I'll go ahead and just introduce our next speaker. And actually, our next speaker is going to be introduced by Dr. Mike Kasperzak. I just wanted to introduce him. He's actually going to be the chair for the education committee with Rebecca Fishman coming up for this next year. He's an assistant professor at the University of Minnesota. He's definitely one of the rising stars in our college. So I'm really happy to have him involved. But I'm going to have him go ahead and introduce our next speaker here. Great, thank you very much, Jenny. So I, in the beginning of the year to get this lecture going for nutrition here, I reached out to USF Department of Nutrition and they recommend Dr. Orman to give, she's very important at the department and has a great approach to breast cancer and nutrition. And so I'll just give the introduction here. So Dr. Amber Orman is a double board certified radiation oncologist and lifestyle medicine specialist focused on breast cancer treatment and prevention. She is the chief wellness officer of Advent Health Medical Group. She is also the co-founder of the HEAL Healthy Eating and Active Lifestyle Program at Advent Health in Orlando, Florida. HEAL is an eight week lifestyle medicine program designed to educate and inspire cancer patients to make positive changes to decrease cancer recurrence and improve overall health span. She is a mother of three teenagers and two poodles, wife to a witty nephrologist, and spends her free time trail running, lifting, rowing, cycling, and summoning Colorado's peaks. So I think this will be an interesting talk and. Yeah, so thank you for joining me, or thank you for helping me to welcome Dr. Orman. And then Betsy just reminded me real quick before Dr. Orman starts. We wanted to see how many people are gonna be attending the Sunday morning session tomorrow, just to make sure that we have enough space. Okay, okay, so about half the people in here. Okay, great, thank you. And then we'll go ahead with Dr. Orman's talk. to you, but it wasn't in the cards for me today. And so I appreciate this. And so today we'll talk about how I manage breast cancer. I'm a radiation oncologist primarily, but we won't be talking about that sort of management of breast cancer. This is more, how can we prevent breast cancer in the first place? But after it's happened, how can we teach patients how to change their lives so that they have drastically reduced their risk of recurrence? And I think, even though of course, the radiation is very important and essential in the treatment of breast cancer, if we don't arm our patients with tools moving forward, then we haven't helped them to our fullest extent. And so we'll go ahead here. I have nothing to disclose. Our learning objectives are as follows, that we will recognize that a plant-predominant dietary lifestyle has a role in preventing breast cancer recurrence as does exercise and soy is not to be feared. And so lifestyle medicine, some of you might be familiar with this field. This is what I became board certified in later, much later after radiation oncology, but it's always been percolating in the background of my life. I started studying nutrition in college and then studied functional nutrition and integrative medicine. And by the time I made it to lifestyle medicine, I felt like that was really the home for me and it made most sense to me. And what it is, is it's using a whole food plant-predominant eating pattern, movement, sleep, stress, avoidance of risky substances, and the way that you interact with other people as an actual way to treat, prevent and reverse chronic disease. And so the whole field of lifestyle medicine is arranged into these six pillars. And what's beautiful about it is that value-based care is here and will be not leaving anytime soon. And lifestyle medicine really works to optimize our healthcare system because our patients have a better experience, they're feeling better. It of course improves population health if we're actually preventing, treating and reversing disease. And it reduces costs as a result of that. But the beautiful thing is that it also benefits all of us as providers because it feels good when your patient actually, they're developing their life in a different way and they're getting off some of their pills and they're just feeling so much better. And so it makes my job as a physician so much more fulfilling when I see a patient just become a new version of themselves. And so the way that I use it is really in an integrative oncology approach in that I'm combining it with my radiation care. I do see some patients primarily for lifestyle medicine more and more as time goes on, but it's really kind of in tandem with my traditional practice. And I think it's important for all of us to have just a little bit of knowledge in this area because over half of our patients are already doing something that we would consider complimentary or alternative. And these are more typically young, female, highly educated, high income patients when we look at the studies. And a lot of them also don't mention it to the providers because they have a fear that they might be told to stop their therapy or whatnot. And so currently we're all familiar with these numbers. Six out of every 10 of us have one chronic disease and four out of every 10 have two or more. Heart disease and cancer are top two causes of death and chronic disease. And these account for 90% of our healthcare spending. And cancer is not going away. We have 1.7 million people being diagnosed with cancer each year and over 600,000 people dying from cancer each year, close second to heart disease. And it's costly, about $174 billion in 2020. Now, when we're talking specifically about breast cancer, we've seen the figure one in eight. That means one in eight women over the course of their life, not one in eight at every time point. And it's the most common female cancer diagnosed, the second leading cause of female cancer death. And it recently became very common worldwide. And so why is the situation so grim? Why do we have so much chronic disease and cancer? This is an interesting paper, if you've never run across this. JAMA puts this out periodically, the state of US health. This is the most recent one. And so these are numbers from 1990 to 2016. And if you look at the left-hand side, we have dietary risk as the longest bar and the bottom of the graph shows us deaths. And so really what this is showing is that poor diet quality is the leading risk factor associated with death in the country. And so when we say that our food is killing us, it's not really an understatement. And so I think that we underestimate the power of that decision we make three plus times a day of what we're going to put into our bodies and see it as inconsequential because of the frequency of it perhaps. And all of the things involved in our nutritional choices, it's a very social thing. It has cultural roots. It is used for emotions and for different states of mind and different ways that you feel. All of these things are involved with how we make our food choices, but it certainly has downstream effects. However, this is opportunity for change. And we know that about 80% of heart disease, stroke, and type two diabetes, and 40% of all cancers could actually be prevented primarily with improvements in diet and lifestyle. And so I'll say that again, 80% of our big chronic diseases and 40% of all cancers could be prevented with diet and lifestyle. But right now, 90% of us do not consume enough fruits and vegetables every day and 75% of us don't move enough throughout a given week. Now, part of this is certainly that these things are not easy to do. Behavioral change is very complicated to achieve and to inspire. But as you know, just like in my medical school, I had no training. And so this is an interesting study. They surveyed oncologists and they said, hey, what's your understanding? And what do you actually tell your patients when we're talking about diet, physical activity and weight management? And they all said, yeah, we know that if our patients are overweight or obese, then that affects their cancer outcomes. And yes, somebody should be talking to patients about nutrition and weight management and exercise, but 83% of the oncologists felt that they needed additional training. And I'm surprised that that number is not higher. And so the average medical school curriculum, I think the number is now five hours of nutrition education is included in your first four years of medical school. I'll tell you again, I had zero. I had nothing in my residency and really no mention of this. And so everything that I've learned was in tandem. And so I was kind of doing a double residency and then later on lifestyle medicine when I was already in attending. And so, but it's a very worthwhile thing. And you know, when we're talking about cancer, it's such a teachable moment. You know, you've said the C word to a patient and if we ever have their attention, it's been, that's a scary, scary thing. And so people are looking for, what can I do? Tell me anything and I will do anything. And so if we have a little bit of knowledge to share with them, just to spark, you know, a self-study even, that's so, so powerful. And so we do have guidelines, the American Institute for Cancer Research, the AICR puts out periodic cancer prevention recommendations. This is the third version. The current list has 10 things and it really says what we would, you know, expect it to say, be a healthy weight, be physically active, eat a plant-rich diet, avoid processed foods, high in fat, sugars and starches, eat little or no processed meat and limit red meat, limit sugary drinks, limit alcohol. And if you really want to prevent cancer, then alcohol should be eliminated. It is a class one carcinogen. Don't use supplements for cancer prevention, but get those things in your food. And if you're a mother, breastfeed your baby, if you can. And then these guidelines also apply after cancer diagnosis for tertiary prevention, for prevention of recurrence. Now you'll notice that avoiding tobacco and sun are not listed on there anymore, even though we know that excess sun exposure, especially at a young age and smoking causes cancer. And so all of these guidelines, of course, align with the six pillars of lifestyle medicine. They're evidence-based. The AICR has a very rigorous process and they focus on an overall package of habits rather than individual behaviors, right? And so nowhere in there do you see daily celery juicing with cayenne pepper and maple syrup for cancer prevention, right? We don't go into the weeds, but we're looking at overall patterns, okay? And five out of 10 of them involved plant predominant nutrition, okay? So what is the impact in breast cancer if we do these things? There's 10 things from the American Institute of Cancer Research. Well, there's three studies I like to share. The vital prospective cohort study, this was in over 30,000 post-menopausal women, a median follow-up of seven years, and they compared the women meeting five or more of the things on the list to those doing none on the list. And we saw that we could prevent new breast cancer by reducing 60% of the time, okay? A 60% reduction in breast cancer incidence. Now, the second study is the Swedish cohort prospective study. They had about the same number of post-menopausal women. They followed them for twice as long. They compared those meeting six or more of the things on the list to those meeting two or less. And we saw we could cut breast cancer diagnoses in half. Okay, and so these are pretty big numbers, reducing breast cancer diagnoses by half, by 60% if we're doing even more, you know, kind of comparing more versus none. And so it shows you that these things on the list are very powerful. This last study looks at all people, men and women pre and post-menopausal. So the numbers are gonna look a little different, but they compared those meeting five or more of the things on the list to one or none. And we saw if we're looking at breast cancer, we can reduce cases by 35%. And by the way, we can reduce all cancer diagnoses by 32%. Okay, so bottom line is, the more things on the list you follow the lower your cancer risk. Now, what if you already have breast cancer? This study addresses this. It's a prospective cohort study. They had 1,500, mostly post-menopausal women. They all had early stage breast cancer, okay, enrolled about two years after their diagnosis. So most of them have completed their chemo surgery, radiation, whatever combination was indicated, maybe they're on a hormone blocking pill at this point. And they saw that if they were consuming five or more servings of fruits and vegetables every day and walking 30 minutes a day, six days a week, we could reduce their risk of death by half, okay. Now, the really cool thing about this study is that the benefit was seen in both obese and non-obese women. Because typically we think, you know, well, that's just because these ladies lost weight. And it wasn't just in the weight loss, even though, you know, obesity is very much tied to increasing your risk of breast cancer. Even those women who didn't lose weight still had a benefit. And what it's really revealing to us is the anti-inflammatory nature of a plant-based diet and regular exercise. Because all of our chronic diseases, cancer included, have a foundation in inflammation, okay. And so when we are not living a healthy lifestyle, the level of inflammation in our body becomes greater and greater and greater. And at some point your immune system is distracted or overwhelmed enough that it's not able to pick off the cancer cells that we all have floating around in our bodies from time to time. And then you come to your doctor with an actual diagnosis of a palpable or imaged tumor. Now, this study is very interesting. This is looking at cancer survivors. It's a meta-analysis, okay, all types of cancers. And they were comparing a high quality diet versus the standard American diet, which we call the SAD diet, okay. And so high quality diet was defined as higher intake of fruits, vegetables, whole grains, and lower intake of red and processed meat, refined grains, and fatty foods. They found that the standard American diet was associated with increased overall mortality in all cancer survivors, okay. The high quality diet was associated with a reduced risk of overall mortality in breast cancer survivors, okay. This next study had 49,000 post-menopausal women, no cancer, at the time of randomization. And they randomized them between a reduced fat plant-based diet. And so reduced fat means that 20% or less of the calories came from fat versus the standard American diet. And it was an eight and a half year study. So they actually told these women what to eat for eight and a half years, and then followed them for another eight years. And of course, during the study, some people are diagnosed with breast cancer, okay. This isn't 100%, and we're not gonna prevent breast cancer in everybody. But if you have been diagnosed with breast cancer during the time of the study, and you were eating a plant-based diet, okay, at eight and a half years, you had a 35% decrease in your risk of death when compared to the women who had been diagnosed with breast cancer, but were still eating the standard American diet. Now, after the eight and a half year intervention, when they said, okay, ladies, go home and eat whatever you want, we're gonna check back in in about eight years, we saw that those people who had had that period in their life when they were eating mostly plants still had a 15% decrease in their risk of death. And so it really speaks to, number one, the power, but also kind of the stickiness of this, right? And so when you have a period in your life when maybe things are all in check, you're eating plants, you're moving your body, you're doing some yoga, you've got a mindfulness practice, you're sleeping well, you feel like you're handling your stress well, you have beautiful relationships around you, and you're not drinking all the time and then maybe something happens. Maybe you go to divorce, maybe somebody dies, maybe you lose your job, maybe a pandemic happens and you become overwhelmed with something and kind of fall off the wagon and you find yourself, you know, frequenting the fast food places and not sleeping well and gaining weight and you're not working out and you're irritable and everything's overwhelming. You're still going to have the benefit from that healthy period in your life. It's not just poof, gone. That's going to stay with you and still benefit you, okay, and getting back on the wagon, of course, sooner rather than later would as well. So what's so magical about plants and preventing breast cancer and saving lives? Well, they help you, number one, maintain a healthy body mass index because like we spoke about earlier, obesity and overweight, those are very highly correlated with increased risk of breast cancer. Plants also contain fiber, okay. Fiber is only found in plants. Keep that in mind. The steak is not tough because it's got a lot of fiber in it. That's animal muscle and that's why it's tough. Phytonutrients, by definition, are only found in plants. These are substances that are antioxidants. They have anti-inflammatory activity. They prevent blood vessel growth. They prevent cancer cells from growing, okay, and your vitamins and minerals come from plants. Now let's talk a little more about fiber. So this is a really cool meta-analysis. It's 17 prospective studies and, by the way, all of the citations are at the end of this presentation. So I know that you have my slides so you can get into the weeds on all of this. But reduced breast cancer incidence with higher intake of total insoluble fiber, okay, works in pre and post menopausal women. Fiber also normalizes blood glucose and insulin. It positively supports the gut microbiome, okay. Quick plug for the gut microbiome. Your gut microbiome, it's a bunch of bacteria in your gut. They want fiber. That's their food. And they want lots of different types of fiber, okay. And when you feed them the fiber that they want, which is a lot of different varieties, again, and 30 plants in a week will get you where you need to be, by the way, they, these little bugs, okay, will secrete all kinds of good things to keep your gut lining happy, okay. And we want those tight junctions tight, okay. And so short-chain fatty acids are very important in this, okay. And you need your gut lining to be robust. If it's not robust, then things are kind of leaking through, okay, to oversimplify this. And they're going into your bloodstream in larger pieces than they normally should, okay. This is very inflammatory to your body, okay. The health of your gut microbiome is also heavily connected to the way that your immune system functions. And so if your gut microbiome is happy, your immune system is in better shape. And so the way that I explain it to my patients is more fiber, happier gut microbiome, less inflammation, stronger immune system, and that equals less disease, less cancer, healthier body. Fiber also reduces circulating estrogen, okay, by literally binding estrogen and you eliminate it in your bowel movements. And then we talked about lower BMI. Now, carotenoids, let's talk a little more about that. They're phytonutrients, which provide yellow, red, and orange pigments to fruits and vegetables. They're antioxidants. And when we look at breast cancer, we know that those who have the highest concentration of carotenoids in their blood have a lower risk of breast cancer, okay. And so when you look through, get into the weeds on the AICR guidelines, carotenoids have a special shout out to them, okay, because the data in this area is a little more impressive. And we also see lower breast cancer recurrence and breast cancer specific mortality in those with higher carotenoid concentrations. Phytoestrogens, okay, this I talk about 17 times a day, soy and breast cancer. Okay, so in 2002, we're all familiar with the Women's Health Initiative trial. The combined estrogen progesterone arm of that trial was closed because we saw increased risk of breast cancer, increased risk of coronary artery disease, and increased overall harm. Well, when we looked at soy and estrogen under the microscope, as you see on the slide here, they kind of look similar, okay, in terms of their molecular structure. And so soy was lumped in with estrogen replacement, hormone replacement therapy as being bad and probably causing breast cancer. There were also some studies in mice where they were giving mice, you know, what would be equivalent of you eating 52 cups of soybeans a day, which I don't know that I could do that, maybe some of you could. But if you eventually overwhelm every single type of estrogen receptor in the body, turns out a mouse will get a breast tumor, okay. But we're not eating 52 cups of soybeans, and we're not mice. And that has never been replicated in humans. But what we do find in the human data is that eating soy, okay, phytoestrogen intake decreases your risk of breast cancer by about 30 to 60%, decreases breast cancer recurrence, and decreases death from breast cancer. And for the men in the audience, breast cancer is not as scary for you, although you can get it. However, prostate cancer is a real issue. And soy can also help prevent prostate cancer. Now, it benefits everybody. It doesn't matter if you're a BRCA mutation carrier, if you're pre or post-menopausal, if you're on an aromatase inhibitor, if you're ER positive or ER negative, across the board, we see the benefit. And it's because our body has different types of estrogen receptors. We have estrogen receptor alpha and estrogen receptor beta. When we have binding of estrogen receptor beta, this has an anti-proliferative effect. And guess what? Soy binds estrogen receptor beta, and it turns breast cancer cells off. Our human estrogen binds alpha and turns them on when somebody is estrogen receptor positive, when their breast cancer is estrogen receptor positive, which is why we give aromatase inhibitors and tamoxifen, which have different mechanisms, but we're getting at the same effect. It's blocking estrogen, and we're really worried about that alpha receptor. Now, phytoestrogen also inhibits blood vessel growth in tumors. It increases DNA repair. It's an antioxidant. It's anti-inflammatory and immune modulating. Okay. And sometimes it can also kick estrogen off of its receptor. Now, I wanted to also talk to you a little bit about the other pillars of lifestyle medicine, as they relate to breast cancer. So physical activity. It's estimated that we could decrease breast cancer diagnosis by about 40% if we were physically active. Now, if you already have breast cancer, you can reduce your breast cancer specific mortality by about 30 to 40% by being physically active, and your overall mortality by about half. Okay. And so those are pretty impressive numbers as well. And this has nothing to do with the food. These are just the numbers for physical activity. Now, why the benefit? Again, weight control, but it also affects your estrogen levels. And it does that because specifically when you're strength training, you release sex hormone binding globulin, and it goes around and binds up estrogen. So it's less available to bind the receptors. Now, when you're working out, think about the morning when you get up, and you're on your game, and you do a little yoga, and then you go for a run, you come back, you feel so good about yourself, and then you make a smoothie. And then it's a nice salad with some tofu and garbanzo beans for lunch. And then dinner is a brown rice and black bean grilled vegetable cashew ranch bowl. And you are on cloud nine. But if you turn that alarm off, and you skip your workout, you get up late, you have a little extra cream in your coffee, grab the donut, now the day is already gone, right? So we're going to have pizza at lunch, and then a couple grilled cheese sandwiches at dinner, and then maybe some ice cream, because why not? I've already gotten off track. And so exercise gets you in the positive upward spiral, okay, where all of these things become, you know, reinforcing for all the others. It improves immune function, it's anti-inflammatory. And as we know, it's a very effective way to treat many altered, many mental health issues, I'll say, depression and anxiety are two of the biggest. Now, we need about 150 minutes of moderate intensity, okay, physical activity per week, including two to three days of strength training. And that's what I'm always emphasizing to my patients, don't just be an elliptical lady, we need you to be strength training as well. And we need flexibility and balance. And so I'm always pushing yoga on my patients, because I feel it's one of the most efficient, beautiful things you can do, because you have your mindfulness practice, all wrapped up in your strength, your flexibility, you know, your posture, after breast cancer surgery, posture is all altered. And so this is a big issue we have women with, you know, chronic shoulder issues, neck, upper back, and as we know, everything's connected. So then the problems just start to spread outward. And then sitting is the new smoking, avoid long periods of sitting. Sleep, we need it. At night, we wash our brains. So toxic metabolites build up throughout the day when we're out in the wild, moving and grooving. And if we don't sleep well, okay, quantity is not enough, you need good quality, you have to cycle through the stages of sleep appropriately. When this is not happening, you wake up altered, essentially, because you haven't cleared these toxic metabolites in your brain, and you feel foggy. This is why you feel foggy when you're like, I got nine hours of sleep, but I'm just still feel wrecked. That's what happened when you went to sleep, you were not cycling through the stages of sleep appropriately. And screen time is our biggest issue. And so, you know, like Monday night of this past week, I was still charting at 930 at night. And that was no good for my sleep that night. I'm sure that disturbed my cycles of sleep. Sometimes it's unavoidable, but get in the habit of no screens, no anything, no phone, no iPad, no TV, no computer, doesn't matter how close it is to your face, you want to start dimming the lights, all the lights, including the screens about an hour before bedtime, so that your brain can start to release melatonin when appropriate. Okay. But what happens is our melatonin cycle gets off, this is connected to our cortisol cycle. And then we have cortisol surging at the wrong time, melatonin not being released, and you get all out of whack. Okay. And so sleep is incredibly important. You want about seven to nine hours, no more, no less, your individual sleep time will fall somewhere in that range, most likely. Stress, unavoidable, but manageable. We know that stressful life events are associated with breast cancer. I see this all the time. I'll have women come in and they say, I don't know what happened to me, Dr. Orman, I eat a plant-based diet, I work out, I sleep well, I meditate, I do it all. And I'm like, it's probably because you do it all. And what's your stress like? And how many people are you taking care of? And is your plate just overloaded with responsibilities? Do you have traumatic life events in the past? And so almost every single one of these cases where it seems there's really no common cause lurking in the background, there's a lot of stress, there's a lot of trauma, there's a lot of grief, they're overworked, there's something along these lines that's been chronically going on. One of my dearest patients, we were just talking the other day and she lost three very important people in her life and multiple pets that were near and dear to her heart all within the period of like six months, went from a normal mammogram one year to the next year after all of these events, a five centimeter triple negative node positive tumor. And that's really all she had out of whack was all of this stress and grief. And so these things cause inflammation in your body. And like we spoke about earlier, inflammation is the foundation for chronic diseases, including cancer. Now let's look at a case. And so this is the lady that went through my HEAL breast program, which is an eight week lifestyle medicine immersion where we talk about all these things with our patients. And she had kind of a run of the mill grade one invasive ductal carcinomas, estrogen receptor positive, HER2 new negative, stage 1A. She had no need for chemotherapy. It was a low risk genomic test. She's 66. She's postmenopausal. This is just kind of the run of the mill, if you will, breast cancer, but she had a lot of past medical history. So she has the alphabet suit coronary artery disease, peripheral arterial disease, hypertension, high cholesterol, type two diabetes, reflux, chronic kidney disease. And of course she has depression. She's on a boatload of medications for all these things and eating the standard American diet with a lot of meat and processed foods, oils, you know, soda, fast food, and just a lot of it not moving at all. Can you believe it? Not sleeping well. And when she'd get up at night, she'd have a little snack. Didn't have any issues with tobacco, alcohol, and drugs, and had a really supportive spouse and church family. So there wasn't a big stress or stress effect or lack of social connection there. Throughout the program, she converted to about an 80% whole food plant-based diet. She was using some of the transitional training wheel meats, like, you know, the beyond burger and whatnot, occasional fish. She was working in intermittent fasting in the form of time-restricted feeding. Okay. So eating all of her meals within a 12 hour time window. And then we eventually got that down to an eight hour time window, which is what I actually personally do in my life as well. She was daily kayaking. She had this pedal powered kayak she was scooting around on. She eliminated the late night eating because guess what? She was eating better and she was mooting. So she was actually tired at night and she was sleeping well. And key, her spouse also started doing these things. And so it's always helpful when the household supports you. When they don't, that's a little extra challenge. Lab-wise, if you look at the left, these are labs from, we'll call it just time zero. And then on the right, it's about a year later. Okay. Now you'll notice on the left at time zero, she's on all of her medications. On the right, she's off all of her medications. Okay. And so I had to work closely with her other doctors because she had a lot of specialists on board managing all these other things. And we were slowly pulling her off. And so really cool. Her creatinine went down from 1.5 to 1.1. Total cholesterol. Of course it went up. She was off the statin, but it continued to go down with the dietary intervention. HDL went up, hemoglobin A1c went from 7.2 to 6.2. Super cool. Resting pulse went down, blood pressure went down. She lost about 30 pounds. And so she's decreased all of her major comorbidities. She's off all of her medications. She remains off all of her medications. She's reduced her risk of the cancer coming back and of dying from it. She's improved her overall survival and she's just a new human now. And so she has the ability to do so much more with her life. And you can see that she is visibly happier with her situation now. And so I wanna leave you with what I see as the most important points. Nutritionally, these are your heavy hitters. So plant predominant nutrition, look at any guideline for any society and they're going to say plant predominant, okay? It doesn't have to be all plants. But I try to get my patients to the point where about 80% of what they're eating is a whole plant, okay, for the most part. Now, some people though, they need to reverse things, right? So we need like the therapeutic version of this eating pattern. And so that's gonna be closer to 100% plants. If you are at a point where you feel good about your health, you feel good in your body and your mind, you're able to do what you wanna do and you're still eating fish a couple of times a week, stay there, okay? But just eat more plants, okay? My patients are always asking me, can I eat X, Y, Z? You can eat whatever you want. I'm here to share with you what the data says and to give you the tools to bring these things into your life. And you've got to kind of decide where on that spectrum of maintenance versus therapeutic approach you need to be. And maybe you get off all your medications with a 99% plant-based diet and you fall back to 80 and that keeps you where you are, you're staying off your meds, you're feeling good, beautiful. So dark leafy greens are very important. Cruciferous veggies, broccoli, cauliflower, Brussels sprouts, these have a lot of anti-cancer properties, okay? Specifically broccoli. And a little trick, you wanna cut your broccoli and let it sit for a little while, okay? This helps the sulforaphane develop in it so that it's more accessible to your body. And so what I'll do when I'm cooking, I'll cut my broccoli like first, go and do a bunch of other stuff and then come back to the broccoli and do whatever it is I was gonna do with it. It was like, if I was gonna cook it or just put it on a salad raw or whatever. Berries, okay? Berries are very, very high in antioxidants. So I always tell my patients when we're talking about fruits to eat more berries and apples than you do bananas and mangoes because they're just slightly better, okay? In a few ways. Mushrooms, mushrooms are very important. Another fun fact, you can actually get some vitamin D from your mushrooms but you have to put them out in the sun. So give your mushrooms a suntan and you'll get a little bit of vitamin D from that without the sun exposure yourself. Unpeeled apples, okay? The peel has a lot of good properties in it, okay? So buy organic, wash it, eat the whole thing. Beans, okay? Now, if this list including beans and broccoli makes your stomach hurt to even think about, that's your gut microbiome. It's not quite ready for a bowl of raw broccoli. And so you have to ease into it, eat smaller amounts, cook it, you know? And so you kind of have to flex your microbiome muscle by introducing things little by little. So if beans are a real problem for you, then start with lentils. Of course, you're cooking your beans. Eat smaller amounts and then increase as you go. And so as you populate your gut microbiome with the bugs that you need, you know, to help digest the plants, you'll have less GI upset. Soy is very important, we went through that. Ginger, garlic, and turmeric, okay? Very beautiful anti-cancer properties. And so I cook a lot with these things. I just had a smoothie with a bunch of fruits and greens and ginger. If you've never put ginger in your smoothie, get ready to live. Ground flax is very important, okay? Phytoestrogen properties, a tablespoon a day is a great thing. And green tea, add lemon because then you will absorb some of those antioxidants more efficiently. Other lifestyle modifications, the physical activity is key. And we need cardiovascular muscle training and flexibility. And I know that you guys are all aware of that. Maintenance of a healthy body weight, okay? Not just for breast cancer, but for life. Overweight and obesity is a risk factor for so many things. Avoidance of alcohol. My patients, I always get the question, can I have a glass of wine every night? Well, again, you can have whatever you want, but we do know that alcohol causes breast cancer. It causes a lot of other things, as we're all aware of. It is a carcinogenic substance. And so it's not a health food. We're finally getting enough data out to hear in the news that alcohol doesn't help your heart health either. So, we used to be drinking the red wine for heart health. And so I tell my patients, if you want to have a drink occasionally, of course do it. There's nothing worse than deprivation to get you way off course when you finally give in. And so make it a clean, organic, no sulfite added wine. Okay, there's a lot of nice brands now. No sugar added. Wine has a lot of sugar added to it sometimes to make it taste better than it would naturally. And so I'll steer them towards certain types and then eat it with antioxidant rich foods like red peppers and berries and a nice kale salad or something to kind of help undo a little bit of the damage that you're doing. And then of course, don't go overboard. Stop at one or two glasses and don't do this nightly. So buy good quality wine and just do it on special occasions. And it's a difficult thing now. And I think people are drinking more and more post COVID. And so I talk about this more and more with my patients. And then don't underestimate the power of emotional support and stress management. These women are also often supporting the whole family whether it be financially or just with household duties, of course, emotionally, they're supporting their family. And we kind of have this, we have to do it all and be it all thought often. And so it's important to give your patients permission to let other people take care of them now because they're not going to be able to continue caring for others in that way if the floor is falling out from beneath them. And so I'm always iterating to my patients, you have to ask for help and people are gonna have this nervous energy around you and they're not gonna know what to say. And sometimes it's helpful for you when they, if they ask you, what can I do? I literally need you to go to the grocery store and here's my list. Or can you go pick up my dry cleaning? Can you pick my kids up from school? If you can delegate some things, it's very helpful and patients really need to hear this from us. The other thing that I talk a lot about is, I hear the, why is this happening to me? And of course we never have an answer for that but steering a patient towards a place where they are able to see that, out of this tragic thing, out of this trauma, out of this grief, out of the stress, there's always opportunity buried in there and there are always positive things buried within that. And it's individual for every patient, maybe some relationships that weren't really serving you throughout fall to the wayside. You don't have to worry about that anymore. Maybe you develop new relationships. Maybe your kids step up and start really helping and you see that they're kind of growing in that responsibility. And so things will be shifting and they're having to let go of a version of themselves that's no longer here. And so in that process, steering them towards the beautiful things that are coming out of this tragic experience is very, very helpful. Sleep, we said it before, but this is when we rest and restore and wash our brains and that stress aspect becomes very difficult. And so we need our patients sleeping. And so talk to them about good sleep hygiene, but also why, why do you need good sleep hygiene and especially the screens, okay? The other tips I didn't mention, really cold room, okay, 67 to 69 degrees is where we think works best. And warm, warm blankets, very dark room. That's also very helpful. And then make sure to mention, your relationships matter. And so if they have a toxic person in their life, that's having an effect on their health, not just emotionally, but also physically because it's causing stress and inflammation. And so this is a time to really re-examine the people around you and patients need permission to do that as well. Okay, and this will be what will be written on my tombstone. I don't care much if a name is on there, but Eat More Plants needs to make it on there. And this is how you contact me. Email me anytime. The website right there goes to our Heelgrass program. We do have an online signup, but it's very difficult. So if you had a patient that was in Florida that wanted to attend our program, it is virtual. They would just email me. That's the easiest thing to do so that they don't get kind of lost in the mix. All right, I'm gonna stop my screen share. Great, do we have any questions? I don't have any on the chat. Okay. So Dr. Orman, there's one question. Let me just pass the mic over here. Sure. This may be a little too specific, but the issue, there are certain plants that seem to cause acidic related bladder or GI symptoms, onions, that kind of thing. Is that something you're aware of? Is that something you would adhere to? There's certain probably individuals who have a predisposition to certain plants causing irritability. Yeah, you're right. It's so individual and hard to identify. And it's almost always related to the gut microbiome being out of whack in my experience. And so if a patient is having a certain issue with a certain food, we'll remove the food entirely and then just reintroduce in small bits. And if they still have the problems, then you just can't eat that for whatever reason. But in that time when you're kind of away from the food, you're supporting the gut microbiome with some good fermented foods on the regular. And so that's another thing I didn't mention. I actually have my patients eating sauerkraut from your refrigerator section, just a quarter cup a day. That helps to introduce some good bacteria into the gut and then all the additional fiber in the diet supports it. And so sometimes doing this and then bringing in, starting with sweet potatoes and lentils, your root vegetables, and later your cruciferous, if they have a problem with the allium family that you're talking about, the onions and the garlics and all of this, then we can try reintroducing them after we've developed the gut microbiome to a better degree. There are a lot of food sensitivity testing panels. I don't usually use them. I like the elimination diet approach because I find that, and I've even had them done on myself. You get these panels back and it'll tell you to avoid certain foods. And I have a very, I've been doing this, I don't know, 20 years, I guess, I've been eating a plant-based diet and pretty in tune to what bothers me and what doesn't. And it doesn't ever correlate to the test. So I don't know that those are very robust. I haven't found one at least that I like to use on the regular, but that's an option for a patient to see, okay, I'm having a problem eating onions. And if I take this test, does it actually tell me that onions are a problem or not? And then maybe it would help you validate the rest of the results. Great. What are your thoughts on the benefits of guacamole? Because in some of the literature recently, it's talked about the benefits as far as cardiac is concerned. Yeah, I mean, that's just generally good fats versus bad fats. And so that's another benefit of a plant-based diet. There's little to no saturated fat in a plant-based diet with the exception of palm oil and coconut oil. And they're not completely like animal-based saturated fat, but I do tell my patients to consume those sparingly. Now your avocados and different nuts and olives and so forth, these are all of your mono and poly unsaturated fats. And so they're very supportive of heart health. Now, if you're looking to reverse heart disease, however, the most effective diet is a low fat plant-based diet. And I'm talking very low to the point where, it's a quarter of a cup of nuts and seeds per day. And you're basically staying away from any oils. Avocado is at a very minimum, all of the plant fats are at a minimum while your body kind of reverses that. This is the Ornish approach. Some of you are probably familiar with some of his work, but he has some very impressive graphics in his papers where they'll show 36 months of a plant-based diet before and after, and the LAD nearly blocked, and then it's like wide open. And so we can reverse cardiovascular disease in that we can clean up the lining of the vessels, but usually you've got to take out all of the saturated fat and minimize the additional plant-based fats as well. Wonderful. Thank you so much, Dr. Arman. That was really great. We really appreciate you speaking to us today. Thank you for having me. I appreciate it. You're a wonderful group. Thank you. And I hope I get to speak with you again. Thank you so much for the invite. Oh, thank you. That would be wonderful. We'd love to have you and hopefully in person the next time. Yes. I love Tampa. I used to live there. I was at Moffitt before Orlando. It just couldn't work out this weekend. I'll tell you, I actually have a 50K tomorrow that I'm running. And so I'm gonna be totally busy tomorrow. So today I had to get all my chores done. Wonderful. Well, best of luck tomorrow. Thank you again. Thanks so much. Bye-bye. Bye.

breast cancer prevention

lifestyle medicine

plant-predominant diet

cancer incidence reduction

exercise benefits

stress management

nutrition

phytoestrogens

emotional support