Heart Health and Diet: How They’re Connected with Julia Zumpano, RD and Leslie Cho, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials Podcast. I'm John Horton, your host.

We explore a lot of different topics on the show, but two of the most common themes revolve around the overall importance of nutrition and ways to keep your heart healthy. With that in mind, today, we're going to try something new by bringing these subjects together for a group chat about how food choices affect your heart. We'll be joined by our resident nutrition expert, registered dietitian, Julia Zumpano, as well as a cardiac colleague of hers. We'll let Julia make that introduction.

Julia Zumpano:

Thanks, John. Given the link between diet and heart health, dietitians work closely with cardiologists to build care plans for those living or recovering from heart issues. That's how I met Dr. Leslie Cho. She's the section head of the Department of Preventive, Cardiology and Rehabilitation at the Cleveland Clinic. I've known her for almost 20 years. We've worked together to help people heal and maximize their heart health.

John Horton:

That's a lot of decades of experience, Julia, which should add up to a fascinating and informative conversation. So with that, let's get started and connect the dots between what you eat in every heartbeat.

Welcome back to the podcast, Dr. Cho. I got to say, I'm always overjoyed to get either you or Julia on our schedule, so to get both of you here at the same time … just beyond my wildest expectations.

Dr. Leslie Cho:

Well, you're too kind. Thank you for having me.

John Horton:

So this is our first mashup podcast where we're taking nutrition and another health topic and showing how they're interconnected. I feel like it would be difficult to come up with a more perfectly matched pairing than nutrition and cardiology.

Dr. Leslie Cho:

That's absolutely true. I mean a very, very well-known physician, you may know him, Hippocratic Oath, right?

John Horton:

Familiar. Yeah. Definitely a little famous.

Dr. Leslie Cho:

1,000 … 1,000 years ago … that let your food be your medicine and your medicine be your food. And certainly, we in preventive cardiology think nutrition is the cornerstone. Healthy lifestyle, exercise, along with nutrition, is the cornerstone of treatment for heart disease.

John Horton:

Julia, I'm guessing that the types of food that won't qualify as medicine probably aren't going to surprise us.

Julia Zumpano:

I definitely want to reinforce what Dr. Cho said. At the Cleveland Clinic and specifically in our department, nutrition is so highly valued and encouraged to all of our patients. And we really look at including more healthy food, not necessarily eliminating foods. We do teach about foods that are healthier for our body versus others, but everything is allowed in moderation. So we really just focus on what can actually be added to the diet to improve the heart health.

John Horton:

Well, we have so much to think about already and we're just getting started here today. So if we're going to break down this relationship between the heart and our hunger, let's take a closer look at how our tickers actually function.

If you wouldn't mind, Dr. Cho, could you walk us through how the heart and cardiovascular system should function when everything's running smoothly?

Dr. Leslie Cho:

The heart is an amazing, amazing organ. It beats 100,000 times a day. It pumps with every beat about five liters of blood. It pipes that blood through 60,000 miles of blood vessels. I mean, that's -

John Horton:

That's a lot.

Dr. Leslie Cho:

Yeah, that's two times around the world. That's unbelievable. Right?

John Horton:

I can't believe that's all in here.

Dr. Leslie Cho:

Yeah, it's all in there, all packed in there. And no matter how small you are or how tall you are, I mean that's ridiculous. And the problem is that when we are expecting so much out of our heart, the heart never goes to sleep. If it goes to sleep, we're dead. So it never goes to sleep. It beats every single day, every minute, every second. And we're expecting a lot out of this pump. And for the optimal functioning of the heart, we want your blood pressure to be low, and we want it to be ideally less than 120 over 70. We want your heart rate, your resting heart rate to be low. They say Lance Armstrong has a resting heart rate around 29. We want your cholesterol level to be low. We want you to be at optimal weight and all of these things because once you start damaging the blood vessel, once your heart is pumping against an excessive force, that damages the heart, but it also prevents your other organs from receiving nutrients.

John Horton:

Well, I got to tell you, I'm still stuck on that 60,000 miles figure. And just thinking about how pipes work, with that many miles of arteries, it just seems like at some point, things can get gummed up over time, and I take it that's where nutrition kind of fits in here.

Dr. Leslie Cho:

Absolutely. I mean, when we're born, we had these beautiful pristine arteries that are like beautiful pipes without anything in it. And with eating and not exercising and smoking and all the things that we put on our body, our arteries become gummed up, as you say. It becomes blocked with cholesterol plaques. And with things like blood pressure, high blood pressure, cholesterol that are out of control, diabetes which makes your cholesterol more sticky, so they're more likely to stick in your arteries, family history, all of the inflammation because you have autoimmune disease, or for some women, polycystic ovarian syndrome. All of these things unfortunately increase the chances of our arteries becoming blocked.

John Horton:

Now, Dr. Cho, when you're in there, can you actually see this gunk and these clogs kind of build up?

Dr. Leslie Cho:

Oh yeah. I'm an interventional cardiologist, so I put stents in people's hearts. And we do something called intravascular ultrasound where we put an ultrasound camera inside the coronary arteries. And that modality has been used to study cholesterol-lowering medications, as well as looking at stents and whatnot. But what you can see is the unbelievable amount of cholesterol plaque that are built up. I mean, it is really amazing. Sometimes, I show people, I show patients the pictures of their intravascular ultrasound. And it's certain … other times, I've actually printed it out and given it to them so that they can put it by their refrigerator or wherever. I have a patient who actually took a cell phone picture of his intravascular ultrasound and made it his home page on his cell phone.

John Horton:

Well, that would make you think every time you go to grab something to eat.

Julia Zumpano:

Yeah. If I can jump in here as a dietitian, something I focus on all the time is eating an anti-inflammatory diet. Dr. Cho, you mentioned some inflammatory-based diseases. We know cardiac disease is an inflammatory. Can you tell us a little bit about how inflammation affects the heart?

Dr. Leslie Cho:

Yeah, inflammation is a powerful risk factor. And inflammation … your arteries become irritated and to try to alleviate that irritation, your cholesterol plaques may lay on it or it may actually become more sticky. We don't really know the true mechanism of that inflammation, but every disease state that increases inflammation. For example, autoimmune disease or being obese — because we used to think fat was inert, but it is quite active. Fat is a very active inflamed substance. It increases the risk of you getting blockages in your heart.

John Horton:

Dr. Cho, you keep mentioning sticky cholesterol. Can you tell us a little bit what that is?

Dr. Leslie Cho:

Yeah, so cholesterol, like for example, your good cholesterol, or we call it HDL, H for happy — they go around your body and they suck out bad cholesterol from your blood vessels. And that wonderful mechanism is called reverse cholesterol transport or cholesterol efflux. But the bad cholesterol, the LDL, or actually apolipoprotein B, any cholesterol that contains apolipoprotein B tends to stick to the blood vessel. And so unlike happy cholesterol, the other cholesterol tends to be quite sticky and they tend to stick in your coronary arteries. And people ask why the coronary arteries and not other arteries? Well, because it has so much flow going down that artery. And the reason why it has so much flow going down that artery is because the heart is such an important organ. And so it requires that amount of flow to be able to pump the 5 liters of blood to the 60,000 miles of blood vessels you have.

John Horton:

So Dr. Cho, when you start talking about the cholesterol and all this stuff, I take it, what you eat is kind of where a lot of that comes from. So when you see heart patients for the first time and kind of start getting their history, how much do you focus on diet?

Dr. Leslie Cho:

Well, we focus a lot on diet. And Julia, who has been with us for over 20 years … I know that's shocking because that means that I would've started at age 10 maybe and Julia at age 5!

Julia Zumpano:

Yeah, I was like 5 or 6, I don't remember. Around there.

Dr. Leslie Cho:

Yeah. You were precocious.

We really try to focus on diet as our main sort of point of intervention. And when I say diet, I also mean alcohol, too. But I really want to just caution all of us. There are people for whom diet is one part of why they have high cholesterol, but genetically, they also have high cholesterol. So it's not a moral failing. People often think it's like a moral judgment. It's really not. 85% of us are moderate absorbers of cholesterol from our small intestine. 15% of us are hyper absorbers. And so I don't want it to be all about like, "Oh, you've been a bad patient, you eat badly."

The eating thing is so fraught in America with moral judgment, and I don't want it to be about that, and I want it to be about eating better so you can have a reduction of cardiovascular disease, but also eating better so you don't have stroke, so you don't have dementia, so you don't have cancer. Because it turns out, and Julia is going to speak a lot about the Mediterranean diet, but that Mediterranean diet, the anti-inflammatory, the low cholesterol diet, is not just good for the heart, it's good for the brain and it's good for reducing your cancer risk. So it really is a comprehensive diet.

John Horton:

Dr. Cho, thanks so much for bringing up the stigma aspect of it because I know we've talked about that before. Because people, they do get really sensitive with food, and there are a lot of different factors that can cause some of these issues, as you said. But also, as you note, what you eat and what you put on your plate does make a big difference.

Dr. Leslie Cho:

Oh, huge. Yeah.

John Horton:

And that's why I know you said you will refer heart patients over to a dietitian and luckily, we've got a great one with us here today. So Julia, if you can kind of walk us through a little bit, what you usually do when you first meet with someone looking to adjust their diet to improve their heart health?

Julia Zumpano:

Sure. So of course, my first step is I take a nutrition assessment — what they're typically eating, I take a look at alcohol intake supplements, exercise activity, and that gives me a full picture. And then, I work on incorporating more of the Mediterranean-style diet because I couldn't agree with Dr. Cho more. I think our patients get very stuck on the numbers on the HDL, the LDL. It didn't move. I did the best I could. I've been trying so hard. But I try to explain to patients that really, it's so much far beyond that. The fact that you're changing your diet, you're reducing some of those foods that can cause in the end disease, it's not just the numbers we're preventing from going up. We're preventing stroke and heart disease and stents and dementia and Alzheimer's and cancer and diabetes and high blood pressure. It's not just the heart disease, the number itself that plays a big role.

And as we talked about, inflammation affects your whole system. So we can be over hyper-focused on the heart, which we know is extremely important. We've just explained it. But all the body works together, so we're reducing inflammation everywhere, which is only going to help the heart work better. So I think it's really key to understand the full picture and to understand how your food affects your whole body versus just focusing on cholesterol, which as Dr. Cho said, we don't have as much an influence as we would hope to have from our diet. But with that being said, we can improve our HDL. As Dr. Cho mentioned, that is kind of that dump truck that takes all that bad cholesterol out. So we can improve that by the foundations of the Mediterranean diet.

John Horton:

So Julia, let me ask you this: When people first come in, are they sometimes surprised when they see such a direct connection between maybe their food choices and then the damage that some of that food causes?

Julia Zumpano:

I think there is some surprise there, but a lot of times, as I mentioned, I think they get too caught up on the numbers and the lowering of those values and they may struggle to see that big picture. So that's where we come into play, to really understand, look at those arteries, look at what you could do to reduce it, reduce the plaque buildup. Whether we don't see that number of the LDL cholesterol drastically change, we're seeing inflammatory markers down. We may be losing weight, our blood pressure's going down. So it's explaining the full picture. And then, when you really present it that way, then they're impressed and they're kind of hooked, too. And I think it's the approach, too, of providing education and making all foods fit and meeting the patient where they are to help them progress and make reasonable changes.

John Horton:

And I take it's a long process, too. I mean, this isn't the sort of thing where you eat an apple on Monday and on Tuesday everything is good.

Julia Zumpano:

Absolutely. I mean, change takes time. So it's a matter, like I said, of starting to work on really incorporating the healthy foods first. So as we know, the Mediterranean diet is high in omega-3 fatty acids from fish. They're trying to get more fish in the diet, tons of extra virgin olive oil. We know there's phenomenal benefits in extra virgin olive oil, tons of antioxidants that have supported heart and brain health. We know that there's a lot of benefits to soluble fiber, so that's another foundation of the Mediterranean diet. So a lot of fruits and vegetables, grains and beans, nuts and seeds. So just kind of focusing on those touch points and really focusing on including those nutrients in the diet on a regular basis and then slowly moving out the foods that aren't as serving to the heart.

John Horton:

Well, let's go over some of those. You brought up some of the things that people should be chowing on if they want their hearts to be a little closer to that highly efficient plumbing system that Dr. Cho was talking about. So I think you mentioned, obviously, more vegetables, fruit, whole grains. I think you mentioned omega-3s, right? That's another big one in the Mediterranean diet.

Julia Zumpano:

Absolutely. So that's fatty fish. Things like salmon, tuna, herring, mackerel, walnuts, and then chia seeds, flax seeds are good sources.

John Horton:

So that's all stuff that will help maybe raise that happy cholesterol and kind of un-gunk you a little bit, or at least add less gunk and maybe help clean those pipes out a little bit. What is the stuff that you want to try to minimize or avoid as much as possible to keep from plugging up those works?

Julia Zumpano:

So we know we want to limit saturated fats as much as we can. Specifically saturated and trans fats. Those are found in processed foods so we know packaged foods, fast foods, convenience foods, baked goods, store-bought commercial desserts — so we know saturated fat is something we really want to limit. If you have a little bit of butter and cheese here and there, that's not the saturated fat we're overly concerned with. That doesn't mean you can eat it endlessly. Small amounts are not a problem. It's really those hyper-processed foods that are going to create the problem because not only do they have saturated fat, they also have sodium and they also lead to that inflammation.

So secondly would be the sugar. So sugar we know induces inflammation. So we want to limit the amount of added sugar. Sugar is in everything. It was interesting, I was listening to a podcast and the podcast was based out of Australia and they mentioned something about high-fructose corn syrup and they said if you live in America, it's pretty much in everything you're eating. So we are known for the fact that it's in everything we eat.

John Horton:

Wow. Yeah, there's so much and Julia, I know in the past when you've been here, we've talked, and one thing you've said that's always stuck with me is when you go to the grocery store to make your healthiest best choices, stick to that outer rim of it where you have all your more fresh foods. You have your produce, you have those healthier leaner meats are out there. And it seems like, in the middle is where you got a lot of that highly processed stuff that just can sit on the shelf for way longer than you want food to be able to just last.

Julia Zumpano:

Absolutely. I couldn't agree more. Definitely sticking to the outside. Those middle aisles … if you're going to get anything in there, you would do maybe some canned beans that are low-sodium and then maybe some frozen vegetables if you're going in the middle aisles, maybe some canned fruit like applesauce or unsweetened canned fruit, that would be fine, I guess especially for a budget-friendly option. But yeah, you really want to stick to the outside. Fresh as much as possible.

John Horton:

So Dr. Cho, if somebody does change their diet — and I'm guessing that these heart issues and those pictures you give them offer a pretty good incentive to change — how big of a difference does it make for the heart and the cardiovascular system?

Dr. Leslie Cho:

I mean, this is kind of a funny question because people want to know the exact number, the percentage of LDL reduction.

John Horton:

I know we always like to have an instant thing, like it's Drano®.

Dr. Leslie Cho:

Yeah. And as Julia said, it's so much more than that. It's so much more than just a percentage reduction. If we look at large randomized studies, it's around 8% to 10% reduction in your bad cholesterol. But there are people, as I said, who are hyper-absorbers. Hyper-absorbers are people who … they eliminate every type of LDL kind of product, and we noticed a dramatic reduction. But I really want to sort of caution us away from that percentage number. And I want us to just think about what else you're doing. You're like decreasing inflammation. Beyond LDL reduction, you are hopefully losing some weight. You are trying to lower your blood pressure because you're not eating bad food.

And also, I want to just make a mention of the fact that alcohol is not a cardio-protective drink. We used to think red wine decreases your risk and it really does not. There's no data.

So much has changed about nutrition and sometimes, people find that very frustrating. And they're like, "Well, they said it was good yesterday, but they don't say it's good today. And so I can't believe anything." And what I want to tell patients is that nutrition is a science. As we get to learn more, we change our perspective. But what has remained the same in the last 25 years is that the Mediterranean diet — a diet that's high in olive oil, high in things like fish — those things are really good for the heart, good for the brain, reduces your cancer risk.

Julia Zumpano:

I couldn't agree more. I mean I think there's a lot of conflict. Eggs or no eggs, wine or no wine, butter, no butter. And then, there's so much conflicting information out there. But as Dr. Cho said, the core foods that have always been healthy remain to be healthy.

When you look at the blue zones — those areas of the world where the life expectancy is far greater than other areas — their incidence of death is much lower in heart disease. They eat whole grains, they eat homemade food. They use a lot of extra virgin olive oil. They eat a lot of fish. They eat together in groups as families, and they move. That we've known forever. If we just stick to what we know, those little details that change here and there. As Dr. Cho said, nutrition is a science. We are going to continue to update and change and provide the most science-backed recommendations. But the core of what we know has always been that standard Mediterranean diet that has always, for decades, centuries, been proven to be very disease-preventive.

John Horton:

Well, I think you guys both made a great point with how diet affects so many other things. Like we had mentioned, weight and how much you exercise play a big role. So it's not just diet. You can't just do that and it fixes everything, but all this stuff is kind of interrelated.

Julia Zumpano:

One thing that I think we both failed to mention was that mood — I see so many people just feel better. They're just like, “I just feel better. I feel lighter. I feel like myself.” Just their mood changes just day to day. I mean, how priceless is that? Just feeling better. They have more energy. Those are some of the most common comments I get. And whether or not the scale tipped a ton or the cholesterol changed a ton, if you're day-to-day feeling more energy and just feeling better, then, I mean, we've made progress. We've met our needs because all about quality of life, too.

Dr. Leslie Cho:

I was going to say the same thing, and it actually has been shown to improve your mood and I think that's a very important thing. I really want to also emphasize that nutrition is a part of your cardiovascular health. So if you had a heart attack, if you had bypass surgery, if you had a stent, you have to be on medications that lower your cholesterol.

Nutrition is a part of that. It is a holistic approach to taking care of your cardiac health. Oftentimes, people say to me, "My goal is to be off of medicine." And what I tell them is, "Well, I have a different goal. My goal is to help you live longer, have no heart attack." So we have to have the same goal. That's a good goal. Yeah, we have to have the same goal. The goal of therapy — whether you are on a Mediterranean diet, whether you are on cholesterol-lowering medicine, whether you're on a blood pressure-lowering medicine — is to make you live longer, have less heart attack, less stroke and not have dementia. That's the goal. We want you to have a high-quality of life. That's the goal. The goal is not to be on no medicine. So nutrition, medication, exercise, all of these things are hopefully going to get you to that goal.

John Horton:

It always amazes me when we do these podcasts, just how so much is interconnected, and you do one thing over here and there's a ripple effect that hits a whole different area of your body. And it sounds like diet is one of those things that obviously, it affects your heart, but it affects so much else and, like you said, even just your mood and how you feel.

Julia Zumpano:

Yep, absolutely. We've been talking a ton about how exercise and diet and lifestyle can really play a big role on heart health. But let's get specific, how can diet alone really affect that blood pressure and cholesterol?

Dr. Leslie Cho:

So let's just take blood pressure for example. We know a lot about blood pressure and diet. So for example, we know that alcohol increases your blood pressure. There is no controversy. This is a thing. It increases your blood pressure. It doesn't matter whether you're drinking the most amazing red wine or beer or hard liquor. It increases your blood pressure. Just by cutting back on alcohol, you can really dramatically reduce your blood pressure actually. And we're talking about people who are moderate drinkers of alcohol.

In terms of cholesterol, there's very good data that when you stop eating foods that are high in trans fat, that you increase your good cholesterol and you can lower your bad cholesterol. So we know that there is that very strong correlation, especially in foods that contain high trans fat. And of course, when you're eating diets that are good for you, that are filling you up, that are not so calorie-rich, for example, lots of vegetables, we know that some people can actually lose weight. Losing weight alone can lower your blood pressure, lower your cholesterol and decrease your risk of getting diabetes. So it really has a very dramatic effect.

John Horton:

From everything that you've said so far today, Dr. Cho, it sounds like adopting healthy lifestyle habits and healthy eating habits can help folks stay off of your appointment schedule. So with that in mind, I'd like to take a moment to talk about the Cleveland Clinic Diet App and the role it can play in heart health. Julia, I know you've worked on that a little bit, so can you give us an idea of what folks can expect if they sign up for that program?

Julia Zumpano:

Yeah, I am so excited about the Cleveland Clinic Diet App. It's been a year-long process. I had an integral role in it and I'm really happy with the content that we're providing to anyone who decides to download this app. It's very holistic. It includes a lot of phenomenal nutrition information. It's not just heavily focused on calories or weight loss. It's really focused on providing you a lot of great information to improve your overall health, including a very good solid base of nutrition strategies. And there's a lot of cool features like voice-activated logging, and really quick, easy things like photo scanning a barcode. So a lot of great features. It can be found in any app store, Android or iOS. So it's a great resource and tool to have to kind of take your health to the next level.

John Horton:

Well, given that, I don't think we can take you and Dr. Cho with us to the store every time we go. That sounds like about the next best thing that we could get.

So I feel like we've put together a pretty good heart protection plan for anybody listening here today. But before we say goodbye and go our separate ways, is there anything else either of you would like to mention about the link between heart health and food choices?

Julia Zumpano:

I think just briefly, I want to explain that we don't want to necessarily look at foods that are good or bad for the heart. I mean, we know that are certain foods that are bad, but just looking at a holistic approach and looking at how you can improve your overall health with the food choices you make, and make those foods that are less healthy few and far between. So just focus on adding more and I think you'll naturally decrease the foods that aren't necessarily as good for us.

Dr. Leslie Cho:

I just want to add that there's so much information out there and oftentimes, I think our patients find it very overwhelming. And it's a good idea to go see a nutritionist if you can and ask your doctor for help when you go to your annual exam. But also, there are places like the Cleveland Clinic website where you can find a ton of information that's completely free. We often think it's a moral failing. It's not a moral failing, and it's OK to ask for help to get back on a good dietary plan. And also, this is a complementary thing — you do it in conjunction with medications for our patients with heart disease, and that's OK.

John Horton:

Yeah. Dr. Cho, I'm so glad you mentioned that feeling of being overwhelmed because I do think that is something that happens a lot. You get all these different things thrown at you with eat this or don't eat this, or your arteries, your heart, I mean all this stuff and people just, you kind of glaze over. But it sounds like from everything that you're saying that there's some simple things that people can do and it's known to be effective.

Dr. Leslie Cho:

Absolutely. I mean, I think it's really important that there are things that have been unchanged for 50 years. The Mediterranean diet was discovered in the 1950s and '60s. It's not like it's yesterday. And so it's really important to ... you can Google “Mediterranean diet” —my god, you can find everything — and so it's important to really look into that if that's what you want to do. But it's also really important to engage with your doctor and on your physical exam or on your annual checkup to really talk to them about, "Hey, I want to make these changes." And if your doctor is really not knowledgeable, then ask, "Can I go see a nutritionist? Can you send me to see a nutritionist?" I think that's totally a great, new way … a great way to start the year.

Julia Zumpano:

I couldn't agree more, Dr. Cho.

John Horton:

Well, it sounds like we have a plan and hopefully, people can find their own Dr. Cho and Julia and make everything better. So thank you so much, both of you, for making the time to come in today and talk. And this was just a fabulous conversation.

Julia Zumpano:

Thanks so much, John.

Dr. Leslie Cho:

Thank you.

John Horton:

What you put on your plate for breakfast, lunch and dinner strongly affects the health of your heart. Show your ticker some love by eating more fruits, vegetables, and whole grains, and maybe a few less double cheeseburgers.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.