Lifestyle Modification: Easier Said Than Done
Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University, on theheart.org on Medscape Cardiology.
Over the past few months -- maybe the past year, it would be fair to say, and it has certainly intensified in the 6 months since the American Heart Association (AHA) meetings -- there has been a lot of discussion in the cardiovascular community about cardiovascular prevention. This came to the forefront in the past 6 months because there was intense interest in the prevention guidelines.[1] But we also have the AHA 2020 impact goals.[2] We have the Million Hearts program, which is nearing its halfway point. We have the United Nations talking about World Health Organization forums on noncommunicable diseases.
The message from this for me is that all of us in the cardiovascular community -- whether we are talking about the practitioner community, the broader public as represented by such entities as the Centers for Disease Control and Prevention (CDC) and the AHA, or those interested in global health -- all of us see the burden of cardiovascular disease as a major public health issue. In fact, one might say it is a major public health scourge.
In our prevention guidelines, which we have talked about on this show, we have tended to focus on risk assessment and have talked less about therapy -- although it is important to note that our prevention guidelines did have a document headlining the topic of lifestyle modification.
But I (and I suspect many of you in practice) find the issue of lifestyle modification quite challenging when taken into the actual practice of medicine. We all talk about it. We all say we should really focus on lifestyle modification when we have our patients who are at moderate to high risk for a cardiovascular event, but we don't necessarily a great job.
So today I am really pleased to welcome to the show Dr. Stephen Devries, who is the Director of the Gaples Institute for Integrative Cardiology. Dr. Devries is a preventive cardiologist with a lot of experience over the past few decades of really focusing on prevention strategies in cardiovascular disease. He is also currently Associate Professor of Medicine at Northwestern University in Chicago. Steve, thank you for joining us today on Medscape Cardiology.
Stephen Devries, MD: It is a pleasure to be with you, Bob.
What Is Integrative Cardiology?
Dr. Harrington: Let's jump right into it. I want to really explore this issue of lifestyle and what we can do both for and with our patients from multiple perspectives, but let's set the stage for our listeners. I should also note that you have coedited a textbook on integrative cardiology with my friend Dr. Jim Dalen -- who, I had mentioned to you off the air, was the Chair of Medicine when I was a medical resident -- so it is nice to see his name there. But I am wondering if you can tell the listeners: What is integrative cardiology?
Dr. Devries: Integrative cardiology is the intelligent integration or combination of natural approaches to health, defined as nutrition and lifestyle combined with the best in conventional medicine. All of the medications and procedures and the guideline-based therapy are included -- but also a larger scope, maybe a larger palette, of treatment options related to nutrition and lifestyle, and activities that can empower patients from their own lifestyle. That is integrative cardiology.
Many people consider integrative medicine to include the use of supplements and unproven strategies, but I don't look at it that way at all. I really think that the evidence base has to be there for whatever we do, but there is a wide range of evidence to support the emphasis on lifestyle and nutrition that isn't applied as strongly as it could be, and that is the goal of integrative cardiology.
Make Nutrition as Important as Medication
Dr. Harrington: That is a fantastic summary, and you might imagine that I both appreciate and enjoy you stressing the issue of "evidence-based." Our listenership will also appreciate that.
It was interesting to me that when the prevention guidelines were rolled out by the American College of Cardiology (ACC); the AHA; and the National Heart, Lung, and Blood Institute (NHLBI) last fall, there was a document on lifestyle,[1] but it seemed to be relegated to the second part of the conversation -- even though in the approach to the patient, it is always stressed as the first part of the conversation. But what got the attention was not lifestyle; it was everything else.
I am looking for help for our listeners (and me) about how to approach the issue of nutrition and lifestyle with patients. Let's start specifically with our cardiovascular patients. Many of the patients whom cardiologists see -- if not most of them -- have diagnosed disease, so let's take that group first before we get to the primary prevention group.
Dr. Devries: Whether it is primary or secondary prevention, my vision is that currently, cardiologists are acknowledged as experts in the treatment of cardiac disease. But I think the future vision that would be great to look to is where cardiologists are dually recognized for expertise in prevention, be it primary or secondary, as well as in treatment.
As you said, when the guidelines came out, the focus was on the statins[3] and the indications for them, and the calculators[4] and so forth. As you exactly mentioned, we all say that lifestyle is the foundation of health, but our practice doesn't always support that emphasis; that is where a lot of attention needs to be paid, and where there is tremendous opportunity. In so many studies, you can barely go to a conference where the final sentence isn't "We need more research on this topic," and although certainly there are areas in nutrition that are controversial and need a lot more research, there is also a tremendous amount that is very well established but not put into practice. I would enjoy the day when guidelines are released and the focus on lifestyle is equal to, if not eclipsing, the focus on what to do with medications.
An interesting study[5] came out just a few months ago that compared a group of individuals who were prescribed statins with a similar group who were not prescribed statins and had lesser cholesterol problems. The investigators looked at the follow-up over 10 years, and they saw that the individuals who were prescribed statins actually consumed 10% more calories than the non-statin users. Although it wasn't proof, it raised the suspicion that many people feel that when statins are prescribed, there might be a subtle implication that there is a green light to be more liberal with the diet, and it doesn't matter as much now that you are on medication.
A more integrative approach says that the statins are incredibly important when given to the higher-risk individuals, but let's address the nutrition and lifestyle to a degree equal to that of the medication. We are really focused on compliance with statins and getting people on them, but compliance with and attention to diet doesn't get stressed nearly as much.
And an article came out in JAMA[6] last year that showed that among 17 risk factors, nutrition was the number 1 for US death and disability; it looms even above all of the other terrible things that we need to work on, such as smoking, physical inactivity, and so forth. Nutrition probably is the number 1 target. It is the low-hanging fruit that we really need to focus on.
Dr. Harrington: I like your analogy or your visual of the low-hanging fruit because as Salim Yusuf showed in some of his recent epidemiologic work around the globe, the decreasing amounts of fruits and vegetables in our diet, along with tobacco use and physical activity, are 3 of the key lifestyle aspects that raise the risk for cardiovascular disease. I, like you, found great interest in that article about the 10% increase in dietary indiscretion, if you will, among the statin users. More than once, I have been to dinner with colleagues who, as they order their dinner, say, "Well, I'm not worried; I'm on my statin." It's a bit tongue-in-cheek, but I don't think that is an unusual sentiment.
Focus on Diet, Not Nutrients
Dr. Harrington: Tell me, what is your diet of choice? I am guessing one that is heavy on fruits and vegetables and low in saturated fats, but I wonder if you could help the practitioner a little bit. Give some specifics about the sort of diet that you think is evidence-based and consistent with an approach toward integrative cardiology.
Dr. Devries: An executive summary would be a Mediterranean-style diet -- which is, as you mentioned, heavy on vegetables and fruit, and involves whole grains instead of refined and more fish and less red meat. In addition, the cooking oils should be predominantly olive oil and canola-based oil. That is it in a nutshell.
But I would like to speak a little bit about the distracters. As you know, there has been a lot of controversy about the role of saturated fat[7]: Is it the big problem that we made it out to be, and did we just cut down on saturated fat and replace it with sugar and end up trading one ill for another, with no net benefit? Probably all of the above are true, but I think that when we focus on individual nutrients, we can really lose the path.
The idea is that we don't consume saturated fat; we consume pizza, desserts, cookies, and cakes. So if you focus on individual nutrients, I think it can be very misleading. It is interesting that when we are talking about saturated fat, among the top 5 dietary sources of saturated fat in the United States are pizza, grain-based desserts, and dairy desserts. The problem may be in part that these foods are high in saturated fats, but there are other things that come with the pizza: the high salt content, the high carb content, and so forth.
What can help clear up a lot of confusion for people is that instead of going from nutrient to nutrient (is it saturated fat, or is it the sugar?), it is probably a combination of both of them, and it is very complex. But if we go to a whole-diet approach, such as a Mediterranean-style diet, I think it really cuts down the chances of being misled and being led astray by focusing on nutrients. Looking at whole-diet patterns that have been proven to be beneficial is, I think, the beauty of this evidence-based approach.
The Lyon Mediterranean diet study,[8] which was secondary prevention, showed a whopping 72% event reduction in the Mediterranean-style diet group compared with the control group who just watched their fat intake. The PREDIMED study[9] that just came out last year showed a 30% decrease in vascular events in a primary prevention trial. We have, I think, really strong data to support a whole-diet approach, and I think that if we focus on that arena vs is it this nutrient or that nutrient, we will be in far better shape.
It's the same thing with the salt controversy. Instead of trying to decide which of the cut-points is the most accurate one for sodium intake, we should look at the US dietary intake of salty foods. The number 1 source of salt intake in terms of the amount in the US diet is, amazingly, bread. Most people would think it would be something much saltier, such as pretzels or soup, but we eat a lot of bread, and bread has a good amount of salt. It therefore ends up being the number 1 dietary source of salt intake in the United States.
Is there anyone who thinks that we should be eating more bread than we currently do? Absolutely not. Pizza is also high in salt. No one thinks that we should be eating more pizza. So instead of wondering about which cut-point to use for salt, I think it is more instructive to look at the foods that contribute most to salt in the US diet or saturated fat or whatever and to look at them as a whole.
That, again, is the beauty of the Mediterranean-style diet. It looks at whole foods and food groups that have been shown to be beneficial.
Dr. Harrington: Steve, I think that is a nice holistic overview of thinking about, as you have nicely put it, the big picture as opposed to focusing on and obsessing about the individual nutrients.
Let me ask your opinion quickly on a controversy that we have talked about on this show before: the so-called Atkins diet, or the paleo diet. They get a lot of press, and there are many people who say, look, the only way I can really lose weight is if I focus on taking all carbs out of my diet and replacing them with protein. What is your current thought, because the data on those sorts of diets are mixed?
Dr. Devries: There are no long-term data on either of those diets. The fact that over a period of a few months or even a year, you might have favorable impacts on some biomarkers, I don't think is the end goal. As clinicians, we are all interested in patients living longer and better; those are the endpoints that we really care about and that have not been shown for those diets.
Dr. Harrington: Right. Do the patients live longer or feel better?
Dr. Devries: Exactly. The interesting thing about diet, unlike drug studies, is that when you are dealing with a diet that either is focused on exclusion, such as a low-fat diet, or one that promotes something, such as a high-carb diet, then in addition to the area of focus (low-fat or high-carb), we also have to look at what you are using to replace this -- what is being replaced, and what is being added.
When most people change their diet, unless they are trying to intentionally reduce the caloric intake (a good goal for many), if they are adding or subtracting something, then something else is being substituted to take its place. When you are looking at a low-fat diet, usually you are also looking at a high-carb diet. So it is complicated that way, in terms of trying to really understand what you are doing with the diet.
With a drug study, you can either add the drug or not -- but for diet, because we all tend to eat the same caloric intake every day, then if we are going to take something out, we are in general going to put something else in. The question is, what is the net benefit?
So even in diets that may not be optimal, if you are replacing something that is even worse, you may be in better shape than you were before. But is that an optimal diet? Possibly not.
Dr. Harrington: And is it sustainable? One of the things that all of us face is that this is quite difficult from our patients' perspective. As you know, we have not just a national, but a global, epidemic of obesity and an increasing incidence of type 2 diabetes. If you look around the globe and look at the maps -- a heat map, if you will -- of the rising incidence of diabetes, it is frightening. It is as frightening as the worst epidemics we have seen around the globe.
How do we help our patients with this? We are all talking about it. We all believe that it starts with nutrition and lifestyle -- as you said, physical exercise, and reducing or eliminating consumption of tobacco products. How do we help our patients? What advice can you give both to doctors and to patients about putting this into practice?
Physician, Heal Thyself
Dr. Devries: One of the best ways in which we can help patients, paradoxically (you might not expect this answer), is to first help ourselves. There are some fascinating data showing that healthcare providers who change their own personal lifestyle are much more likely to counsel patients with regard to lifestyle.[10] The first area is self-care -- not only for our own health, but because there is a great downstream effect.
Beyond that, you should get a meaningful baseline through intake forms that include more detailed questions about diet. The idea behind that is that everyone is busy, and busy cardiologists may have only 1, 2, or 3 minutes in a clinic visit to address nutrition -- but I firmly believe that 1 or 2 quality minutes can make a huge difference.
Decide that you are going to focus on one nutrition topic for this visit. It may be the case that the patient before you drinks a lot of soda, so maybe those 1 or 2 minutes are devoted to the importance of eliminating sugar-filled beverages. Or in another case, it could be the importance of adding dark-green, leafy vegetables or dark-red or purple fruits (blueberries and strawberries), which have been shown to be helpful.
Take 1 or 2 quality minutes, and make them count. And most of all, you should impart to the patient the idea that nutrition is really the foundation of health, and that even though patients are getting the medicine (they need to be on their medication), the nutrition part is still a priority that goes hand in hand with the medication.
Dr. Harrington: There are several things that you said that I will repeat, because I think our audience should reflect on them. Number 1, the notion of "provider, heal thyself" is a terrific one. I would agree with you that as I look at some of my colleagues who are pretty effective in this space, they tend to be my colleagues who have adopted a very fitness-focused, nutrition-focused lifestyle themselves. So that's a point worth emphasizing.
I love the idea of taking 1 to 2 minutes per visit and devoting it to a specific topic that is germane to that patient. It is something that we can all do, and it is worth highlighting.
And the final point is to think of good nutrition as foundational for health. That is certainly a phrase that resonates with me, and I suspect with many of our listeners as well.
Steve, I want to thank you for joining us here on Medscape Cardiology. This has been a terrific discussion about integrative cardiology, combining nutrition and lifestyle with the best in conventional medicine in an attempt to improve the cardiovascular health of all of our patients.
Steve is the Founder and Director of the Gaples Institute for Integrative Cardiology. He is also an Associate Professor of Medicine at Northwestern. Thanks for joining me here today.
Dr. Devries: Thank you so much, Bob. It has been a real pleasure.
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Cite this: Heart-Healthy Diets Deciphered, With Dr. Stephen Devries - Medscape - Jul 14, 2014.
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