How do Diet and Medications Play a Role in Cardiovascular Disease?

Podcast Transcript

Announcer:
Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family, Heart Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Julia Zumpano, RD LD:
Hello, my name is Julia Zumpano. I'm a registered dietician with the Department of Preventative Cardiology at the Cleveland Clinic.

Dennis Bruemmer, MD, PhD:
Hello, my name is Dennis Bruemmer. I'm a physician in the Department of Cardiology here at Cleveland Clinic, and I direct the Center for Cardiometabolic Health in the section for preventive cardiology.

Julia Zumpano, RD LD:
We're here today to talk a little bit about cardiovascular disease risk and prevention and diet and medications. We get a lot of questions from our patients regarding how diet and medications play a role and can they be used together or can we prevent being on medication with a strict or controlled diet? And I think this is a great question. I really think it's very individualized. So it's person by person. We look at each patient individually, their risk factors, their specific diet, their current medications, and then we make it more of an individualized decision.

Dennis Bruemmer, MD, PhD:
Yes, as Julie mentioned so nicely, we have a large number of patients that comes and sees us for exactly these questions for what we call prevention and treatment of cardiovascular risk factors to ultimately reduce the risk for coronary artery disease and cardiovascular outcomes. So a number of these risk factors are what we call modifiable. That means we can actually do something about them. And when we talk about modifying and affecting these risk factors, always lifestyle change, meaning diet and exercise, should go hand-in-hand with, for example, medications or other means that we provide to the patients as tools to reduce their risk of a heart attack.

Dennis Bruemmer, MD, PhD:
So those risk factors are frequently weight-related diabetes, high blood pressure, high cholesterol, but also behavioral aspects like smoking. So those are the major risk factors for cardiovascular disease. And this is what we try to do in our section to educate patients about what is right and what a patient's supposed to do, and what happens if patients actually affect their risk factors. How would that their risk lowering for the future of cardiovascular disease? So we'll be discussing some of these questions today. In particular, I think what is the ideal diet? What do we recommend? And how does the diet kind of interact with medications that we use and at which steps would be actually provide medications to patients?

Julia Zumpano, RD LD:
Another common question is can diet be the only strategy? So we can, in some cases, lower risk factors with diet alone. Again, this is a patient by patient assessment. So a diet that would help lower your cardiovascular risk has been known and shown to be the Mediterranean diet, which is very rich in omega-3 fatty fish, very rich in nuts and oils, fruits and vegetables, legumes and beans, legumes, beans, and very minimally processed foods. Very limited in refined sugars, white flours, red meats, processed meats and processed foods. So we know that this diet is very helpful to prevent cardiovascular disease. And it depends on to what extent you can follow this diet to, and what other lifestyle habits that you can include in combination with this diet to help see if diet alone including lifestyle can really prevent your risk alone without the need of medications.

Dennis Bruemmer, MD, PhD:
Yes, I think it's very important for our patients to interact with the nutritionists. And I think here at Cleveland Clinic, we try to keep things as simple as possible and as easy as possible for the patients. And as natural as possible. If you think about how has the human built, we're hunters and gatherers and Mother Nature has been worked on us species for millions and millions of years to develop us, and Mother Nature usually is pretty good about what it does. So I think if we consider us hunters and gatherers, we only pick some vegetable here, we get a root there. We find an apple here. And then, well, once in a while, we get really lucky and we get some protein. We hunt a rabbit or get a bird. Okay.

Dennis Bruemmer, MD, PhD:
So I think the diet that evolved out of this to be the most natural diet for us is a Mediterranean diet. And as Julia mentioned, fruits, vegetable sometimes lean protein. So the hunters and gatherers, they had no farming. They didn't bake bread. They didn't grow potatoes. They found one once in a while, so carbohydrates were fairly restricted. Protein was fairly restricted. Eggs, well, you had to be really lucky to find an egg, and milk was very rare too. So I think that's probably the most natural diet. And it's little fruit. So if we look at evolution, and we can go in all species, one of the very few interventions that we can actually do to pretty much any species from yeast, to fruit flies, to worms, to mice, to humans, to dogs, is if we want to have all these species live longer, you have to eat less. That's been pretty much proven. So I think the right diet and little of the diet. So that's probably as simple as we can discuss this.

Dennis Bruemmer, MD, PhD:
And we have evidence to support that. We have trials that have looked at various diets, and of course these trials are always somewhat difficult because they are typically shorter. They have our controls or patients are often few, but I think we have the best diet to support cardiovascular benefits. So meaning heart attacks, stroke, and death from either of those are reduced with a Mediterranean diet, and that's been studied and proven. So I think that's why this is the most natural way.

Dennis Bruemmer, MD, PhD:
And then, we can be particularly effective in protecting heart problems down the road. If we combine the diet ultimately with medications if needed for certain risk factors. And that then is very individualized as to how much risk does a patient carry? How aggressive do we need to be? Does the patient already have coronary artery disease? Does the patient have diabetes? Does the patient have a family history of heart problems where the genetic traits come in? So that's what we discussed earlier. That's how we need to individualize each approach for each patient.

Julia Zumpano, RD LD:
I think, Dr. Bruemmer, you make a wonderful point, individualization, and that's what we do with the Mediterranean diet. We also look at what your current diet is like, and we make adjustments to get you closer to a Mediterranean style of eating. So it may look different for you than it may another patient. It really is looking at what you're currently eating, and we're slowly trying to adjust your diet, remove some of the processed foods and get a little bit more of the foundation of the Mediterranean diet infiltrated into your current diet, and slowly move into a kind of what is your personal gold standard Mediterranean diet, which may look different than what some of the research papers say. But we know that if we're making an impact on at least changing some of the negative foods that can negatively impact your overall health, then we're still making significant progress.

Julia Zumpano, RD LD:
So another thing you mentioned too, was the medications. And I think another common questions are how medications are introduced and what medications are commonly used.

Dennis Bruemmer, MD, PhD:
Yeah, Julia. I think, again, the word individualized, for many of the risk factors that we treat diabetes, high blood pressure, high cholesterol, the first step is always lifestyle. And lifestyle means diet and activity. Again, I go back to my simple hunter and gatherer. You had to run five miles to get this little rabbit, so it's not easy. They didn't come packaged in a box in the freezer. So it has to go hand-in-hand with activity, certain thresholds of activity and diet.

Dennis Bruemmer, MD, PhD:
And then, we discuss how severe are those risk factors that we are actually looking at? How high is the blood pressure? Do we need to introduce medications? And when we talk about medications, these are evidence-based approach. That means there's a reason to use these medications, and we have studied these medications, and we know these medications are effective in not just treating the blood pressure, but actually ultimately reducing the negative effect of the blood pressure on the cardiovascular system, meaning heart attack, stroke, and death of either of those. So, again, if we have patients with elevated blood pressures, we may introduce one or two medications. And sometimes we have patients that carry such a large modifiable risk, I call it. Let's call it weight problem. And if the patient loses a lot of weight, some patients may be able to get off their diabetic, for example. And that would be, I guess, from our standpoint, the ideal way to practice medicine, right? We can prevent and we can treat initially, and maybe patients can come off.

Dennis Bruemmer, MD, PhD:
Now, other patients that already had a heart attack, for example, they need a certain low cholesterol to protect them from the second heart attack. So in those patients, we do not want to take them off their medications because the LDL cholesterol, for example, has to meet a certain threshold because we know that that protects heart attacks. And we kind of try to work our way around genetics here because the LDL cholesterol is in part determined genetically. So we want to beat our genetics, and that's where the medications come in and are very effective in lowering the LDL cholesterol beyond what the diet could do alone. So some patients can not be taken off their medications and we would not advise that.

Dennis Bruemmer, MD, PhD:
So I think, again, it's a very individualized approach and we have to look at the patient, not just the risk, also what a patient is willing to do. How committed is the patient to weight loss? As I'm sure everyone knows, New Year's resolution, trying to lose weight is typically gone by the 2nd, by January 2nd. So we have to be committed actually to make a change. We frequently have patients who are very committed and they lose about, some patients 50, 60, 70, 80, 100 pounds of weight. So I think the willpower that the patient brings with combined with support and patient empowerment from our side, that's the road to success.

Julia Zumpano, RD LD:
Absolutely. Thank you for joining us today and hope you are able to take away some good information and be on the road to a healthy heart.

Dennis Bruemmer, MD, PhD:
Yes. Thank you very much for joining and keep up the good work.

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