Hello everyone, welcome to our August Lifestyle Psychiatry Caucus webinar. We have today a treat for everyone. It's Dr. Kaushik Reddy, who's an interventional cardiologist at the James A. Healy VA Medical Center in Tampa, Florida. And over the course of over maybe 16 to 18 years, he's played a crucial role in developing many programs at the hospital, and now serves as director of interventional cardiology in the coronary care unit. He was the first interventional cardiologist to be board certified in lifestyle medicine. And he's also has a distinction, very small group of people have this distinction of lifestyle medicine intensives. You can ask him more about that if you want to know what that is. He has published many papers, has been in leadership positions in the ACLM, the board of directors, and he's the founding co-chair of the Cardiology MIG and the VA DOD MIG. It's a pleasure to have him. I was just looking at a TED Talk before I joined here. If you guys, I'll put it in the chat a little bit later so you guys can see it as well. Dr. Reddy, thank you so much for joining us. Thank you. Thank you, Dr. Murlo, for that kind introduction and also the organization and Dr. Murlo both for the invitation. And I'm like, oh, wow, you know, I am a cardiologist like you heard. And yeah, I always tell my people, hey, look, I'm smart enough to tell you that a lot of, you know, you know, stress and depression have direct cardiac implications, but I'm not smart enough to pretend that I'm going to be the one treating you. So that's the extent of my, you know, knowledge about psychiatry. But in terms of, you know, lifestyle medicine, and I asked Dr. Murlo, like, you know, do you guys want me to do my conventional cardiology, like an umbrella overview of lifestyle medicine and say, yeah, that's what we want to hear. So here we are. And again, thank you for the invitation. And in terms of the title as to how I came about that, that, trust me, that in itself is a presentation as to why and how I came about that presentation. And that said, I have no conflicts of interest or disclosures of financial or any other kind. I've been a career, you know, academician with the VA and the USF here, so no conflicts of interest there. And the first and foremost is, you know, my very presence on this stage is, let me minimize this. My presence on this kind of a virtual stage is, or any across the country when I speak is because this is actually, I'm going to advance the slide, oh, there we go. This is my, this is my stage. This is where I live. This is where I literally had to rush home this afternoon, handing a procedure to one of my, my partners to be able to be here because this is where I trained. This is where I work. This is where I teach. So this is unusual for the likes of me to step outside the confines of that, what I call the dark dungeons of a lead shielded cardiac cath lab and make a humble plea for myself, my colleagues, my family, my patients, my friends, anybody who, you know, I have a reach is to, because most of what I do is preventable. And another harsh reality is that, you know, Doug Morrison is, is one of the legends in cardiology. He famously wrote this, that nothing, nothing, nothing, not statins, not angiotensin receptor blockers, not beta blockers, and most assuredly neither bare metal or drug diluting stents or even bypass grafts. The last part is the key component here is either a cure for coronary disease or is risk-free. And for me, it's the risk-free as somebody who invades human bodies on a daily basis for quote unquote, a treatment, uh, it, they come with a lot of risk, uh, for something that is preventable in close to 80% of us. And that said, I'm still the guy who does some very complex procedures on a daily basis, except I do them fearing a lead that has carrots on it. I'm also an interventional cardiologist who proudly under every pair of scrub top that he has, um, uh, where, uh, this embroidered, you know, a carrot and a stent it's, you know, as you all know, a carrot is not a stain in a replacement for a stent, but call it a metaphor, uh, or a message on a scrub top, a larger message. And that message is this, what Dr. Merlo was talking about is at the request of the VA at the national level, uh, I recorded this in the thick of COVID in the basement of our hospital. And what has now become what I probably call the 15 or a 16 minute version of what has now become my life's mission, uh, is to spread this word about nutrition and evidence-based lifestyle strategies for the prevention of cardiovascular and many other diseases. And, uh, you can go to YouTube and just simply type carrot and a stent it's usually the first hit and, uh, you know, let us know what you think. And I usually start this presentation with three questions. The first one is what is my why? Right? I, my, my plate, uh, is already double, triple full with everything that I do as a cardiologist and now lifestyle medicine and prevention and other responsibility. And, uh, and, and to me, it's a fun obligation is because primarily because of this I slash we all, we took an oath and most physicians and most people in healthcare don't know this, that these, these words, the simple sentence was added to the, you know, the, in a millennia old, uh, oath only in 1969 influenced not by a policymaker or not by an interventional cardiologist or some subspecialist, but by a single primary care physician from California that I will prevent a disease whenever I can for prevention is better than cure. And we take this oath, not as specialists in the silos of a cat lab or a dialysis unit or an intensive care unit, but as medical students, that means they should be like the foundation of no matter where we branch off off after medical school. But you know, why have we forgotten that? So the next one is what does health actually mean to us, including as physicians and healthcare professionals? When was the last time we took a moment of time and actually try to answer this question for ourselves that health being not just the mere absence of disease or infirmity, but the presence of total physical, mental, and social wellbeing. And this is defined by the World Health Organization when, when, when, when the organization was founded and the definition still stands. And the next question, I literally ask this, my patients every Friday, when I teach, I'm going to talk to you about as to what that is briefly toward the later portion of the presentation is to why do you want to be healthy? And if I were to put each one of you on the spot and actually make you answer this question, you will come up with some very, very meaningful reasons, very personal, or even make you write an essay as detailed, as emotional, and as verbose as that, that essay may be, all those categories will fall into only two broader reasons as to why a fellow human being wants to be healthy, quality and quantity. Although I'm showing this as two separate reason, two separate boxes, you don't need me to tell you that they are intricately related and inseparable. So what I want to do is to take you through a quick journey through a, through a graph, plotting you know, plotting a graph using those two reasons why any one of us wants to be healthy. You know, social anthropologists call this concept of rectangularization of life. Some of you may know this is that, you know, to do that, I want to take you back a century. In 1920, an average person in this country died at 45 and quality of life went down very rapidly. You know, I cringe when people say good old days, now, olden days were not good. And for those reasons, you know, kind of, you know, the graph looked like a triangle. In 24, we have made tremendous progress, tremendous progress compared to that generation. But unfortunately, our life's graph looks like this bizarre convoluted shape down the slope of which we are accumulating diseases early on. Now why would I say that, you know, and you know, on the screen, I saw a mother with babies, right? Childhood obesity, childhood medical conditions, childhood disease, childhood dietary patterns, to a point that diet induced risk is now the leading cause of disease, disability and death, not just cardiovascular, but all. And you know, the decision that we're making as a society to be in our babies of breastfeeding at six months has generational implication. Childhood obesity, like none of us ever imagined possible, diabetes and male sexual dysfunction are on the rise. Like I never imagined possible when I graduated medical school some almost 30 years ago, hypertension and hyperlipidemia combined close to 65% of the population that we know of, and no wonder heart disease continues to be the leading cause of death, a stroke or two and congestive heart failure. Yes, I am living longer, but guess what, folks, I'm busy being dialyzed at a unit and not having fun with my grandchildren or children on a cruise ship, but guess what, I'm alive. So if you add those conditions like that, the combined loss of quality of number of years in America is about 23.6 years. That's so many years an average person is losing to lack of quality in his or her life. What I argue is that is, can we at least make an attempt to maintain a quality of life at a very high level and come the time I randomly chose 100 and we drop. I call this concept simply the concept of living longer and dying short. Now from a triangle to a bizarre convoluted shape, the graph looks like a rectangle, hence social anthropologists calling it rectangularization of life. I simply call it life in a box because no matter how hard I try, sooner or later, that's where we will all end up. If I may paraphrase one of my mentors, Kim Williams, I don't want that fall to be mine. Meaning I'm not afraid of death. I just don't want it to be my fault. When I say my fault, I want to bring this to your attention that health being an inside job for the most part, for the most part, of course, there are exceptions to this so much so that I actually break the word heal healthy into heal thyself. That said, you know, again, when I, when I use the word fault, it is not with the intent of shaming somebody or blaming a person, individual or a system or a society, but it is the intent of bringing to everybody's attention that for the most part, staying healthy also comes with a sense of personal responsibility. When it comes to that, these words written in Chicago Tribune in 1975 ring true even today that the idea of preventive medicine is faintly un-American. It means first recognizing that the enemy is us. Now when I, again, I'm not trying to blame or shame anybody, but the idea is to bring to everybody's attention, this clear distinction, majority of what we do is not health promotion. What we do is disease management, skillfully inserting two stents into somebody's coronaries while disease is preventable in the midst of an ongoing massive heart attack is not health promotion. It is disease management. And I can give you limitless examples like that so much so now I question our own paradigm if the letters MD next to my name merely mean manager of disease. What diseases are we talking about? These are not some rare, you know, autosomal recessive disorders. These are common, everybody, almost every single one of us have someone within our first circle of life are currently suffering or lost a battle to these diseases that are affecting six in ten of us with at least with one, four in two of us with at least two, costing us enormous amount of money in addition to loss of life. Now just want to make a point, I picked the leading causes of death in 2020, the year of catastrophic global pandemic where everything was chaotic, policy, public health, politics, everything was, you know, and personal protective equipment. In the middle of that chaos, COVID-19 killed 345,000 people in America. Would you believe me if I told you in that disastrous phase, heart disease that is preventable in 80% of people killed twice as many people. The only year this was not the case where heart disease was not the leading cause of death in America was during a very brief period during the 1914 pandemic. Same thing continued in 21, 22, but the trends of this cardiovascular disease have not been, you know, as bad as we think. We have made actually a tremendous progress compared to the 60s and 70s, just we call this concept the concept of bending the curve and majority, a vast majority of this bending the curve is primarily due to single public health policy of telling America to quit smoking or tobacco is bad for you. And we're still, you know, seeing the benefits of that one singular public health policy. But unfortunately, what we call in cardiology, the golden era of cardiovascular medicine over the past two decades, it's as if somebody took a ruler and flattened the curves. We are no longer bending the curves. If anything, there is a slight uptick despite all the advances in medicine, pharmaceuticals, policy, or, you know, systems improvement. I should not say policy systems improvement and, and procedural skills. And because of this, right, when I came to America in 95, there was not a single state in the union where the obesity rate was more than 20%. Today, we cannot find a state in the union where the obesity rate is less than 20%. All of this happened in just, just in one generation. And as a consequence of that, the biggest killer is making a deadly comeback, killing younger people, killing women who are non-smokers or falling victims to a preventable disease due to combination of skyrocketing obesity and diabetes. To showcase this to the general public about how dangerous this is, Wall Street Journal in 2019 wrote an essay about a young man who had been taking his blood pressure medications, been taking his cholesterol medications, exercised and ate healthy, quote unquote, but unfortunately died of a massive heart attack at 49, leaving behind a beautiful family. Now, if that's the case, I just want to show you in terms of secondary prevention, how are we, you know, every time we say we, when talking about society, healthcare professionals and the general public, how are we doing by individuals who have established heart disease? These are the highest risk when it comes to cardiovascular disease, because you already had an event, a stent and a bypass operation. What percentage of those people as of 2022 are meeting ideal cardiovascular, you know, risk factor control status? Turns out diabetes is controlled in less than half of people. Same thing with blood pressure. Cholesterol numbers are not controlled in 70% of people, right? 80% BMI is not controlled. Same thing, 22% of people are still smoking. Physical activity, 80% of people, almost 80% of people are not physically active. Now wait for the shocker. While diet induced risk is the leading contributor to cardiovascular disease. What percentage of Americans with established heart disease are eating a healthy diet, not as defined by the American college of lifestyle medicine, but as defined by the American heart association, you're ready for this 1%. And no wonder the editorial that went with this research paper called the current situation, the failing cardiovascular health, a population level code blue, right? So if that's the case, if the current trends continue, everything, every single cardiovascular risk factor is expected to go up anywhere between 20 to 40%. And in addition to risk factor, the disease burden is expected to go up by somewhere between 30 to 35% by 2060. That is the prediction. If this is the degree of burden in America, is America engaged in empowering itself in acquiring the knowledge to prevent a disease that's killing this many of us. To do that, I did a national Google search in 2019 to see if heart disease shows up. And as Mike Greger would say, some of you may know who this man is, is that he's frustrated that nobody Googled how not to die from heart disease. So while I come across like I'm blaming the society, how about my own community as in cardiovascular specialists? So a colleague of mine, not too far from here at UF, they did a beautiful analysis of a survey of 930 cardiovascular health professionals. 90% while diet-induced risk is the leading cause reported minimal or no training, minimal or no training in nutrition, right? Observation one. Question number two was Mr. and Mrs. Cardiologist, is nutrition important to you? And 80% said yes, almost close to 90% said absolutely, nutrition is important. How important? Is this your responsibility to teach this to your patients? Absolutely. 70% of us said close to 70, close to 68, 70% said yes, yes, it is. We have to teach this to our patients. So far, so good. If that is true, again, Mr. and Mrs. Cardiologist, are you being the change that you want to bring to the world, meaning that are you eating three to five servings of fruits and vegetables as outlined by your own societal guidelines? Turns out 70% said no. No wonder heart disease continues to be the leading cause of death amongst American cardiologists. So hence, there is an urgent, urgent unmet need that needs to start here with our children. This is the prevalence of cardiovascular risk factors amongst American youth. Just want to draw your attention to the red box that just popped up in the middle of your screens is ages 12 to 19. When the American Heart Association surveys this every year, ages 12 to 19, the signal for healthy diet score shows up as 0.0%. It is statistically undetectable. It is not some utopian, unattainable, crazy, like, it is a very healthy, practical, doable American Heart Association healthy diet. We don't invest in that when we need to invest in that window of opportunity. Three to five years, I would say even earlier, because prevention is a lifetime continuum. When people ask me how early I say from womb to tomb, or from lust to dust, or if you're a Hindu or an Indian in origin, I joke around with my community saying that you should have started lifestyle medicine in your previous life, because if you didn't, karma is going to come back to haunt you. Because if we don't do that, look at disease scores on this classical New England Journal of Medicine paper, if we don't invest in our children's cardiovascular health, the risk of events goes exponentially higher. And as a consequence of that, we pay a price, and most of that price, in addition to loss of life and suffering, in terms of actual dollar price, majority of that goes into hospital care and physician services. For that reason, our hospitals are constantly full. And I happen to be one of those people who believe that if our beds are filled, it means that we have failed. And I should not even be a person doing these type of presentations, because I have no training in prevention, I have no training in primary, well, I did have training in primary care, but I'm an interventional cardiologist who is eagerly waiting in a cardiac cath lab to save people's lives when everything else fails. The only reason I'm stepping out of the cath lab rushing home on a workday to do these presentations is, folks, because we as a society are failing everything else. And here is the proof, people who are actually trained to keep us healthy are the least financially rewarded. If you don't believe me, I'll give you a classical example of smoking cessation. I can't think of outside the context of public sanitation, antibiotics, and vaccination, I can't think of a better and more influential, you know, public health policy or counseling is smoking cessation does not even pay a physician a single RVU. The same patient shows up to my cardiac cath lab, well, not mine, but I work for the VA. But if I were to be in private practice, I do an elective stenting of the procedure, that procedure pays me 45 fold higher dollars, not 45%, but 45 times more money. For that reason, we have this inverted pyramid where the entire care is in tertiary medicine, secondary care. So the onus is on all of us to flip this pyramid back on its hell, back on its base, where the system, which is all of us actually cares for health. So how do we change that? In asking that question, I show this beautiful, you know, question mark shaped vegetables, but the New York Times last year was not so kind. How do we fix the scandal? That is, they called it scandal, that is the American healthcare, right? So what can we do, right? There's an information piece, that is today's lecture or presentation, right? But there's also an implementation piece, which is massive. How do we take the science of lifestyle medicine and prevention to make it practical, accessible, and also financially viable? But in America, if it doesn't make monetary sense, it ends up becoming nonsense, right? That's the capitalistic model. So to do that, nobody, nobody comes even close to what the VA has done, right? We produced a document called the Whole Health Passport. It's a turnkey event, public property, anybody can download it and implement a lifestyle medicine practice at a massive practice or a small scale practice. It's available, the Whole Health Passport. There's a policy piece that's missing, which is the National Academy of Sciences took the VA's model and they built a policy model around it and implementation models, and they called it Achieving Whole Health, a new approach for veterans and the nation. And the center is what's shown in the diagram is that very intricately linked the concept of whole person health, where you start with you being mindfully aware, and then you build these circles and support systems about working your body, surroundings, personal development, food and drink, recharging your mind, body and spirit, family and coworkers, that kind of stuff. To do that, I run two clinics, and I'll be more than happy to do, you know, any additional discussions and presentations as to the operations of those clinics called HEAL and CALM. At the VA, I run them on every Friday. But in terms of policy or implementation, I want to discuss three slides about how do we do it, is primary care. It's not the cardiologist or endocrinologist. The onus should be on primary care physicians, and they should be supported, not just the onus, but the support should go to primary care. But the question is what is high-quality primary care is pay for primary care teams to actually care for people, not doctors to deliver services. Ensure that high-quality primary care is available to every individual and family in every community. If they don't have it, we need to train teams where people live and work, right? And design information technology that services patients and family. And it's an interprofessional team. And it's accessible and implementable across all states in the country. And here is another model. This was recently published in a European Journal of Cardiology, is where it's a continuum of care where you identify people at risk, go to general practitioners or a primary care doctor, register them into a healthy living program. What a novel concept. What a novel concept, where there's a teamwork of dietitians, psychologists, psychiatrists, right? Exercise physiologists. And then the meetings could be in-person and groups, right? And then I'll use all the digital tools and follow up. And then you keep them healthy. It's not this endless loop of diagnosis, disease, diagnosis, disease, hospitalizations and death, right? So, but that's another entire discussion. But in terms of information and education is what we're gonna talk about is the pillars of lifestyle medicine. To that end, American College of Lifestyle Medicine and the American Board of Lifestyle Medicine are on a mission to spread and empower physicians and anybody in healthcare to learn the skills of how to educate ourselves and take this message to implementation. To do any of that at a patient level or at a personal level is to be mindful. Mindful about what? The kind of mindfulness I teach is not the kind that I expect people to attend one of my presentations and show up next week with a halo behind their head and a rosary in their hands. That's not the, although that would work for a lot of people of spirituality-based mindfulness changes behaviors. But the kind of mindfulness I talk to my patients and friends and families about, be mindful about one thing, the answer that you gave me when I asked you why do you wanna be healthy? And once you're mindful about that, the journey doesn't have to be perfect, but it has to be a process towards betterment. And to do that, you guys know this better than, a zillion times better than I do, is that it's not that just because you wanna be mindful, you're gonna transition into a mindful person, but it's a process where you start with the beginner's mind, be nonjudgmental, take time, acceptance of both successes and failures and don't make it a competition, especially don't make this process a competition about weight loss and trust the process. And if everything fails, start all over again. And I like showing this beautiful cartoon and I don't know where I got it from, it makes a lot of sense to me, is that somebody went through this path and he or she is now on top of Mount Health and they're doing us a favor and saying, guys, don't struggle, we know the path here, take a ladder, heck, take two ladders, except that they pull a trick on us. Which ladder would we take? That's all I ask my patients is take those steps, take those steps so you don't or you're less likely to step into my cardiac cath lab or the CCU. So now let's go into the evidence, is it all just talk or is there evidence? So the first and foremost thing I wanna talk about is social support. To do any of this without social support, none of us are gonna succeed. This is like the foundation, the way I view lifestyle medicine is the social construct is the foundation. And the beauty in that social construct is that within those shared relationship is there is a sense of being cared for, there's a sense of being loved, there's a sense of self-esteem that builds into that network of mutual obligations and then you're more likely to do consistent health promoting behaviors and the current Surgeon General and the National Academy of Sciences have done an amazing job of putting these two documents, one in 22, one in 23, extensive, extensive scientific documents actually outlining the disaster of a pandemic or epidemic that we have of loneliness and social isolation leading to not just cardiovascular but many diseases and I strongly urge if you haven't yet to go through that very long and almost like combined 600 page documents. But similarly in cardiovascular health, in the cardiovascular journals, this is a hot topic because poor social connections lead to poor lifestyle and poor psychological behaviors and that leads to poor adherence with again, health behaviors, doctor's appointments, medications and when they need procedures and one thing leads to another, your blood pressure is going up, your BMP is going up, your creatinine is getting worse before you know you're diagnosed with a bunch of diseases and mortality. And just from a heart disease and a stroke perspective, people with poor social relations significantly increased risk of both heart disease and stroke, right? These are pretty influential papers and the next pillar is avoiding toxins. The reason I showed tobacco is that we were in a country not too long ago, we're ignorant enough to show despite having pretty solid information, put pregnant woman lighting up and advertisements read that it helps you deliver a smaller baby or cardiologist or men dressed up as cardiologist with a white coat that read the best cardiologist in town smoke camels. If you really wanna go into details, so just reading that book, The Cigarette, A Political History, it's an eye opener. And here in the previous slide, I said, doctor's choice is America's choice. It was intentional because that was one of the campaign slogans by the tobacco industry. But today, what do I mean by doctor's choice, being America's choice is because I practice and many doctors practice in hospital systems and where we allow the sale of burgers, balloons and bypass operations on the same floor. If we do that, I have a simple question, do we have the moral authority to look in the eye of our patients and say eat healthy? Right, the next pillar is, and the next toxin is alcohol. If you're emptying bottles of red wine, do it because of 25 other reasons, but please don't drink alcohol thinking that it's good for you because it's not, it's never been and the data is just keeps on piling up. And based on this very large UK Biobank study kind of concluded that there's actually no safe limit to alcohol consumption, even when it's a habitual drinking. And based on the data, the World Heart Federation in 2022 changed their position, stating that there's absolutely no safe limit. We are hoping in the US that the next version of the ACCHA guidelines would follow. Stress, I don't need to talk to this audience about stress, but New York Times called it a very nice review for lay people, stress may be your heart's worst enemy. And we know this from this famous paper in 2004, at least in cardiovascular medicine, where I tell my fellows that this should be tattooed on your hands, that influence of every single risk factor versus what happens when you add the P's toward the right of the graph is for any single risk factor, if the P's are the psychological and social stressors, the risk of events goes up exponentially high. And I was able to partner with a couple of big names and write a book chapter on this a few years ago. The next one is physical activity, right? It's very poor. You know, number of people who are physically active is just, it's really bad. And the kids, you know, not even a third of America is meeting the bare minimum guidelines. We are not expecting people to come back with six pack abs and supermodel bodies. This is what we are expecting to do. Go for a walk, five days a week, 30 minutes if you can. If you're able to run, at least three days a week. And then in the middle, at least two sessions of strength training, because the psychological benefits, the antiarrhythmic benefits, the clot prevention, antithrombotic, the benefits are limitless. The benefits are limitless, so much so, if you are an elite athlete, or if you're on the lower side of your VO2 max, compared to an elite athlete, your risk of dying from any cause has a hazard ratio of 5.0, 500% higher risk. Okay, and that's how it compares to smoking. And exact same data was duplicated from a VA database, showing the hazard ratio of four. Age and gender matched individuals are not based on a VO2 max from your iPhone or an Apple watch, but objective treadmill testing. So exercise is literally medicine, and every step counts. And the most benefit, this is what I tell my patients, is just start walking. It doesn't don't count, just from doing nothing, even at 1,000 steps, 2,000 steps, just look at the gap, look at the slope of those curves. Right, and the next pillar is sleep, and nobody said it better than Gandhi himself, that each night when I go to sleep, I die. And the next morning when I wake up, I am reborn. Right, and that's another phenomenal book by Matt Walker, and anybody in the lifestyle medicine space probably knows, if not, please read that book. And although Gandhi said those words with the tone of philosophy, the man's words came to be true, is that the magic window is somewhere between seven to eight, or six to eight, something like that, of nocturnal sleep, for all-cause mortality, CBD, anything to cardiovascular, and diabetes. And now, some objective data is coming out from large data sets that less than six hours and more than nine hours, is there is a bidirectional association, hence, you know, people can draw some degree of causal inference, because we'll never be able to do long-term randomized sleep deprivation trials, although one was done, not long-term, short-term, couple of years ago, is that, I think about 20 people, young individuals, same biological system, crossover design, randomized to four hours of sleep deprivation, sleep restricted to only four hours versus nine hours. And there was a washout period of about three weeks, and then switched arms. Although the weight did not change much, on an average, each individual ate 308 calories in excess, but what was very concerning, right, and their truncal adiposity, measurable on an MR, went up by 7.8 centimeters. That is an inflammatory organ by itself. And this happened in a matter of 21 days. And we all know, those of us who, and all of us who trained in medicine, every post-call day, we eat too much, at least I did. So I'm finally happy to see that American Heart Association, finally in 2022, added sleep as life's essential, right? So simple tips, consistent time to go to bed, keep the bedroom quiet and dark, temperature on the lower side, no electronic, easier said than done. But one tip that I kind of insist that my patient at least put it into practice immediately, is avoiding large meals, caffeine and alcohol before bedtime, at least four, and I said before, at least four to six hours. Again, easier said than done, the demands of life, but that's where the science is. And exercising helps you sleep better. Now, the next big one is nutrition. Why nutrition? Why does it, and another thing about nutrition I talk about is that don't talk about nutrition in terms of carbohydrates, fats and proteins. Yes, there is something, but in practicality, because when was the last time any one of us went to a grocery store, picked up the phone, called our spouse and said, hey, hon, I'm at the grocery store, should I bring eight fats, nine proteins and six carbohydrates for breakfast? Nobody shops like that. But why does a cardiologist need to talk about nutrition? Don't we have enough to learn about stents, right? So this is the most recent global burden of cardiovascular disease. And just look at the US, just look at the US. The orange color coding or the pink is ischemic heart disease that's a leading contributor to cardiovascular death. This is America. Different color codes are different parts of the world, but let's just focus here in the US. And where is that risk coming from? It says majority of it's coming from metabolic risk. Metabolic risk related to what? It's our behavior. Behavior related to what? Diet. Just look at the color coded portion of it. That's how much it's coming from. The second one, the black portion of it, of the graph is hypertension, which is directly related to behavior, for the most part, especially nutrition. So this is why a cardiologist, so this slide is slightly out of place, but this is what I meant earlier. But the key here is this, is to avoid this type of food. Highly palatable, calorie rich, perfect combination of refined carbohydrates and saturated fat. And we are evolutionarily programmed to get hooked onto this. 58 to 62% of American calories come from junk like this. And for each additional serving, there is 7% incremental cardiovascular mortality. Right? Nutrition in relation to cardiovascular risk factors, the most prevalent being hypertension. FDA approves a medication if a pill can lower blood pressure by three millimeters. Most medications lower blood pressure by six to 10. DASH diet, which is not even 100% plant-based diet, the original DASH trial did not restrict to salt, but if you do so, DASH diet with less than 15 millimeters, less than 1500 milligrams of salt a day, we can lower blood pressure by up to 20 at a population level. Let that sink in. Right? Class one indication with level of evidence A, DASH diet. Right? Same thing with lipids. Right? There is a linear relationship between saturated fat and predicted serum LDL. This is not debatable. There's a linear relationship. Right? And then when we replace a saturated fat, don't replace it with trans fats. Don't replace it with refined carbohydrates and processed carbohydrates, but refine that with whole grains and mono and polyunsaturated fat foods. And same thing with diabetes. Why diabetes matters? If you're a male, and if you're diagnosed with diabetes in your 30s, you lost 13 years of your life. If you're a female, you lost 16 years of life. For every decade earlier, you lose three to four years of your life. That's why it's a cardiovascular risk equivalent. And in terms of where does lifestyle fit into it, we have three large global trials showing that lifestyle plays an impressive role in preventing diabetes. 58 to 60% reduction in this landmark paper, the U.S. Diabetes Prevention Program. Close to 40% reduction from China with a 30-year follow-up. Same thing in Finland, 34% reduction with a 10-year follow-up and a similar large-scale trial is right now going on in India. So hence, the plant-based diet made it to guidelines, right? And this is an impressive book by Roy Taylor on diabetes. I usually ask my patients to read this. Inflammation is a big thing in cardiovascular medicine, right? To lower that from a nutrition point of view, cut down processed foods, cut down refined sugars, eat more green leafy vegetables, eat each plate should look like a rainbow. And we know this from a large randomized control trial that was conducted at the NYU and Affiliate VA in Manhattan by Benita Shaw that looked at patients with established heart disease and she had the genius of randomizing them to a healthy American Heart Association diet and a 100% plant-based diet while they are on a high-dose statin. One of the most commonly used inflammatory marker, high-sensitivity C-reactive protein compared to American Heart Association diet while on a statin went down by an additional 28%. Hence, a plant-predominant diet made it to the guidelines with a class one indication, right? Same thing on the other side of the pond. A healthy diet is a cornerstone. A Mediterranean eating pattern, replace the saturated fat, reduce the salt intake, eat a plant-predominant or a plant-exclusive diet supported by class one indication, top to bottom, right? And the new thing that's coming up at a federal policy and also medical society level, this concept of food is medicine. I used to say food as medicine. The American Heart Association issued a presidential advisory on this based on the White House initiative and so did the American College of Cardiology. Actually, how to implement this? And we published a paper and I'm an author on this paper. We just published this literally two days ago. The food is medicine, food is medicine, the time is now. Now, when I say food is medicine, the time is now and eat a plant-predominant diet, there is a plant-based diet and then there is a plant-based diet. So the healthfulness of a plant-based diet is the key because there's a clear gradient in hazard ratios for cardiovascular risk. The exact same data was duplicated within the VA system, looking at 351,000 people, looking at their healthfulness of the plant-based diet index and the lines separate like impressive from all major chronic diseases, cardiovascular disease, cancer and diabetes, some of the leading killers. And that's the difference of eating healthful plant-based diet and same observation in both ethnicities. So when I say eat a plant-based diet, people think that I eat like this and I joke saying that this paper was published in the International Journal of Shaming Vegans. That's not the point, but using some very simple inexpensive ingredients like this, here are some of my plates. This is actually food that I cooked. This is my food, these are my plates. And speaking of my plates, this is American College of Lifestyle Medicine's plate and we wrote a bunch of papers. Anybody wants to read on, these are the papers that I say must read. And in working with the American Society of Preventive Cardiology, we actually put a consensus document on how to actually eat healthy for cardiovascular disease prevention. And this is an unbelievably good paper by Geeta Sikand. She is a dietician. It's like a literally turnkey bullet item, 10 strategies for preventing heart disease. And these are two, I'm gonna share on one more, two free resources, one by the American Association of Black Cardiologists. The name of the book is Heart and Soul, right? And I literally print this and give this to every African-American patient of mine and their family. Go home and eat this way. Just eat off of this book for two months and come back. And men and women who did this, invariably I take them off of blood pressure medication, which is a huge burden in our African-American communities. And then here is this, the federal government of the United States. We published a book, Practical Plant-Based Cooking. You wanna implement this in your healthcare system? Free download. Just go to Google and type Practical Plant-Based Cooking. Hands down, the best book I've ever seen, period, 107 pages. So now, does it take a courage? Does it take courage to say a message like this? Courage is a trial where we tested. Cardiologists will know where I'm going with this, but where we tested stenting versus medical therapy for stable heart disease, and there was no difference. That's where I'm using the word courage to say a different message, meaning that for an interventional cardiologist to say what I'm saying to you all today, does it take courage? So let's take a look at the COURAGE trial. These are people with established heart disease, and we didn't know back in 2003, do we stent them? Do we put them on medication? So we did a federally funded, a VA funded randomized control trial, and trial finished and said there was no difference. And ensuing 15 years, continuous follow-up, and what did we find? Who are the people who did the best? Are the people in the editorial that went, written by one of the legends, legends in the field of preventive cardiology, and she wrote, do not smoke, eat healthy, and exercise. That's what we learned after 15 years of following a randomized control trial for stable ischemic heart disease. But the thing is, it's not new. It's not new. People with established heart disease, this paper is written by Bernard Lone, who won a Nobel Prize, who's gonna be on the dollar coin in 2025 from the state of Maine. He famously wrote that this disease can be managed medically by just risk factor management. And for having the courage and the freedom, these are all the trials in cardiology. So to the non-cardiology audience, you won't get the punchline. But for having the courage and the freedom to say these words about ischemia, Bernard Lone is my hero, so much so I actually give his book to my incoming cardiology fellows as a must-read book. I also give Beth Freitas' book, the Lifestyle Medicine Handbook. Then there is another but. The other but is, Doc, the disease runs in my family. We have said that ourselves. So did John Warner, president of American Heart Association, a day before he himself had a massive heart attack and had a cardiac arrest while attending and presiding over the American Heart Association annual meeting. So when are we gonna go get all genetically tested? Now, this really doesn't really add much. It does not lower your risk, because here is the odds, right? Is the people with a high genetic risk who live a healthy lifestyle have just about the same event rate as people with nothing? That's the power of lifestyle medicine. And we know this from impressive trials. Multiple large-scale trials clearly showed 50 to 60% reduction in actual events despite having high polygenic risk scores. Same thing is also true for what we fear the most in cardiovascular medicine. Familial hyperlipidemia, lipoprotein little a elevation, 64% reduction, we still don't have a medication to treat this. Right? Same thing, dupli-second data set showing the same thing. And in people with known heart disease without even taking sleep into account, if you live a healthy lifestyle, you can add 20 years without an event, 20 years without an event. And if you add sleep, same thing, 20 years without an event. Impressive, impressive data. And this is a classic paper titled, Healthy Living is the Best Revenge because healthy living lowers the risk of all chronic disease by 78, diabetes by 93%, heart attack by 81, stroke by 50, cancer by 36%. And yeah, this is another thing that just came, it's not published yet, that if you wanna add a 24 years if you're a man and 21 years if you're a woman, these are the things, be physically active, no opioid addiction, that was recently added, everybody knows why that is, smoking, stress management, diet, avoid binge drinking, same pillars that I've been talking about from the past. And then there's another but, if there's one paper, well, before we go to the one paper, here is a gradient, earlier I showed you the heat map of American obesity, but here it is by race and ethnicity. This is the paper, a short read, Moral Determinants of Health, because we have become repair shops, that's what we have become, we have become repair shop of ills caused by the moral determinants of health, conditions of birth, education, work, social circumstances of our elders, community resilience and basic fairness, right? If you don't believe me, this is some of you live in New York, from Midtown Manhattan to South Bronx, life expectancy declines by six months for every minute on the subway, I trained in Long Island. This is true, right? So built in neighborhoods, healthcare access, economic stability, education, social and community context, all of these have a direct impact on our health. And that's why I love this logo put forth by the American Heart Association, where everything I said right now, in that magical, you know, life's essential aid, where everything that I said is tightly wound together by the psychological and social determinants of health. If we don't address those two as foundation of health, we'll actually be doing disservice to our patients. So my message is, we have to spin these wheels of prevention through all major organizations, the American College of Life Style Medicine, ACC, AH, and the Veteran Health Administration, large entities, because we have to spin these wheels. Those are our four wheels, at least for a cardiologist like myself, because our vehicle is ready to fall apart, right? But to do this, to regain momentum towards health, every physician, every public health policy, and every action has to happen at a personal, a clinical, and a community level. A living legend of a cardiologist was recently interviewed and asked this famous question, what are the biggest research gaps in cardiology to improve care? And the living legend said, I think the most important thing is that we get rid of cardiologists. What do I mean by that is the next challenge is prevention, prevention, and prevention. So now this is my last slide. So what's the deal with carrots? That's the deal with carrots. Entire six pillars of life style medicine, I even chose to add the seventh pillar of social determinants into my carrots. So I will stop here. These are the ways I'm fairly active on Twitter and LinkedIn, but those are my emails. If you wanna get in touch with me, sorry if I went over, but I will stop here and I'm happy to take any questions. Thank you so much, Dr. Reddy. What an amazing presentation. I'm getting all these people sending me private messages that he's fabulous. Can you stop the sharing the screen so we can maybe see you a little bit bigger? Wonderful, wonderful. So always we do the first question with Dr. Viz, our president, Dr. Viz. Thank you, Dr. Merlo and Dr. Reddy. This is a really phenomenal and especially as an interventional cardiologist for you to take this. So really, I really applaud you. And as you pointed out, among physicians, there is still so much ignorance and you mentioned about the various organizations. We need to take on the mantle. So the American Psychiatric Association has taken on the mantle. Our theme is on lifestyle medicine, lifestyle psychiatry for positive mental and physical health. It's not simply freedom from illness, but really the positive aspect too. And we have actually appointed a work group. Dr. Gia Merlo is doing an amazing job and there's a lot of enthusiasm among people. And one thing is also, you also alluded to the environment. I am still appalled that in physicians' conferences, you get just donuts and sodas and you do not really get much healthy options, no nuts or carrots or whatever it is. And we need to change that. And also you mentioned about, you trained in New York and obviously we are fortunate now to have a mayor, who actually has transformed himself through lifestyle medicine and he's really doing admirable job. Now our hospitals in New York City, one of the options, they do have a whole food, plant-based food as an option. And so I think we as organizations, we have to do a lot, especially in the public health sphere. I really applaud you for leading this effort. Absolutely. Thank you. Thank you, sir. And then speaking of food at conferences, those of you who have not been, come to one ACLM conference, as you can tell by the head nod by Dr. Merlot, come to one ACLM conference, you'll say, whoa, am I on planet earth? So it's very different. It's very different. We live what we preach and we practice what we preach, but it is, I wouldn't say it's an uphill, it's not an uphill battle. Things are changing. For the White House, at the White House level to hold a national symposium titled food is medicine to bring all stakeholders. It is, does it have to be a hundred percent whole food plant-based diet across every human being? That's utopian, not practical, but a plant predominant unprocessed diet is supported as a class one indication. And if people want to go a hundred percent plant-based, it's a personal choice. But I agree, Mayor Adams is doing an amazing job, Dr. McMachan and the whole team, and they are really setting up an example for large. And Tampa, we are not far behind and in terms of taking the message to the community. Some of you may know this, but we now, and I say we, the American College of Lifestyle Medicine, I'm just a member now, but I was on the board. I was involved with a lot of fun stuff, but the college is now officially affiliated and partners with the Blue Zones program, whose mission is basically transform entire communities. And very soon in January, I believe sometime in mid January, there's going to be an option to train and get certified as a Blue Zones certified healthcare provider. Meaning, yes, we really want to take this message to the community where people stay healthy, right? And there's always going to be need. I know I'm not that naive to say that, oh, just because FACLM and everything is going to go away, there's always going to be a need for the likes of me to do procedures and what have you, but 80% of this is preventable through healthcare policy, public engagement and true investment in health promotion. But again, thank you for your leadership on behalf of your organization. And Gia is a kind of a rockstar within the space of lifestyle medicine. So we know her well and we know her work well, yeah. Thank you so much, Kaushik. And I don't know if you're presenting at LM24 in October, I'm presenting there. I'm not because I'm on the selection committee and I'm on the, what do you call that? The planning committee. So if you're on the planning committee and the academic committee, you're automatically excluded, you know that. Yeah, I resigned so that I could try to present this year. Yeah, they asked me, so I'm not presenting this year, but I'm presenting. This is like my 10th or the 12th presentation this year. And I just came back from a four city tour, but so, yeah. Yeah, beautiful. So there are a lot of questions and we do have a study, we have study groups. There are six study groups. So all the pillars we're studying and we have a study group starting at eight. So I hope we can just go over a little bit and maybe start that a few minutes late, if that's okay. Ajawad, do you wanna go and maybe go into that study group and make sure that people can invite them here, maybe? She's my co-facilitator, co-chair. Okay, so let's go over some of the questions if you don't mind. Sure, absolutely. Yeah, Ethan, you asked a question that he already addressed but we can have him address it again. Is the idea of glass of red wine daily health a fallacy? Yeah, if you look at some of the most recent data, it's not, I wouldn't say it's a policy, but there's also the counter argument is that, people literally a glass, right? Technically we don't measure from a health metrics point of view. We measure alcohol as a drink. And let's be honest ourselves. When was the last time we actually had a measuring device or a measuring cup to pour a drink, right? An average American glass of red wine is about, I think about four drinks. And it is listed as a class one carcinogen, the most recent cancer prevention guidelines. They actually, they issued in 2021, they issued cancer prevention guidelines specifically as they're related to diet and physical activity. Under the diet section, there's a very, very interesting sentence. It says, the number one, number two risk factors for breast cancer in women after age 40 is obesity and the consumption of any amount of alcohol. And when I read that, I pulled up the citations, did they derive the right conclusion? And it looks like it. So, and there's a reason why it's also listed as a class one carcinogen and it's avoidable. But if you are one of those people where statisticians call healthy user bias that you're doing everything else right to perfection and you're literally drinking one drink every other day, who am I to fight with that, right? But the reality though, at a population level, people are actually not drinking only one drink of red wine. They're drinking a lot more than that. Thank you. Thank you. Dr. Barron has a comment question. Dr. Barron, David. Yeah, thank you so much for a wonderful presentation. I wonder if you could comment on a frustration I've had for a lot of years and that's the role of public policy and advertising. You talked about cigarettes. When did people start smoking? A lot of it was when cigarettes became like, I don't know, five, six, whatever dollars a pack they are. I ran into an issue with the city of Philadelphia. We went to the school system and said, let's see if we can cut out junk food and soda and look at the food. And basically it came back to, well, it's financial. So I wonder if all this wonderful data will be somewhat lost if we don't deal with politicians and public policy people and saying, you know what? If the reward for every young kid is to go to McDonald's and get a Happy Meal or to get a candy bar, that we're really fighting an uphill battle. That reward is something all the education in the world isn't likely to change. How do we come together with people, learned people like yourselves? We're behavioral scientists. We understand what drives behavior, but really start to have people make, it's easy. It's actually, you have to make a hard choice to go buy the good foods now. It costs more money. You have to go to the separate markets. And for me, I get very frustrated. I deal with athletes, very high-end athletes. We got the NFL to say, the kids, pay money to go have the kids play 360. And that was a fairly productive thing. But I really get frustrated when I hear all this elegant data and people like you are committed to this and are so knowledgeable. But yet, if we don't deal in the translational molecules to Main Street, dealing with politicians, with the financial side of things and make it less rewarding and have the advertising business start making it more desirable, then I'm fearful that we have an uphill battle that we might not win. We do. I wanna say two things. One, I love the way you kind of passingly said that. I'm gonna use it, molecules to mainstream. I'm gonna steal it. One, two, and two, and I understand your frustration. I feel your frustration, but I'm optimistic. I'm optimistic in the sense that in the history of American healthcare, we are better today, historically speaking, like I showed the bending the curve, has consistently been due to public health policy. And I thank you for bringing that up. And when I say why I'm optimistic is primarily because what's going on at the federal level. You know, that stakeholders meeting, literally industry was there. Healthcare systems were there. Medical organizations were there. The largest integrated healthcare system in the country, probably in the world, Department of Veteran Affairs was there. So one of the things that would translate into is that it's unrealistic to use the example of McDonald's. The classic example I use is one, something that we could literally borrow from the other side of the pond, what the United Kingdom did almost 20 years ago. Met with the industry, a similar meeting, I would say. They had a very realistic and a meaningful goal is working with the industry. Can we lower the amount of salt that you're adding to British processed food? And from that day forward, you should look at the incidence of stroke and ischemic cardiomyopathy in the UK. It just plummeted. And those are the things that can be done at a policy, at a federal policy level, working with the industry that have a far reaching impact. That's why when people ask me, if somebody gave you a billion dollars, I say I would spend 99.9% in getting one disease under control at a population level is hypertension because stroke, cognitive decline, retinopathy, heart disease, ischemic heart disease, cardiomyopathy, and kidney failure. Imagine how many billions of dollars we'll be saving. I don't know if I answered your questions. It is happening and I'm optimistic. The school lunch programs are changing. I'm very happy to look at the current, the panel that was put together to write the new guidelines for USDA 2025 dietary guidelines. Some really impressive people from Harvard and Stanford are on the panel. So guidelines are gonna be planned predominant, but in terms of policy, it's gonna change into the way we market food, the way we promote this junk food at schools. So that's gonna take time, but I think it's moving in the right direction. Thank you so much, Dr. Reddy. I'm gonna- We'll make a big advance in working with people. So it's easier to make the right healthy choice. Yeah. That's another thing you said, that's why I said information and implementation is that if we empower enough people to bring about a behavior change, nobody's gonna sell them high fructose corn syrup if they don't wanna use it. Yeah. Okay, guys, we need to stop because I don't wanna take Dr. Reddy's more time. I promised him we would only take him for an hour and we really- That's okay. I can answer a few more questions. This is a very engaging group. Yeah. Yeah, sure. But I wanted to just say that there were some questions about the intersection with mental health and cardiac disease. And I think that that's another presentation, but I would, and I think that that's something that maybe Dr. Reddy and I can put together and we can actually do that at one lifestyle medicine conference a year from now. But it's a very important topic because there is a lot of bi-directionality there. And so, and there are data points and there are many articles about that. We will get into that in the study groups. So that is an important thing. I don't know if you wanted to address that more, Dr. Reddy, but I just wanted to- No, this is, if you look at cardiology journals, I mean, every week there's something being published on it. Recently, last week, actually, I was at American Society of Preventive Cardiology. It's impressive that all these things are happening. Believe it or not, American Society of Preventive Cardiology held their inaugural lifestyle medicine master's class for cardiologists. And I was one of the invited speakers and I was happy to meet one of my co-speakers was Dr. Glenn Levine, who is a bit of a legend in the field of stress match, psychological and social stress and heart disease. And he spent an entire hour talking about it. So there is, and I see this, it's my own clinical practice. I don't have the credentials to counsel patients, but I'm smart enough to recognize depression, psychological health and stress. And I, almost on a weekly basis, I send my cardiology patients to a mental health specialist in the VA system. So the bidirectionality is the right word, but I like that idea and the challenge is to put a talk together where a psychiatrist or somebody inside, a psychologist or a cardiologist come together and kind of, hey guys, it's just two sides of the same coin kind of thing. Yeah. Hey guys, we do need to stop. Thank you so much, Dr. Reddy. It was a wonderful engaging time. We did record this for those of you who came late and we really appreciate you being here. And- Absolutely, thank you. Yeah, thank you so much. And we'll talk again soon, hopefully. Yeah, those of you who are not coming, come to a Lifestyle Medicine 2023 Orlando, right? All right guys, take care. Good night. Thanks for having me again. Thank you.

Lifestyle Medicine

Cardiovascular Health

Prevention

Diet

Exercise

Stress Management

Plant-based Diet

Public Health Policies

Mental Health

Healthcare Model