Dr. O'Neill, he gave us two lectures at OMED and he is giving us the opportunity of two here. And this one is on lifestyle and your heart. Graduated from the University of Kansas with a degree in history of art and then received an M.D. from the University of Kansas School of Medicine. He completed an M.P.H. in residency in occupational and environmental medicine at Harvard and later completed a degree in writing at UCLA. He recently retired as lieutenant colonel and senior flight surgeon from the Air Force, having served his duty in Kansas City Air National Guard. He has consulted and worked for major corporations, including Polaroid, U.S. Army, Navy. He is the author of the textbook, The Bloodborne Pathogen Standard, a pragmatic approach, and producer of An Introduction to Occupational and Environmental Medicine. He is currently the Civilian Occupational Medicine for the Navy Bureau of Medicine and Surgery based out of Falls Church, Virginia. And please welcome Dr. O'Neill, who contributes so much and is an excellent lecturer. Okay, can you hear me okay with this? Let me try this as a forward, backwards, okay. Hi, everybody. I'm really happy to be here. I'm from Kansas. That's really what we're proud of from Kansas. He missed the Big 12 Tournament because he was in the hospital. And the, I think it was KU Med Center said that he did not have a heart attack, he had a routine procedure. Well, it's since come out that he had two stints. And if anyone's seen pictures of him, recently, he looks a little big and a little paced. So that's something we don't know if he's going to coach today or not, Kansas plays in the first round at one. Others, I'm actually, I'm really thrilled to be back here. I went to KU Med School first two years here, the last two years in Wichita. But the last time I was in Kansas City was for memorial service for my best friend in junior high, and my KU Med School roommate, he went on to do orthopedic surgery, became the top back surgeon here in Kansas City. And he was the residency director for the St. Luke's Ortho Residency Program, which was right across from the hotel, two years ago, of a heart attack. And at the obituary, it said, he loved the New Orleans cooking of ball prudum, which of course is lard and butter and roe and stuff like that. So I'm happy to be back here, sad looking at that. I last saw him at a high school reunion about four years ago. He was a big guy, a high school wrestler, but he got pretty big, but he exercised three times a week playing tennis. That exercise did not override the dietary problems, and he died at age 63. So I had started learning about this stuff a few years before, but as I get more and more, my friends pass away like this, I start looking more about what the causes are. The answer to the question, the one thing that you would do for the public health, and it would be change your diet. That's what we know. I'm going to get off my, I guess I am on a stand or something, but I want to talk now about lifestyle. I assume you all, have you heard of the term lifestyle medicine? Yeah. Do you know that there's an American College of Lifestyle Medicine? There is actually a medical specialty in the country. They now have some certification. They're trying to work on getting boarding, started 10, 15 years ago. And there's other stuff, alternative medicine, all sorts of different things. But what lifestyle medicine wanted to do, physicians and nurses together, and actually have looked at the problem, one, an introduction to lifestyle medicine, but also to talk about a very specific aspect of lifestyle medicine in your heart. I will not discuss anything. I'm not making any profit. I don't have any business disclosure. Lifestyle medicine defined, American College of Lifestyle Medicine is the use of life in the treatment and management of disease. And then the American College of Preventive Medicine goes into a little more depth and says a scientific approach to decreasing risk and illness burdened by utilizing interventions such as nutrition, physical activity, stress reduction, smoking cessation, avoidance of alcohol abuse, and rest. 80% of chronic disease in the United States is due to lifestyle. 80% of chronic disease, obesity, diabetes, smoking, hypertension, hypercholesterolemia, stroke, heart attack, and multiple, multiple different sessions. Understand this is chronic, not acute. Acute will play into some. So let's look at conventional medicine, lifestyle medicine. Conventional medicine basically treats individual risk factors. Conventional medicine treats lifestyle risk factors. Conventional medicine, patient's often a passive recipient, lifestyle, active participant. They are making the changes themselves. Conventional patient not required to make big changes, lifestyle, yeah, big changes. The treatment for conventional is often short term, for lifestyle, it's hopefully for your whole life, be long term. Medication is often the end treatment, and medication may be used as an adjunct to lifestyle changes. In many cases, people may be on diabetic medicine, they change their lifestyle, they may be able to take off that medicine. Emphasis on diagnosis and treatment, and the emphasis in lifestyle medicine is on motivation and compliance. The goal is disease management for conventional, for lifestyle, it's disease prevention. General consideration of the environment, basically that's what we do in lifestyle medicine. We consider the environment people are living in, the side effects balanced by the benefits, well in lifestyle medicine, the side effects are what we're trying to get from this. Referral to other medical specialists, lifestyle medicine, we typically refer to other types of stuff. Independently on a one-to-one basis in lifestyle medicine, the doctor is a coordinator, the health professional team. Conventional medicine is pretty expensive, lifestyle medicine is cheap. I have a friend in Lawrence, he has diabetes, he was very excited to get a new drug, not on insulin yet, but he gets an injection, like it's to take once a month, he was super excited about it, and I asked, well how much does it cost, he said, nothing. It came from his insurance, actually the one shot cost over $700, which was actually more than his food budget, so it's a whole other thing that goes about expensive versus cheap. Conventional medicine treats symptoms, lifestyle medicine treats the causes. Think about it for diabetes, sugar does not cause diabetes, unless you have non-alcoholic liver, fatty liver disease, but you can actually have somebody that has a normal amount of sugar for metabolic needs, and the sugar does not cause it. What causes diabetes is glucose intolerance, and then you have to figure out to treat it, what's going to do that. If you treat somebody with metformin, and lower their blood glucose, it does nothing long-term if they continue to eat the same food, have the same inflammation, the same stuff that causes the glucose intolerance. If you treat somebody with metformin, without making a change, you need insulin. It's a possible symptom, disease prevention, treating cause before the symptoms happen, and this is really what got me into this about six, seven years ago. In my 50s, I had three friends die of heart attacks and strokes, and I looked at that, I started looking at the data, I did some presentation on cardiovascular events and commercial drivers, DOT certified, and I started putting the data together and looked at these studies and realized, I'm going to start making some of these changes myself, and I've been on this journey for the last five years. Prevention, I'm not going to go over this very much, but primary prevention prevents disease from occurring, for example, avoid excessive sun, check skin monthly, early melanoma. Also just a note, when I was here at AU, my father had passed away from a metastatic melanoma, he thought, and he lived actually a couple years longer than I thought, he got to see me graduate from med school, but going through this trauma of him having metastatic melanoma affected his brain and lungs and stuff, when I was in med school, taught me more about the practice of medicine than any course that I took. I ended up taking a year off because I wanted to be at home when he was terminally ill, but people at med school got all upset, said, you can't do that, said, no, this is really important to me. I actually look very closely at stuff, 20 years ago it was a melanoma, it was two millimeters too low, if I never practice medicine again, it was worth me going to med school to self-diagnose a melanoma at that stage, and I very aware of it. Tertiary, it's a surgical remover, stuff like that, I'm not going to go much more into that. American Board of Preventive Medicine, I think most of you know this, there's three medicine, public health and general preventive medicine. Well, the thing about preventive, in order to prevent something, you have to know what causes it, and this is what distinguishes us from something like, let's say, an ER doc or somebody comes in with a heart attack, they're really not going to be worried about what causes it, they're going to be worried about treating it and keeping them alive, not really about what the basic cause is. So, we're the people that are really, cause, because if you don't know the cause, you cannot prevent it. Remember when I talked about sugar does not cause diabetes per se, it may cause elevated glucose, but the other cause is insulin resistance. Lifestyle-related conditions, in the U.S., two-thirds are overweight, I'm not going to go over a whole bunch of this, you probably know a lot of this stuff. Difference of lifestyle-related conditions, four-fifths have a poor appetite, three-quarters have inadequate physical activity. I'm going to go through this, it's in the slides too, you may have heard some of this. One out of 33 Americans have healthy weight, do not smoke, are physically active, and have adequate fruits and vegetables per day. I'm still a little close to it, but the reality is we know these things, we look at it, and people have to get educated. I can tell you now, the young med students and nurses getting trained are learning about some of this stuff, they did not when I was in med school, and a lot of us when we were in med school, we're not talking about it. Unique role of lifestyle medicine, it's a strict focus on lifestyle behaviors, success really depends upon patient motivation, if it's not going to happen. You try to do it, but the problem with this is when you see somebody now on RVUs, cannot go over this, it's not going to work, and so a lot of places have group, billable group things where you get 20 or 30, because it's the same information that goes over stuff. You can't just tell somebody to do this, to lose weight, to eat well, to stop smoking, it has to be, you have to have light bulb moments, you have to use the experience with other people, and it takes a long time, you cannot just do this. The system is set up, you have somebody that has pre-diabetic, high cholesterol, starting in their 30s, they come to the lab, they're given medications, and they do this for 10 or 20 years, you come and you look at the labs, it takes you 5 or 10 minutes to do that. The system is not set up to encourage prevention. Applies to every practice, every patient, collaborative, a team of health professionals, limited number of interventions, one of them you can see right here, exercise, prescriptive lifestyle intervention. We have found in multiple studies, if a provider, physician or nurse, prescription to exercise 30 minutes, 5 times a day, it's a prescription to say have more plants and whole food, whole group, to get a night, because people want to have something given to them, prescribed to them, and now it looks a little more official. Cognitive behavioral therapies, motivational counseling, and coaching. Lifestyle medicine intervention has proven to help all of this type of stuff. I'm not going to go over it. There's a difference in lifestyle as an incredible difference as it relates to socioeconomic stuff. Probably, there's a high level with socioeconomic related to access to healthy food. If you go to a 7-Eleven, that's all processed food. There's really little nutritional value. There's calories in it, but little nutritional value, and if you eat ultra-processed food, you have the calories, but your body still has an urge for nutritional value, and it says eat more of this, and they don't get it. Anyway, so there's lots of lots of different things that lifestyle medicine has been shown. Lifestyle medicine proven to prevent obesity, changes in that. Exercise is certainly one, but exercise is not the main one as it relates to cardiovascular health. Anybody heard of Jim Fixx? Jim Fixx was a guy that was in his 80s. He ran. He said you can run. You can eat anything you want to as long as you're running and exercising. Best-selling books. Jim Fixx died of a heart attack while running at age 52. Exercise is important. It is not the main factor in some of these things. Obesity, I'm going to talk a little bit about. Anybody heard of BMI? Body Mass Index. Let me give a little history on BMI. There was someone, a belt in mathematics called Cattley, wanted to find out the normal height and weight ratio and skin ratio and stuff and came up with what was called the Cattley Index, which is weight over height squared, and he found that the average human being at that time had a Cattley Index of 25, height over weight squared. Well, jump ahead to the 1950s. Some of you know that, but some of you just wanted to figure out who was going to die the latest. Actually, who's going to die the earliest so they can charge them more money. So they looked at all these actuarial tables and found out the best predictor, but not perfect, the best predictor of a population, human population's life expectancy is height over weight squared. And they found out if your BMI is over 25, life expectancy starts going down. And initially, in the 1940s and 50s, BMI of 25 to 30 was called Obesity Level 1. That's when life expectancy started going down. Obesity Level 1, life expectancy, general life expectancy, not a specific disease. So BMI of over 30, Obesity Level 2. Americans had gotten big enough that over half Americans were qualified as obese. So then the definition of Obesity Level 1 was changed to overweight. Overweight. So now the definition of over BMI, over 25 is now overweight, does not mean that over 25 to 30, life expectancy starts going down. And there are quite a few people that are overweight that have heart attacks. The exception to that is for men that have muscle mass. BMI, life expectancy curve, does not start going down until 27. That's how I rationalize me being a little overweight. But the point is, if you look at that, I'm not making a judgment. This is what we're looking at. Life expectancy, not only life expectancy, but medication costs and use start going down, go up, life expectancy down with BMIs. Has nothing to do with an individual's health. I can tell you all the Kansas City Chiefs are overweight or obese. Almost everybody is. But that's different. Being gladiators is different than having a long life expectancy past age 70 or 80. Does that make sense to you? It's not perfect. It cannot be used for an individual. Hypertension. Same thing with hypertension. There's three major factors in hypertension. Number one is weight. That's you have an extra two inches of fat around your stomach. It's at the end of the fertilization system. Your heart has to pump harder to get the blood there. The analogy is, if you have a football field with one sprinkler in the very middle, and you add 10 yards of grass at the end, how do you get the water from the center? You have to increase the pressure. Light bulb moment when I talk to my patients. Oh, I get that. The second one is obstructive sleep apnea, which is also associated with weight, but they are independent risk factors. If you stop breathing at night for 20, 30 seconds, your oxygen saturation goes down. Your heart and body has to overcompensate pumping blood with less oxygen. They must pump it faster and harder. So the blood pressure goes up. If you have untreated obstructive sleep apnea, you treat sleep apnea. Your blood pressure goes down. It bleeds over actually. It almost dies. In the same weight I was, I was in the Air Force in my 30s, I'm the same weight I was in my 30s as I am right now in my mid-60s. The difference is a little less muscle, a little more stomach stuff here. My blood pressure is significantly lower now than when I was in my 30s. So it's a fallacy that says Americans' blood pressure has to go up as they get older. It's related to lifestyle issues. I often talk to women, not women, but to people about, oh, guys are at the gym lifting weights. It actually takes your heart more energy and effort to pump blood through dense muscle than it does fat tissue. So think about that. All the guys, not all, but a lot of guys are lifting weights, getting more muscle, blood pressure goes up. The women, again, they're doing aerobics. Guess who lives the longest? There's probably some correlation with that. I'm not going to go into a whole bunch of stuff on this, but there are a lot of things that we're finding out now. We now, the latest studies have shown that it may not be the main problem. Cholesterol of eating animal products, something in animal products that causes inflammation and makes that cholesterol adhere to it. We now think it's probably LDL cholesterol, and not only LDL cholesterol, but oxidized LDL cholesterol. And the question is, what is causing the oxidation of this? And why do I say that cholesterol may not be the main player? It may be because people that only plants still have cholesterol. There's no cholesterol in plants, it's only in animal products. If you eat no animal products, you're gonna build it, you're gonna create your own because estrogen and androgens. But the people that do not eat animal products do not have the inflammation in the artery wall. They have the cholesterol, that cholesterol does not adhere to the artery wall. Does that argument make sense to you? So the question is, we do not know what's causing inflammation. Think about people that die of heart attacks. And maybe somewhere between 30 and 40% of Americans die of heart attacks. Each year depends on what population you're looking at. Let's just say 30% of Americans die of heart attacks. Of that, one third have angina. The arteries narrow down, the heart cannot get enough, you have pain there. But two thirds of people that die of heart attacks have no, because people that are like this, that have angina, a third, narrow down, two thirds of the people that die of heart attack, a flap breaks off and clogs the artery and clots. Those two thirds of the people, of the Americans that die of heart, and I'm gonna say that's, let's say, 25% of Americans die of heart attacks with no warning because a flap of the inflamed endothelium breaks off and clots off. You can have a normal EKG and you can have a normal treadmill test the week before and still die. When I made that realization, that's when I said, I'm gonna change my lifestyle so I'm not gonna be one of the 25% of Americans that die of heart attack without having any warning. Yes, sir. We will get to that. And that's the thing that's really, this is the thing that I was really excited about because honestly, I can still drive blindfolded to Arthur Bryant's barbecue here in Kansas City because that's what I, this, I mean, it's pretty amazing. I used to live in Austin, Texas, same thing. I can go to, I used to be able to go to the same stuff. Anybody know who Chadwick Boseman is? Black Panther. He died of colon cancer, age 43. There was a huge epidemic. Meat products, barbecued meats and stuff like that. Highly carcinogenic. That's a whole other discussion I'm not getting in. Metabolic syndrome, I'm not gonna go into this. A whole bunch, sort of diabetes, hypertension, pre-diabetes, all sorts of stuff, huge issue. This is something for those, I was in for an OcMed, we're gonna talk about what it costs to the workplace. It's hard to see, I know, but this is total healthcare costs. This is for a company, total healthcare costs. This is metabolic syndrome. The one real high up is metabolic syndrome with an exercise, metabolic syndrome, inadequate exercise, $3,855 for healthcare costs. The one right over here, this is metabolic syndrome with adequate exercise, drops down to 2,700, very close to, I know this is metabolic, yeah, what is this? Metabolic, ends up with sufficient, this one is with sufficient activity, and this isn't. Basically what it says is, if you have metabolic syndrome and you have no exercise, it's really high, no metabolic syndrome, and exercise is about $2,000 less per year, per person. You think that adds up for a company? Absolutely. This is another reason I got into this, because it helps save companies' costs. If you have a worker that's obese, any idea what chance they have of having a musculoskeletal injury over someone that's not obese? About a 30% increase, 25 to 30% more likely to have a musculoskeletal disorder in a worker that is obese. I'm not making judgment, I'm just telling you what fact is. Part of that is, there's more weight. If you fall down on it, it's gonna have more, a problem of damaging more stress on the back and other types of issue. Okay, diabetes, won't go into this. Type one, type two, it's switched around. It used to be called childhood. It's no longer called childhood diabetes, because we're getting so many kids that are getting type two diabetes. Cardiovascular disease, risk of, it changes lifestyle. You stop smoking, your risk of having a heart attack goes down by at least 36%. Physical activity, 25%. Moderate alcohol use, about 25%. And dietary changes, 44%. The thing for Bach then is the dietary changes. And that's what I'm gonna spend time on. Heart failure, lifestyle medicine, great increase of people that have heart failure. This talks, I'll go into some of the reversing stuff right now. Four lifestyle changes that affect mortality rate with cardiovascular disease. Dietary changes, I'll spend a lot of time on that. Smoking cessation. I'm not gonna go into that much, because I think most of you all already know that. Increased physical activity, really interesting data in the last couple of years. And we're getting a lot of data in the last 10 years that we didn't have before, because now we have electronic medical records. Instead of 30 years ago, we could do 200 people. I had to do paper records. We, like a button, get a lot of stuff and get a lot more information. And moderate alcohol use. Okay. Increased physical activity. We do. What we found out is to get a good level of that, you need to exercise moderately for 30 minutes five times a week. Now, if you bump that up to an hour five times a week, that's your max. If you exercise more than, what's that? Five times, 300 minutes. If you exercise more than one hour, five times a week, added life expectancy, added health benefit to that. Why do we know that? Because we look at people that run marathons and do other stuff. They actually have decreased life expectancy, because there's a lot of stress on your heart. There's a lot of stress on your immune system. If you bike on a bicycle, more than 20 miles a week, life expectancy goes down. You know why? You get hit by cars. Okay? And you have to think about the whole thing. The big picture. It's not just about the health. 20 miles on a stationary bike, like I do. I have it so I can watch Netflix on a stationary bike. There's no decreased risk. But if you have, it's after population. So what we know now is people that go, and actually if it's a fast walking, it took me 50 years to realize I hate running. And I ran sprints in high school. Now I'm going on a long walk, because it doesn't hurt. What I liked about running was when I stopped, because it felt better. But what we've found out now is fast walking for half an hour, not only do you feel better, but there's a psychological thing of being outside in fresh air, but also we're now getting studies about increased risk of cancer if you sit down and stuff like that. So increased physical activity. You had a question? Yeah. Okay. Moderate, intense recommendation. Moderately intense where you can still talk to somebody, but you can't communicate. And it's going to be individual for what you're proposing. Pardon? I don't care. As long as you finish a mile. How's that? I'm not going to go into it in specific. All I know is you start slow, you can move faster. I walk fast enough, but I also ride on a stationary bike. Again, these are hard to have specific things or just guidelines. Go out and do moderate, a fast walk. I'm going to say do a fast walk. And if you go to places, the Mall of America starts up, they're bussing in elderly people, now my age people, just to walk around the mall. And that's exercise. I did that, but I also, it damaged my pocketbook, but it was good for my health. Yes. I am an exercise to do this. Lots of studies said, if you do. Also, if you do really intense, what was the thing that was, where they're doing jumping around and doing stuff? I forgot what it's called, pardon? Yeah, high intensity. It's not good if you're over 40, cause you're more likely to injure yourself. You've got to balance again, doing what I forgot what it's not aerobics, but they're jumping around. Pardon? No, it's something, it's circuit training and stuff like that. So it's, if you're over a certain age, you're more likely to damage your body if you're doing really intense stuff. Does that make sense? Benefit, the good thing is, benefits with relatively low level. Just getting someone up and around and walking is really important. Dietary changes. I'm going to go into this. I'll go into more of these studies cause I find these very fascinating. Dietary changes, probably 44, 50% reduction and even greater reduction. So let's start with some of the studies. When we do studies about cardiovascular, it's impossible to do an accurate prospective study because we cannot follow somebody for 40 or 50 years and look at this stuff. There are a couple of studies, there's a doctor study, we'd get some good information on that. But the best way to do experimental studies is we can't follow them for 40 or 50 years. So what do we do? We get people that already have cardiovascular disease. They've survived the heart attack or they get a diet to show there's some occlusion. So we take people that already have cardiovascular disease and we follow them for two to five years and we have a control group and we try something and don't try on the other and see if there's any difference. So this is stuff about diet with people that already have cardiovascular disease. Does that make sense to you? Cause we're not going to get the studies done when we're waiting for 40 or 50 years. So we're going to look at people that already have some type of problem. We're going to change intervention. And this is a study in 1989 called the DART study, diet and reinforcement trial, about 2000 men. Unfortunately, a lot of these men who had survived follow up advice. They were told reduce to fat, increase fish and take increased fiber. Just told that. They weren't monitored. No significant difference of reinfarction or cardiac death. Zero difference, relative risk is zero. If you just tell somebody to change something, ah, not going to make much difference, but also said reduce fat, increase fish, increase fiber. This is the one that was really amazing. This was 1998. Does anybody heard of Dean Ornish? Okay, so this is the Dean Ornish study. This has really changed. The eight patients with moderate severe coronary heart disease, five year follow up and random. That's pretty close to being vegan. Anybody, well, I'm not a vegan, although I only eat plants. Anybody know why I'm not a vegan if I only eat plants? I'm wearing a leather belt and leather shoes. I'm talking about the definition of what vegan comes into, okay? The classic definition of a vegan is somebody will not do anything that kills animals. So I say, then I follow a plant based. The politics of this is huge. It's the same way if I talk to a patient and I say, I want you to have a vegan, walk out the door and close. You know what I say? I recommend you eat more plant and less animal products. They can grasp that. I can't tell, I was in Missouri, rural Missouri, looking at one of the army bases. And I went somewhere and said, do you have anything that's vegan? And the lady said, I don't even know what that is. And I'm like, okay. I'd want a salad with no cheese on it. But so the Ornish study looked at this as basically vegetarian diet with 10% fat calorie, get 10% fat calorie. It's pretty much plant-based. And the control diet was per personal physician advice. And this is what the doctor at this time in 1998 was saying. After they assessed it, after five years on the vegetarian diet, they had 0.89 events per patient and control diet had five events per patient. So basically two, two and a half times greater events occurred for the people that are two and a half times less risk of 2.47. You had a question? You're just, you're stretching. Okay. So what this means is this is a study. And I remember reading this stuff. Oh, well that survived heart attacks. And two years later, they're running marathons. And these were people that are in the initial study. Okay. So this is back to 1998. JAMA, angina pectoris experimental group patients had a 91% reduction in reported frequency of angina after one year. Not on medicine, on the diet. 91% reduction in angina. This is the inflammation in endothelial cells. It's going down. They were healing up. The analogy would be like, if you hit your shin every day on a counter or on a coffee table and it gets one ready and you hit it every day, it's going to do that. Well, stop hitting it. It will completely heal up. And what we think what was going on in this. This is remarkable. Over 90 experimental people who already had a resolution of their symptoms. This is another study by Ornish about the same time. It's a multi-center lifestyle study and had over 300 people on it. Again, already had problems, but almost 200 on a vegetarian diet with 10% fat calorie, which is pretty much whole plant. A hundred, almost a hundred on a controlled diet. Recommendations are. And then they looked at the cardiac events. And in a three-year period, there wasn't a lot of difference in the events, but what there was a difference in is how many people got angioplasty or CABG. And in the group on the they had less than two times as many bypass grafting. And that alone saved almost $30,000 per patient. Very short study, but even the cost of that, if you look at the monetary costs, significant decrease, not a huge difference in the outcomes. Dietary changes. Anybody heard of the Mediterranean diet? Okay, I'm gonna talk a little bit about this. In Greece, Southern Italy, Spain, lots of olive oil, like cereal. Some, sorry about that. I'm talking like an Italian and using my hands. Vegetables, high fish consumption, relatively low meat and meat products, but lots of dairy. So a lot of stuff on the Mediterranean diet. So here's a study that came out in 1999, that Lyon diet study. Lyon's a city in France, it's not about lions. It had mice in groups, a little over four years, about 200 on the Mediterranean diet, and about 200 on a controlled diet for their personal physician. And then they looked out after the four years, the composite outcome of heart attacks and cardiovascular deaths for 100 patients a year. So for the Mediterranean, it was 1.24 out of 100, and the controls were four. So the difference here, the relative risk is low. It's protective, but 3.28, let's just say three and a half. Three and a half times less recurrence for people on the Mediterranean diet. You think that would get noticed? Absolutely. And let's just say, remember 3.5, okay? Let's go now to, this is another proof. This is a COURAGE study done in 2007, about 3,000 people, over 2,000 with ischemia, and 2,000 into two groups of about 1,000. One had maximal therapy. Again, diet, further recommendations, eat healthier, maybe chicken and not so much this and that or whatever. And then the other one looked at the optical medical therapy plus interventions, percutaneous coronary interventions, either stents. And so what it is, the difference is the diet was, the difference was the interventions. And what'd they find out after four years? No difference in the recurrence rate. If you had the stents or the balloons done, if you're on the same diet, it doesn't help. That make sense to you? No protective factor if you have these interventions done and you don't make it. It's a view through the exams. If somebody has a stent put in, you can clear them, and then you have to redo it after five years. Why? Because the rate of recurrence by year seven is like 75%. And last year, it was really, really high. So this basically showed that interventions do not make any difference unless it's a lot of help. So, that's what they noticed in 2006, 134 patients. Again, confirmed coronary artery disease, they followed for two years. 77, 77 on a vegetarian diet, 10% fat, basically whole plant-based. And they had 57 that didn't adhere to any diet. So the cardiac events, yes. Seven years after the prior one. It's by different people. Yeah, I'm talking about the Lyon study, I'm sorry. I'm talking about the Lyon study, right. Sorry about that. Thanks for picking up. That's a Lyon. By different people. But it's the Mediterranean diet. The study in 2007 was not diet, it was interventions. That's what the difference was. So, in the courage study, they looked at the, sorry, next one. And they have, I'm gonna just, vegetarian, again, they switched it to vegetarian. I'm gonna just, vegetarian, again, they switched over now to a plant-based diet. And they had, of this group, 57 were not adhering. They just said, no, I'm not gonna follow this anymore. It's two years, I'm not gonna follow it. So, the cardiac events, the people that had events after two years in the vegetarian, or I'm gonna just say plant-based group, 1.5% at events. And the non-adherents, the people that dropped out and went back to their normal diet, 18% of them. That difference is a factor of 12. That's a pretty big factor. Remember what it was for Mediterranean? Yeah, that's three, three and a half, something like that. So, this is really pretty, again, vegetarian with, this is not Mediterranean, which included fish, meat, and cheeses, and stuff like that. So, this just plants a huge difference. So, this is another thing from this is Cardiology 2008. Significant improvements in angina were found during the 12-week period, to 74% becoming angina-free in three months of changing to a plant-based diet. An additional 9% moving from the limiting to the mild angina category. So, this is basically 80%. 80% improvement of angina in three months going on a plant-based diet. Here are some pictures. Talked about reversals. Here, you see the point up there where that's secluded? It's got the plaques around it. And over here, same person a couple years later. This is non-intervention. This is dietary open, yes. Here's another one. Yeah. Okay. I've got three of these slides. You can see up there the occlusion a little bit. And it's not just, I'm not a physicist, but the flow, when you cut the flow down from 50% and open about, it's more than double that goes through because of the stuff. Pardon? It's square root factor. So, if you're down, and for chest pain and 40% occlusion. So, that's a pretty significant. Here's the heart attack. This is what it looked like. You can really see how rough, you can see that. And two and a half years later, he looked at this stuff, changed his diet because you cannot do this on medicine. There's no medicine we can have that's going to help. Here, look at the difference there. Two and a half years later, reversed. What else do you see in this x-ray? Anything else significant? That's right. Because if you have the atherosclerotic plaque, they're going to occlude the smaller vessels. They now then open up and you're getting more flow, not only in the large vessels, but the small ones. Now, think about that. If you have atherosclerotic plaques in your heart, they're also going to affect the rest of the vessels. Percent correlation in dementia and your diet. Because imagine what happens if your arteries in your brain get down to that same thing with your kidney, with blood pressure. Low back is higher correlate because you have the abdominal aortic arteries that come out. And if they're occluded from the plaque, you're not going to get adequate blood flow to your discs and spine. We're now looking at this as a major cause of chronic low back pain and looking at that. Certainly, with erectile dysfunction, that's now looked at as a precursor sign of cardiovascular disease. Anybody heard that? Anybody seen the movie? There's a thing out called The Game Changers. It's about professional athletes. And they looked at that. And how do you get them to say, oh, so the study is about the changes in penile erection and artery flow, Matt. And then they may listen to some of that a little more. But it's not just the heart. And the next study that Dean Ornish, he hasn't given things. He's been doing the last five or six years. It's going to be the effects of lifestyle on Alzheimer's and dementia. This is going to show. I can't. He's not going to see. I just heard him speak a couple of months ago. He's not going to say what it is because you wait till you get everything there. But we know if we can open up the arteries in the heart like this, this is staggering, staggering. You're not going to get this with a bypass. You're not going to get it with a stent. On your own healing. So here's the list on this. This is done in 2014. Caldwell Esselstyn. Sorry, I get excited. Esselstyn is a cardiovascular surgeon, and he got really tired of seeing people come in and back and forth to do stuff. And he looked and said, instead of treating this, I want to prevent it. He has become one of the 10 top people in this country. So he did a study, dietary intervention, with almost 200 people, followed them, already had coronary artery disease. He's often sent people that the surgeons say we can't do anything. You can see some of this stuff online. And he did a documentary called Forks Over Knives. If anybody has, if you'd be interested, look at Forks Over Knives and you'll see Esselstyn. So he had 200 people, 177 vegan diet with 10% fat calories and no added oil. Why do you say no added oil? Because it's just caloric. A tablespoon of oil has 120 calories in it. If it's olive oil, it may not inflame the arteries, but it's still calories. It's a whole other discussion on diet. And of that, 21 of the people who, through the three points, dropped out, were non-compliant, went back to their regular diet. So that became sort of the, the ac events. If you look at MR, in the, in the almost four-year period, stroke, CABG, PCI, non-fatal, in the vegans, the plant-based, out of the 177, one, one had a cardiac event in those four years. Of the non-adherent, 13 of the 21, or 62% had it. What is that difference? 102 times difference. Now, the thing about the Esselstyn study compared to the earlier, there was no control over this. Esselstyn met, I think, every two weeks with the person in the study and their spouse, and they followed them every couple of weeks to make sure they were compliant. So the prior studies that may have showed three or four or 12 times, didn't really have much about compliance. This is the study that showed compliance. And I can tell you, if I had a heart attack or had something, and I saw this study and said, my chances have a recurrent or less than 1%, if I follow this regimen, would you follow it? I would. And I made the decision that I'm going to follow it before I had an event. Does that make sense? So I can tell you, I would have had, I didn't have any symptoms, but I can tell you, I would have had stuff. I don't really even care what my cholesterol levels are now. I do as a marker, but for me, I'm doing the stuff that's preventive. So this is something that I do to look at. I just want this to be sort of a light bulb moment. You should look at online. There's something called Forks Over Nine. Great. They do it much more eloquently than I do. Another thing on, I think Netflix called What the Hell, it's What the Health. And you can look at that. And then the Game Changers, which is about athletic performance. And in the military, since most of them are under 40 or 45, it's really hard to say, oh, we're going to do all these big things so you can live 80 to 90. But they added, the military added the performance factor. So the military, because we basically bring the healthiest population of people into the military. They get out their unhealthy and the least healthy population. So something's going wrong post when all you can eat is chicken wings and other stuff that doesn't really help with it. So the military, pardon? I just watched something that is. Yeah. But those are also, again, keeping alive. There's a difference about what you have for mediators versus what you have for people that live old. And the Game Changers, two of the hosts are Arnold Schwarzenegger, who just got tired of seeing his friends die in their 40s. Because if you're weightlifting, you're doing stuff, they're dying of heart attacks and strokes and a heart attack. Remember all the stuff? So he switched. They're both wealthy and smart enough. Doesn't matter what political party you're from. They talk with Dean Ornish and they went on a plant-based diet. So those are, it can be done. But this is a study that really looks at this is changing the diet with compliance. Okay. I'm going to buzz through the other stuff real quick. Multifactorial cholesterol, inflammation, animal versus protein. The big thing we do not know, we don't know what causes the inflammation, the artery walls that causes the LDL cholesterol to adhere. We thought at one time it might've been animal protein casein. That's probably not it. We also think it may be something in endotoxins, bacteria from animal products, all the stuff. There's thousands of times more bacteria in those than there are in plants. Think about cheese. What is cheese? It's a bunch of bacteria that's going on. So we don't know if the bacteria, we don't know what causes it. And it may be something that goes into, that oxidizes the LDL. We know there are a lot more in colors and different vegetables and stuff. The science is new. I don't care what the cause is. What I care is the studies show you live longer and better with lifestyle changes. And the letter to editor of 2004, although diet and lifestyle modification should be a part of disease management for patients, cardiovascular disease and diabetes, many patients may not be able to comply with substantial dietary changes required to die. That's giving up. There are more and more people that are understanding this. That's like saying in the 1970s, so many people are smoking. So many doctors are smoking. Let's not even try. If you go to a major city, pretty much all of the great restaurants will have some type of plant-based option. Again, I'm saying plant-based versus vegan because that scares people. Smoking cessation, a third reduction, if you stop smoking, what people do not understand is four times more people that smoke die of heart attacks related to smoking than die of lung cancer or COPD. Four times more people die of heart attacks related to smoking. And that can affect somebody at age 40, 50, 60. The reason we're looking at the cancer is because pretty much everybody that has lung cancer smokes, maybe 98%. Not everybody that has a heart attack smoke. So that's sort of the way we look at our public health. Things that have cancer risk are much more scary than things that aren't. But the reality is the biggest benefit of stopping smoking is the risk of having a heart attack. That make sense? And for people that smoke, you stop right now, you will decrease your risk of having a heart attack. Yes, sir. It's a huge, that's a whole other conversation. We've got a cheese supply, so they put cheese in the crust. I was a medical doctor in a small town in Kansas, a big medical center there. They had a pizza factory there, made 4 million pizzas a week. They had no vegetables on them because the vegetables rot and spoil. It was cheese, bad salami, which is basically made out of tendons and toenails. That's a whole other discussion. But one of the, was it, I think, 18 or 19-year-old kid ate all of his meals there for, had a heart attack. They then stopped serving free pizza at their cafeteria. I won't get into it because I don't want to get sued. The money from the other side coming in. There's a lot of stuff that goes on with this. All the people that I've mentioned, Esselstyn, Ornish, all have been barraged by the food industry. And they try to go, it's ridiculous. I go on evidence-based medicine. That's where the stuff is. OK, so on the smoking, here's the thing. Your heart, after smoking, your heart gets better. Two weeks, physical heart attack begins. A year, a year after stopping smoking, your risk of having a heart attack is down by 50%. And within two years, you have no increased risk of having a heart attack. From your smoking, the risk, the bang for the buck for people to stop smoking is decreasing your risk of having a heart attack. Does that make sense? And most people are not thinking about that. Here is a really interesting study done with doctors in the first half of the last century. It starts after doctors born in 1930. Cigarette smokers pretty much everybody smoked there. If you get to age 70, non-smokers had 10 years extra life. Takes 10 years off. So here is the interesting. Here are the doctors in the study that stopped smoking age 35 to 44. And the ones with the dotted line, those are the ones that stopped smoking at 35. There's not a big difference. So if you get someone to stop smoking before they're 40, your life expectancy is about the same. If you're smoking then, there's still a 10-year loss of life, mid-life. I'll go through the rest of alcohol. I'll be done in four minutes. Alcohol, not going to go into this. Multiple studies have shown populations that have a small amount of alcohol have increased life expectancy. We think this is due to stimulating liver enzymes and being able to stress something. Some stress can be good. You exercise to stress a muscle, you get better. So the theory is, if you have a small amount of alcohol, then it may increase your ability to decrease liver inflammation and toxicity. And what it is, again, you may have heard this one or two drinks, one drink of wine, two beers. It's coming from lots of studies on this. Now, the latest data is, this is just related to cardiovascularly. The latest data is, we're not certain if there's a safe risk of cancer. And in total mortality studies, there is still some increase if you have a small amount. If you have more than two drinks a day, your life expectancy goes down because you may get in a car wreck, you may stab somebody, you may shoot somebody, you may have liver cirrhosis. But a small amount may stimulate the liver. That may override any of the cancer risk. Does that make sense? A lot of studies coming out now just looking at alcohol and cancer. Now, that said, thank God beer is plant-based, or I don't know if I could follow this diet, and wine is pretty much plant-based. I've sort of officially avoided looking at the alcohol and cancer studies because I'm not ready to do that right now. I will have some green beer tomorrow, OK? But that's it. So that's alcohol. We do know cardiovascular risk alone, small chronic amount is protective. Very quickly, this is a study in 19, after 26 years continuous medical practice in East Africa. A colleague and I recorded the first case of coronary heart disease in the 15 million inhabitants of those countries. Patient was an obese East African judge consuming cholesterolized diet. 1956, first reported case of coronary heart disease in 15 million inhabitants. Pretty remarkable. Jumped a couple of years ago, African-Americans in cardiovascular disease, the number of causes of Black males and Black females dying of cardiovascular disease. It's not genetic. It's old. Oh, absolutely. I'm just using this as a contrast to the study, and it is everybody. But the African-American population does have a higher rate of cardiovascular disease, probably diet related. You look at their diet, it's a little different. Governor of the United States, he almost died of, had a blind stuff. He was a borough president, and he and his wife looked at the study, and he was about the book before I knew about it, then he got elected. But that book is what I give to African-Americans, because as a white guy, I cannot talk to them about the risk of eating chitlins and other types of classically African-American food. But that book by Eric Adams is great. But yes, I'm just talking about it as contrast to the studies that the whole country had not seen it. Now we're looking at the number one cause in Blacks. Again, lifestyle medicine practice patterns. About 50% when you see somebody, about 50% of smokers aren't counseled to stop smoking. And when I talked to them, I said, stop smoking so you don't have a heart attack. Most people don't talk like that. Only 25% are offered assistance. You can look at the slide on this. Women are not advised to exercise. People over 75 need to be advised to exercise, which is going out and walking and doing what the doctor recommends. Patients are to approach interventions tailored to the patient. They're unique, psychological, social, cultural. Change orientation to a chronic care, chronic prevention perspective. Treatment focus on a nervous factor profile. Don't focus on individual risk conditions. Don't focus on your HDL cholesterol level. Best thing to look at now is the ratio of triglycerides divided by LDL. Those are studies that are coming out now. But again, it may not be the cholesterol. It's what causes the LDL cholesterol to adhere to the artery walls. Multidisciplinary team, community outreach. Lifestyle changes in medical therapy should be the mainstay for most patients with stable coronary heart disease. Focus on eliminated all unhealthy behaviors. It would not have gotten there without medical therapy. My bias right now is it's not really medical therapy. It's lifestyle therapy. Make sense? American College of Lifestyle Medicine. You can get more information about lifestyle changes. I can just say personally, I started this journey about five years ago. I feel better at age 65 than I did in my 40s. I had no idea in my medical career that I would find something that would make my life so much better. I did not teach this. I learned on my own. There are people that are now starting to teach this. I encourage you to start this journey. If one light bulb goes off, I want you to think about that. I want you to think about the fact you can reverse damage you may have done to your body the last 40 or 50 years. And I'll stick around for questions afterwards because I'm past my time.

lifestyle medicine

heart health

chronic diseases

nutrition

physical activity

plant-based diet

cholesterol

economic burden

exercise

longevity