56. Nicole Harkin, MD - Part II of II: Lifestyle Interventions for a Healthy Heart

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in health care. Alright, what is going on everyone, welcome to this week's episode where this is our second part with Dr. Nicole Parkin doing a deep dive into cardiovascular disease. Now if you haven't listened to part one, I highly encourage you do so, which was last week's episode, episode 55, where we delve into the basics of cardiovascular disease. We discuss risk factors, cholesterol, statins, and so much more. In this week's episode, we are going to be discussing lifestyle interventions. So we first start off with understanding what preventative cardiology truly is and what Dr. Parkin's approach is with her patients. We then break down the lifestyle interventions into their different components. So we touch on the benefits of the plant-based or essentially incorporating more plants into your diet. We also talk about supplementation, exercise, and of course, as you know, we love to talk about sleep. Yes, we even talk about how sleep can affect cardiovascular health. Now I don't want to delay you any further, so let's get on this journey and let's get further into this deep dive into our hearts. Alright, hello everyone, welcome back to another episode of Medicine Redefined. This one is a part two with Dr. Nicole Parkin. So I'm going to say this right off the bat, if you haven't listened to part one, highly recommend listening to that verse, getting the fundamentals down in regards to cardiovascular disease, lipidology, and then this episode, we're going to be touching on kind of high-level interventions, especially from a lifestyle focus, nutrition, sleep, et cetera. So welcome back, Dr. Parkin. Thank you guys so much for having me on again. I'm excited to be here for part two. Yeah, absolutely, as we are. So let's get right into it. We want to focus this talk mainly on your approach to patients and kind of, when a new patient comes in, when you're looking at it, not only from a pharmacological perspective, but also an intervention perspective that we obviously know exercisely, all these things matter. Take us through, I guess, just general overview for now, when a new patient comes into your office, what's your approach? Yeah, so it really depends on the patient. I have a very tailored and personalized approach depending on who the patient is. Is this primary prevention? Is it secondary prevention? What are their risk factors? What testing have they already had done? What further information do we need to really determine sort of their overall cardiovascular risk and then figure out how to optimize it? Are they eating a standard American diet right now? Are they a whole food plant-based, no salt, no oil, no sugar? Where are they on that spectrum? So every patient, obviously, is different and I think that's really important and where it sets preventive cardiology, clinic approach apart from sort of other kind of standard visits, which just aren't as well equipped to really go in depth and analyze these approaches. So we know from data that the average patient seeing the average cardiologist gets no more than three minutes of lifestyle modification advice and typically that ends up being eat healthier, right? And we know that doesn't work. And so really looking at a patient from an individual as an individual, figure out what are their goals? What are their barriers to change and where do we need to go from there? So in terms of a high level approach, I typically have my patients fill out a pretty in depth intake form prior to seeing me, I also like them to upload any prior testing, both diagnostic as well as laboratory in advance the appointment so that we can really hit the ground running. And I also include on that form, you know, what are your goals? What do you identify as your major risk factors and what are you hoping to achieve? And then just as, you know, going through a typical visit in terms of their personal history, their family history, their medications, their supplements, you know, all the things that we're used to sort of really getting into. But then I also do a pretty in depth lifestyle intake. So I do ask them a lot about nutrition, not only what's a standard sort of breakfast, lunch, dinner, snack situation for them, but also how often are they consuming red meat, unprocessed red meat, packaged foods, things like that, to get a really good understanding of sort of where they're at. I also ask about sleep with quantity and quality. I ask about stress levels sort of rating them on a scale and all of, and then exercise obviously as well, what they're currently doing. And then we go through together the current tests that they have done and then decide sort of what other further testing might help us fine tune what their risk is. And I think we talked about this in in part one, some of the typical tests that I typically look for in order, again, depending on the patient and where that's appropriate. And then we circle back and we will get everything together and then really figure out where what is their biggest risk factor that we need to really work on and modify and what's our approach going to be. As in line with our guidelines, more often than not, it is a lifestyle first approach. So how can we make changes, make tweaks to your diet, your exercise program, what have you to achieve our goals. And then we reevaluate. And then if pharmacologic therapy proves itself to be necessary, then then we talk about that at that point. Yeah, I mean, the word that comes to mind is comprehensive, right? I mean, you talked about just even prior to seeing the patient and how much data that you're looking at. And we spend a lot of time, as you mentioned, talking about diagnostics, particularly lab markers, but I really love the fact that you talked about, hey, what are your goals? What are you hoping to get out of this? I think that's so important to highlight right at the beginning. And then I think that that this concept of therapeutic alliance that Dan Pope came on a long time ago, talked about, although he was referring to it from, you know, musculoskeletal rehab standpoint, but I think that applies here as well. I think that if you can identify the patient's goals, you're much more likely to have that relationship with therapeutic alliance. So I really appreciate that. Thank you. I think that when we're focusing on lifestyle medicine, right? One of the things that we've talked about offline is when we look at it, depending on who you're talking to, the pillars are, you know, sleep, exercise, distress challenge, or stress challenge, you're looking at nutrition, right? Am I missing anything else? Or is there any other bucket that you look at it from that perspective? Big ones lifestyle medicine also specifically delineate substances such as alcohol and tobacco separately as well. And then community support, love, that sort of thing as well would be kind of the last pillar. So I have a framework in my mind of how like I like to approach it when I'm looking at it from cardiovascular health, but wherever you want to start, which one do you think out of those is kind of the bedrock? If there is even one or wherever you'd like to start, we can go down that pathway first. The bedrock. I like that. And we have to say that in terms of, you know, levers that we can pull that truly impact in oftentimes dramatic ways, nutrition is really king, I think, in terms of how can we make major changes that can either lower blood pressure or lower cholesterol or all of the above? Awesome. So let's start there. And it's interesting where you pick that one. I mean, right off the bat, we're going to pick the most polarizing topic. I love it. This is going to be the biggest one to tackle, but I appreciate that. I think that, you know, again, I get it the sense every single time we have the conversation that again, it's talking to the patient and really assessing where they are. What kind of diet you just mentioned, are you taking a lot of meat, you know, what's your current diet like and then we can help you get to your goal. So this is a highly contested, highly debated topic, right? Different, you know, is red meat, as you mentioned, is that bad for you? Red meat and cancer, you hear about that and then, you know, every single study comes out whether or not it's a good study is a different discussion, but it's all over the media and people in different camps, low carb, high carb, low fat, high fat, keto, fasting, all the kind of stuff, they'll take that study and they'll say, well, this is what's really good for you. The way that I always think about it is, well, it depends which lens you're looking at it from, right? For instance, let's just take the discussion of, okay, well, can you, can you start my world of fitness and sports medicine and where I'm treating a lot of athletes, right? Unless if you're taking a physique competitor and they need to hit a goal of protein intake, right? So can you be an all-plant or a vegan diet and be a high-level physique competitor? Sure. You can. You have to appreciate that it's going to have some challenges, right? Can you, should you, right? And so for our lens, from a cardiovascular perspective, what is your overall philosophy when you're looking at nutrition, when you're having that conversation? I know it varies individual to individual, but do you have one? Yeah, I think that from an abundance of data, both randomized control trials, epidemiologic data, short, contained feeding trials, and as is reflective of the ACCAHA guidelines, we know that ideally, our diet should be composed of as much vegetables, fruits, whole grains, legumes, nuts, and seeds as possible, and how, in what context and with what other things, those are sort of the margins at which we debate about those things. But I think that, and it's interesting you mentioned from an offset that this is the area where we see the most, is the most highly contentious, and it's interesting because it isn't, it isn't, right? Like if you listen to the media and these different fringe camps about diet, I think it does end up getting really confusing really quick for the average person, but I think if you bring together sort of nutritional experts across the globe, there's actually a lot more commonality when it comes to these diets than you would otherwise think. So sure, maybe they argue over, you know, the relative component of starchy versus non-starchy vegetables, but I don't think anyone is saying that vegetables in general are bad. I think most nutritional camps would agree that processed and packaged foods and sugar is not good for you. So I think there actually is, if you actually line up sort of a helpful plant-based diet, a helpful Mediterranean diet, a helpful low carb diet, you actually see a lot of commonalities. And then sure, we can definitely talk about the differences afterwards. But when you look at from a helpful cardiovascular perspective, I think the ACCAJ guidelines did a pretty good job of sort of delineating what is known, what is not known, and what should we, we really emphasize. And again, then it gets back to sort of what are the patient's goals, where are they at right now, and where they want to go. In general, moving patients towards eating more whole unprocessed foods is definitely supported by the data. So Dr. Harkin, one of the touted diets out there that has been at least shown, I put quotes on this, to reverse heart disease is the Dean Ornish diet, which I believe he created in the 70s. And I think I'm getting this right, the Dean Ornish diet is at least, it's low fat, I think is like the main thing, and that it's whole food plant-based. But to me, I find it interesting at least that creating the 70s, that's around the time where we thought that was terrible for you, and we've since changed our mind since then. But one, what are your thoughts on that diet, right? I think that word reverse there is pretty key, we talk about reversing or stabilizing heart disease. So if patients come up to you and they ask you about this diet, or they've tried this before, what's your take at least on the Ornish diet? Yeah, so the Ornish diet is, as you said, it's actually a vegetarian diet, so it does not allow low fat dairy in it. And it was created by Dean Ornish, as you said. And it was also importantly part of a comprehensive lifestyle program. So in his studies, it did incorporate moderate exercise, stress management, social support, and all of these other things. And importantly, they were pretty small trials, but they were randomized, and they did show improvements in, as I recall, exercise tolerance and reduction in angina, reduction in needs of medications, and things like that. So I think as with any sort of smaller trials, they're very provocative and hypothesis generating, but I think in terms of disease reversal, we have to be very cautious with how we say that. And I think when patients ask me about that, my response is, you know, most modern cardiology trials. What we're looking at is not, most of them are not repeating angiograms and looking at plaque burden, right? That is not a typical endpoint for a cardiology trial. Most cardiology trials were looking at mace, right? So we want hurt outcomes, you know, revascularization, heart attack, cardiac death, you know, big heart outcomes. And ultimately, that's what matters to patients, right? They don't care if their plaque went from 30% to 20%. Now, if they're angina one away, that's really important, right? If they don't have a heart attack, that's really important. So I think that we have to be careful in terms of does plaque go away, maybe? But in general, that's not likely the largest, maybe partially, that's happening and take statins, for instance, statins do likely reduce plaque in studies. We now know that there's definitely plaque burden that gets reduced, but that's very unlikely to be the major mechanism, at least at first, by which they're reducing cardiovascular endpoints, right? We know that statins early on, as soon as someone has an MI, you give that and they have better outcomes in 30 days. That's not plaque regression, right? That's endothelial dysfunction changing, that's inflammation, that's all the other things that happen. So I think it's a really interesting conversation, but I think that ultimately it's not really what matters. And so I think I prefer with patients to really focus more on how can we make you feel better and a little stronger? If your plaque goes down by 10%, great. I like it. Yeah, that's a good point. Awesome. So you mentioned that there isn't anybody who would say that plants are bad for you. I would argue there are some very... There's the common ground, that's true. Right, right. And they would argue that some of the toxicity and plans and whatnot, and I don't think that we're going to visit that aspect of those conversations. But if I'm not mistaken, are you planet predominant or are you vegetarian only at this point or for your personal dying? I'm saying based. So I was vegetarian. I became vegetarian a little more decade ago now and then plant based within the last couple of years. Gotcha. So for those who don't know the differences, what does plant based versus vegetarian mean? Yeah, so plant based has variable definitions, but for the most part it's defined as either plant exclusive or plant predominant. And specifically distinguishing from, say, vegan or vegetarian diets is defined not only by limiting or completely eliminating animal products, but specifically focuses on consuming whole food products. So as much as possible, whole foods in their whole form without being as processed. So the foods can be minimally processed, bred for instance, or even something like tofu, but ideally not processed. So distinguishing it from, say, a vegan diet which can and often may include highly processed foods like french fries and Oreos, that would not be inclusive of a whole food plant based diet. Awesome. To your earlier point, I would point the listeners to John Brody's podcast. I think one of the very first series that came out, the thing was called Diet Debates, very interesting where it's a three part series and they're looking at, and to your point, his podcast was all about finding the common ground between different points of view. And it's actually quite interesting that when you really sift out the people who have the loudest platform, but just the message on either ends of the spectrum, most people kind of fall in that camp. And so I think that was pretty interesting. But you talked about a little bit about the mechanism statins, right, or you touched on briefly. And I think no discussion can be complete science-based discussion without talking about mechanisms. So I think the American diet, which is heavy on meat consumption and processed foods and whatnot and very little on plants and most folks agree who are in that middle ground that we need to increase our plant intake, as you've already said, mechanistically, what's so good that is beneficial for our heart health? Yeah, so plants are, and when we say plants, again, we're talking about vegetables, fruits, whole grains, legumes, nuts, seeds, potentially plant oils as well. So in general, we know that that plants are high in things like fiber, things like potassium and magnesium, polyphenols, typically in the heart healthy fats, such as poly and mono unsaturated fat, and they tend to be very low in cholesterol and saturated fat and sodium and things like that. And so we can go through sort of different mechanisms by which all of these things are helpful to our bodies, but essentially, we know from sort of long-term epidemiologic with perspective and retrospective studies, looking at large populations and whether you're taking numerous populations and looking at, say, end-hene's data, or if you look at specifically sort of plant-based communities like the Adventist, Oxford, things like that, regardless of sort of where you fall on the spectrum. In general, we see that the more plants you consume, the lower the risk of heart disease. Now, obviously, there's lots of limitations to epidemiologic data, but it's patterns that we're looking for, right? And when you see it time and time again, you see it in people who eat exclusively plants or who eat some plants, I think that it becomes very helpful and it definitely can inform us. So that's sort of a lot of the big data that we have in terms of heart health outcomes. And then we can also break it down into sort of the risk factors, right? And that's where we get more of the renalized control trials and the feeding trials and things like that. And so we know that eating plant-based diets, like, for instance, say the portfolio diet. That's a specific plant-based diet that's very helpful and we do have randomized control data that shows that it can lower LDL cholesterol significantly. And so we can look at different plant-based diets in terms of how they can lower cholesterol, blood pressure, body weight, inflammation, and all these other risk factors. And so taken together, that's sort of how we understand how the impact that plant-based diets can have on our heart health. Yeah, I find the various mechanisms to be quite interesting. And it obviously would be several hours here if we try to explore every single one of them. But a study that I read actually recently just kind of screened the abstract when I was thinking about our discussion later today was at least the lens of looking at the gut microbiome. And we had Dr. Will Bolser-Witz come on and we had a two-part series with him talking about all the different aspects of how the short-term fatty acids and feeding or gut microbiota can really help augment cardiovascular disease and a bunch of these markers that we've touched on in the first episode. So I think that's also something that's cool, still relatively new. I think mainstream, I think the gastroenterologists will tell you that they've been having these conversations for a long time. So I'm sure that he's well familiar with this. Now the other thing talking about the sad diet, most of us are practicing in America as we're recording this in March and here, at least when the patients come to you and they'll say, well, Dr. Harkin, that all sounds dandy, but for the July comes around and I need my hot dog and I like the hamburger and I like all that kind of stuff. And just like plants can be challenging, I mean, meat, it's delicious and they're not ready to give that up. Obviously, you strike me as a person who doesn't get the patient to, you know, just completely switch and you're working with a patient as you mentioned several times. How do you work with them with that, right? Well, we're not going to completely abandon meat because it's not, and I'll be all, but let's make it safer. Let's make it better. Yeah, absolutely. So exactly as you said, I think it's all about really meeting the patient where they're at and figuring out where, what's the low-hanging fruit and where can we make important, but impactful changes that feel doable to the patient, right? And it has to be sustainable. So if a patient comes to you and says, I cherish my hamburger once a week and there's no way I'm giving that up, then they're in that pre-contemplative stage, right? They're not, they're not making that change. And so let's talk about other things or how can we mix it up, maybe, and see if they're open to that. So I think it's all about creating those, those, I mean, I think we talked about the smart goals last time, but really, you know, specific, measurable, achievable, and time-based changes that are specific to the patient and what they want to do. And so I think goal number one is creating those goals together because as if they have sort of input into what changes they're making first, they are more likely to adhere to those. And then, and then figuring out where to go from there. So oftentimes, I try to focus on what can we add into the diet, first and foremost. So if they're not eating hardly any fruits and vegetables, we go through, okay, how can we get some more in, right? So maybe it's the snack, or maybe it's the lunch, or what, how can we tweak things so that we can get them in? And what are the barriers currently, is that you don't like them, or you think you don't like them? Let's explore which ones you do like, or maybe they just aren't used to cooking them. And so maybe they want to subscribe to some, any of these millions of, of services now that, you know, you can get food, healthy food delivered to you. So brainstorming ways where they can kind of figure out how to make some of these easier changes can be really helpful. Yeah, the, you know, subtraction by addition method is something that I've come to be a fan of, particularly, you know, big shout out to EC St. Kowski, a previous guest, and she talks about her 800 gram challenge, right, when you're eating 800 grams of plants and vegetables and fruits and whatnot. Just because of the volume, you don't have room left for a lot of the other, quote, unquote crap. And so I'm a fan of that now, especially, you know, no conversation on nutrition is complete without talking about supplementation, of course, right? I mean, that's, that's where people want to start with, unfortunately, and it's not that basic impairment. And, and I hear about this on a daily basis, I think darshtas as well, and I'm sure you do. So, in that realm, again, I want to highlight supplements are supplemental, hence the name, but understanding that, are there some that have merit when it comes to cardiovascular health and from your perspective? So, at this point, there's not that many supplements that really do have much benefit, unfortunately. And from a cardiovascular perspective, most of the supplements that we have been enthusiastic about and the cardiovascular community have not typically panned out when they've been studied in randomized control trials. And so, you know, antioxidants have been studied vitamin C, vitamin E, I mean, you name it, it hasn't particularly panned out. So there are not that many supplements that I routinely welcome in for my patients. I do tend to discuss, in exclusive plant eaters, vitamin B12 is important to supplement. And so, I do have my patients supplement with that. The omegas are going to be a somewhat controversial topic as well, and that can be the entire bug gets on itself, but the, you know, a meta-analysis that Cochrane did and others have done, you know, really isn't showing a major benefit of omega-3 supplementation for the average individual for cardiovascular risk reduction, obviously the population that has shown benefit is high dose for grams of EPA and individuals with cardiovascular disease who have triglycerides above 115 milligrams. And so, that's sort of the one population which we have seen benefit in our CT. And so, that's sort of the one population. I do think there is some debate within the plant, be it's community, whether or not individual source, exclusive plant-based may benefit from supplementation with omega-3s simply because they aren't consuming fish. We just don't have a trial that supports that really, so that's an area, a big gray area. So, I think it's not wrong to do to supplement in that case as well, and sometimes you will look, and because you don't, because you can't get, so you can, in plants quickly, you can get omega-3s, but they're the short-chain. And so, so algae oil actually is a way that you can supplement and get the long-chain. And so, so many are doing that as well, but again, it's definitely a gray area there. Vitamin D is another one that both omnivores and plant-based individuals are often deficient in, and as I'm sure most of you listeners know that's a sun exposure, when we get through sun exposure and most of us are wearing sunscreener inside, so many of us are deficient, so that is another one, a thousand IU a day, that I have most of my patients take. But in terms of taking something to actually lower cardiovascular risk, we really, you know, there isn't a lot out there that is helpful. I think that fiber is one where I do look at that closely with my patients, particular if we're trying to lower cholesterol. If they're not able to hit sort of their soluble fiber targets, we will add sometimes like a psyllium husk or something like that to help get that lower, simply for LDL cholesterol lowering effects. And plant and animal steriles are another supplement that I will sometimes use with my patients again for LDL lowering effects. I love it. Dr. Harg, I think you have a crystal ball in front of you, because you're answering everything we're like about to ask, and we're like, oh, there it is, there it is, she's got it. So, awesome. No, that was a perfect review, I was going to say as far as omega-3 is, yeah, that's what I do, I do an algae oil, because like you said, I do the chia seeds, I do the flax seeds, but with that ALA conversion, you know, and I actually tested my omega-3 like doing a quant test last year, and I was actually on the lower end, so I actually got to retest it's been a year now. So, quickly, do you ever test omega-3 or like omega-6s with your patient population, or do you not really think that ratio matters too much when trying to make change? Great question. And I think this is another area where there is some controversy, certainly, I think the, I think as with many things in nutrition, it's much more complicated than anyone understands right now is the answer, and I don't think anyone truly knows. I do check, I think the omega check is interesting, again, I don't think that it is the end all be all, but I will take a peek at omega-3 levels, as you said, and that's one of the areas understanding that there's total gray area, where if it's a low, I will potentially, you know, discuss that with omega-3 supplementation with my patients. And then the omega-6-3 ratio was very popular for a while. You know, we have too much omega-6 in our diet, from all our processed and packaged foods. It's pro-inflammatory, we need to eat more omega-3s. You know, I think it's a balance, right? Just like anything, we do need both omega-6s and omega-3s, and I think omega-6s has definitely gotten unfairly villainized over the last decade or so. Again, I don't know that we know definitively the answer to that, but undoubtedly, it is important to lower our consumption of processed and packaged foods as much as possible. I don't think anyone knows the exact perfect ratio. The most people say around 10-to-1 is less than 10-to-1 is ideal. I don't know that we know that exact answer. I want to ask you real quick before we jump into another pillar here is another supplement that a lot of people like to take with the dinner time around the world, which is red wine, which has been known with Resveratrol, touted as an anti-aging supplement. And I know you recently wrote a blog post or an article on this. So if you can just tell us what's the scoop with red wine? Is it healthy? Is it not? Yeah, so red wine as much as everyone would love that it was super healthy. It's definitely, again, a good, an interesting area of controversies. So there was a period of time where red wine became very popular from a cardiovascular risk production standpoint when something called the French paradox was recognized, which was that the French seemed to have lower rates of cardiovascular disease than would be expected, given their high intake of saturated fat from butter and such. And so it was postulated that potentially their consumption of red wine may be contributing to that. And one of the active compounds, as you mentioned, Resveratrol was thought to be potentially responsible for that. We've since studied it more and realized that the amount of Resveratrol that we consume, we're having a glass of red wine is very unlikely to be an active enough amount to really be having the effect. And there was also certainly some data gathering issues with the French paradox observation in terms of an inaccurate representation of the amount of cardiovascular events that were occurring in the population. So what we do see from large epidemiologic data is that there does appear to be sort of a j-shaped relationship with alcohol. And in the sense that obviously those who consume large quantities of alcohol have a higher risk of mortality, but it seems that the lowest point of mortality vis-a-vis alcohol consumption is sort of at that moderate level, which is defined in the literature as one glass of alcohol a night for women and two for men. In terms of other, it's definitely there's confounding variables there certainly. And so we have to be very cautious how we interpret that data. And so in general most of us don't recommend that people consume alcohol for its cardiovascular benefits, but that if they do consume alcohol, they consume it in sort of that moderate a fashion as I described. Definitely what we know is very clear from the data that binge drinking, which is having more than that, particularly kind of on the weekends, how many of us consume it is detrimental to our health and can leave. It definitely is associated with the worst endpoints but cardiovascular a fib, MIs, things like that, but also other things like liver disease and such. Awesome. So we're taking our top down approach here and we've addressed the attrition. Well, we haven't completely addressed it, but that's the best we're going to do today. And I'm going to give you the choice. I'd like to either go towards sleep in cardiovascular health or exercise, which one would you like? Do you like choice? There's choice. All right, let's go with, let's go to sleep. Why not? Awesome. All right, so sleep it. We all love it. We get none of it. Everybody, the three of us, and of course medical training, you've got a couple of children. I've got one and feels like a couple because of the first time I heard. But we were talking about this offline. And I think now the conversation on sleep and the loss of sleep as being an epidemic is the volume on its higher and higher. You know, we've talked about this with a few different guests. And when you're looking at it, particularly from cardiovascular disease, you know, both of us read this book, who I wasly by Matthew Walker, a very, very good book. But you know, there were some stats in there that were talked about, you know, now reported to be controversial. But the role of coronary R disease, the role of heart attacks, I remember him talking about daily savings time and how when we spring forward, the incidence of heart attacks increases like in the neighborhood of 25 percent. And whether or not that's attributed to the hour of sleep loss, I mean, that's up for debate. But also when you're falling back, the incidence of heart attacks on that Tuesday following the Sunday is down 21 percent. And that really got me thinking about this. Okay, well, what is the effect? And you know, I'm curious to get your taken from cardiology perspective in your setting of the literature is with the correlation of MI's and sleep loss or sleep deprivation. Where do you stand on that? Yeah, so you know, I think that the literature is fairly clear that insufficient sleep duration, which is typically defined as less than seven hours a night. And then also, conversely, too much sleep, long sleep duration, which is usually defined as overnight hours, is associated with increased mortality, specifically cardiovascular mortality. And you know, we've again, similar to most of our lifestyle pillars, a lot of what we have is epidemiologic data like that and then biomarkers. And so the different biomarkers that we've looked at, you know, we certainly, we've seen associations with insufficient sleep duration or poor sleep with things like inflammation, higher levels of insulin, you know, all these different biomarkers. I think the one that's best studied and is most provocative is blood pressure. So blood pressure has, you know, variation, dynural variations, and it fluctuates over the day, and then it's supposed to dip at nighttime. So we, when we're interpreting amuletory blood pressure, this is actually, I think, one of the most useful reasons to do an amuletory blood pressure monitor is because you can actually look and see what someone's blood pressure does at night. And it is supposed to dip. And if they don't, and it's very able to define, but it's usually if someone doesn't, if their blood pressure does not go down, meaning dip at least 15 to 20% overnight, then they're considered a non-dipper. And that non-dipping status is associated with increased risk of cardiovascular disease, even above and beyond just the diagnosis of daytime chronic hypertension. And so it's, and, and that link between poor sleep quality and insufficient sleep duration is most closely associated with this non-dipping status. We also see it in individuals with obstructive sleep apnea and other sleep disorders. And so I think hypertension is certainly probably important in terms of it's, it's how it increases our risk of cardiovascular disease when we're not sleeping enough or when we're not getting good enough sleep. Yeah, so that indirect mechanism seems to make a lot of sense. I'm curious, what is your, you know, explanation if you have one about the prolonged sleep greater than nine hours or greater than 10 hours for increased mortality? Have you given some thought to that? I mean, I think, I think it's likely just a marker or something else. So you have some sort of chronic disease state, something that is, is making you sleep longer. Right. And I think that again, I'm, again, paraphrasing in Dr. Walker when he talked about, you know, his explanation was that most of those folks maybe are dealing with some type of cancer or some type of chronic disease as you just mentioned. And the fact of the matter is the body or the sleep wasn't able to quote unquote, save them. And so I think, yeah, that's, as you mentioned a couple of times now with these observational studies in epidemiological data, it's very, very challenging, but sometimes the science isn't perfect and the best that we have. You know, an interesting paper that I read this morning and this was published in Plus Biology. Again, the senior author is Matthew Walker. Peter T is on it too, Darge, for you. I'll send it to you guys if you're interested. And they looked at the one of the proposed mechanism of atlosplerosis. It's interesting because they took some of the Mesa folks and they, the objective markers they were looking at was seven days of actigraphy. And they were really looking at sleep fragmentation or one night of PSG data. And they documented the white blood cell count. So particularly neutrophils and monocytes. And they correlated that with CACS course. What they found both, you know, well, on both instances between actigraphy and PSG data that the neutrophil count after a night of sleep deprivation would increase one night for PSG, but also actigraphy, oh my god, actigraphy over seven days. I don't understand plaque formation as well as you do and you explained a little bit, but is that something that is plausible to you in terms of how that could cause premature heart disease or CAD in particular? So maybe just being reflective of overall inflammation perhaps, not sure, but that's that's definitely interesting. Yeah. Is there, are there any other proposed mechanisms? You talked about hypertension, right, with the confounding stuff like age, sleep apnea, that kind of stuff like that. But in terms of looking at atlosplerosis, what is your understanding of or our understanding of, you know, how that happens? To my knowledge, that isn't known. I think that as with most of sort of these lifestyle mediated issues, it's still not fully understood. I think that we have definitely demonstrated that insufficiently quality and quantity is associated with many of these different biomarkers, which then increases risk for cardiovascular disease. I think also similarly to something like stress, when you're super stressed or super tired, you don't make great choices, right? So then there's the indirect issues that play as well, where we don't exercise because we didn't sleep enough or we eat, you know, comfort foods or what have you. So I think there's likely, it's likely very multifactorial and there's both direct and indirect consequences of play. Yeah, I'll disclose last night about making poor choices. I think it was 11 o'clock after multiple nights of sleep deprivation. I had these peanut butter dark chocolate bars and I had just four of them at 11 o'clock without even thinking about it. And this is a point of debate again in this household, the why we should even have these, but let's restrict ourselves. Okay, my favorite one was that I'm fasting right now. You're making me hungry. You can't, we can't have food talk as long as 24 hour. Let's let's first exercise. This is definitely my favorite one. It's the one that comes easiest to me to do and it's just, you know, a part of my core identity, I think. And when I look at it, of course, to make it simple for folks, right, we're talking either aerobic or clinical cardiovascular exercise, right? And most people look at it or a lot of strength training, resistance training, right? And I think those are the big general buckets. Before I ask you about that, I'm curious, what does your exercise regimen look like? Hmm, good question. So I am, I typically am, so it's, it's definitely morphed over the years. And I will say that some of that is reflective of kind of having a better understanding of the need to have both quote unquote cardio and resistance training. I think I definitely was really into to running and a lot of cardio and pretty much exclusively doing that. Right now, my balance is a little bit better, although not as consistent, which is interesting. So I typically for cardio a couple of times a week, I am on the peloton. And then I actually recently got a tonal. And so I have been doing more strength training. So I'm trying to do at least two to three of those during the week as well. So I have found that to be really helpful for me as someone for someone who earlier in my life did not do much weight training at all. It's, it's pretty plug and play and makes it pretty easy. So why the weight training, at least, you know, for the general public, I think many people can understand obviously why we do the running, aerobic training, get the heart pumping, but not many do the weightlifting. What's the proposed mechanism behind that being beneficial for heart disease? Yeah. So I think that is also a very good question and not 100% fully understood. So, you know, briefly for for your listeners, as I'm sure most of them know, for cardiovascular disease prevention, the ECCHA guidelines really do focus on the aerobic activity. We're really trying to get 150 minutes of modern intensity exercise a week or 75 minutes of vigorous aerobic activity. And as you said, it's kind of easy to easy or to understand kind of the human and the amount changes and all these things that like why that that is good for us. Interestingly, the ECCHA doesn't specifically recommend within the guidelines to do strength training. I think their language is that it is should be encouraged. But I'm like a lot of other, I mean, I think most of the other guidelines, I think for diabetes and for sports medicine, I think most of the other guidelines do specifically call out kind of resistance training. And that's I think reflective of the fact that the level of evidence we have for for strength training in terms of cardiovascular prevention is not as strong. That said, I think it's it's definitely emerging and it's definitely very provocative. And so, so I've started to really emphasize that with my patients as well because I think most of them are getting that aerobic activity that they should be getting and not focusing enough on the strength training. And so I think the areas in which the data is the strongest is we do have some epi data to show that individuals who do some strength training have a lower risk of heart disease. But I think the data is the strongest with specific cardiovascular risk factors. So, so body composition being one of them. So definitely in terms of reducing visceral fat. I think the other one where we have a decent amount of data is for hypertension management actually. So there's a couple a handful of randomized control trials that show that resistance training definitely can reduce blood pressure above and beyond just that what can be achieved with aerobic training alone. And then also in terms of glucose regulation and insulin resistance, we also see that that its resistant training is actually better than traditional aerobic activity and actually kind of combined with aerobic activity to get the most reductions. And I so I think when it comes to kind of looking at these different these different pretty vascular risk factors, those are pretty provocative and really interesting to me. Yeah, I think the inside I'll add out to that in terms of resistance training. What I remember learning back and under addicts that science is well when you increase in the immediate post exercise phase when you're lifting heavy weights and if you're doing Valsal or something like that, you're going to increase blood pressure. And so when you increase that after load, your heart has to work much harder. There's this concept of the athlete's heart. And we often see right ventricular heart hypertrophy as a response remodeling wise, but we also see sometimes left, although most of the time that's pathologic where you don't want that. Is that correct? So we do see both. Yeah, so we see LVH and actually we also see increased systolic like volumes in in resistance training athletes that typically does resolve with deconditioning, although at this point, we don't typically recommend deconditioning. So we don't necessarily consider it pathologic. Really the main reason we would we would have people decondition was just to make sure that it wasn't you know, that it wasn't pathologic. So that it was you know, hypertrophy recording my apathy or something like that. But the increased contractility that would come with the ventricular thickness, would that not explain it in terms of in terms of kind of the overall benefit to answer darsha's question in terms of the mechanisms? Because if you have ventricular hypertrophy, your your contractility would increase, right? Correct. Typically, I mean it depends. So so yeah, so we didn't but we didn't so so in terms of the athlete's heart, we don't consider it necessarily like pathologic in that it's increasing your risk of developing heart disease. Gotcha. Okay, and so from again, now quote unquote cardiovascular said or the aerobic training, right? My understanding is again, so you bring more preload, right? The heart's capacity of how much it can hold before it pumps all that blood out throughout the extremities, which will down the road allow it to have a lower heart rate. So it has to pump less frequently, right? And so you can have cardiac output can remain high. Is that kind of how the conversation you're having with folks when you explaining why aerobic exercise is beneficial or are there something else like is there something else that you're talking about? Oh, sorry. So going back to aerobic exercise. Yeah, I'm going back to it. Yeah, so I mean, we see all kinds of changes in terms of the things that occur within the body in response to aerobic training. So there's all of these different sort of a humaninemic changes and then there's also, I mean, we see, you know, increased HRV, we see, you know, obviously decreased blood pressure, we see, you know, increase insulin sensitivity. I mean, there's tons of different changes that occur within the body in response to aerobic training. Awesome. Go ahead, Dr. Dr. Is there a limit that you'll put your patients on in terms of running and how much aerobic exercise? I mean, I think there's data out there that suggests like a lot of marathon runners actually can develop a fib later on just by the mechanisms that we're talking about, right? Is there anything like that that? Yeah, so I think we are increasingly realizing there is such thing as too much of a good thing. Most of the benefit, so we do, so as I said, we recommend 150 minutes of modern intensity exercise a week. We definitely see continued benefit up until around 300 minutes a week and then from there definitely likely a plateau. As you said, there's definitely been some studies with, you know, really high level athletes having actually a higher levels of coronary artery calcium in, you know, so they've done studies with high level athletes and they have higher rates of CAC and then a fib, as you mentioned, there's been some of that as well. So I think that there is probably such thing as too much of a good thing and I think that's another way in which I, some of my patients who are doing lots and lots of aerobic activity, it's a good way to sort of let's diversify your routine a little bit and add in the resistance training not only because there is potentially that signal of harm at very, very high levels, but also because of all of these amazing benefits from strength training as well. I like that. Yeah, and just to mention kind of Peter T.S. model for exercise with longevity. You know, he talks about having a solid aerobic, anaerobic stability and strength program and we kind of have all those four aligned is where you'll kind of be the most optimized if I can say. Awesome. So yeah, and also just sorry, I would just also mention that I think we're talking about sort of discreet moments of intentional activity that we're doing, but I think also what gets missed a lot is sort of all the other movement that we should be doing throughout our day because you know, being sedentary is really associated with some of the highest levels of mortality and there's actually some data to show that even if, so if you sit at your desk all day long and you do your 30 or 45 minutes of exercise, that may not even discount that sedentary activity. And so I think it's also important that yes, we get our 30 to 45 minutes in of whatever our activity is that we're choosing to do, but then also carving out moments of other moments in our day where we're not just sitting at the computer all day. So if you can take a walking meeting or if you can take the stairs or like all these other ways that we can increase our meat, I think that's also, you know, important and bears mentioning because it's not as sexy as the other stuff, but it's actually really important. That's a very, very, very important point that you brought up that I don't know I'll talk and I missed her there, but no, thank you so much for bringing that up. Then something I've been doing at least is after a meal trying to just even do like a two to five minute walk, right, just to get those steps in, also kind of help the sugar regulation and everything. So very good point. All right, I want to move on now to stress, right? Something that we can all use a little bit of now in a good way, but with COVID and with us being in the healthcare, I mean, stress is always at all time high. I feel like for us, what is the biggest marker at least in the cardiovascular world that you're seeing with stress? Is it blood pressure that usually, you know, you're seeing? Yeah. Yeah, so definitely stress, you know, I think that's another area of within lifestyle medicine that is poorly studied, but we certainly do have data that indicates that, you know, chronic low grade stress is likely associated with increased risk of cardiovascular disease. Previously, the data was mostly looking at kind of acute periods of high stress, like PTSD and stuff like that. The chronic low grade is probably not so good for us either, but in terms of pathways and things like that, certainly the blood pressure association is where it's best studied. And interventions like meditation and other stress production techniques while we don't have a lot of data, what we do have shows that we can reduce, you know, blood pressure with specifically transcendental meditations, what's been studied best, but we do have some evidence that it can be helpful. So maybe the more important question, what's your intervention when it comes to this? I think that when we talk to most folks who are maybe in this space, right? I mean, this is maybe the most challenging. Personally, for me, it's probably the most challenging. We're all in medicine. I mean, stress is ubiquitous in our daily thing where parents now, you talked about getting steps in running after your children, that's a workout, right? I'm sure. But, you know, when your patients are coming to you and you're talking about this distress tolerance, what's your conversation like? How are you approaching that? Yeah, so I think, so first I have them, you know, talk to me about, first I have them rate their stress, and I find that a really useful point in terms of figuring out where are they? I do have educational patients that give me a one, and I'm like, okay, what are your secrets? Teach me. But most people, especially right now, are pretty high. Give it, you know, an eight or nine, and so that helps me frame the conversation because you only, you know, I do do our long intakes, but again, there's a, you only have so much time, and so I like to know where, how, how much stress are they having, and is this something that we really should address? And so, so I first have them start there, and then if they are having a lot of stress, I talk to them about, or I ask them, rather, you know, where is their stress mostly coming from? And sometimes we're able to do some problem solving in terms of finding the root cause, and working on trying to find ways to reduce that stress if it's one discrete thing. But more often than not, it's, again, this chronic low grade stress from a million different sources. And so, so I talked to them about stress reduction strategies, and so some people are open to meditation, other people aren't. I think that it's actually quite helpful that there is so many different apps. I think there's like an app for every personality at this point, for meditation. And so, most people just need to hear that they should give it a try, and that, and that there are options, and you don't have to be good at it, and that I feel like I'm quote-unquote not good at it. I don't think many people think they are, and that's not the point. The point is sitting and doing it. And so, so yeah, I have people try the different apps, depending on their personality. If they're not at all interested in meditation, we discuss other ways for stress reduction. It can be as simple as making sure they give their best for under-collar reunite, or taking a bath, giving themselves permission to take a bath, and read a book, or whatever. So, oftentimes it's not this like groundbreaking, amazing stuff that no one's ever heard of, but it's having that conversation, and having your doctor tell you, this is important, and you need to carve this out, and let's figure it away. And it doesn't have to be long. Like, I meditate 10 minutes before bed. Ideally, I have longer, but I don't right now, and that's okay. And so, it's all about kind of having someone help you figure out a way to put that into your life, and try to really make it a priority, and also just doing your best, and not aiming for perfection. I love that. I think meditation brings a lot of perspective, not only in the moment, but also to the rest of those lifestyle pillars, right? When you actually get the time to sit down and reflect, you start to look at everything else in your daily routine, and I think that's where you also get to see the change. So, not only from the stress perspective, but also from, okay, the diet, the exercise, how do I kind of get better by 1% every day? I want to touch on another method, at least that's kind of been booming now, which is in the biohacking world, which is the sauna, which I don't even think should be a biohack, because I mean, there's so many great benefits that we now know. And when I listen to other cardiologists on podcasts, I've routinely been hearing that this might be of a proposed treatment in the future, where we'll actually write on a script saying, go to the sauna for 20 minutes. What is your take on sauna's based off like the papers you've read? And if people can even tolerate it, right? I mean, I don't think it should be probably for everyone, but you probably have to be at a baseline somewhat of a healthy level in order to get into a sauna. Yeah, no, I definitely have, I can think of one patient who was not in a place in his health where I recommended the sauna, because I actually was concerned he was pretty unstable. But yeah, so I think sauna is really interesting. I think it, like a lot of things that we're starting to learn, is really interesting in terms of the impacts that it potentially could have simply because of how it can stress your body in a good way and get our bodies used to that. And so I think it's really interesting. I think we're definitely not at that place where most of us are quite prescribing it yet, but I think the data is certainly interesting and emergent. Awesome. Well, Dr. Harkin, as we come to a close here, I want to, of course, thank you for two amazing discussions. But I'd be remiss if I didn't ask you about the future of preventive cardiology. More specifically, I think that the first discussion that we had, we spent a lot of time talking about areas where we were trying to understand why the current standard of, you know, the standard of care, the way we practice it, why are we looking at specific markers? Like I'll do a particle number, APOB, even though the European guidelines suggest that. And you know, somebody who listens to this and they're convinced that this might be key or instrumental in their role, how can patients have a conversation with their provider for the need of these advanced testing, which may, you know, alter their care or they may be more informed so they can make other decisions so they can, you know, affect different pillars of lifestyle medicine or whether it's pharmacological treatment, whatever that might be. This is a question I wanted to ask you last time, but I didn't get a chance to, so I'm going to ask now is how can they have a conversation whether it's cardiologist, primary care provider, whoever it might be? Yeah, I think that's a good, a really good question because by and large, most people will not necessarily have a preventive cardiologist as a member of their care team, although hopefully that will change. I do think that, you know, whether it's based on risk factors or just you hit a certain age, I really would hope that everyone would be able to access at least once a preventive cardiologist to really kind of get a lot of their personalized questions answered. But that said, I think that like the American Society of Brewery and Cardiology emphasizes that it's not just cardiologist that can be practicing Brewery and Cardiology, right? It's endocrinologist, it's internist, it's works medicine docs, it's really anyone who has an eye towards, you know, preventing cardiovascular disease, which hopefully is all of us physicians and and other members of the healthcare team, given that it is the number one killer globally. And so, so I think that certainly one, hopefully all of us will do a better job of having these types of conversations so that more healthcare professionals are exposed to these different topics. And while it can be difficult to keep up with, you know, every emerging piece of literature and none of us can, hopefully they're, you know, at least exposed to some of kind of these topics that are increasingly becoming important. But in terms of kind of a patient specifically being able to access some of these things, you know, I think it's discussing with them. I think it's really important that, you know, say you're seeing your primary care physician for your annual physical and, you know, he talked, what do you think is my cardiovascular risk? Like, have you plugs me into the ECCAHA 10-year risk calculator or, you know, whatever it is, maybe not that that specific exact language. Or they could, why not have you? After listening to this, they will. Because I think that, you know, your average PCP has like 8 million things that they need to check and do. And so be just kind of bringing that to their forefront of their mind and reminding them that this is something that's super important to them is a great way to kind of start the conversation. And maybe the doc will be like, oh, yeah, your risk is pretty low for xyz reason. And so maybe you don't need additional testing at that point. But potentially they will be like, oh, you know, I haven't checked it. You know, let's check and see what's your risk. Or, you know, the next question would be, hey, do you think I would benefit from the coronary artery calcium score or, you know, whatever it is? And again, not everyone needs these types of tests, but at least it's, you know, if you're interested or you think you might benefit having those conversations. And if you feel like your provider sort of goals are not in aligned with yours, then finding someone who has, you know, who is more in line with what you're looking for. Not everyone's going to be the right fit for everyone. It's not a personal thing, and that's totally fine. But I think that, you know, starting to have those conversations in a really, you know, just non-judgmental non-accusatory way. But hey, I was thinking about this. Hey, I read this. What do you think? And starting that conversation. So on the flip side, hey, I just checked ASPC. I actually didn't even know it was a thing. I'm definitely going to look into becoming a member. That's awesome. You should. In Louisville, Kentucky, looks like in July. So that's awesome. You know, if a healthcare practitioner or somebody who has an interest, right? I mean, you mentioned last time that cardiology is very, very cool. I obviously think so as well. And I think you've made a pretty good case that it is cool in these last two discussions. If not, it is very, very important considering the burden of cardiovascular disease. And if providers want to learn more about this type of stuff, right? Some of the advanced testing, preventative cardiology, and specific. What resources could they use or to learn more about the stuff? Yeah, absolutely. So I think that so the ECC has Cardio Smart, which is a lot of patient, but also provider resources. They have some podcast series at this point, lots of handouts that you can use for your patients. The American Society of Preventive cardiology, I think it's another great organization that has a lot of great content that it's being put out in terms of guidelines and things like that. Definitely familiarizing yourself with the ECCHA guidelines. There's the the primary prevention guidelines and then digging deeper, right? So if you're interested, you know, reading the guidelines and then looking at the resources, looking at their sources, going into the primary literature, if you have time. It's really, you know, illuminating and that's where you can start to kind of better understand where these these guidelines are coming from. You might not forget the most important one. I think wholeheartcardiology.com. Absolutely. So my blog, my website's wholeheartcardiology. And yeah, I have a blog and a newsletter and all that kind of stuff. So it's mostly geared towards patients, but I actually have a handful of my primary care docs that routinely refer to me that have subscribed and say they actually really enjoy it. Awesome. Well, Dr. Harkin, it's also International Women's Day. So happy International Women's Day to you. You know, in cardiology, women are definitely underrepresented, represented and you're just proof of that as as to why we need more and the value that you create. So thank you very much for coming on here. Final question for you is how do we add the health back and health care? Great question. I think by all of us advocating together for what we need, I think that both physicians and patients are like are frustrated with where we're at. And so I think that the more of us on both sides of the equation that speak out, the better. Because they think that patients just come to me time and time again, you know, why is no one talking to me about this for? I can't believe I'm hearing this for the first time. And I truly, you know, it is just, it's frustrating that no one's getting the care that they want. We spend so much money as a nation on our health care. And yet we are sicker than ever. And so we all deserve better. Love it. Yep. Kind of, kind of, kind of said it better. So thank you so much again. Thanks so much for having me. All right. Wow. What an episode. I hope that was beneficial for you all. And again, if you haven't listened to part one, go ahead and go back to episode 55 with Dr. Harkin, where she will explain essentially the basis of cardiovascular disease. I mean, we go into cholesterol, statins, risk factors. And we start to talk about how our understanding of cardiovascular disease is changing and how we might have had some things wrong in the last decade or so and how we can at least empower the consumer, the patients to get the testing that they need to understand their own cardiovascular health. And if you stick with us here in the upcoming weeks, we are going to have another cardiologist coming on to talk about something a little bit more futuristic. And that is going to be wearable technology. So excited to produce that episode as well. And as always, if you are enjoying this episode and this series of medicine redefine, go ahead and share, subscribe, rate, and review. And just some news, we are officially on TikTok and YouTube now. So if you enjoy seeing short clips, you can go ahead on YouTube and TikTok. We have video form now of some of the clips from our podcast for your viewing. And as always, the medical disclaimer, everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician, patient relationship is formed and anything discussed in this podcast is not represent the views of our employers. I recommend that you seek the guidance of your personal physician regarding any specific health related issues. And with that, we'll see you next week.