Monica Aggarwal, MD, on Preventing CVD Through Lifestyle Modifications

The impact of cardiovascular disease (CVD) continues to progress in the United States and worldwide. In this podcast, Monica Aggarwal, MD, explains the lifestyle modifications that are key for the prevention of CVD and how clinicians can encourage their patients to make the changes.

Additional Resources:

  • Micha R, Peñalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA. 2017;317(9):912-924. doi:10.1001/jama.2017.0947
  • Devries S, Agatston A, Aggarwal M, et al. A deficiency of nutrition education and practice in cardiology. Am J Med. 2017:1298-1305.doi:10.1016/J.AMJMED.2017.04.043
  • Paxton AE, Strycker LA, Toobert DJ, Ammerman AS, Glasgow RE. Starting the Conversation: performance of a brief dietary assessment and intervention tool for health professionals. Am J Prev Med. 2011;40(1):67–71. doi:10.1016/j.amepre.2010.10.009
  • Wang Z, Bergeron N, Levison BS, et al. Impact of chronic dietary red meat, white meat, or non-meat protein on trimethylamine N-oxide metabolism and renal excretion in healthy men and women. Eur Heart J. 2019;40(7):583-594. doi:10.1093/eurheartj/ehy799

Monica Aggarwal, MD, is an associate professor with the Division of Cardiology and the director of Integrative Cardiology and Prevention at the University of Florida/Shands Hospital in Gainesville, Florida.



Colleen Murphy: Hello everyone and welcome to another installment of Podcasts360, your go-to resource for medical news and clinical updates. I’m your moderator Colleen Murphy with Consultant360 Specialty Network.

Today I am joined by Dr Monica Aggarwal, an associate professor of medicine in the Division of cardiology and the director of Integrative Cardiology and Prevention at the University of Florida. Thank you for talking with me today, Dr Agarwal. 

Monica Aggarwal: It’s great to be here. Thanks for having me.

CM: Obviously, the world is currently facing the COVID-19 pandemic, but you’re here to talk about different than my cardiologist may soon be facing. So let’s go over that first. What’s the pandemic that may be on the horizon for cardiologists and their patients?

MA: So I do find this sort of an ironic time and ironic title. At the American College of Cardiology [meeting], we were going to present this case as preventing the pandemic. And how funny life has become—and not funny as well—where we’re now focusing on a viral pandemic. The pandemic that we had referred to when the title was created was just sort of think about sort of the progression of cardiovascular disease that we’re seeing in the United States and really in the world. Heart disease continues to be the number one killer of men and women in the United States and in the world. And with the rate of interventions in terms of percutaneous intervention and stents and with the advent and better medications over time, and of course lifestyle management, people are doing better, but the incidence of heart disease is not decreasing. And so what is important to appreciate is that what are these risk factors that put us in this situation where we’re sort of getting more and more heart disease incidents? And it really comes down to a lot of sort of lifestyle factors we have in the [United States] and in the world right now. And as our society has become more at home, and sadly even more at home now, we have become more stagnant as a society. Most of our jobs are behind a desk or moving very little. We are seeing significant amounts of obesity in our population and even in our young. And there are studies that correlate the amount of TV and time that a person, that a child, is watching to sort of their rates of obesity. There is also a significant issue with our nutrition. [An] article in JAMA [showed] the number one cause of mortality in the United States is now poor diet, so that’s a really big area that I think that needs to be focused on. We’ve moved away from cooking our foods and doing fast, quick meals. Mom and Dad are working [outside] the household. People are making these faster meals and looking for a lot of instant quick fixes. Boy, I have 3 kids myself, so I know that well. But because of that, I think we’ve just forgotten sort of what food is supposed to be, how it’s really an important part of our day to day, and how eating healthy, nutritious meals that are slow cooked is actually very important.

But also things like, besides lack of activity and poor diets, our stress levels are higher. We are sleeping less. The average adult should sleep between 7 and 9 hours per night. You look at the average. Most people are sleeping—certainly in our community as physicians—are sleeping so much less than that number ideal goal of 7 to 9 hours per day. Our stress levels are higher. I often tell people to consider it like our cell phones. When our cell phone goes to 7%, there’s a slight panic. We look for a cell phone charger and we put our phone in and we allow our phones to recover. But what we haven’t done is we haven’t done that to ourselves. And so, because we are a 24 hours a day, 365 days a year kind of system now, where we listen and respond to emails all times a day, and we are on all of the time, we sort of forgotten how to restore our body. And I think that because of all of these things like poor diet, stress levels, and poor sleep, we’re seeing sort of this crisis where people are developing more disease, earlier disease. And what I mean by disease, again, to clarify in the world of COVID-19 is cardiovascular disease.

And, you know, to say it is also interesting what we’re seeing is that this viral COVID-19 is also affecting more patients with cardiovascular disease.

CM: You just mentioned the lifestyle modifications that can be targeted and how key they are in preventing cardiovascular disease. How would you say that those modifications fit into the overall cardiovascular disease treatment landscape?

MA: Well, it’s interesting you know we all learn as medical students and residents and fellows that we should advocate lifestyle changes from the get-go. In fact, on every board question, the answer is always, “A lifestyle change.” So adding lifestyle changes into our day-to-day practice, that’s not a new concept. We’ve all had this concept, that, yes, we know that lifestyle intervention is important. The problem is that we as physicians aren’t very good at advocating it because we haven’t really been taught how to do lifestyle changes. We teach our physicians and our future physicians to say to exercise and eat better, but we don’t actually teach our physicians how to then educate their patients on how to make those changes. So lifestyle intervention has been part and parcel of therapeutic intervention since forever, but I’ve had even physicians, tell me, “Well, it’s easier to give people Lipitor and put a stent in them than have them do a lifestyle change because people don’t want to change.” And so there’s a lot of this concept that those interventions, well, are almost easier to do than lifestyle. 

CM: That actually brings me to my next question. You just said that a lot of times, clinicians are taught that these lifestyle modifications are key, but they’re not taught the “how” in how to talk to their patients about the changes and how the changes should be implemented. So what are your suggestions to your peers on how they can approach patients about these lifestyle modifications? Because these are personal choices that patients are making, and sometimes the conversations can be difficult to have.

AG: Oh sure. So, you know, definitely a challenge. So just to step back a little bit. We surveyed the American College of Cardiology, and we published this data where we surveyed cardiologists and cardiology fellows, and we look to see how much nutrition education they were getting in their medical school, residency, and fellowships. And the number of people—it was over 90% of physicians and may have even been closer to 95% of physicians—said they were getting little or no nutrition education in their whole training cycle, so student, resident, fellow. And it wasn’t getting better because when we specifically looked at the fellows in training, they also had the same numbers, so we’re just not teaching it. What I do at University of Florida is I do focus a lot on my students and residents, trying to teach them early on about important changes. And I do find and believe that when you work with students, residents earlier and they’re watching you practice a different way, they do change. And I’ve seen it with my own trainees how significantly they’ve changed. They’ll even call me years later and say, “Guess what I did?,” or “This is what I changed,” which is pretty fabulous. 

But practicality: How do you actually get physicians or how do I help physicians move this agenda of lifestyle initiatives forward? I run a prevention clinic at UF where I do 1-hour long clinic visits. Now people say to me often, “Well that’s not practical.” Doing a 1-hour visit isn’t practical for most of us, especially if you're in private practice, and I agree with that; I agree that that’s not practical. So often I do things, because I also have a clinic where I can’t do 1-hour visits, where I have the 15- to 20-minute visits, but I still incorporate lifestyle intervention. So how do you do that? Well, I do find that surveys that start the conversation. In fact, here's a great survey called Starting the Conversation Survey which is a nice validated survey that physicians can easily download and put into their office and patients can answer the questions on there before you even walk in the door. It’s 10 questions asking, “How do you eat, How many times do you eat fast food, How many times a week do you have sodas, How many times a week do you eat fruits and vegetables?” It’s an easy check sheet to fill out. And then it becomes easier for the clinician to walk in the door, and after they’ve done their visit, they can then look at that paper and say, “OK, hey, wait, look, we need to be focusing a little bit more on nutrition.” 

And what are some of those basic nutrition facets we should be focusing on? Well, one of the things that I tell patients and tell physicians that I’m teaching or in-training physicians is focus on small changes at first. If you tell somebody who’s used to eating McDonald's daily to then say, “Oh yeah, actually. You can’t eat any of that stuff. That’s it. We’re changing all of that.” Most people can’t do that, but I start with simple things. Like, number one would be, let’s say, eat 5 to 7 servings of fruits and vegetables per day. And 5 to 7 servings serving is not 3 strawberries, a serving is a cup of uncooked vegetables, a half a cup of cooked vegetables, or a baseball-sized fruit, and we should be eating 5 to 7 servings of those per day. The average American eats about 2 to 3 servings of fruits and vegetables. And frankly, the average cardiologist eats about 2 to 3 servings of fruits and vegetables per day. So that's one good change. The second thing I often will tell patients is—and it all depends on where they come from, because again, if you come in and you’re somebody who eats McDonald’s every day, then you’re not going to be inclined to just eat fish, for instance, but if you’re somebody who eats mostly fish, then they’re like, “Oh, great. I’m in the right place.” So again, it always depends on where person starts to figure out where they’re going to go—but often sort of focusing on things like number two, saying things like, “Eliminate all of your red meat, especially your processed meats [that] have the worst nutritional data associated with it, or the processed meats like bolognas and salamis and these prepared meats that you can get in the grocery store, but also then to sort of move toward removing red meat. Red meat is high in saturated fat. There's data related to the gut from the Cleveland Clinic that showed that patients who ate more red meat created more of a metabolite called TMAO and whether that isn’t necessarily predictive that a person is going to get cardiovascular disease, [the researchers were] able to associate that patients who had or people who had more TMAO in their bloodstream also had higher cardiovascular event rates. So then there’s the sodium. There’s the nitrates that comes from processing and saturated fat and cholesterol that comes in your red meat.

So if I were to say number one would have been fruits and vegetables, number two would be eliminating red meat, number three is usually adding things back like grains that are whole and then teaching people what whole grain means because everything these days says “whole grains” and most physicians have no idea that there's so much marketing trickery that goes on here. So many things that 100% whole grain can be whole grain but highly refined, and that's very tricky. And they can be adding things like salt and oil and sugar to their bread, but they can still call it whole grain bread. So looking for breads and foods that have few ingredients and really having no additives like no preservatives, no salt, no oil and sugar, which are very commonly placed in breads that are on the shelf of your grocery store, but just having things that are from bakery are usually going to get you good. And in general, sort of remembering that as a general rule, really is eat foods that are fresh. If you have ingredient lists with more than 3 or 4 things on them, then you should ask yourself why. Next is to say if you don’t know what those ingredients are, then you probably don't want to be eating them. 

CM: That’s great. The tips that you give are nutrition-based. So would you say that nutrition modifications are maybe the ones that your peers should target? I know before you had mentioned sleep and the fact that Americans are not moving as much nowadays. So would you say nutrition is the key target here. 

MA: Yeah no, I guess I should have explained further; I got caught up in nutrition there. So certainly, I often will start the conversation in my clinic with a nutrition conversation. And then I usually evolve it over multiple visits to bringing in other thing. I find that, you know, even though our AHA guidelines and our ACC guidelines recommend that we should be exercising 30 to 45 minutes of high intensity or moderate to high intensity exercise per day, most of our patients are unable to do that or they find that to be a barrier. And so often I remind people that even if you increase your steps by 2000 steps per day, then you're going to decrease [your] event rate. And I remind people that any level of activity is more than not moving. And so sometimes they'll start my patients off with saying walk 5 minutes every day. And I'll tell them to start the alarm and go 5 minutes and make sure they're backed by 5 minutes and they'll say, “That’s it? I can do that.” And I find that patients will come back to me often and say, “You know, it's because you said to me I only had to do 5 minutes that I felt it was attainable and I was able to do that.” So I do focus on exercise and I build it up, but I build it up slowly. Not everybody can run 30 or 45 minutes, and so I'll start with that, and I’ll also add in strength building exercises. We can't forget that even in the guideline, we do talk about strength building, but we don't emphasize that enough in our clinic. We’ll tell people to go for a walk, which is great, but also building balance and strength is extremely important, or isotonic exercise. So I do focus on that as well. 

I do also talk to patients about cutting out their phones, switching off their phones at 10 o'clock at night, keeping them off until the morning and not answering them as they wake up in the middle of the night or checking their emails at night. If they wake up and really having sort of a device-free time from like 10 p.m. to 6 a.m., which is a huge challenge even for physicians, maybe mostly for physicians or sort of high-intensity, high-level job activity patients, they really struggle with that one, and try to get people to at least sleep—if they're sleeping 5 hours, I try to increase it to 6; if people are sleeping 6 I try to get them to 7 with a goal with people sleeping 7 to 9 hours per night.

CM: Well, certainly sounds like the work that you're doing and the insight that you gave us today can benefit patients’ cardiovascular health and hopefully prevent the potential cardiovascular pandemic. So thank you so much for your time, Dr Aggarwal.

MA: My pleasure.

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