Sharon: Welcome to the RACGP webinar, Dietary Prevention of cardiovascular disease: A discussion with your patient.
Hi everyone, my name is Sharon from RACGP and I will be assisting with the webinar today along with some other members of the RACGP team. Before we start I would just like to acknowledge the Traditional Owners of the respective lands on which we are meeting today, and pay my respects to Elders past and present and I would also like to acknowledge any Aboriginal and Torres Strait Islander people present.
We will start the webinar today with helping you to work out how to use the webinar system with some tips and tricks. As you may be new to webinars, we thought we would take a few moments to help you feel comfortable with the learning platform and your learning options to communicate with us. Throughout the webinar we will refer to your control panel. The control panel provides you with tools to select if you are using a microphone, speakers or phone. So listening in and also to ask questions. During the webinar, all participants have been set to mute from our end. This ensures that any background noise is eliminated, enabling us to stick to the time schedule. If you have questions throughout the webinar, please send them through the questions box on the blue and grey panel. If you have any questions for us, please just send through this as well. As a test, we would love to see where you are from. So, if you do not mind, please type in the suburb or the state that you are currently in and we can see them coming in on our questions log. We will give you a minute to do that now. It looks like we have got people coming from Warrnambool and Queensland, Northern Territory, Box Hill, Townsville, Perth. That is great, everyone seems to be using the program really well. So keep putting them. We will keep a record to see where everyone is from today.
So we will now start the webinar officially now that we all know how to use the system. So again, welcome to the RACGP and St. John of God Subiaco Dietary Prevention of Cardiovascular Disease, presented by Dr Janssen. Dr Janssen is a cardiologist who consults at St. John of God Midland as well as at St. John of God Subiaco. He runs weekly clinics in Kalgoorlie and monthly clinics in Geraldton and also teaches medical students in rural areas.
Tonight’s webinar will be discussing the dietary prevention of cardiovascular disease, including diets like paleo, keto, DASH and Mediterranean in combination with lifestyle advice. Also the challenges we as doctors face when discussing health with our patients when they, the patients, ask GOOP first and we will provide you with the evidence based research which will enable you to have a conversation with your patients about non-medicine based strategies in the management of their cardiovascular disease risk.
Our learning outcomes are, to identify the barriers health professionals face when talking to our patients about diet and lifestyle, to discuss the science based advice around food, supplements and lifestyle in managing cardiovascular disease risk, and to describe tips to guide your patients towards getting the information they need and want. So I will hand over to Dr Janssen now. So, welcome Dr Janssen.
Dr Janssen: Hi, Sharon. Thank you very much for having us today and thank you very much guys who are joining in from the other end. We are not talking necessarily tonight about weight loss management per se, but I would like to make some general remarks about food first. We have to realise that everything in life needs to get its energy. If you do not eat, you will get weak and you die. The food we eat is extremely diverse. However, we have to realise it is only a few basic elements, carbs, proteins, fats, vitamins, minerals, fibres and do not forget, water. Some industrial treated foods also contain artificial taste, colour or preservation chemicals but they are not part of our natural foods. I will tell you, give me your food and I will give you the health disadvantages. When we talk about not healthy, it is often a matter of doses. The most important advice we can give our patients therefore, is to eat in variation, but not a lot of it, except maybe for veggies. Do not only focus on some types of food, even though they might be super-healthy. Fruit for instance, is full of vitamins, fibre and anti-oxidants and I am sure it is good for you. But eating too much fruit definitely can keep you fat or make you fat, especially if you use fruit to make calorie-rich smoothies, juice or cocktails.
Variation also means you do not buy your food always at the same shop. You need to spread the risk. There is always something that could go wrong with the production, the transportation or the packaging. And if you spread your variation, you also get a chance to get some new ideas and learn some different cultures.
There is a lot of confusion about food. For years we hear that we should prefer plant-based foods over animal fats, so to use margarine instead of butter. In today’s world, many studies suggest the contrary. In the old days, you had to stay clear of fats and count calories to reduce weight. Now days, sugar seems to be the culprit. One day you read the benefits of whole grain products, the next day that you have to stay clear of carbs. Hello? People do not know. Your patients do not know any more what to believe and they are losing their faith in science and capitalise for the promise of wonder diets who we know never work. Or they just revert to the same-old same-old which did not satisfy them in the first place. Maybe we know our oldest research is wrong. Some of this you do. After all, they contradict each other 100%. They cannot be good and bad at the same time.
But foods can have advantages and disadvantages. People that preach revolutionary or extreme food advice or theories have a great responsibility because within the confusion they create, they may close more doors to healthy living than they open. Even if there is some merit in their advice, they need to realise that eating food is not only a matter of a health aspect but also organisational, practical, social and financial. You will need to find the time to buy the right food, to make it, to take into account different preferences and taste buds of people you are cooking for. It also has to be an advice you can follow. Not eating bread for instance, is for most too difficult and therefore not practical. So in this talk we will focus on my dietary prevention of cardiovascular disease advice in patients who have known disease and I will touch on my advice with changes for people that aim to live a little bit longer.
So let us start now first with a little bit of science, in particular the science about obesity. Here we go. So, this is a complicated slide that I am going to explain partially but I want to highlight the fact that actually there is a lot of science going on in our technology about food. There are three major components of daily energy expenditure. It is the obligatory energy expenditure which represents the energy required for upkeep of our basic biochemical processes at the cellular level within the body. Number two is that we have physical energy expenditure which is the energy spent during exercise. And the third one is adaptive thermogenesis which is the production of heat and response to our environmental or dietary factors.
Differences in adaptive thermogenesis which raises the energy expenditure beyond the obligatory energy threshold are potentially responsible for the intra-individual variation in total daily energy expenditure, and thus our susceptibility for obesity. This adaptive thermogenesis involves the uncoupling of ATP. Do we remember that from our physiology? ATP synthesis from the electro-mechanical and electro-chemical gradient driven by the electron transport chain. This occurs this process in the mitochondria of the specialist organ known as brown adipose tissue, and that is what I call here, the BAT. It is nothing to do with Batman, alright? BAT is functionally distinct from white adipose tissue which predominates in obesity and is primarily concerned with energy storage. And the energy wasted mechanism in BAT which liberates energy in the form of heat is mediated by uncoupling protein 1, or called UCP1. And why is this important? Well the importance of BAT thermogenesis to maintenance of body temperature in mammals is known for a long time but it only has been recently established to be functional in humans, too. And we have now found it in new borns and we know that it plays a protective role in the response to the negative temperature gradients between the in utero and neonatal environment. And it is now also found during adolescence.
It was not until 2009 that we found that functionally active BAT in adult humans has potentially therapeutic value in the light of our current pandemic of obesity. Now that is very important. And why is that important? It is important because the out of Africa, the cold adaptation and evolution which happened when our race went out of Africa into Europe and north east Asia as is pointed out to you with the ice flake, we changed. And different races changed. So the heat adaptation and your BAT content changed. And that means that there is a racial difference, depending on your BAT content in how you are going to deal with over-eating. So if you have more calories in, what is happening with that? So when we see our patients, we now have scientific evidence that from a genetic point of view, there is a difference to how people adapt to that. I think that is an important point to make that there is a genetic difference in how people will react. Now the problem with over-eating is that although our body is very good in recognising when we have hunger, when we under-eat, we do not have good mechanisms to realise when we over-eat. What is happening with the energy we over-eat? That is where our BAT metabolism comes in.
Right, let us go to the next important topic. The next important topic is that scientists can caught up in this problem. Doctors do not. The public maybe do not. But business does. This slide is a marketing slide, an internal marketing slide not for you to see, but I got hold of it, to see how they can market, this is a Chinese company, probiotic supplements. The market size is 20 billion in China in 2018. And they are developing different species of probiotic supplements that they are going to market for $150 US a packet per month. And you see the current market competitors are big companies, like milk companies, like French companies like Danone, Yakult. We have genetic companies. They are all going into this phase of our health as far as food is concerned. You know what happens when people are putting a lot of money into specific products? You get a lot of advantages but everybody is running for the buck, to get in there at the first time. Remember the first Apple Newton? The blue tooth that you could write to other people with? It crashed because there was not a great uptake. They learned from that. If you put enough marketing money in, you will sell it.
What are we facing? And this is also from the marketing area. You have life, but you have different phases of life. You have early childhood. You have adulthood. You have middle age. Retirement. The senior years. And I am talking about senior years as being in your 90’s. Not only how can we address the different problems of the people in a certain time of their life like the acne, or what can we do to reduce the lack of muscle strength which the loss of increases our fall risk. But also people are asking questions, well what can I do to slow aging and live better? How can I prevent Alzheimer’s? And this is all about also, food. So when you talk to your patients about lifestyle, this is where the patient is coming from. This is where the industry is coming from. And that is why we have a duty to lean about these things so we can talk with them and give the patient a more objective advice.
I am having a gin and tonic. So this is your patient sitting in front of you, and this is the left coronary artery, this is the left main and this is the left artery. You see a narrowing here. You see here a big narrowing here and you see some rubbish over there. So this patient has proven coronary artery disease. He also has a mitral valve ring for people who look at these pictures more often. So what are you going to advise this patient? Apart from a mechanical solution for a temporary problem. Because do not forget, if you bypass this vessel or if you put a stent in this vessel, you only fix the mechanical problem that not enough blood goes from A to B, but you are doing nothing for the disease prevention. So apart from the mechanical re-vascularisation, you have to have a discussion with the patient about what else the patient can do to try and prevent a narrowing from re-occurring. So, if you have this disease and you want to have advice about lifestyle, then that should include stories about the food intake.
So, this is from my computer two days ago. It is a rising challenge for our medical profession. We recognise that unhealthy diets are indeed a major contributor to obesity, diabetes, also to dental caries which is a big port of entry of disease, cardiovascular disease. Mental health conditions, do not forget that. Everything works together, or sometimes against each other. And cancer. So these are the very diseases that we deal with and cost us a lot of money. And maybe there is something that we can advise patients about their day to day behaviour to change. And if you are able to do that, then maybe we do not have to challenge our politicians by introducing the sugar tax.
Here we go. Now, our profession has registered that and we have clinical approach schemes like this one. What to do if we face people with an increased weight for instance. But basically I think we should have this frame of mind in everybody. We should in everybody think about their microenvironment. About their weight goals. Think about the racial differences. As far as that is concerned, my tip would be to steer away from treating people’s weight per se. I think for many patients, it might be easier to treat their hypercholesterolaemia, to treat their knee arthrosis, to treat their bloated feeling, to treat their acne or their endocrine metabolic disorders. Their diabetes. The pain in the back. And explain to them that if they would be able to lose a lot of weight, then those disease patterns would change and it would be much more manageable. I have though, I must say, anybody that walks into my room over 150 kg, I advise to go and see a surgeon to get bariatric surgery, because there is no question in my mind and I think there is very good evidence that that is the single most effective treatment to reduce their risk by 30% straight away. Because I know that the result of any non-surgical intervention will be very poor and if it is successful it is going to take a long, long time. And if they come into the cardiologist office already, then they have sub-selected themselves as being a high-risk person. So this type of scheme is from the American Academy of Paediatrics, very helpful to guide you to what you can do. You can talk about which pharmacological therapy is available to you here in Australia. You have got three or four different drugs that are currently accepted. And there is a lot of experience with trying to use that. We know now what is happening post-surgery. What are the complications of a gastric band that we do? And we know what we have to do as far as the nutrient signalling is concerned with the brain. How it can interfere with that.
Now, let us turn to our patients that do diets. Now currently the 5:2 diet is popular, but it is very old. We had the 5:2 diet already in the 1960’s. But the British doctor, Dr Michael Mosley and his wife, they have made it more popular with a BBC program. And that is good. And that is good because the more we have out there, options for people to do something about it, the better it is. And at least some of these programs are actually very positive programs. They are to a degree balanced and if we adopt them, we have the opportunity to teach our patients for their individual case, this could be adapted so it might work for them. Now we also have a lot of other information about things like the 5:2 diet. There was recently published a study in the UK by Dr Rona Antoni in March 2019, which showed that comparing a 5:2 diet with an 800 and 2,500 calorie diet as opposed to a diet of 1,000 calories every day, that it could have after six weeks, a meaningful, lasting, positive change in the endocrine metabolism, also leading to a significant production in triglycerides with a similar weight loss. So we are getting also the understanding that some diets and lifestyles work much better than other ones.
Now, I like this slide. I have to take a little piece of paper because I could not remember what this was all about. And this is about actually all the different diets that we have had that were very popular. And if we start here with let us say the Graham’s diet. That was one of the first ones. He was a Presbyterian minister, Sylvester Graham. He died in 1851 and he approached diet as an education, combining strict religious beliefs with themes common to the temperance movement of the nineteenth century. And he got his diet from the 10 Commandments and envisioned the stomach as the healthful minister of your body. Look at that. So this diet is from 1820’s, and it is considered by some to be the first fad diet. Where it led to is, to cornflakes and to crackers. Our crackers that we buy now are the result of the Graham diet. Who would have thought? It is also thought by some people to be the first vegetarian diet. And who would have thought that?
Now the other diet that I think is very interesting here is the Zen Macrobiotic diet. Here the first one. This is one from the 1960’s, and that is in the flower power time and the hippy time and those people, let me find the right thing, went into macrobiotics. And that is the principle of yin and yang and the inter-relationship between opposites. It would have organically grown foods, 40% whole cereals, grains, 20% fresh veggies, 10% beans and been products, 10% sea vegetables and a sprinkling of fruit, white meat, seeds and nuts. Now it became that popular that at some point in time, they thought it was so extremely to a normal American diet, that the American Cancer Society wrote that the diet poses a serious hazard to health and is not beneficial in the treatment of cancer. You can see where all the confusion came from for the people in the street. But, in retrospect, it is the precursor to a number of plant-based, high fibre and low fat diets as well as some of the organic food movements. And now we think that those things are probably very beneficial.
Now, this one is one that I really like. It was this, the Drinking Man’s diet is only 50 pages. It is still in press. It has been there since 1964, and it has its own generation. So this is Mad Men era. It says, look as a man, this is what you drink. And it is a cultural phenomenon for more people than you will believe. It sold more than 2.4 million copies and is translated into 13 languages. Now this diet pathed the way for the Atkins and Dukan diets. Like I said, who would have thought?
Now go to this, vitamins. This is a recent article from I think the Australian. And you will have the comments that the use of vitamins is just making expensive urine. Now, but hey, wait a second. Vitamins are one of the earliest and best studied part of our food. Remember scurvy. Now, I think that we have a good knowledge that vitamins are important in our immune system. Vitamins are very important in our cancer-fighting system. Vitamin C is very important in the lining of your arteries and I think that there is a revival of vitamins and there is some evidence that a multivitamin for people over 60 is perhaps not a bad idea as a prophylactic.
Hildegard of Bingen, by some people and I am one of them, seen as the female equivalent of Leonardo da Vinci. She was a nun in Germany in the medieval times in the twelfth century and she was a doctor. She was the first German recognised botanist. She ran gardens, philosophy, advised popes, advised emperors at the time, and she already advised to fast. She advised to restrict calories. She says not to eat after 6 o’clock at night. She has to have a long fast in between. A lot of the things that we believe have merit today, she already put forward. So, it is important in discussion with a patient when the patient comes in with some story about Women’s Weekly magazine’s article about something, that a lot of the things that people currently are advising, celebrities or other people, are cherry-picking stuff that has been around for a long time. What we have to do is try to guide patients to a good regime for their life. Now if your patient comes in with this one, then go with it. Carbs are not the enemy, that what she says, and she looks good, doesn’t she? But you can also look at this one. Beyoncé, very famous. Her diet is plant-based. Now whatever they say might not be true. Whatever they say might not actually be what they themselves will do. But the magazines, they will publish it. So what is published is true, isn’t it? Then you get this one. One colour of food each day of the week. Now, can you believe it? But people believe in the rainbow. Here we have more sensible, do not deprive yourself. It is okay to give in to your cravings. Right? And we have got, we know him too. Now if it really would be so healthy, then probably we would have the same life expectancy as people in the Stone Age, wouldn’t we? But that does not matter. The driving force of all these people is making money. My dad used to say there are only two things that drive people, sex and money. Power. You need to try and discuss with the patient that the patient is sitting with you the health professional because they put a trust in you that you give a professional advice. These people, you would not want them to fix your car. You would not want them to take off the mole from your forehead. Why would you take their advice on a diet that they know nothing about? But there are good things, there are always good things among the things that they say.
Now is there something wrong with a low-carb diet? No. But is there something wrong with a low-carb diet all the time? Yes. Is there something wrong with a low-carb diet for somebody with diabetes at the age of 11? Definitely. Is there something wrong with a low-carb diet for someone with Alzheimer’s at the age of 99? Probably not. But they will not live that long, probably. So you have to have a discussion with your patients about how to interpret this. But you should not say, oh that is bullshit. Excuse my French. You do not say that because you have to have the patient with you. So if you have people that say, oh but you know I read this. You say, oh that is very interesting. Actually there are a lot of good things about that and maybe we should, what is it you like about that? And what is it that you do not like about it? And what would your goal be? So you have to try and address it in a positive way so that the patient is happy that you are thinking with them instead of trying to brush their concerns away.
If I do not talk to my patients with heart disease, I have another problem. There are a lot of books like this one by Dr Esselstyn, and there are some other ones, that are very popular. They are very popular because it says M.D. on them. They are doctors. They have got grey hair. I do not have grey hair luckily enough. And they wear a white coat like I do. And that must be true, mustn’t it? And they have their personal experience and they are 20 years in the business. There must be something right. What people do not understand is that really, if everything that these people would say were true, wouldn’t we all long ago have done it? Wouldn’t we have made it the law? It is not that simple. There are very good things in it, and what is true is that yes, since 2014 we know you can reverse atheroma. You can reverse heart disease in many people. But it is a combined effort and it is racially different. And it is culturally different. And it depends where you get your food from. So, it needs much more discussion. I am still happy if people come in with this book, because it means that they are interested enough to take care and be interested enough to want to make a change for the better. And that is where we can help them.
Now, so if we put everything that is currently available on one slide, then in 2018 the best diets or diet-like advice that you could advise your patients were the DASH diet which focuses on fruit, veggies, whole grains and lean meats. And the Mediterranean diet, the flexitarian diet, and then you get something like Weight Watchers and the like. Now, what is it today? Today, the Mediterranean diet takes the top spot. What is that? Why? Because there have been some studies like the PURE and PREMED done in Spain and the combination of Spain, France and Greece where it is shown that if you have a Mediterranean based diet and you add in extra virgin olive oil and extra nuts that you are beating the DASH diet or the traditional Mediterranean diet with outcomes and then you look at incidents of endpoints like heart attacks or deaths and you can also look at more subtle markers like high sensitivity C protein and the like.
What I also like and advise often, is for people a flexitarian diet because if somebody has three vessel disease, hypertension, peripheral vascular disease, memory loss and I measure that with doing PET scans or CT scans, then just a tablet, just a statin, just an aspirin or anti-platelet agent, just Metformin might not be enough. They are exercising, they reduce their weight, they do the 5:2, but it still might not be enough. Now, in those patients you might want to go to a more vegetarian approach as there are studies done where they saw groups with no or little meat and no animal products and all, and they saw a significant reduction in the occurrence of cardiovascular disease. But in patients who then find that difficult, I would go for a flexitarian diet. And what I like about a flexitarian diet is that it is flexible. You have to give people a choice. It has to be interesting. They have to get into a routine that they can stick to. And we will talk about some of the other diets in a second, and for most people the biggest problem is that they are too hard to make part of your day to day life.
Now, one of those that I would like to discuss is the keto diet. Now what is the keto diet? Basically it is a diet that causes the body to release ketones into your blood stream. And most cells prefer to use blood sugar which comes from carbs as the main source of energy. But here we start breaking down stored fat into molecules called ketones when you have no sugar in your blood. So that is the basis. Because you do not have carbohydrates in the ketone diet, it is rich in proteins and fats. So you have plenty of meat, eggs, processed meat which I want to have a warning about processed meats, sausages, cheese, fish, nuts, butter, all seeds and fibrous veggies. But because it is restrictive, it is hard to do in the long run. So I usually advise that they do that if people thinks it is a good idea for them, to lose a lot of weight, because you do lose a lot of weight, but only for four weeks or so. And then go onto a more flex diet. Now I think that the ketone diet, the main reason for that is if you really want to lose weight. I think that if you have certain diseases, a ketone diet also might be of use. The ketone diet first showed a good result in kids with epilepsy. So in some mental diseases it might also be of value. But then I say, do not try this at home. Do this with a specialist. But do not brush it away.
Going back to the Mediterranean diet, if you enhance it with extra virgin olive oil and nuts you can get relative risk reduction of almost 30% for coronary artery disease, for stroke, see the difference between coronary artery disease and stroke. It depends really on the mechanism of the stroke. 21% for cardiovascular disease other than coronary artery disease, cancer – a big one. Now that also I think has to do with the modern day technology that introduces artificial sweeteners, rapid growth, items in our food chain that sometimes are shown to be carcinogenic. We have a 22% all cause mortality reduction. Respiratory disease does much better with a Mediterranean diet. Neurodegenerative disease. Very few patients really worried about Alzheimer’s because their mother had it were shown these figures and said, look this is proof. Yes, but there is not a famous chef on the television who I read his show is being axed because MasterChef takes over. Infectious diseases reduction. That has to do with your immune system. And kidney disease which has to do with all of the above. So these are facts that you can show your patient that might help. So, when they come in with a certain idea, you can discuss that whatever the idea is, a good fit in something like a flex diet or Mediterranean diet. And what I do is I go to Doctor Google and print of some examples of these types of diets and I give it to my patients as a handout. So they do not go onto the internet and get lost and a lot of misinformation.
Right, what about the current challenges? There is a lot of stuff out there that we have discussed and which has been around for let us say since the 30’s, 40’s, 50’s and 60’s, and most of that was industry driven and most of the studies were done in the United States. The PURE study and it was the Prospective Urban Rural Epidemiology study and this was one of the better ones because the problem of epidemiology studies in food is that it is very difficult to measure things. Go back home or you are home, and ask your spouse or your child, what did you eat three days ago at three o’clock in the afternoon? They would not have a clue. And if you ask them how much was it, they will say, oh, two biscuits, may be three? How many potatoes did you have? So it is very difficult to get to a good outcome. Now, both in PURE and the PREMED, they made sure that they knew exactly or as good as they could, what has happened. And what happened here is that they saw if you ate too many carbs, you get a higher mortality. There was no relation to the total fat or the types of fat and cardiovascular disease and mortality. Yes, it is okay if your patients have pork belly. The only thing is, it needs to be cooked nicely. They need to enjoy it and it should not be too much. And we do know that a high intake of saturated and unsaturated fat is associated with lower risk .That is interesting, isn’t it? We also find in PREMED that you have an additional 30% relative reduction in risk, if you eat more olive oil or more nuts compared to simply reducing saturated fat intake. So again, it demonstrates that if you single out something to do or not to do, that is probably not the right thing to do. You have to be flexible and you have to add in enough of the good goodies.
Now a quick remark about olive oil. Do not buy Spanish or Italian olive oil. Buy Australian olive oil. Why? If you buy olive oil from Europe, you have no clue what you are getting. There is no quality control. In Australia, we produce one of the best olive oils in the world and we have an Australian institution that actually checks the olive oil. If you have an olive oil which is high in antioxidants, they are better. If you buy local olive oil, so if you are in New South Wales or Queensland or WA, buy the olive oil from there. Short transport time, much better for everybody and you know exactly what you get. And you can look it up, because every decent olive oil will have their olive oil tested in Australia. There is a very interesting article I think three or four years ago, where they showed a lot of these so-called extra virgin olive oils from Italy, I do not remember the brands, where actually changed. They put in inferior and old olive oil into the olive oil because you can do that in Italy, but you cannot do that in Australia. So that is you know, just simple things that make sense. But think about that when you do that.
So what do I do when I see somebody and we talk about all this? I make it short and sweet. I say, do not starve yourself. That is not healthy. Eat mindfully. Hildegard of Bingen said already, eat mindfully. Also, I know that if you chew longer as well, you will eat less. Our portion sizes are too big. Get rid of your Ikea plates and buy antique plates from your grandmother. They are smaller for the right portion. Try and buy non-processed food it you can. It is difficult if you live in the bush, but try and buy non-processed food. Try to have no refined sugar. So not combine low carbs with fat. Eat the whole fruit. A lot of the goodies, the fibres are inside the skin that you throw away. So do not be a nut and only eat the skin of the apple and throw the apple away, just eat the whole thing. Do not use commercial juice, make your own juice. Have lots of veggies. Interesting article coming out of the US. When kale became a superfood, a lot of farmers jumped on the bandwagon and tried to make a killing by growing kale. To make kale, they had to put a lot more pesticides and stuff like that to have two or three crops per year. What did they find? The skin of the kale has all kinds of pores. It is almost impossible to wash the pesticides out. So here you are, you try to do a good thing for your family, you buy kale, you make kale three or four times a week, but you cannot get rid of the pesticides. So it is ironic. So try and buy your veggies locally because then you know what is happening. Reduce your trans fats and omega 6. Less of that is better. Try to have meat which is produced without all the hormones and all the penicillins and all the other stuff that we use to make a cow give 100 litres a day. That is not good. That is where A2 proteins come from, those stories. Charcuterie is fine if you make it yourself. Otherwise there is too much rubbish in it. Try your dairy without sugars and try to find dairy which does not have the enzymes that we feel are promoting gluten intolerance. Have plenty of good water. And that most of the time ironically enough, is not the one in the plastic bottle that you buy, but is your tap water. And, last but definitely not least, buy a dog. Go for a walk because the regular exercise you do every day is very important. Why is that important? Because you have time to talk to your wife about what happened during the day, it is good for your relationship, good for your sex life, good for your kids. If you get a dog, you have to get out, hail or rain, hot weather, cold weather, the dog requests you get out so you are going to do it.
If you are commercially interested, I suggest you do this. I tried it for a while. It was a lot of fun. You go and buy your nuts and you put Dr JJ’s Heat Nuts for sale. 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts. There is good evidence that if you consume half a pack a day, you will have a 20% to 30% reduction of risk and that is a very good snack.
The other thing I advise patients, is if you take this, this is the wife of Michael Mosley who we discussed before, this latest book, the Fast 800 Recipes, is the best bit of everything that we discussed. So really, it is more flexitarian than anything else and it is practical. People like practical. You can just start on page 1 and just cook the whole book and it gives you some justification and some stuff.
Now, the last thing is what if the patient comes to you and says, what should I do to improve my health? One of the answers you can give, is you can say buy a bike and cut the carbohydrates. Alright? Thank you very much.
Sharon: Thank you so much, Dr Janssen. I would just like on behalf of RACGP and St. John of God Subiaco to say thanks for attending and helping out with the webinar today. We will be sending out two surveys, the first of which will be straight after the webinar finishes with some optional questions about where your practices are. But we will also send out a formal evaluation in the next few days. So, we do have some questions coming through. Dr Janssen is happy to answer some them. They are typed. So if you will just bear with us, he will just read through some and answer some.
Dr Janssen: I have got a question about meditation 30 minutes a day. That is good, yes definitely. So meditation, yoga, Pilates, Tai Chi have been shown to have a great positive effect in prevention and treatment of cardiovascular disease, as well as rheumatism. And that is not just me, we have flash MRI studies that show that such is the case.
Lite ‘n Easy. Lite ‘n Easy is typically one of those things. It is a good commercial enterprise but it means that patients are interested. It does give them a definite calorie reduction and people find it successful. The problem is that it is going to be expensive so I try to motivate them to see what Lite ‘n Easy is and then to try to replicate it themselves.
Vitamins, whether they help to increase metabolism. The answer is yes. But what I do is I measure vitamins in my patients and I treat them if they are deficient.
We have another one. Keto diet might damage the body. That is what I am saying, you have to look at the individuals. So I use it only for reduction of weight for four weeks and then go on to something else.
Then do we have alternatives for statins? Two quick remarks about statins. Number one is I get quite a few people referred to me with a question, oh they have a high cholesterol I prescribed a statin but the patient does not want to do it. What I do is explain to the patient that I only give a statin if we want to reduce the risk. So if they would like to know what their risk is, I do a CT angiogram or a PET scan of their brain, or something that measures atherosclerosis. Let us give an example, if they are 60 and their cholesterol is 7 and they have normal arteries, no plaque in the arteries, then my argument is well, it seems to me very reasonable to not do anything, just have a healthy lifestyle. And if you are worried about it then do another scan in maybe five years or ten years’ time. And you know, there might be something better than the statin if such is the case. Because you are not treating cholesterol. Cholesterol is not a disease. You are treating people with atherosclerosis and that is something we should remember.
Can you use other stuff instead of a statin if people are intolerant? Yes. We have Repatha which is a monoclonal antibody. There is another drug in stage 3 trials that will surpass statins within the next two or three years. And to think, 80% of the risk reduction people can achieve by exercise, eating healthy and being more measured in their day to day activities. Be more relaxed.
Is long term fasting dangerous? Long term fasting is dangerous, but we should not forget that most large religions like Christianity or Hinduism, have 40 day fasts. But they break fasts at night time. So long term fasting in principle is dangerous.
The question is what vitamin deficiency to we check for patients? I check vitamin C, vitamin D and check B12. Then we check antioxidants. I check zinc and selenium. Why these ones? Because they are readily available in the laboratories that I use.
Take another one. There is here a question, do you find patients on high dose statins for coronary artery disease complain of memory impairment? The answer is I have some patients that complain about memory impairment even if they are on low dose statins. There is no scientific evidence, and believe me they have been looking at that very carefully many times, that memory impairment is related to statin use. If people are adamant, then I do not put them on a statin. Sometimes, I do advise them to have red rice, but I do tell them that in red rice the component that makes their cholesterol lower is actually a natural statin. It is a weak statin. It is a little bit weaker, it is comparable to pravastatin, a little bit weaker than simvastatin. And even saying that, they will still use the red rice and are very happy with that.
What about advise on alcohol with a diet? That is a very good question, thank you. Alcohol from a cardiovascular point of view is healthy because any alcohol has antioxidants. I do not like beer that much because the calorie versus alcohol is in favour of the calories, so I advise patients not to drink low strength beer, not to drink mid strength beer, not to drink alcohol-free beer, but to go for an artisan made full strength beer, but only in moderation. Red wine. The story about alcohol and the wines is that alcohol per se is an antioxidant. They found in some grapes, also flavonoids. Like you also find in freshly roasted coffee beans. That is why fresh coffee might also be of benefit. Now, those flavonoids occur in grapes that are used for red wine, also for white wine. They have not tested all the wines in the world. So the amount of antioxidant effect differs from wine to wine. Beer is the same thing. As it is made only from hops and water, there might be a difference in the amount of antioxidant depending on where the hops was grown and which type of hops they used. So my general advice is drink what you like, drink with your friends it is social, it is good, drink in moderation and if you drink more than two standard drinks a day, then you have to have alcohol free days and have your doctor check your liver. Because if you get a fatty liver, you get diabetes. So too much alcohol is definitely not good for you. But a little bit of alcohol is fine with me.
One more question. Why is there such a big fuss about turmeric these days? Well, turmeric is a very good antioxidant. So you can use it. However, turmeric in powder form does not work. Turmeric needs to be cooked and it is better absorbed if you use it together with cracked pepper. And fresh turmeric, if you cook with it your hands turn yellow so you have to wear gloves. Plastic gloves are not good for the environment. So my advice is yes, turmeric is good for you. If you think your turmeric pill helps, do not forget there is 30% placebo effect there, then let them do it. Otherwise, why not have a nice vegetarian Indian once or twice a week? They use plenty of turmeric and everybody will be happy.
Thank you very much, it was a pleasure.
Sharon: Alright. Thank you Dr Janssen. We will be signing off the webinar now, so thank you everyone for attending.