Online Health Chat with Mladen Golubic, MD, PhD
January 14, 2013
Poor lifestyle choices, such as smoking, overuse of alcohol, poor diet, lack of physical activity and inadequate relief of chronic stress are key contributors in the development and progression of preventable chronic diseases, including obesity, type 2 diabetes mellitus, hypertension, cardiovascular disease and several types of cancer. Even though doctors encourage healthful behaviors to help prevent or manage many chronic medical conditions, many patients are inadequately prepared to either start or maintain these appropriate, healthy changes. Most patients understand the reasoning behind a healthy lifestyle even if they don’t understand the disease processes that can occur when they don’t maintain healthy habits. Despite an understanding of what constitutes a healthy lifestyle, many patients lack the behavioral skills they need to apply everyday to sustain these good habits.
Nevertheless, healthy lifestyle modifications are possible with appropriate interventions, which include nutritional counseling, exercise training, and stress management techniques to improve outcomes for patients at risk and those who already have common chronic diseases.
Medical studies show that adults with common chronic conditions who participate in comprehensive lifestyle modification programs experience rapid, significant, clinically meaningful and sustainable improvements in biometric, laboratory and psychosocial outcomes.
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On Cleveland Clinic
Wellness experts at Cleveland Clinic Center for Lifestyle Medicine within the Wellness Institute have successfully used a system of group-based, hands-on interventions for more than four years. These interventions include nutrition, culinary techniques, physical activity, and stress management approaches of therapeutic yoga and behavioral health coaching to improve outcomes for patients at risk and those who already have common chronic diseases.
The department's commitment to helping patients maintain good health and improve function extends through outpatient clinics, inpatient rehabilitation hospitals and consultation in skilled nursing facilities. Physicians are required to maintain a general rehabilitation inpatient and outpatient practice, and they are expected to develop their careers in rehabilitation subspecialty areas.
Learn more information about Cleveland Clinic Center for Lifestyle Medicine. Programs offered at Cleveland Clinic Center for Lifestyle Medicine include Lifestyle 180 and Lifestyle U.
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To make an appointment with Dr. Golubic or any of the other specialists in our Center for Lifestyle Medicine at Cleveland Clinic, please call 877.331.WELL (9355).
About the Speakers
Mladen Golubic, MD, PhD is the medical director for the Center for Lifestyle Medicine. Dr. Golubic specializes in lifestyle medicine, cardiovascular disease reversal and integrative medicine approaches to lifestyle-related cancer management. Dr. Golubic completed his residency in internal medicine at Huron Hospital, in Cleveland. He graduated from University of Zagreb School of Medicine, and earned his doctorate degree from Sveuciliste u Zagrebu in Zagreb, Croatia.
Dr. Golubic has also worked as a project scientist at Cleveland Clinic in molecular biology, neurosurgery and integrative medicine.
Let’s Chat About Lifestyle Choices: Root Causes of Chronic Diseases
Cleveland_Clinic_Host: Dr. Golubic, let’s begin with some of the questions submitted
Vegan Diet and Heart Disease
Peppy: What is your opinion of the heart disease benefits of the vegan diets offered by many doctors and former U.S. President Bill Clinton?
Dr_Golubic: As long as the vegan diet is based on unrefined plant foods (no white bread,pasta or flour), it is a healthy diet. U.S.News and World Report ranks Dr. Dean Ornish’ vegan diet as the leading heart-healthy diet in the U.S. We use literally the same vegan diet, but ours was created by former Cleveland Clinic cardiac surgeon Dr. Caldwell Esslestyn.
KareninBluffton: I saw the documentary ‘Forks over Knives’, based on the vegan diet of Dr. Caldwell Esslestyn (retired Cleveland Clinic physician). It led me to believe that eating a wholly plant-based diet with no meat, no dairy and no oil will help prevent and reverse heart disease as well as cure some cancers. Is this true? Have you helped people change from our typical Western diet to vegan diet? How can I find a local physician to monitor me if I want to do this?
Dr_Golubic: Yes, we are quite successful at guiding people to transition to the plant-based nutrition of Dr. Esslestyn. This type of diet benefits more than those patients with coronary artery disease. It helps patients suffering from a wide spectrum of chronic diseases that are related to poor lifestyle choices, including obesity, type 2 diabetes, and several types of cancer, such as prostate, breast, and colon.
KareninBluffton: I am trying to switch to a vegan diet. We are advised not to eat anything with a face or a mother. What about oysters taken from pristine waters? Wild salmon from Alaska?
Dr_Golubic: As we say in medicine, the dose determines whether something is poison or medicine. If your aim is to halt or reverse coronary artery disease, you do not need to worry about missing the salmon or oysters from pristine waters. There is nothing in those foods that you cannot get from readily available plant foods. Saying all that, there is no data to suggest that eating any of these foods once a month in small quantities will harm you.
Peppy: It seems strange that the Esselstyn diet and the Ornish diet do not include healthy raw nuts when they are proven to help heart patients. So vegan fat sources are out for heart patients, such as nuts and avocado?
Dr_Golubic: On both diets you can eat flax or chia seeds that provide all the essential fatty acids of both omega 6 and omega 3 families that you would otherwise get from nuts. In our other programs, such as Lifestyle 180®, participants do eat nuts and fish, but the aim of this lifestyle intervention is not the reversal of coronary artery disease. We have demonstrated that such a diet can dramatically reduce risk factors that lead to chronic disease development. For example, after one year patients lose an average of about seven percent of their body weight, improve their blood cholesterol, and sugar and inflammation levels. They also report reduced perception of stress, better mood, and a better quality of life in general.
KareninBluffton: Will Dr. Esselstyn’s vegan, plant-based diet cure a thoracic aortic aneurysm?
Dr_Golubic: I do not know. In aneurysm development, atherosclerosis may play a role and therefore eating Dr. Esslestyn’s diet may be helpful, but that’s only speculation.
rhsleigh: Recently I started reading Dr. T. Colin Campbell’s book called “The China Study”. Even in the early chapters it seems clear to me that the evidence is overwhelmingly in favor of a plant-based diet. Why is this information not more widely spread by physicians and other health professionals?
Dr_Golubic: The main reason is the lack of large-scale, randomized clinical studies that use plant-based nutrition. That kind of evidence is superior to epidemiological type of evidence, which is exemplified in “The China Study”. Health professionals themselves are disinterested in eating this type of diet, and therefore they are unlikely to recommend it to their patients. The third impediment is the opposition to plant-based nutrition by certain segments of the food industry. Think about how long it took to acknowledge that tobacco is a poison. We are about 20 years behind the tobacco study when it comes to food.
Vegan Diet and Vitamin Deficiency
Peppy: Several studies comparing vegan, vegetarian and Western diets have shown vegan diets result in the same lifespan as a Western diet. Vegetarian diets added seven additional years of life over the other two diets. Why is this? Is there a deficiency created by eating vegan such as with vitamin B12? Vegans supplement to get vitamin B12, but maybe synthetic supplements or non-animal sources just aren’t working?
Dr_Golubic: I do not know the reasons. Most of those studies were designed as retrospective studies and may be biased because of other factors. As far as we know, vegans who take vitamin B12 supplement do not suffer of any nutritional deficiencies.
sherstol1_1: Is there a benefit to having B12 injections, as opposed to sublingual B12 if you have a deficiency?
Dr_Golubic: Yes, if your gastric lining is damaged because of disease, you might not be able to properly absorb vitamin B12 supplements taken by mouth. Therefore, injections of vitamin B12 will be necessary.
AHA Diet vs Vegan
Peppy: The American Heart Association (AHA) recommends two servings of fatty fish a week for heart patients. Are you saying not to do that?
Dr_Golubic: The AHA recommendations are clearly beneficial when used instead of the typical high-fat meat and potato diet. However, as shown by Dr. Dean Ornish, patients with coronary artery disease who were randomized to the AHA diet did worse than those randomized to a low-fat, plant-based diet of Dr. Ornish or Dr. Caldwell Esslestyn.
Diet and Carotid Artery Disease
Peppy: Is there clinical evidence of any certain diet that reverses or stops carotid artery disease?
Dr_Golubic: Carotid artery disease is one type of vascular disease. Plant-based diets, such as those by Dr. Caldwell Esslestyn and Dr. Dean Ornish, which have been shown to reverse arteriosclerosis of the coronary arteries, would likely have similar affects on all other arteries in the body including the carotid arteries. Needless to say, besides an optimal lifestyle that includes physical activity, no smoking, and regular stress management practices in addition to diet, you need to follow the advice of your physician regarding medications.
Jsweetie: Do you believe the anti- inflammatory diet as suggested by Dr. Andrew Weil is a beneficial diet?
Dr_Golubic: Chronic inflammation is the root cause of most chronic diseases. Therefore, lifestyle changes, such as dietary, stress management and physical activities, which are known to reduce inflammation, may be beneficial. There is a lot of debate about what is the most optimal anti-inflammatory diet. For example, does one need to eat omega 3 fats from fish or not, and so on. The current evidence points to the benefits of true plant-based diet without fish or dairy. Click for more information about anti-inflammatory diets. Dr. Weil’s anti-inflammatory diet is clearly beneficial for anyone who moves away from the typical high-fat, meat-based American diet. Whether this diet would be the most optimal for somebody with severe coronary artery disease remains unknown.
jml666: What are your thoughts on the Paleo diet? In your opinion, is it compatible with someone with IBS? (You mentioned a plant-based diet being beneficial.) I just finished reading “It Starts With Food”, and have considered trying it. (Hence, I would be eliminating sugar to start with).
Dr_Golubic: I think there are good components of the Paleo diet, but I think that evidence favors plant-based nutrition. Saying all that, if you find that eating a Paleo diet is helpful for you, I do not see any reason why you wouldn’t continue with it.
Dietary Changes for Bariatric Conditions
PENN: I have had two bariatric surgeries. Cleveland Clinic sent me to Robert Wood Johnson University Hospital in New Jersey in 1996. I had another surgery by Dr. Philip Schauer at Cleveland Clinic in 2006, but I did not lose weight. Are there special food plans for bariatric patients? Do you have more information on how to ‘turn on or off’ genetics, according to Cleveland Clinic Chief Wellness Officer Dr. Michael Roizen?
Dr_Golubic: As you have heard our lifestyle choices have profound effects on ‘turning on and off’ a large spectrum of genes. That is true for physical activity, meditation and particularly food choices. For example, a patient with a genetic predisposition for coronary artery disease can reduce his or her risk of heart attack to a level similar to a normal population of people just by eating large quantities of green leafy vegetables. In regards to patients with bariatric surgery, all principals of healthy lifestyles apply. As for the general population, you would benefit from eating a plant based-diet, and engage in regular physical activity and daily stress management practices.
jml666: I have had irritable bowel syndrome (IBS) for 15 years. I was managing with it quite well up until 6 months ago when I also was diagnosed with GERD. I have tested negative to all food allergies, but I decided to go gluten free over two months ago, and now I want to eliminate sugar from my diet as well. I had my physical last week and was told I am vitamin D deficient and borderline diabetic. I am 44 years old, female, five-foot and five inches tall, and weigh about 155 pounds. I am somewhat active, but not as active I would like to be. I have been reading that diet and your digestive tract contribute significantly to chronic diseases. I wanted to know if what I’m doing is moving my health in the right direction. What other resources and advice you can provide to ensure that I can maintain good health?
Dr_Golubic: For your vitamin deficiency your primary care physician might have already put you on a vitamin D supplement. Just make sure you take it with the largest meal of the day because this is a fat soluble vitamin, and it is poorly absorbed in the absence of fat. It is a good idea that you want to eliminate sugars, syrups and refined carbohydrates from your diet. Eat 100 percent whole grain products, legumes and vegetables instead. Along with daily physical activity, this will help you control your blood sugar and reduce your risk of progression to type 2 diabetes. There are many options for 100 percent whole grains that do not contain gluten. The health of your gut is important to your overall health because the bacteria that reside in your gut are highly metabolically active, surpassing the metabolic capacity of your liver. Our dietary choices determine which types of bacteria reside in our large intestine. Therefore, focusing on a plant-based diet as outlined above will have benefits for gut health as well. You may find that the regular practice of stress management techniques, such as yoga, meditation or tai chi will help you with your IBS symptoms. This is a low-risk proposition without any side effects or interaction with any medications that you may be taking—it just requires dedication to daily practice. You can learn many of those techniques on your own—or even better, you can take classes taught by professionals in these techniques. We offer an online stress management program called Stress Free Now that you can access and use in your daily life.
sherstol1_1: Could you please tell me if you notice more chronic health problems in patients that have had bariatric surgery? I had an Roux-en-y gastric bypass in 2006, and lost 90 lbs. I have, unfortunately, gained all of the weight back over the past 5 years, due to extreme stress, lack of exercise due to fibromyalgia pain, and poor eating habits. My health has deteriorated so much since my surgery. I don’t feel like I can even think right and stay focused to do small tasks anymore. I’m in a constant brain fog and am extremely depressed.
Dr_Golubic: I’m sorry you’re not feeling well. What you can do under the circumstances you described is to focus on stress management practices. Even with your limited physical abilities you will be able to practice mindfulness meditation—a technique that was shown to benefit patients with chronic disease such as fibromyalgia. Finding stress relief will also help you with making healthier food choices and mindful eating will help you control portion size. Again, focus on eating mostly plants and avoiding animal foods. There are at least two studies that suggest that some patients with fibromyalgia may benefit from eating a vegan diet.
Dietary Changes for Hormone Imbalance
Jsweetie: Are there any lifestyle choices that help with non-preventable diseases such as pulmonary fibrosis?
Dr_Golubic: To my knowledge, no. However, choosing a healthy lifestyle may be beneficial by improving your general overall health.
Dairy in Diet
Peppy: The diet by Dr. Dean Ornish allows some dairy—I think a cup a day, whereas the diet by Dr. Caldwell Esslestyn does not allow dairy at all. Should all dairy be dropped?
Dr_Golubic: I think it’s better to focus on where both diets overlap and that is 99 percent of it. One serving of low fat dairy foods in the context of an overall low-fat, plant-based diet may be insignificant. However, that determination has to be made on an individual basis.
gatorfrog: Do dairy products and/or sugar contribute to chronic health issues?
Dr_Golubic: The answer to both is yes. Overuse of simple sugars and dairy products is epidemic in our country as are chronic diseases, such as obesity, diabetes, cancer and heart disease. You can get all the calcium from green leafy vegetables without the extra protein and fats that come from dairy. Instead of simple sugars and syrups, choose foods and products that are unrefined, 100 percent whole grain.
Juicing vs Eating Healthy Foods
j2izzo: : I’ve read a lot of information online suggesting that fruit- and veggie-based smoothies are a good way to increase your fruit and vegetable servings. I’ve read other sites that suggest juicing is a better option as the juice is readily absorbed. What are your thoughts? Is one method better than another?
Dr_Golubic: I will disagree that juicing is a better option than eating whole unrefined fruits and veggies. Our Stone Age genes that we all carry today know well how to deal with foods that we chew rather than have the blender chew for us. Chewing and eating slowly produces beneficial hormonal changes that prevent us from taking in too many calories.
Lifestyle and Cholesterol
dodlam: If you are already borderline high on cholesterol, how can you reverse the bad effects of cholesterol that has already happened?
Dr_Golubic: In general healthy lifestyle changes can slow or even reverse the progression of processes caused by damage because of high cholesterol or high blood sugar. Put in other words, diabetes, obesity, hypertension, high cholesterol and heart disease can be reversed.
Long-term Behavioral Change
ej1954: I find that making lifestyle changes is very difficult in the long run. Short-term changes can be achieved, but long-term changes to diet and exercise habits are very hard. What tips can you offer on making long-term behavioral changes?
Dr_Golubic: I agree this is a very common issue. It is very difficult to follow a healthy lifestyle in our modern toxic environment where unhealthy lifestyle choices are default. There is no magic formula on how to overcome that on an individual basis. The key is to focus on making daily progress rather than being perfect. Do consistent small daily steps such as walking daily at least 15 to 20 minutes, meditating daily or doing yoga for another 10 to 20 minutes, and eating a low-fat diet based on plant foods. What is often helpful is having a buddy who is on the same path as you, and also having supportive family and friends.
sherstol1_1: How do you go about changing your tastes for foods you dislike? I dislike most fruits except for apples and watermelon, and also most vegetables, except for corn, potatoes and green beans. This makes it very hard to eat a healthy diet. It’s not only due to taste, but also texture. I find it’s terribly difficult as a 47 year old. I know I like all the wrong things, including carbohydrates, meat, sugar and so on. Is there a way to change my tastes at this age?
Dr_Golubic: What is takes is persistence in educating your taste buds. We are not born with a dislike for many foods. Rather we are conditioned to avoid them because of our growing conditions. If you look at little children or domesticated animals taste buds can be trained to like new textures and flavors within a couple of weeks.
katheyring: I know you recommend yoga. What do you say to people who seem to think that yoga is part of the Hindu religion.
Dr_Golubic: The yoga techniques developed in the Hindu culture are applicable to all humans. There is nothing uniquely Hindu or religious when one practices breathing techniques, meditation or body postures. These techniques are completely suitable even for hard-core athletes.
Center for Lifestyle Medicine Gym and Trainer
PENN: At Cleveland Clinic Center for Lifestyle Medicine, I know there is a personal trainer. Does this program include the use of exercise equipment? May we return to use the equipment after the program?
Dr_Golubic: Yes, our lifestyle intervention programs include exercise and we have personal trainers. Our gym, however, is exclusively designated to patients who participate in those programs.
Cleveland_Clinic_Host: I’m sorry to say that our time with Cleveland Clinic Mladen Golubic, MD, PhD is now over. Thank you Dr. Golubic for taking the time to answer our questions today about the influence of lifestyle on disease and ways to manage our health.
Dr_Golubic: Thank you all for the terrific questions. I hope you have a wonderful day.
Cleveland_Clinic_Host: To make an appointment with Dr. Golubic or any of the other specialists in our Center for Lifestyle Medicine at Cleveland Clinic, please call 877.331.WELL (9355). You can also visit us online at clevelandclinic.org/wellness/reclaim_your_health.aspx
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