Should I eat more “healthy fats” or less? More protein at every meal or less? Are grass fed beef, chicken, and lamb really healthier? Do I add butter, coconut oil, and uncured bacon to nourish my body? Eat high carb? Low fat? Paleo? Vegan? Mediterranean? Isn’t it enough to drive you mad?
To figure how out to eat for health, it’s instructive to turn to the Blue Zones of the world. These are communities around the world (including Okinawa, Japan, and Loma Linda, California) with the highest concentration of centenarians (people living over 100 years of age). Although the dietary patterns of Blue Zones vary, what they have in common is a high percentage of plant-based, whole foods that provide optimal nutrition.
In Okinawa, Japan, for example, on average, only 6% of the Okinawa diet was from fat. About 9% of calories were from protein and 85% of calories were from complex plant carbohydrates like grains and legumes with a strong preference for sweet potatoes. The results? Okinawans enjoyed rates of heart disease that were 80% lower compared to those in the US. Rates of breast and prostate cancer were 75% lower, and dementia 67% lower.
So what can we learn from this? Increase your calories from plants and decrease calories from animals — or increase your P/A ratio (“plant to animal”). You can never go wrong and it is a simple strategy that has not title to incite an argument or confusion.
How do you handle the crosstalk of all the dietary recommendations from “experts”, some real and some self-appointed? If the first, second, and third thing out of an expert’s mouth is not “eat more fruits and vegetables, raw when you can”, run for the hills. Perhaps Michael Pollan summarized it best on the cover of his book In Defense of Food: Eat Food, Not Too Much, Mostly Plants. Take a high P/A ratio to your plate and bowl and add you will have a strategy to optimize the years to your life.
The reason that I opened a based gourmet restaurant, GreenSpace Cafe, in Ferndale, Michigan was to make it easy for guests to have a high P/A ratio in an elegant setting and no hassle. In fact, all the items have a P/A ratio of 1 as we use only plants in all items. The extensive menu dazzles, nourishes, and provides a sustainable and cruelty-free feast from A-D (appetizer to dessert with a libation if you choose).
We know that food is medicine that provides direct information for our genes for health and longevity or disease and sickness. It is a decision based mainly on your P/A ratio in your diet and the quality of the whole plant foods you choose (sorry, potato chips do not cut it). Live longer and better with the highest P/A ratio diet you can muster. If you travel through the Detroit area, and you should, visit GreenSpace Cafe and sample the highest P/A ratio in town, putting the cleanest fuel into bodies in the Motor City.
Reading the Headlines About Vegetarians and Depression is Depressing: The Media Response After “What The Health”
Actually, it would be premature to anticipate people copying the lifestyle of a remote tribe living in the Bolivian jungle, but the news has been abuzz with the report that the Tsimane people have an incredibly low rate of heart disease compared to Western populations. The Tsimane live in villages of about 60 to 200 people. They often live relatively long — the most common age at death is 70.
In data published in the journal Lancet and announced at the American College of Cardiology, the results of coronary artery calcium scoring (CACS) using CT imaging in 705 adults living in remote villages between 2014 and 2015 were reported. The non-invasive heart check via CACS is the best predictor of heart disease and a direct measure of atherosclerosis. These residents of primitive villages were transported to a medical center for the evaluation.
Based on their CACS, almost nine in 10 of the Tsimane people (85%) had no risk of heart disease because of a CACS of zero, 13% had low risk and only 3% had moderate or high risk. These findings also continued into old age, where almost two-thirds (65%) of those aged over 75 years old had almost no risk and only 8% had moderate or high risk. These results are the lowest reported levels of vascular aging of any population recorded to date.
By comparison, a US study of 6814 people (aged 45 to 84) found that only 14% of Americans had a CT scan that suggested no risk of heart disease and half (50%) had a moderate or high risk — a 500% higher prevalence than in the Tsimane population. In the Tsimane population, heart rate, blood pressure, cholesterol, and blood glucose were also low, potentially as a result of their lifestyle.
The Tsimane spend only 10% of their daytime inactive. They live a lifestyle including hunting, gathering, fishing and farming, where men spend an average of 6–7 hours of their day being physically active and women spend 4–6 hours. This is far less than the average 50% of time spend in sedentary activities in Western societies.
The diet of the Tsimane was composed largely of complex carbohydrates (72%) high in fiber such as rice, plantain, manioc, corn, nuts and fruits. Protein constituted only 14% of their diet largely from animal meat caught in the wilds. Their diet is very low in fat with only 14% of their calories being fat calories. This is as low as the traditional Okinawan population known for longevity as a Blue Zone and in the range of the famous heart disease prevention and reversal studies of Dean Ornish, MD and Caldwell Esselstyn, MD. The diet was also very low in saturated fat, averaging 11 grams, and had no measurable trans fats. By contrast, the typical U.S. adult diets have more fat — about 16 percent protein, 33 percent fat and 51 percent carbohydrate, according to Centers for Disease Control statistics. Smoking was rare in the population.
The graphs below show the CACS in women and then men up to age 85 in the Tsimane population in aqua compared to a range of populations in the United States in the MESA trial. It is striking how little coronary calcification was found even at advanced ages compared to the comparable age groups in Western populations.
This chart compares levels of plaque in coronary arteries in the women and men of various cultures. The Tsimane are lowest. The lines reflect the 75th percentile in each group. Source: The Lancet
While the lifestyle and health of the Tsimane people may soon change with the availability of transportation and exposure to Western conveniences, the lessons for longevity and freedom from heart disease are clear. Decisions not to smoke and to pursue an active lifestyle of exercise, walking, standing and even fidgeting have all been shown to favor heart health and are borne out by the CT findings in the Tsimane.
In an era when the role of dietary fats, “healthy fats”, and saturated fats have opposing schools and has led to public confusion, the remarkably low fat diet of the Tsimane is a pattern supported once again for youthful heart arteries. Very few people in Western societies follow a diet consisting of 14% or less of calories from fat but the relationship with the healthy heart arteries of the Tsimane argue for largely whole food, plant based diets with very little or no butter, full fat dairy, animal meats, oils, or eggs. The trend in California of blending butter and coconut oil in coffee to create a very high fat drink, known as Bulletproof Coffee, has clearly not reached the jungles of Bolivia. Their exceptional heart health speaks volumes about not following that trend or high animal food diets in general.
Several news outlets reported on information released 12/8/2016 from the Center for Disease Control/National Center for Health Statistics that life expectancy in the United States has declined for the first time in twenty years. PBNSG asked Dr. Joel Kahn to comment on these findings and offer suggestions on what we can do about this trend. Here are his comments:
Many have predicted that the combination of the Standard American Diet (SAD) and the flooding of our environment with air, water and personal product pollutants would impact the life span the USA and now we have the first sign that this horror may be coming true. After decades of enjoying a longer lifespan, the tide may be turning for the worse. What is to blame? Clearly the number one factor is the horror of Franken Food over the last 50 years. Gas stations, vending machines, fast food, sweetened beverages....all in gigantic serving sides provided a deluge of excess fat, sugar, salt, additives, antibiotics, genetic modifications, and hormones. Combine that with sedentary lifestyles and environmental pollutants in the air, water, and particularly plastics like bisphenol A, parabens, and phthalates and you get the perfect storm of life shortening trends.
The solution is a whole foods plant based (WFPB) diet naturally low in salt, oil, added sugar, pesticides and hormones. A WFPB diet can provide all nutrients, protein and vitamins (except B12) needed from birth to death. It is the answer to the pressure on the environment and the terrible conditions which 95% or more of animals live and suffer through to provide us calories. Eliminate animal products (eggs, dairy, and all meats) and eats fruits, vegetables, legumes, nuts and seeds to have the optimal lifespan and health span.
It may seem far afield for a cardiologist to give advice on achieving the perfect orgasm.
Yet if there's one thing I've learned since becoming a heart doctor almost 25 years ago, it's this: Plumbing is plumbing, whether above or below the belly button. And without our blood vessels dilating and swelling male and female genitals, the big "O" becomes the big NO.
It is the one year anniversary of the announcement by the International Agency for Research on cancer(IARC), an agency of the World Health Organization known for expertise in analyzing scientific data for health risks, that meat acts as a carcinogen (http://www.iarc.fr/en/media-centre/pr/2015/pdfs/pr240_E.pdf). The analysis placed processed red meat at a risk similar to the notorious pesticide RoundUp at best and comparable to diesel fumes and tobacco at worst. These were very strong words that shocked many and made headlines worldwide (https://www.washingtonpost.com/news/wonk/wp/2015/10/26/hot-dogs-bacon-and-other-processed-meats-cause-cancer-world-health-organization-declares/). In case you missed it, the IARC, comprised of 22 scientists from 10 countries, reviewed over 800 studies and found that:
1. Processed meats like bacon, ham, salami, sausage and beef jerky are class I carcinogens, they highest risk assigned and cause cancer with sufficient data to make a firm conclusion. The relationship was strongest with colorectal cancer (CRC) and stomach cancer.
2. The risk increases incrementally with the amount of these meats that are eaten. Each 50-gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18 percent.
3. Fresh red meats like steak and roasts, but including pork and lamb, were considered as probable causes of cancer to humans (Class 2a) with links to colorectal, pancreatic and prostate cancer.
The report of the IARC followed similar prior reports like that of the World Cancer Research Fund (http://wcrf-uk.org/uk/preventing-cancer/ways-reduce-cancer-risk/red-and-processed-meat-and-cancer-prevention) that drew similar conclusions.
Now new research has applied this announcement to indicate how the recommendations of the IARC along with other lifestyle measures can reduce the risk of CRC https://www.ncbi.nlm.nih.gov/pubmed/27752849). Six dietary and lifestyle recommendations (body weight, physical activity, energy density, plant foods, red and processed meat, and alcohol) were examined in terms of their association with CRC incidence over 7.6 years of follow-up in 66,920 adults aged 50-76 years at baseline (2000-2002) with no history of CRC.
The analysis indicated that participants meeting 1-3 recommendations enjoyed a 34-45 % lower CRC incidence, and those meeting 4-6 of the targets experienced a 58 % lower incidence of CRC. The lowest CRC risk for women related to body fatness and red and processed meat and for men it was avoiding alcohol intake and red and processed meat.
The tragic nature of CRC in the US is enormous. In 2014 about 140,000 were diagnosed in the US with CRC and nearly 50,000 died of this disease (http://www.cancer.org/research/cancerfactsstatistics/colorectal-cancer-facts-figures). African American men and women experience the highest rates of CRC, as much as 50% higher than whites.
Similar to the current debate about the crucial role of substituting animal saturated fats with healthy options other than processed foods rich in sugar (http://www.huffingtonpost.com/joel-kahn-md/saturated-fat-remains-the_b_12094842.html), a strategy of replacing a breakfast of sausage and bacon with a plant based bean burrito or a lentil patty would be anticipated to produce a dramatic reduction in the risk of CRC (https://www.ncbi.nlm.nih.gov/pubmed/26077375). On the 1 year anniversary of the IARC, choose plants over animal products. At least one major hospital system has announced a total ban on processed red meats to be implemented in 2017. Others must follow suit.
Follow Joel Kahn, M.D. on Twitter: www.twitter.com/drjkahn
It is funny how two lives can run parallel courses thousands of miles apart to eventually become intertwined. I am a cardiologist trained in interventional therapy (stents) for coronary artery disease (CAD) who has become a passionate advocate of lifestyle and prevention of CAD before stents are needed. I exercise daily using high-intensity protocols. I am appalled by the current status of hospital food. I emphasize the need for increased fruits and vegetables in the diet with reduced added sugars and value the pattern of eating in the Mediterranean (MED) basin as a model for balanced nutrition. I am a student of the voluminous nutritional research by Dr. Ancel Keys, the world renowned physiologist who introduced the MED Diet to the United States in 3 best-selling books after decades of seminal research on diet-heart relationships. Finally, I have recently traveled to Museum of the MED Diet in Pioppi, Italy, and the winter residence for nearly 40 years of Dr. Keys and his wife Margaret.
Dr Aseem Molhatra is a cardiologist practicing in London who is 20 years younger than me but who shares the same credentials listed above. I praise the fact that he fights for better nutrition for children with a campaign to lower added sugars in the diet and shuns processed junk foods. However, we have quite different opinions in terms of the role of dietary saturated fats, mainly from animal sources such as red meat, butter, full fat dairy, cheese, and eggs. Dr. Molhatra gained international attention with an editorial in the British Medical Journal titled “Saturated Fat is Not the Major Issue.” He presented selected references he used to conclude that the health of the public suffered when it was led towards a low fat diet rich in added sugars. He blamed the research of Dr. Keys, who he claims “demonized” saturated fats. He relies on a meta-analysis in 2010 on the topic and a randomized trial examining different versions of a MED diet on CAD outcomes. His National Obesity Foundation, which receives funding from meat producers and pharmaceutical manufacturers, has been criticized for a recent proposal on managing obesity in the U. K.. The irony is that his NOF report was accused of “cherry-picking” studies to support its claims, the very same claim that has been erroneously hurled dozens of times at Dr. Keys since his death. Dr. Malhotra recently released a documentary on his visit to Pioppi, Italy, The Big Fat Fix. Finally, he was recently featured in the New York Times holding a cup of coffee with butter and coconut oil blended into it while advocating for more cheese, eggs, and bacon in the public diet.
Space does not permit a full listing of all the issues I have with Dr. Molhatra’s new documentary. I will not comment further on the fact that he used multiple videos and photographs from the collection of the University of Minnesota without copyright permission (personal communication Henry Blackburn, MD) or that he climbed the fence of private property that was Dr. Keys home in Italy. I will also not respond to a strange claim that in his late 80s’s (Dr. Keys lived until just shy of his 101st birthday), he was unable to publish a paper on HDL cholesterol, with the implication that it was some sort of fundamental change in his thinking on the role of saturated fat and CAD. Both his son Henry Keys and Dr. Blackburn deny there was any such manuscript (personal communications, Henry Keys, MD and Henry Blackburn, MD). For sake of brevity, the following comments are offered in bullet points.
1) The 2010 meta-analysis mentioned above on which Dr. Malhotra relies was resoundingly criticized by a leading cardiovascular epidemiologist Jeremiah Stamler in the very same issue, a rather unusual event for a medical journal. Neither the authors nor Dr. Malhotra have responded to Dr. Stamler’s lengthy review of the study. The fact that Dr. Krauss, senior author on the meta-analysis, has long received funding from the meat and dairy industry, is overlooked by Dr. Malhotra.
Finally, the fact that in more recent publications the same research group has noted the benefits for preventing CAD by reducing dietary saturated fats substituting polyunsaturated oils, fruits, vegetables, fish and nuts is missing from the documentary.
2) The “demonization” of Dr. Keys began soon after his death in 2004 and can be attributed to errors in research on his long career by Gary Taubes and others. His is accused of manipulating American food policy to favor low fat, high sugar foods. Nothing could be further from the truth. Indeed, Keys never testified before the U.S. Senate working on such policies. A review of Dr. Keys’ best-selling books, co-authored with his wife, are replete with recipes substituting butter and cheese with copious amounts of olive and other vegetable oils. They would never be categorized as low fat meals. Dr. Keys and over a dozen co-authors performed the first long term observational study of widely different cultures in the Seven Countries Study. Their research was the first to identify that while both Finland and Crete had diets with about 40% of calories from fat, deaths for CAD was low in Crete due to the reliance on vegetable oils low in saturated fats while highest in the world in Finland where butter and cheese were the staples of the diet. Finally, Dr. Keys called for a reduction in dietary sugar as early as 1959 in his books, decades before Dr. Malhotra was born. The reality was that in analyses from the Seven Countries Study, dietary sucrose did not predict CAD with anywhere near the statistical power that dietary saturated fat, particularly butter, did.
3) The MED diet was given a new and dangerous spin in Dr. Malhotra’s film. While visiting the Museum of the MED Diet in Pioppi, he alters the MED diet food pyramid into something very different, a low carb-high fat (LCHF) plan. He removes the base of cereals, pasta and bread and emphasizes this again later in the film when he places the bread basket far out of reach. Instead he adds butter, full fat dairy and cheese, and even coconut oil to his prescription pad for the MED diet. This alteration of the MED diet pyramid, including foods like coconut not indigenous to the Mediterranean basin, might be easily overlooked. In reality, this is an obvious perpetuation of the LCHF diet promoted for decades beginning with Robert Atkins, MD and others. The actual MED diet, as studied in PREDIMED and other trials, emphasizes the central role of cereals. By removing carbohydrates as breads and cereals and adding in high saturated fat ingredients, this LCHF diet raises major concerns for CAD. A LCHF diet is associated with an increase in all-cause andCAD mortality in large databases. That a cardiologist would promote a LCHF diet in view of this known risk is concerning at best and seemingly dangerous at worst.
Another critic of Dr. Keys and the Seven Countries Study, Nina Teicholz, accused Keys of fudging his data, recognizing it is hard for Keys to respond since his death! She implies that he misled the public into the current obesity epidemic. While the topic is complex, and the recent reports of sugar industry payoffs (unrelated to Dr. Keys) 50 years ago are very concerning, the real fudging can be found in The Big Fat Fix. This documentary and the other writings of Dr. Malhotra ignores the copious new data on the confirmed risk of dietary saturated fats and CAD. Also ignored is the documentation that a no added fat, plant based diet can reverse CADand improve blood flow to the heart. His writings and film contribute greatly to the confusion amongst the public about what to eat. Dr. Malhotra lectures about confusion as a classic strategy from the tobacco industry “playbook” to delay the public view linking smoking to cancer. We should be alarmed that the Big Fat Fix is taking a page out of that same playbook at the risk of the wellbeing of the public. This is not a personal attack as I know Dr. Malhotra to be an intelligent and personable individual. Rather, for the sake of the health of CAD patients, known and developing, I call upon him to rethink his passion for adding saturated fats to the diet of patients with known or occult heart disease and instead join me in advocating for diets with more fruits and vegetables low in added sugars. The olive branch that includes olive oil is extended. Physicians swear to “primum non nocere” or “first do no harm”. As there is no safety data for his recommendations in heart patients, Dr. Malhotra would be wise to review that credo. Meat, dairy products and artificial foods usually high in saturated fat remain the main felon in CAD with added sugars an obvious accomplice.
Dr. Joel K. Kahn, MD, FAAC
Adam is a well-known Detroit businessman who is legendary for his huge smile, energy, and successful restoration business. We became friends at a CrossFit gym a few years back. On social media, Adam was known for food posts that were usually centered around his love for bacon and burgers. He was about as meat-oriented as anyone I have ever met. As we all know, change has to come from within, and so we maintained our friendship despite the fact that we were polar opposites when it came to food.
In March of this year, Adam texted me to tell me he was ready for a change. He hadn’t had a health crisis yet (he is in his 40s), but he knew his diet, heavy in processed meat, could not work in the long-term. I was shocked, pleased, and, of course, supportive when he suggested going fully plant-based for 30 days. On top of this 30-day challenge, a huge departure from his normal diet, was the added challenge that he ate nearly every meal out at restaurants. So he was going to have to do some extra maneuvering.
The Bacon-Lover’s 30-Day Vegan Challenge
To document a baseline, we arranged for some advanced blood work at the Kahn Center for Cardiac Longevity at the end of March. On April 1, he jumped right in, switching out eggs and bacon for oatmeal and fruit plates. Lunches of soups and vegetables began to appear on his Facebook page. Dinners of steak house appetizers, tofu stir fries, and entrees from my plant-based restaurant GreenSpace Café got him through the first few days. He bravely and publicly posted about his diet switch on social media and received a lot of positive support. There were, of course, a few taunts and invitations to return to the dark side.
He found grocery shopping difficult at first, so I helped him through a couple shopping trips. We filled his baskets with fresh whole foods along with a few processed vegan choices. To his credit, Adam quickly decided to only eat whole-food, plant-based meals.
He stuck to the program 100 percent, and began to notice that he got better sleep and had increased energy and greater brain clarity. He was not overweight, so he didn’t need to lose weight, but he did mention his bowel movements were easier with all the added fiber from the fruits and vegetables. He made it through the 30 days successfully.
May 1 was the day we had scheduled for his repeat laboratory studies. To be honest, we were both nervous. What if there were no changes from his abnormal baseline lab results? We knew that 30 days was not a very long time, and perhaps wasn’t long enough to see significant changes. We were both overjoyed when the results returned.
Advanced Lab Results After 30 Days on a Plant-Based Diet
Adam’s first baseline blood level showed a seriously elevated C-reactive protein at 6.1 mg/L. High sensitivity C-reactive protein (hs-CRP) is a marker of inflammation that has been linked to heart attack, stroke, diabetes and cancer. Adam’s repeat level was 0.7, a dramatic and meaningful decline to normal.
Adam’s baseline microalbumin/creatinine ratio had been a very worrisome 8.5, indicating his arteries were sick from his food choices. This simple but powerful urine test reflects the health of the arteries in the kidneys and throughout the body. If elevated, it predicts increased risks of heart disease, heart attack, and stroke. Adam’s second test, just one month later, showed an undetectable level! This dramatic improvement shocked and pleased us all.
Adam’s total cholesterol fell from 224 mg/dl to 196, his LDL cholesterol fell from 142 to 115, and his LDL particle number fell from 1714 to 1474. These are significant improvements in just 30 days.
I’ve practiced medicine for over 30 years and have eaten a plant based diet for nearly 40 years. Even after all that time, I am still so impressed at how quickly the body can recover when excess salt, sugar, fat are removed and whole plant foods replace meat, dairy, and processed foods. I am proud to report that Adam is still eating a plant-based diet, encouraged by the way he feels and the results of his laboratory reports. I recommend all of my patients dive headfirst into a vegan challenge of at least 21 days in length. The patients that take the challenge feel so much better, and many continue long-term as Adam is now doing. It’s inspiring to see!
Dr. Joel K. Kahn, MD, FAAC
Citing Sources: www.forksoverknives.com
Case study: A 48 year-old man, athletic and highly successful in his career, enjoys a day of surfing. While walking back to his car, he collapses and cannot be revived. A heart attack is to blame for his sudden death. Rare? Unfortunately, this is neither rare nor hypothetical as the world lost a good man recently and my heart goes out to his young family.
How can this happen? Although I did not know this man, I imagine he saw doctors and had checkups. Perhaps he even had a stress test along the way. There is a disconnect in the identification of early heart disease that is not true of some other important ailments. For example, consider the fact that when you turn 50 you are asked to have a colonoscopy to look directly at the colon for masses. Women are asked to have a mammogram to look directly at the breast for growths. But heart artery blockages, the number 1 cause of sudden death over age 30, are still not looked at directly. The standard recommendations at a physical exam include measuring blood pressure and cholesterol and maybe performing an ECG, all of which are indirect and inadequate examinations of the status of the coronary arteries.
I know there is a better approach, the coronary artery calcium scan (CACS). It is endorsed by the Society for Heart Attack Prevention and Eradication (SHAPE), the American College of Cardiology, and hundreds of peer reviewed research studies.The American College of Cardiology has given a high endorsement (IIA) to the use of CACS in persons with known risk factors for silent coronary disease.
The “mammogram” of the heart, as the CACS is known, is low-cost ($80 in my community) and offers a direct examination of the heart arteries. There is no contrast or IV injection and the test takes about 1 minute.
Who should not have a CACS?
If someone already knows they have coronary artery disease such as a previous cardiac catheterization showing blockage, a previous heart stent, or a previous heart bypass surgery, there would be no need for a CACS. People who know that they have blockage in other parts of the body, like an artery of the brain called the carotid artery or the arteries of the leg, remain debatable candidates for the CACS.
What about risks of the CACS?
Other than a small out of pocket cost (insurance covered in a few states like Texas), other concerns are the possibility of creating undue stress, missing soft plaque without calcium, and the dose of radiation. For decades, cardiologists have relied on exercise nuclear testing using treadmill examinations. One measure of the dose of radiation is called a milliSievert or mSv. An exercise test with Cardiolite may expose a patient to 12 to 15 mSv of radiation. By comparison, a cardiac catheterization done in an efficient manner may expose a patient to about 10 mSv of radiation. In centers with the most advanced multislice scanners, the imaging has gotten so fast that the radiation dose of a CACS is less than1 mSv and on par with a mammogram.
Furthermore, a new research study has demonstrated that a CACS over 400 adds independent prognostic information even over the most advanced nuclear stress test.
Why do a CACS?
A CACS may provide life-changing information. For example, the European Society of Cardiology said that “there is overwhelming evidence that coronary calcification represents a strong marker of risk for future cardiovascular events in asymptomatic individuals and have prognostic power above and beyond traditional risk factors.” The same position statement indicated that in asymptomatic individuals a calcium score of zero was associated with a very low risk of heart events over the next 3 to 5 years (less than 1 percent per year). Individuals with a coronary calcium score greater than 1000 have an eleven-fold increase in risk of major events even if they are without symptoms. This is a huge difference.
No one should be surprised by heart disease. A CACS at age 40 or 45 can identify if there is a burden of silent calcified atherosclerotic plaque. If silent heart disease is found, a range of measures from plant based reversal diets, exercise, stress management, supplements, and monitoring can be implemented. In my clinic, I monitor patients with abnormal CACS and work on reversing their plaque with all of these strategies. Yes, $80 can save a life (perhaps $150 in your community). Do not wait. Call your local hospitals to see if it is offered, find out the cost, get a Rx from your health care provider, and schedule a CACS today. Finding out your score can help you ride the waves knowing the true status of your heart health.
Dr. Joel K. Kahn, MD, FAAC
Credit: Huffington Post, with permission of Dr. Joel Kahn
In this piece, renowned cardiologist Dr. Joel Kahn shares what you need to know about eating for optimal health. If you're interested in learning more, check out his mindbodygreen class, Everyday Hacks for Long-Lasting Health: How to Eat, Move & Live for Longevity.
There seem to be more opinions on optimal eating patterns than there are stars in the sky. So when a major scientific contribution to nutrition comes out, it's important to take note.
Such a report was published in a major medical journal this week: It's the largest study ever comparing animal protein sources (red meat, poultry, fish, eggs, and dairy) with plant-based protein sources (bread, cereals, pasta, nuts, beans, and legumes). It examined over 130,000 participants, spanned 32 years, and was authored by some of the world's leaders in longevity and nutrition (Dr. Walter Willett of the Harvard School of Public Health and Dr. Valter Longo of the University of Southern California). In other words: Before you express any opinion on what your breakfast, lunch, and dinner should comprise, you need to pay proper attention to this study first.
Here's what you need to know:
What did the study look at?
A group of 131,342 participants in the Nurses’ Health Study and the Physicians Health Study was followed from as early as 1980 until 2012. They completed questionnaires about their dietary intake, and the follow-up rates were an amazing 95 percent. Overall, there were 36,115 deaths with 8,851 due to cardiovascular disease (CVD), 13,159 from cancer, and 14,105 from other causes.
What did the researchers find?
In short, the higher the intake of animal protein sources, the higher the rate of CVD and mortality. In contrast, those who ate more plant-derived protein had lower rates of mortality and, in particular, CVD deaths.
What else should you know?
Participants who were obese and had the highest alcohol intake who also ate animal protein sources had the highest death rates. The association between eating animal protein sources and increased death was strongest for those with unhealthy lifestyles. Those with the unhealthy lifestyles and increased death rates ate more unprocessed and processed red meats, eggs, and high-fat dairy and less chicken, fish, and low-fat dairy. The association of increased death rates in those who consumed more animal protein sources was also stronger in participants with diabetes mellitus.
The researchers calculated that opting for plant protein sources in place of animal protein would greatly reduce CVD deaths. They also found that switching from eggs to plant proteins was associated with a 17 percent drop in cancer deaths.
The strengths of the study were the large sample size, repeated dietary assessments, and high follow-up rates for up to 32 years. The weaknesses included the observational nature of the data.
The bottom line: Eat plants for your protein
The study authors concluded that "high animal protein intake was positively associated with mortality and high plant protein intake was inversely associated with mortality, especially among individuals with at least one lifestyle risk factor. Substitution of plant protein for animal protein, especially that from processed red meat, was associated with lower mortality."
Of course, it's only a matter of time until counterarguments about the advantages of grass-fed and organic sources of animal meats, eggs, and dairy surface. But the data are robust, and the message is clear. Animal proteins, as found in meat, eggs, and dairy, are unaffected by the manner of animal husbandry and there are multiple pathways linking animal proteins to inflammation, disease, and death.
The time is now to limit or eliminate animal protein food sources in favor of the wide range of delicious and healthy substitutes found in every grocery store. We must replace our gluttony for eating animals with responsible and compassionate choices.
Joel Kahn, MD, FAAC
Oh, the controversy over green smoothies and juices! Are they great for you...or not so great? Of course, if you're choosing between a green juice and a doughnut, there shouldn't even be a moment's discussion. But beyond that, the web is studded with debates and arguments for and against green juices and smoothies.
As I write this, I'm drinking a cold-pressed juice of chard, kale, celery, cucumber, lemon, and spinach, without added fruit. Am I causing harm or helping my health?
Let's dive into the science. In the last few years, a new system has been identified in our bodies that supports heart health: inorganic nitrates. Leafy greens and some other vegetables, like beets, are rich in them. When we swallow these nitrate-rich vegetables, they are rapidly absorbed in our GI tracts and appear in our bloodstream. They can be converted by the way of enzymes into nitric oxide (NO).
Let's all give a big cheer for NO. This miracle gas is made in the lining of our 50,000 miles of arteries (endothelium). When our arteries produce a lot of NO, our arteries relax, our blood pressure is normal, our blood is less likely to clot, and our arteries resist making plaque. There's another reason to be grateful for NO. When we want to have sex, it's NO that causes blood vessels to dilate and engorge the parts that need to grow. In other words: When you want to say yes to sex, say NO.
So when we eat leafy greens and drink our green juices and smoothies, the dietary nitrates power our blood vessels and improve the overall quality of our lives.
Then what's the controversy? There's an argument that to get the effects of dietary nitrates, our food needs to come in contact with bacteria on our tongue that convert the nitrates to make NO in our arteries. If you quickly gulp your green juices or smoothies past your tongue, you may not permit time for the bacteria to munch on the dietary nitrates.
But there is a secret, second pathway that you should know about. When our blood level of nitrates rise after eating or drinking plant-based nitrate-rich foods, the nitrates enter our salivary gland and are concentrated in our saliva. Our saliva may have nitrate concentrations 10 times that of our blood. How convenient! The green drink we swallowed 45 minutes ago may be secreted right on to our tongue to enjoy the bacteria-nitrate interaction. So if the bacteria don't get your dietary nitrates the first time down, this "entero-salivary" recirculation makes sure they get them the second time around. Is that not amazing?
So, fear not the green juices and smoothies. In fact, enjoy them! (But leave the fruit content low or absent.)
Here's one of my favorite detoxing green smoothies that will make your arteries say Hallelujah.
- 1 cup green tea, chilled (or 1 teaspoon matcha green tea in water)
- 1 cup loosely packed cilantro
- 1 cup loosely packed organic baby kale (or another baby green)
- 1 cup organic cucumber
- 1 cup pineapple
- juice of 1 lemon
- 1 tablespoon fresh ginger, grated
- ½ avocado
Place ingredients into a blender and puree until smooth.
Joel Kahn, MD, FAAC
I don't like to be an alarmist. The world is not coming to an end tomorrow. But the fact that we've created a far dirtier planet cannot escape posing some serious concerns.
In my field of cardiovascular disease, air pollution as a trigger for heart attack and death is rarely mentioned but is highly supported by quality research. Indeed, in a rather shocking analysis, living near a freeway was equated as a health risk to passively smoking 10 cigarettes a day. And the famous Framingham Heart study recently added to the huge database of research studies by identifying a relationship between air quality and cardiovascular inflammation.
So, perhaps like you, I hold my breath as long as possible when a truck or bus burps dark black fumes on the sidewalk—and I will not visit Beijing without a gas mask!
Of more immediate concern is indoor air pollution, right in your own home. The World Health Organization recently published a document that shocked me with statistics that might just push me into alarmist mode. Some of the facts they report on air quality in our homes and health include:
- Around 3 billion people cook and heat their homes using open fires and simple stoves burning biomass (wood, animal dung, and crop waste) and coal.
- Over 4 million people die prematurely from illness attributable to the household air pollution from cooking with solid fuels.
- More than 50 percent of premature deaths due to pneumonia among children under age 5 are caused by the particulate matter (soot) inhaled from household air pollution.
- There are 3.8 million premature deaths annually from noncommunicable diseases including stroke, heart disease, chronic obstructive pulmonary disease (COPD) and lung cancer that are attributed to exposure to household air pollution.
Did you read the same words I read? Over 4 million people a year die from illnesses related to household air pollution. Of these deaths, 60 percent are due to stroke and heart disease—the conditions that I, as a cardiologist, am striving to prevent at all costs!
Two scientific studies have looked at the utility of high-quality air filters in the home to reduce indoor air pollution and heart disease measures, with different results. One demonstrated some reduction in the impact of nearby traffic air pollution in a residence using an air filter while another failed to show any benefit. A recent review on the topic favors a home air filter, with benefits for conditions from asthma to blood pressure. But clearly the jury is still out on the topic.
Until there is more information, here are five simple steps you can use to keep your indoor pollution down:
1. Keep your floors clean with door mats, regularly mop to pick up the dust, and use a vacuum with a HEPA filter.
2. Keep your home lower in humidity, as mites and mold love moisture. Fix leaky plumbing, vent the clothes dryer, don’t overwater plants, and use an exhaust fan when cooking, bathing, or running the dishwasher.
3. Make your home a no-smoking zone—that includes a wood-burning fireplace and grilling indoors. Do not have indoor fires whether for pleasure, heat, or cooking.
5. Avoid fragrances that use synthetic and volatile organic compounds (VOCs) that plug in, get thrown in the dryer, or are sprayed in the bathroom. Enjoy natural good smells as much as possible.
Considering all this, I've placed a powerful HEPA air filter in my bedroom. I have two rescue dogs that sleep on my bed every night after visiting every bush and flower bed all day long. Plus, the windows are open with screen doors blowing in all kinds of outside matter that I'd rather be filtered out. And I'm guilty of not taking my shoes off at the door (despite my wife’s reminders). I take comfort in knowing that the low-grade hum of a HEPA filter I hear at night is circulating and filtering the air I breathe. It may be a consideration for your home, too.
Joel Kahn, MD, FAAC
How To Defend Your Vegan Diet To Your Skeptical Doctor
In this piece, renowned cardiologist Dr. Joel Kahn shares the benefits of a plant-based diet and explains how to present them to your own health care provider. If you're interested in learning more, check out his mindbodygreen course, Everyday Hacks for Long-Lasting Health: How to Eat, Move & Live for Longevity.
I've followed a plant-based diet since 1977, when the salad bar at my freshman dormitory at the University of Michigan was the only choice that looked edible. Today, I'm now an academic cardiologist as well as the owner of an award-winning plant-based restaurant in Ferndale, Michigan. That means I receive many questions about plant-based nutrition. One of the most common questions I get: "My doctor isn't supportive of a plant-based diet. What information can I share?”
Fortunately, the Kaiser-Permanente Medical Group, one of the nation's largest health plans, produced an excellent document, “Nutritional Update for Physicians: Plant-Based Diets,” that's a great resource to share with your health care provider. It appeared in a peer-reviewed journal and includes many scientific references your provider should respect. The paper presents a balanced view of plant-based nutrition—including five main benefits of the diet and five concerns—and can help your doctor understand your health journey. Here's a summary:
The key benefits of plant-based nutrition
1. It fights obesity.
In a review of studies on the topic of weight management, the report notes a number of main findings:
- “A vegan diet caused more calories to be burned after meals in contrast to nonvegan diets."
- “Vegetarian diets are nutrient dense and can be recommended for weight management without compromising diet quality."
- “A plant-based diet seems to be a sensible approach for the prevention of obesity in children."
- "Plant-based dietary patterns should be encouraged for optimal health.”
This information, along with the supporting references, can assist you in explaining why you're following a plant-based diet.
2. It can prevent diabetes.
The report also reviewed the fact that plant-based nutrition may offer an advantage for the prevention and management of diabetes. They noted that a "low-fat, plant-based diet with no or little meat may help to prevent and treat diabetes” and that “people on the low-fat vegan diet were able toreduce their medication."
3. It lowers high blood pressure.
When it comes to managing blood pressure, the report also found that “vegetarian diets were associated with lower systolic blood pressure and lower diastolic blood pressure."
4. It can reverse heart disease.
The strongest data for the health benefits of plant-based nutrition are for heart issues. The authors reviewed data from Dean Ornish, M.D., including the startling finding that “regression of even severe coronary atherosclerosis after only one year” was observed. In another study group, “vegetarians had a 24 percent reduction in ischemic heart disease death rates compared with nonvegetarians." Those are pretty convincing statements.
5. It could reduce mortality.
Need one more powerful reason to choose plant-based nutrition for your health goals? The Dietary Guidelines Advisory Committee notes that “plant-based diets were associated with a reduced risk of cardiovascular disease and mortality compared with non-plant-based diets."
The main concerns about plant-based nutrition:
The authors note that “generally, patients on a plant-based diet are not at risk for protein deficiency." They go on to say that “a well-balanced plant-based diet will provide adequate amounts of essential amino acids and prevent protein deficiency." Let’s give a giant supportive cheer—that should help answer the #1 objection you'll likely hear from your doctor.
Iron stores may be lower if you follow a plant-based diet. But the authors also note, "iron-deficiency anemia is rare even in individuals who follow a plant-based diet."
3. Vitamin B12
According to the report, “individuals who follow a plant-based diet that includes no animal products may be vulnerable to B12 deficiency and need to supplement their diet with vitamin B12." That is a fair statement and a good plan of action.
4. Calcium and vitamin D
There are a number of plant-based sources high in calcium, including greens and tofu. And vitamin D is found in soy milk and cereal grains. The report also notes: "Supplements are recommended for those who are at risk for low bone mineral density and for those found to be deficient in vitamin D." I'd advise you to ask for a blood level of your vitamin D-25OH.
5. Fatty acids
Linoleic acid (an omega-6 fatty acid) and alpha-linolenic acid (an omega-3 fatty acid) are the two essential fatty acids. Vegans are most likely to be deficient in omega-3. “Foods that are good sources of n-3 fats should be emphasized," the report says. "They include ground flaxseeds, flax oil, walnuts, and canola oil." Increasingly, blood tests that measure omega-3 levels are available and not expensive. I advise them for all of my patients, vegan or not.
Overall, the Kaiser-Permanente update is a great resource to help you explain your diet to your health team. The authors note that “the major benefits for patients who decide to start a plant-based diet are the possibility of reducing the number of medications they take to treat a variety of chronic conditions, lower body weight, decreased risk of cancer, and a reduction in their risk of death from ischemic heart disease”—that's a powerful endorsement that more in the medical world need to read and incorporate.
I recently handed out many copies of the Kaiser-Permanente paper to guests of my restaurant, which is often populated by medical residents, students, and health care providers. Print out the paper yourself, and share it with your health care team—I hope it makes your journey easier.
Joel Kahn, MD, FAAC