they're not perfect, but they do offer us some level of understanding of pattern, which I think is important. So let's go through what we know we know that the dash diet was a study that was initially done on hypertensive patients or looking at hypertension. And when you put patients on a dash style diet, again, just to remind us that's enriched in fruits and vegetables and low in fat and cholesterol. You see a significant drop in blood pressure. So here's weeks on the X axis and blood pressure on the Y. And you can see that the red line is the dash style diet and you can see that we can drop blood pressure significantly with a dash style diet with patients in the in the dash study um who were on the um were on this diet were able to drop their systolic blood pressures by almost 11.5 millimeters of mercury and diastolic by five millimeters mercury. I think it's important to note how soon that can happen. You can off drop your blood pressure very quickly. You can see that change happened almost at about two weeks. So two weeks of eating more plant based low fat diet can impact your blood pressure. This is one of my favorite slides as well because it really looks at blood pressure effect compared to medications that we commonly use for blood pressure. I want to remind you that the original dash study was just looking at a primarily plant based low fat diet. It was the follow up study that looked at the sodium because remember we often think of dash and we think of sodium. So that's true. But it was the follow up study that then put people on a plant that plant primarily plant diet. Um and then put people on a low moderate and high level of sodium. They were able to able to show that on its own a dash style diet was impactful. But on top of that low that that diet plus low sodium was even more impactful. So let's take a look. So if you look at the unity line here and this is effective systolic blood pressure on the X axis, you want to be on the left side of the unity line. You can see that the average ace inhibitor has a significant drop in blood pressure, 12 mm of mercury beta blockers, calcium channel. Well look here a sodium reduction in patients with elevated blood pressure. Just sodium reduction and not a adjustment and diet can drop your blood pressure about seven of mercury. But if you put people on a dash diet with high sodium you can drop people's blood pressure about 11 millimeters of mercury. And a dash with low sodium in a in a patient with high blood pressure can drop somebody's blood pressure 20 millimeters of mercury. So despite so while I love these medications, as much as the next next guy remembering that you can almost be arguably be more impactful with a dietary change than even the medications that we use. What about dash and lipids. Well dash diet is high in carbohydrates which is often a criticism of the diet. It does and it hasn't shown to decrease your LDL cholesterol, but it also decreases your HDL. So for a while there there was confusion of whether there was gonna be impact on CBD risk and that initially there was no felt to be no thought, no effect on the triglycerides When patients were on a dash style diet. I really like the omni heart study because it takes the dash diet to the next level and starts looking at the dash style diet and says, well if carbs are, we have too many carbs in our diet, our triglycerides can go up. But what if we switch out those carbs and give people more protein and unsaturated fat. So a dash style diet with a little bit more protein and a little bit more unsaturated fat. The protein diet that they gave people an omni heart was about 50% plant sources for their protein. What you can see is that when patients. So here it gets carbohydrate here, protein in the middle and unsaturated fat. So this is the carbohydrate diet is the more standard dash style diet and what you can see is that they all had an impact on the blood pressure in patients. But arguably, um, the protein and unsaturated fat when you switched outlet fewer carbs and put in more protein and fat, healthy fats than we were able to see us more significant drop in blood pressure. Most notable was the impact on triglycerides. So the carbohydrate, uh, the dash style carbohydrate diet here, um, where you can see when you added in more protein and more unsaturated fat. You saw more impact in terms of triglycerides. In terms of mortality, we know that each five point increase in adherence to the dash diet was associated with a reduction and CVD mortality, stroke mortality and all cause mortality. And if you look at a meta analysis that primarily just it does show a reduction in CVD CHD and stroke risk. But I like this slide in particular because it really shows well how much, what's the right amount of fruits and vegetables. And we really want to start, we start seeing that curve change around four servings to five servings of fruits and vegetables per day. I'd like to remind people here that is serving of fruits and vegetables is not three strawberries uh, serving as one cup of uncooked vegetables, a half a cup of cooked vegetables or a baseball sized fruit. And this is a per day amount. Um, and we'll talk a little bit about at the end about how we get people, how I get people to think about food differently And that four or five fruits and vegetable servings isn't actually that much. This is this lifestyle heart study that I like to bring up because even though there are some criticism of Ornish's data, It is impactful and it is actually the impetus for why we have intensive cardiac rehab. What dean Ornish did in the 1980s with his group was he put patients with heart disease on a intensive lifestyle change. But he put him in these cohorts of people which they all got to spend time together. He put them on a 10% fat vegetarian diet. He focused on aerobic exercise, stress management. Uh and there was psycho social counseling. 35 patients of his 48 patients were able to complete the study. And what he was able to show was that there's his coronary stenosis on the Y axis and years on the X axis. And he was able to show that while there was aggression or progression of plaque in the patients in the in the non intervention group, there was actually regression in the intervention group. Now this is This needs to be taken with a grain of salt. This is done in the 80s or when there was people were not on optimal medical therapy right now. And that's often a criticism of the study that because patients were non optimal medical therapy that we used currently, that the data would not be the same. That's probably true. But I do like this because I think it suggests again that even in patients with known heart disease, we have the benefit, maybe not of causing plaque regression, but at least halting or reducing plaque progression. Um What about a low fat vegan diet? So we've talked a little bit of dash. We talked about a little bit about vegetarian. What about a vegan diet? So again, just to remember, a vegan diet means no animal products including no eggs, cheese, uh no eggs and cheese um Or dairy. If you put patients on a vegan diet and you compare them to an american diabetic diet. So this is type two diabetic patients that were assigned to a low fat vegan diet. And that was compared to the guidelines from the american diabetic association. And they were put on this dot these diets for um 74 weeks. And what they were able to show was that there was a significant drop in weight cholesterol urinary albumin and A one C. Drop of 1.23 points. Remember that Metformin averages about the drop of a one C. Of about one point. And you can get that similarly with a dietary change. This is from the adventist two study. Um Remember the adventist group is 1/7 day adventists are primarily plant based organization. Uh And this shows non vegetarian, semi, you know, different terms. We're going to just skip to non lacto ovo and vegan and you have your B. M. I. Diabetes and hypertension. And you can see that the group of people who had the most impact. Uh In terms of these three risk factors was the vegan group, you can see that there's a drop in the B. M. I. Um with lacto ovo. But look when you people move to vegan look at the significant drop in risk of diabetes and hypertension. What about inflammation? Does heart disease affect inflammation? And do we care? This is a study done out of N. Y. U. Where they looked at 100 patients. This is the last year or two years ago. These are patients who were randomized to eating 100% plant, the whole food plant based diet right out of the Cath lab. So they came out of the Cath lab and they were randomized to this plant diet versus the american heart Association recommended diet. And what they were able to do was they were able to show a significant drop in inflammatory markers namely or HS Crp by putting people on a vegan diet compared to the american heart association diet. Here's another study looking at Hs Crp where 27 patients with C. A. D. Um were put on a primarily plant based diet. And they were able to show here a reduction in interleukin six which is an inflammatory marker. Uh And also in a dilation of vascular, this is um a vascular function that we were able to show an improvement in vascular function uh in that time period. This is important. Why will remember. And this is a nice slide that I like that just came out this year. Um That reminds us that patients who have C. A. D. Are still or that with or at high risk for CVD have a significant amount of risk in terms of residual cholesterol, inflammatory from biotic risk, triglyceride LP a little A. And diabetes. These are patients, despite being on contemporary evidence based therapies still have this significant amount of risk. When we add in the dietary change, couldn't we make so much more impact? This is a slide I really like because even though it's only one patient, it's just blue beautiful. This is a patient who refused to go on a statin who had an abnormal stress test after three weeks of being on 100% plant-based diet, he had improvement of his nuclear profusion flow. He also had a calf at day zero before he had his change in diet which shows clearly an abnormal corner artery. After 32 months of being on a plant-based diet, he had improvement of his coronary flow. You know, again, one patient, 11 is is not anything in terms of large numbers, but I just think that that's such an impactful image of a coronary, let's make a slight shift towards the mediterranean diet. The mediterranean diet, I think for people who may not know as much about diet is to remember that this is typically a by uh considered. This is a mediterranean diet pattern. If you look at the bottom of the pyramid. It's primarily a plant based diet. Let's review that fruits, vegetables, whole grains, olive oil, beans, nuts, legumes and seeds, herbs and spices. On top of that is fish. And this is what I call is the No Go zone, which is the poultry, eggs, cheese and yogurt meats and sweets. The things that make it different from 100% plant based diet is the olive oil in the top of the no go zone and really a little bit. And of course obviously the fish. But these are making the extremes of difference. The mediterranean diet was has become super popular because of two large studies. One is the Leonhard study and the other is the Pretty Med. Leonhart is a secondary prevention study and the pretty med is primary. These slides are not when they downloaded. I wasn't super happy with them. But they do emphasize the point where when patients who were put on these are secondary prevention patients that were put on a plant based, I'm sorry, a mediterranean style diet compared to the standard Western diet. What they were able to show that there was a significant 69% reduction in cardiac death or nonfatal MI. The data was assessed at 27 months But after the study concluded the effects extended out for 46 months. So even after you have that dietary change and the intervention was stopped, the benefit was still notable. The primary prevention group was the pretty med study that was of 7500 patients that were high risk patients. So they had multiple risk factors for heart disease, often diabetes plus other risk factors. Um And they were randomized to either being on a standard Western diet which was the control diet or being on a mediterranean diet with either high amounts of nuts or high amounts of extra virgin olive oil. That's what Eva stands for on this diagram. And what they were able to show with the composite cardiovascular endpoint, which was M. I. stroke or death from cardiovascular cause. Was that putting patients away from a controlled diet and putting them on a Mediterranean diet with either the nuts or the EBU resulted in a significant 30% reduction in composite endpoint most notably. However, this was reduced was driven by strokes. So many people distinct that the reason that the mediterranean diet didn't have as much impact on cardiovascular events is because of the high fat intake noted in a mediterranean diet. Again, that's not clear. Um what is clear is that if you look specifically at the mediterranean diet and the people who had the most pro vegetarian pattern. So here's the mortality on the Y. And this is the pro vegetarian quintile. So the four and five and people who had the most pro vegetarian mediterranean diet and they had the lowest mortality. Very popular. I'm not sure why that's happening. And I apologize what about a ketogenic diet because a lot of peaceable I see on twitter, which I'm active on And I see a lot of cardiologists recommending a ketogenic diet or say, well that's fine because it's low in carbs, which you know, that's why we need to focus on this ketogenic diet. So is that true? So let's talk a little bit about ketogenic. Well, what is it? Well, a ketogenic diet, it's classically about 5 to 10% carbohydrates in your diet, which is very, very low. So less than 50 g. And on top of that people eat 70 to 75% of their food as fat. Now these are considered we're supposed to be eating healthy fats in a standard well formulated ketogenic diet, that would be the healthier fats And then they have about 15-20% protein. A study was done. A study was done that looked at patients are on a low carb, moderate carb and high carb diet. These are all ketogenic style diets. I'd like to figure focus on the low carbohydrate diet here where 74% which is more of a standard ketogenic diet where 74% of the diet was fat, notably typically about 100 g of saturated fat per day, 100 g of saturated fat per day. So what they looked at specifically is patients with metabolic syndrome to see if there was an impact in there and reduction in the metabolic syndrome, right? Because most people talk about ketogenic diet is the diet that's going to make you lose weight. What they were able to show was what they were able to show was that in metabolic syndrome patients again, low carb here, moderate carbon, high carb. When patients were on a low carbohydrate diet, it's no question that there were no that there was a reduction in metabolic syndrome when patients ate less carbohydrates. So putting people here on the low carbohydrate diet, there was more shift towards metabolic reduction and metabolic syndrome. Just the reason that keeps happening is because some of these slides were pre taped. I apologize for that. I didn't account for that when I when I was making these slides, when you look at the low carb diet and diabetes, what you can also show is that when you look at diabetes and a low carbohydrate diet, you can also see that there is a significant reduction in hemoglobin a one c. So having low carbohydrate diets is impactful in terms of patients with uh putting them on a ketogenic style diet. But what happens to the cholesterol? Unfortunately, what happens to the cholesterol is that it could be anyone's guess. Um there's a significant variation in cholesterol in patients who go on a ketogenic diet. Um namely, there's also a member that 100 g of saturated fat in that diet. So is that okay to eat saturated fat to that level. I mean, we have years and years of data that showed that eating saturated fat is associated with coronary artery disease. Remembering back in 2016 that says higher dietary intake of major saturated fatty acids are associated with increased rates of coronary heart disease. So we have had years of data to show. And this is from the National lipid Association. Here's changes in mortality on the Y axis and specific type of fat on the X. So you can see here, here's the unity line here at zero and you can see that trans fat of course is associated with the highest change in total mortality, but saturated fat is right there next to it. Whereas below the unity line of zero is mono and poly unsaturated fat. We also have many studies that show when you shift away from eating saturated fats to unsaturated fat, you reduce the relative risk of cardiac events. So here, again, the unity line here at one reduction and events here on the left and multiple studies showing that with a shifting from saturated fat to poly unsaturated fat, we make people better here also showing saturated fats versus unsaturated fats versus carbs. This is from the National lipid Association and previously published in Jack, which shows that when we actually substitute saturated fats with trans fats, do we make people better? So in other words, any type if we're taking out the saturated fat. Do we make people better if we switch it to any of these number of things. So here's a change of risk. We're zero in the Unity line and we want to be on the left of the unity line here, which would suggest that we're decreasing risk. So if you take saturated fat and you shift it over to trans fats, well, certainly you're not making people better, but if you change it from saturated fat to mono unsaturated fats, then we do make people better. I like in particular, I'd like to point out the carbs because people focus again on the carbs being bad. Well, yes, if you take saturated fat and you switch them for refined starches and added sugars. So refined carbohydrates, yes, you make people worse. But if you change those saturated fats to carbohydrates from whole grains, you make people better. And that's the important thing. So why did Time magazine have this compelling cover that said Eat butter About 20 years ago. And then more recently, the pure trial received so much hype as being showing and validating that saturated fat is not our enemy. The pure trial was a global study by Salim Yousef's group and it showed 130 they looked at 135,000 patients. And what they were able to say at their conclusion, they say the high carbohydrate intake was associated with a higher total mortality, whereas total fat and individual individual type of fat were actually associated with lower mortality and actually went on to say that carbohydrates are actually associated the highest mortality and saturated fat is not so bad. So wait a second. We just went through all those studies that said that saturated fat is the enemy. How can this one study that just comes out and for say that that's actually not the case. The reason is is because we haven't really study never isolated out what kind of carbohydrates they were looking at. So they all of the carbohydrates. The refined and complex carbohydrates were all lumped together. So it all depends what you replace it with. For instance, if you take saturated fat that looks like on the left and you replace it with a highly refined pasta dish similar to the one on the right, you will make people worse. But if you change it from this to something more whole grain with with complex carbohydrates, you will make people better. This is the editorial we wrote to um comment on the pure study. To remind people that the people who had the highest level of refined grain intake, they actually had the highest or refined grains, sorry, had the highest mortality, highest CBD and highest cardiovascular event rate compared to the people who had the lowest amount of refined grain intake. This is a from Lancet in 2000 and 18 where they remind us that if you look at energy from carbohydrates here on the X axis and hazard ratio on the Y. That when you eat too many carbohydrates here. That is true. This is typically going to be people who are eating mostly, or at least in part refined carbohydrates. You are going to worsen mortality but also reminds us that people who eat too low carbohydrates will also have a worsening mortality. So all carbs are not alike. We have to remember that we want to eat more complex carbohydrates, eating mostly foods on the left and in the middle, but certainly not eating carbohydrates from the right again, just to remember that complex carbohydrates label reading and emphasizing how to read a label in your clinic will really be beneficial to your patients. So the bottom line and the ketogenic diet is that it's not recommended for patients with heart disease because it's number for multiple reasons. But it's too high in saturated fat, too much variability in the LDL cholesterol. And while there is an improvement in weight loss and in blood sugars in later studies were showing that even when you carry out a low fat versus a ketogenic diet over time at one year, there's only about a one kg difference between a low fat versus a low carb diet. A few minutes on the paleo diet. Just to remember that a paleo paleolithic or the hunter gatherer diet is a diet that focuses more on protein. So this is seafood, meats, fish and eggs are at the bottom of the pyramid. And then they also focus on fruits and vegetables as well and really just avoiding sort of refined foods, which is very, very important. So cutting out some, cutting out dairy corn and beans, potatoes and all of your refined sugars. So it's a diet that's typically high in protein about 19-35% um moderate in fat and low in carbs. Uh, and emphasizes more fruits and vegetables, pasture, raised meats, eggs and fish and shellfish. What do we know about the paleolithic diet? Well, the problem is, we don't know a lot. There are very small studies that have been done on the paleolithic diet that shows some small improvements in lipids, blood pressure and cardiovascular risk, some that have shown improvement in lipids. And then later that lipid data was debunked. The more recent study that was just came out in the last couple of months, looked at us, it was a spanish study that put 18,000 patients and looked at 18,000 patients in a mediterranean court and assessed by a Palios score. So basically, the people who had more paleo in their diet more protein rich pasture raised meats kind of foods. What did they have in terms of their mortality benefit? And what they found that after 12 years that people who had uh, that there was an inverse association between your Palios score and CBD. So you think, oh, great. What are you talking about Monica? The high pal eo is associated with low CBD. You're just showing that. But when you look at that more closely, you can see that that was primarily driven by just avoidance of ultra processed foods, which we know for sure that if you reduce ultra processed foods in your diet, you will reduce your cardiovascular disease rates. We also know that when you look at patients again and this is the adventist two study that if you replace meat from protein from an animal source to a plant source, you do reduce risk in terms of mortality rate. Another favorite slide of mine is this one by song at all. Whereas so they looked at patients where they substituted plant and animal protein and looked at plant protein and looking at different different um illnesses. And you can see that patients if you substitute and processed meat and move it to a plant protein. But we all know that one. We don't want to be eating bologna, but even unprocessed red meat. You can see that that favors plant protein, uh fish poultry here, fish, egg and dairy all seem to have impact. Egg does cross the unity line though. So the bottom line on paleo is that they're small. They're super small studies. It's weakly positive and that the largest study that we have that did show an inverse relationship between police and CVD was primarily driven by reduction in processed foods. So it's not a study that we are not a data, a diet that we can recommend to patients for heart disease prevention. Is there any room for meat at all when this is a study that came out this year as well. Really looking at people if you just eat mostly plants and you just need a little bit of animal products. Does it still work? Absolutely. So if you had a plant centered or some people call it plant forward diet and a little bit of meat here and there, do you still reduce cardiovascular risk? Absolutely. 52% lower risk of incident CVD. I'm eating a plant centered diet uh over time. So again, just to remember that it doesn't matter if you eat a mediterranean diet or 100% plant based diet as much as that. You focus primarily on the bottom of the pyramid, which is that it's primarily plant based and not looking like this, which is I took this something similar out of our fellows room recently. Um And then just to remember that there is such a thing as an unhelpful and a healthful plant based diet. This came out of Jack in 2017. Looking at plant based diets that are age helpful or you unhelpful and this is hazard ratio for heart disease. And remembering that H is healthful and below the unity line means that there is a reduction and events and so you can reduce event rates with a healthful plant based diet but that you increase events with that unhealthful plant based diet. Again, just to remember that we want to be eating whole grains. Um, less saturated fat, no trans fat and really all those healthy fats. And that's I borrowed that from walter Willett and focusing here again on eating more foods on the left side and less on the right. Um, so remembering that the bottom line is really that a whole food plant based diet is probably the most optimal diet with with or without fish, A little bit of oil and a little bit of animal products. It doesn't probably matter so much. It's just to focus on primarily being as plant centered as you can. That's whole grains, legumes, nuts and seeds, fruits and vegetables. Remember that carbohydrates are not the enemy, but the refined carbohydrates is so that if you eat saturated fat that is bad. But the refined carbohydrate is even worse. I want to focus on eating about 5-7 servings of fruits and vegetables per day. And really just reminding patients and yourself that Any dietary change is good. This is from the New England Journal in 2017. Um, putting people on a primarily mediterranean dash style sort of all plant forward diets and you move them away from a Western diet that you improve risk. So 20% increase in diet quality was associated with an 8 to 17% reduction in death from any cause. Um, this is from the cardiovascular prevention group um, series that was presented in Jack, showing that the dietary components matter. So you want to stay on the left side of this unity line in terms of risk for heart disease and CBD incidents. And you can see that when you start you want to focus here primarily on fish, fruits, vegetables, nuts and whole grains. So I will start to show this to my patients. People call it the Agarwal Pyramid, where I tell people that every day all day I want them to eat fruits and vegetables, beans and lentils, complex carbohydrates, nuts and seeds and spices. I can't really stay away from that. No go zone which should be red meat, pork fried foods, added sugars, fake sugars, dairy, chicken and fish are sitting in the middle where I tell them just once in a while uh and not something that should be on a regular basis. Fish can be more common here. So I just wanted to sort of spend the last minute or two just talking about what we're doing at the University of florida. I do run a prevention clinic there where I provide one hour long visits. People often ask in these in grand rounds how do I build? I build based on time um where I give patients a I have a yoga room, we focus on meditation and primarily focus on nutrition. We did publish and and then presented the A. C. C. In May where we were able to show that our prevention clinic is more impactful uh intern compared to a general clinic and an interventional. So uh this is a general clinic and interventional clinic at the University of florida versus our prevention clinic. And we were able to show that we have a more impactful reduction, not only in B. M. My cholesterol was also significantly impacted. This is above standard guideline directed medical therapy, aggressive prevention and primary and secondary prevention. We were able to show that our clinic was able to do better than both general and interventional clinics. I also wanted to just briefly show what we're doing at the hospital. We this is Shands hospital in Gainesville florida. Um We really changed the whole paradigm of what we're doing there when our patients come in. Uh they are offered 100% plant based menu. So all of our patients that come in with cardiac disease are no longer told. Yes, you've had a heart attack, you had a stent put in here. Your medications, go to rehab, eat better, Good luck. Um but we actually try to educate them. We provide them with the plant menu so they can try and have opportunities to try foods that they're not used to eating. We also provide them with an education booklet um Which I've just mentioned to Samir earlier that I'd be happy to share with you, which is about 10 pages long, which educates patients on how to feel better and empowers them to make the changes. So it talks about exercise and diet just stuff that we all know or no we should be spending the time with our patients on and whether we don't know it or we don't have the time for it. These kind of packets really do help. Um We also focus a lot on medical education at UF. Where I do a lot of the teaching because just to remember we're just not doing a very good job providing high level of nutrition education for our students. Uh And as a cardiologist we're just not doing all that well ourselves with our own health. If you look at this is a survey that we did through the of the A. C. C. And published in the American Journal of Medicine where we showed that uh the dietary patterns of cardiologists and you can see in the MG group the number of people eating at least three servings a day was 29% At five servings per day or four or 5. You're really just getting a lower than 20% of the group is eating five servings a day of servings of fruits and vegetables which is the optimal goal. So I think education is really important. We do run a cmi culinary teaching conference that's highly was highly our first one was in february 2020 right before Covid. And we haven't had one since and hoping to restart that next year. So you have two choices. We could perform triple bypass surgery where we could take a vein out of your thigh. Open up your chest so we can so the vein onto your corner artery. This cost them more than $100,000 and we'll keep you laid up for about two months. Or we could put you on a vegan diet a vegan diet G doc. That sounds pretty extreme. Obviously that's somewhat simplistic. I just think that's a really funny little slide to remind us that diet does matter and you can make significant impact with diet. Thank you so much. All right, Monica. That was fantastic talk. I'm just gonna switch modes here. Thank you very much for the talk. Thank you for all the work you've done in this field. I think it's cardiologist. We get so caught up in the latest medication or is pc I better than cabbage And we forget the impact that we can make and in other ways on patients. So great talking. I appreciate you joining us. Thanks, Monica. That was terrific. Wonderful talk. I I just got to make one comment and then one question that some of the questions in the chat but one comment is I can't agree more about the council in the office. But the truth is We get 15 or 20 minutes to see a patient. We'd love to talk about diet. We're trying to struggle through their medications and manage their heart failure and Blah Blah. It goes on and on and on so that it's just insurance companies do not pay for dietitians for the most part in our region. Very frustrating. But just to comment, my other question to you is how do you tie exercise into um The whole dietary piece? Obviously exercise is important. And how much do you think that counterbalances or plays into the equation of prevention? And how do you, how do you how do you advise your patients exercise and accomplish that? Yes and thank you for the questions. So regarding the first comment. Yeah it's super hard. You know I also My other hat is general cardiology and lipids. Um and so I have those 15 minute visits as well in that clinic. And so yes it's a struggle. So one of the things I would suggest regarding that is is you can build based on time. Um that's not optimal. I really like for acuity. I can see in 15 minutes. Um or a level five if I'm sending them to the Cath lab and if I spend 30 minutes um counseling you you could argue that I'm not making as much money. Um But the other thing you can do is you can use surveys like the starting the conversation survey which is a great survey. You can pull off the internet um That I actually give out in my clinic every day, every single patient gets it. Um And it just ask them about what they're eating. And so even if you look at it for one or two seconds at the end of the, of the visit and say, hey, you know, I notice you're, you're in the fruits and vegetables, you're in the less than one section. Let's work on that for next time you've made impact because you have to remember that the physician's role, if you ask a patient what who makes the most impact and change. They always say the physician and that's been studied that the physician makes that impact. So even just that one or two seconds of, hey, I want to see next time two more fruits and vegetables every single day. I wanted to see this move the other way regarding your second question about exercise. So there's no question that so many of these studies are are not clean because they are, are compounded or confounded sorry, with bi an exercise component. But then there, so, and then so many, you know, so many criticisms. I could also make about food frequency questionnaires and etcetera, etcetera, etcetera. So there's no question that exercise plays a role. We have lots of data from intensive cardiac rehab and the cardiac rehab data that shows that we should add an exercise. The problem I find with patients is that patients, especially with heart disease, there's the motivated 55 year old male who's like, yeah, let's go, I'm gonna do rehab. I'm gonna be great and they do awesome. But there's so many of our patients who are wheelchair bound or who are unable to do any of the exercises that we say. So The 50-75 minutes of exercise per day. Good luck or per week. You know like good luck. You know they're not gonna do it right. So often I just start with I find that sometimes making the dietary changes easier for them because they're so immobile and that seems counterintuitive but it does make it easier for them and then I'll do a lot of exercises with them in the chair and I do recommend recommend and sometimes I do just an exercise talk but I do recommend people just focus on chair exercises. Ask your patients are you able to get out of the bed? Like are you able to get out of the chair? And if you'll find out so much information actually my joints suck. I can't my knees by this. And so there's so many exercises you can do in the chair and I have a bunch of them that I give to the patients actually I make them do them with me in clinic. I make them actually do this. The exercises with me. So I know that they have them in their head before they leave. It's not perfect but it is making impact. Thank you. There's one question in the chat that um I'll read do you worry about increasing non organic soy protein and diet due to effect of pesticides on gut microbiome microbiome. So um Yes, the short answer is yes. I mean, um so pesticides are and genetic pesticides are a real problem and that concern and that effect on gut gut microbes and on soil health. I mean there's that's a whole topic of planetary health and the issues where we're destroying the soil which is destroying the microbes which is destroying and affecting the quality and nutrient quality of our soy products which is then affecting and then then we eat them and then we're affecting the microbiota as well. So the answer is yes. Um You know, I think in general, I I do like soy products. Um So I try to just emphasize the people to eat foods that are at least the least processed amounts of soy um and sprouted often I'll do recommend sprouted tofu and sprouted soy products as an option, but imperfect. Uh The world is uh complicated right now. Um Just one other question for me. Um I know you mentioned that patients listen to physicians most, but is there a role for some of this? And do you have some trained nursing staff or even a PPS that actually do a lot of this with your patients. And is that a way to get around some of the time constraints? Yeah, I mean, the problem is big is bigger than this. The problem. You know, we can bill based on time or we can add in that time and it's all built under one code. Right? Um, but dietitians aren't covered for cardiovascular disease. Unlike with diabetes a big problem. Um, so yeah, you could, if you have resources. I, at University of florida usually had volunteered dietitians who would want to do and so I often get the dietary students to come. They want to work with me because they want to learn and it helps me. So I'm able to push them over to the dietary student. Um But it's a very, you know, the system is so flawed, right? We're focused so much on acuity based care and not on value based care. Not on prime. We're on secondary prevention versus primordial prevention. Right. I mean so many big gaps here, but if you have access and funds to provide a to have somebody in ft component um that they can be with you in clinic. I mean you're better than me. I don't have that benefit. Um But I do use the students quite actively and that's something you could do. Terrific. Okay, so Amir any final thoughts were at the time and Monica. Thank you so so much for a wonderful talk. Um It's such a common thing we deal with with all our patients all day long asking about diets. I learned a lot. Thank you. That's nice of you to say thank you so much and thank you for having me take care guys. You too. Bye bye bye