Dr. Panigrahi, Dr. Talreja and Dietician Kelly Honeycutt outline the medically designed cardiac rehabilitation program to help improve heart and cardiovascular health for cardiac patients at Sentara.
Thank you so much, Dr Panny. And this is really a tribute to the work you and Sharon Henley and the entire team have really done along with the administrative team at Princess Anne Medical Center. So many of you will remember last year, we did a number of great grand rounds. One on lipidology. We discussed creating an intensive cardiac rehab, experiential program. And I think the majority of you got this flyer in the email at some point and I suspect many are wondering whatever happened with that. So let me close this screen. All right. So the taste of Ornish program was a experiential four part program that was done in early October of 2023. We had a number of providers who attended and we had four sessions a Tuesday, Thursday of one week and then the following Tuesday and Thursday of the next week, there were four hour sessions in the typical orangish pattern. And frankly, they were remarkable as one of the participants I've spoken with the other participants and we've agreed we wanted to share with you our experience. So from my perspective, what I would say is over the years, I have certainly read and paid attention to between books and websites and lectures, what's been going on with the Ornish program. In fact, I remember early in my career sitting at the A H A and listening back in the days when Dr Atkins was alive as well to Ornish and Atkins really going at it at each other in discussion as to what nutritional program is the healthiest, but book knowledge has its limits. And I think Sotera has done a nice job through the nutritionist medicine conferences. And then culminating in this eight years of the Ornish Lifestyle Medicine program that Dr Pane Grai and his team have really been remarkable in putting together and educating our community. The four pillars of eating well, moving more, stressing less and loving more are what they taught us during our experience in this program. Um The entire team played a role every day. Each working with us in sequence, it was a four hour program and each day we spent one hour on each of those components and starting with eating well, they educated us on what's safe, what's not, what are the benefits and risks of different foods. And I'll be honest, I think for many of us as health care providers, we went through our medical school and residency and cardiology, fellowship trainings and had fairly limited exposure even if we sought on our own to keep involved. And so I have to admit, I think each of us will echo that we learned a ton. There's a lot I learned that I didn't know a lot of data that we went through. That was interesting. And this is us sitting in the classroom at the Princess Anne Medical Center and learning from the team you can see here and you're going to hear some of this from Kelly directly who's up there on the slide along with Sharon Henley. The food was really impressive. You'll hear that echoed in some of the comments from our colleagues. These were a couple of the foods we were served live at this program. On the left is a chili for sloppy Joe's in the middle is a dessert of fresh veggie, uh fresh fruits rather. And on the right is a candied pear and Bok Choy and uh vegan stir fry with brown rice. So we learned how to eat well, how to cook well. And it was really remarkable. This is my wife and I, she's a pediatrician and attendant as well. And this is the Sloppy Joe's Night with a really healthy outlay that frankly tasted absolutely wonderful. In addition to that, you see us on the treadmills, there's a lot of machines that our patients get on for exercise. And I think part of the value for me of this program is uh getting in that setting that our patients will, will be in themselves and being able to really tell them what to expect. I think it makes a difference when we providers, one really encourage our patients and tell them the importance to their health of participating in programs like this. And then two, I think when you can say something about the people they're going to meet or what they're going through, it helps encourage their buy in. And it makes us feel like we know more of what's going on. You see, Doctor Panty on the far left here, you see a lot of the orange team inter digitate in. Peeking in the back is uh Doctor mckechnie and his wife, Dr Choi and I are there and all of us participated at some level here. Again, you can see there's a lot of time spent on the treadmills, the bikes, the other machines they have and on this uh this group of slides, you see us on the different days of the program all working together again and Dr Panny was kind enough not only to come and participate and help educate us, you see him on the treadmills with us during some of this as well. So I have to say, I think we all found it to be a lot of fun to mingle with colleagues and to really put some time and energy into making ourselves healthier. After each exercise program, we would do some stretching exercises. You see here, you see Doctor CEI there on the far left, you see Scott, we had a number of our, a PP team uh participating as well after the exercise, which we typically started with. And you can imagine we're all rushing in from busy clinical jobs to get on the treadmills and exercise. Then we would have these heart rate monitors on us and recover and see our heart rates come down nicely as we sat and rested and meditated. Then we went on to nutritional education with dinner and then to the other two parts of the program, which we'll talk about group therapy. I only have this one picture of it's a protected area. It's a space where not even uh participants who want to just watch and not be part of it are allowed in. It's really only the team themselves and you see all of us sitting in this circle as we start doing group therapy and talking and I'll share a little bit more about that in the slides to come. And then again, the counseling port, the yoga part. Uh I didn't take any pictures because we were asked to keep that, uh keep that uh respectful of all the participants in there. I asked each of the people that participated to give me a quick comment to share with you so you can get a feel for what a number of us thought. I'll read what doctor uh OSI said, the Ornish program for physicians turned out to be more than just a powerpoint slide deck, emphasizing lifestyle overhaul or transformation. Reflecting on it. I describe it as sowing the proverbial nutrition, mustard seed, an initial foray into discerning between what is labeled food and what is truly a nutritionist nutritional for our bodies. As one gains further insight with the lectures and the group sessions, it becomes a journey of dietary acculturation in a modern world packed full with unrelenting marketing, ready to go meals, fast food options, all packaged and delivered with a large portion size mindset. The concepts discussed in the lecture sessions may not initially come across as pragmatic but eventually unfolds with such clarity in its simplicity. And I really would echo that he's captured beautifully and very eloquently how our mindsets changed over the four sessions. He says, yes, it may not be possible to stick with the program's ideals consistently. But I think the experience eventually hopes to commit us in our own unique way to pursue a lifetime enlightenment of what we've traditionally regarded as a food slash diet versus what really nourishes us coupled with simple consistent exercise and an introspective reflection of our psyche all shared with a common interest group. It forms the basis of what fuels a healthier us, a safer society. And he's beautifully hit on all the different aspects of this. And I think although his is going to be the most eloquent of the ones I'll show you, it really captures what you'll hear from the rest. Doctor mckechnie and Sonia mckechnie participated as well. And Ron said, the staff provided a motivated balanced and cardio centric approach to health and healthy living and longevity. It is a benchmark for high quality preventative and rehabilitative vascular care. He also comments that it was great to exercise next to D PAC. My heart rate recovered quicker than his. I'll comment more on that later because the data actually doesn't uh doesn't uh fit with that. But April Rawlings, I love the breakdown of the Orangish program. The four components of improving health, including exercise, nutrition, stress management, and love and support. The meals were complete and delicious. Best vegan sloppy Joe, which you saw pictures of earlier. She said my personal favorite and best takeaway take time to enjoy your surroundings. The inbox to zero will never happen. Not for me. Anyway, I enjoy getting to know a few colleagues and sharing our thoughts on a more personal level. Scott Burns. You see here said I was impressed by the quality of life improvements that can come from being a part of a health focused community. I left with the impression that adherence to a healthy lifestyle would improve significantly if we set patients up for success through programs like Ornish, which don't just give patients information, but actually show them what they're capable of and how they can feel through eating exercise, eating healthy meals and dealing with negative thoughts productively in a supportive environment. I'd recommend it without hesitation to a loved one. Dr Choi a pediatrician. Said the program was truly incredible. Each member of the staff put their heart into sharing the wisdom across their segment of the Ornish teachings. I was hard pressed to share my feelings in the first session and by the end had learned to feel comfortable amongst my peers to share each night. I left with a sense of ease and relaxation. And what I would say is the four sessions across the two weeks of practice was truly eye opening. It really is a remarkable program seeing is believing we are as, as providers. We often keep up to date on the latest academic journals and know the science behind what we're doing. But it's very different to live the life from just reading about it or knowing in theory what to do. And often we in cardiology when it comes to fitness and nutrition are kind of the worst at knowing what we should be doing and not making time in our own busy lives and successful careers to do what it takes to take care of ourselves. This opportunity to do the full program really changes lives and resets decades of poor habits and choices. And just to reiterate, I did get to the target heart rate faster than mckechnie. When we were sitting together, the owner staff will vouch for that. I will share that after the program. I really found it so great that I signed my parents both up to complete the program and they did the full 18 week session and absolutely loved it. They, they did it out of pocket just because they don't have the medical indications for it, but it was money well spent because it really has been to this day changing in their lifestyle. I would like to end my comments by just saying, thank you to Dr Panny and to the entire team, they deserve massive kudos. As Dr Panny mentioned, as we transition from the orange program to the Pritikin program, I think this idea of intensive cardiac rehab is incredibly, incredibly important. I think my summary is the future of intensive cardiac rehab is absolutely bright. What Ornish lifestyle medicine has done for our community is remarkable and the entire team deserves tremendous recognition. I can say that not just as an academic or or someone looking from the outside, I can say it as having participated in it now, even in the short way that we did participate with the move to the Pretium program and the expansion of the intensive cardiac rehab abilities across the entire system to each Centa site. I think the future is even brighter to reach an even larger patient population. The one thing I will say is it will be incumbent on all of us providers, whether we're physicians, administrators, A PPS nurses, anyone on the health care team, this is the kind of program that I really believe can change uh the patient's lifestyle, you know, so often the semi intervention we do in the middle of the night can absolutely life saving in that environment. But what's going to give them great quality of life and prevent them from being back in the Kath lab is engaging patients and really encouraging them in this program. One thing I hear again and again from patients is that what makes them commit to this is when their health care provider really pushes it at them. And I think that's important for us. We physicians must not only educate ourselves on the efficacy of lifestyle changes, but we really have to offer this to every single patient that we see. So yes, when we um talk with participants about lifestyle changes in regards to diet, one of the number one things that I talk to them about is the health benefits that come from the natural foods that are available to us. The soluble fibers are found in whole grains like oatmeal and faro fria barley. Um also the starchy vegetables such as all varieties of potatoes, um winter squash, like the butternut squash, um and also corn and peas. Again, they also have lots of soluble fiber and also phytochemicals. The things that make um all the fruits and vegetables have their beautiful colors and flavors. Um These offer many, many health benefits and there are hundreds of them. Um So we do focus mainly on incorporating lots of whole grains, not refined um carbohydrates or anything white um even rices and pastas, we recommend being um whole grain along with breads. Um a focus on nonstarchy vegetables, fresh fruit, um beans and legumes as well as lentils, whole soy products because they offer many, many benefits such as omega three fatty acids, um vitamin B 12 and a great amount of plant based protein, um small amounts of nuts and seeds because uh research has shown that they do have some health benefits, however, because they can be extremely high in both fat and calories. They are limited to small portions and we do um have some room for fat free dairy products, um reducing the saturated fat that is available in those and reducing the cholesterol down. Um Most of the fat free milks have 5 mg or less of cholesterol, which is one of our recommendations. So really, it's not just about eliminating and reducing animal products, but really it goes a step farther and replacing those with foods that have lots of health benefits, both for cardiovascular disease, but also for other chronic diseases. Um a simple way to take a look at your plate and see if you are doing well as far as including lots of fresh fruits and vegetables is number one to choose whole foods. Um I do talk to participants about reading labels on foods, but ideally because we are a Whole Foods plant-based program, we really like to focus on foods that do not come with the label So things that you will find around the parameter of the groceries or um you again, whole grain breads and uh greens and pastas and rices. Lots of, again, the starchy vegetables and fruits. Um ideally, we'd like for 50% of the plate to be the colorful foods and vegetables and fruits that are available to you. Um You can even go as far as 75% if you really wanna load up on the good stuff, that's gonna really help her prevent chronic disease. A quarter of your plate to be um lean proteins, preferably plant based um beans, legumes, tofu. We do also um recommend if you want to choose eggs to do no more than two egg whites per day and eliminating that yolk that has lots of saturated fat and cholesterol. Um and then the last quarter of your plate to be the whole grains. So, um when you do something like this, you also naturally reduce the amount of calories that you're taking in because the colorful fruits and vegetables tend to be lower in calories and higher in water. So it also helps with hydration too. So, um that's a nice simple way to take a look at your plate and see if you are doing well as far as um lots of servings of nonstarchy vegetables, starchy vegetables and fruits for fat studies are showing. Um So we've known for a while that uh unsaturated fats do have some health benefits but in moderation, fats, all fats are 9 g. Um, I'm sorry, yes, or nine calories per gram. And therefore, um, reducing fat will automatically reduce calories. So, if you're looking for weight control, that is one way to take a look at it. We do, um, recommend looking at oils within packaged goods and making sure that they are from an unsaturated source. Um, however, we really encourage people to try to move away from cooking with oils and fats such as butter um to reduce the amount that you take in throughout the day. Um and instead cooking with things like water, other sauces that are low in fat or fat free or even um vegetable broth. And then research has also told us that saturated fats, we know as um increase your LDL or your bad cholesterol and it also can increase triglycerides. So if you are already at risk for cardiovascular disease and you're trying to reduce your risk, we really recommend staying away from these mainly saturated oils such as coconut and palm kernel oils, um cholesterol that are found in egg yolks, uh and also butter and margarine. So those we recommend staying away from and then real quickly, just to give you a brief overview of what we recommend when looking at a food label, I'm sure most people are familiar with the food label. It's on almost every pack. Well, on every package good available step, number one would be to take a look at the serving size. Um, because this right here has 4 g of fat. Um, but if I was eating more than the serving size here, I would have to multiply that number. So if I was eating, um, uh, three cups instead of 1.5 cups, that number would turn into 8 g of fat and not four. We recommend trying to maintain 9 g of added fat for the day. That's fat that the manufacturer puts into the packaged goods such as added oils. Um So keeping that low by 9 g of fat per day and you do get additional fat from the whole foods that you're eating. So this is just in reference to packaged goods. We recommend keeping saturated fat and trans fat as close to zero as possible. Again, these are known to promote inflammation and to promote the increase of LDL cholesterol and triglycerides, cholesterol. A recommendation for the Orangish program is to try to keep that to less than 10 mg a day. Um There is no cholesterol and plant based food. So if you're sticking with the mostly plant predominant diet, you will naturally reduce your cholesterol intake. Uh We do recommend taking a look at dairy products and also if you take a fish oil supplement, uh there tends to be some cholesterol on fish oil. So we recommend taking a peek at that and seeing how much you're taking in just for your supplement alone for sodium. Good rule of thumb is to take a look at the percentage instead of the number of milligrams, less than 5% is the best. That's considered low sodium. If you see anything creeping up to about 20% that is a no go. And we recommend not getting that item. When it comes to sugars, we focus on added sugars, not the natural sugars that are found in food. So total sugars is not something that we are concerned with. Um or that we don't focus on rather, but we do look at the added sugars and those are things that the manufacturer again as in such as Malto Dextrin and added um other added sugar sources. Um recommendation here is 25 g for women and 35 g or less for men. And to keep that low, a good rule of thumb is to keep your added sugars per serving less than 5 mg, I mean less than 5 g. Uh and that will help to keep your total added sugar intake on the low side. And then one thing that we instead of keeping low, we really recommend more is better is of course, dietary fiber. Fiber is one of the um nutrients that we are finding does so much for our body and also for our gut and our microbiome. Lots of research coming out on not a recommendation for fiber um is to look for items that have at least 3 g of fiber or more, especially for your breads, if you have a bread that claims to be a wheat or a whole grain bread and it has less than 3 g of fiber. I recommend putting that back and finding one with more fiber. So as a quick overview, these are the different nutrients for total fat. We recommend less than 9 g and that is actually per day and not per serving, saturated and trans fat. Keeping as close to zero as possible. Sodium, anything less than 10% is, is a um is OK to do added sugar is less than 5 g per serving, less per fiber, more than 3 g per serving and cholesterol trying to keep that less than 5 g per day. Um And if you're deciding to do the uh nonfat dairy products, we recommend no more than two servings per day. And that is to keep that cholesterol level down because there is cholesterol even in your nonfat dairy products. And then the last thing that I'd like to touch on is just taking a look at the ingredients. So once you look at that nutrition label and everything's in check and green and good to go there. Taking a look down at the ingredients list. Number one thing is to keep in mind is that the ingredients are list um an order of abundance. So for this label here, the number one most abundant ingredient is the stone ground, whole wheat and the least abundant ingredient is the soy less of them. Um When looking at whole grain products, especially breads and pastas, you wanna look for the word whole, if it says enriched, enriched wheat flour, it is, it is a refined product. So you want that whole word to be there. Um And then also looking at the source of oils and fats and making sure that it is not um coming from full fat dairy, egg yolks, full fat cheese and things of that nature. So that is just kind of a quick overview of what our recommendations are for the Diet at the Ornish program and uh very similar recommendations for the predic program. Thank you. Mhm. Thank you all. Uh I'm going to within the next 30 minutes summarize what uh we are encountering today in the United States and globally. And this is a responsibility as physicians to improve uh the public's health. It's imperative for us to understand what we are dealing with today. Um Heart disease is still the leading cause of death in the United States. And for the past 100 years, it has been the leading cause and we thought about four years ago that cancer will be the leading cause and the heart disease will be the second. But that never happened. This is on account of the rising case of obesity and it's uh accompanied case of diabetes and that trajectory has altered as a result close to now over 900,000 people succumbed to heart disease and stroke. The star marks indicates that uh these are the ones will have a positive impact with change our lifestyle, with a healthy diet and exercise, et cetera, which I'm going to go over. It has been recognized by leaders in the field and aerobatic medicine for thousands and thousands of years that in order to promote health, nothing will benefit human health and increase your chance for survival to the life on earth. As much as the evolution to a vegetarian diet. And uh the recent update from the preventive and the reversal journal came to the conclusion, this is very much the American Heart Association's life's essential checklist. Only one out of the pie by Americans has optimal cardiovascular health. So we have a a lot of heavy lifting to do and the optimal is only 80% of the light since eight, not 100% 80%. And if you take that into consideration, only just a half percent of the population have a perfect score. And what is the life says since year eight before 2022 the American Heart Association has exemplified life's simple seven. And later on, it was realized that the two hours sleep uh as a modality for a healthy lifestyle that increased to essential aid, that includes practice of a healthy diet, physical activity, the lack of tobacco exposure, sleep body mass index, and the measurables one, the lipids blood glucose and blood pressure. So, where we stand, this is from the study compiled, uh, by Lloyd Jones and the American Heart Association published in, uh, not too long ago, a little over a year ago when they analyzed the enhanced the, um, cohort according to the essential heat matrix, died, physical activity and body mass index. We are a very miserable state in those United States. Less than 60% dieted in wars only accounts for 30 for 36%. So these behavioral factors is changeable, but much more effort needs to be done because the type of lifestyle we have gotten used to in the post industrial seven days and the cardiovascular health. Uh according to the essential aid, the population, different ethnic groups are differentially affected. And as you could see here, unfortunately, the non-hispanic black community has the greatest burden and Hampton roads. We have a large representation as a result, obesity and diabetes and its problems are extremely high and we are the epicenter of diabetes. Hampton Rose, I'm falling in the state of Virginia. So coming back to why all this, why uh not uh the dash diet, not the Mediterranean diet. There are so many diets have uh been promoted in the lay press. But what is about the diet, honest diet that does help to reverse heart disease, that no other diet has come close to it. And I'm going to kind of emphasize this point so that we all take an effort to implement this in our daily living and prescription. The honest diet when it was published back in 1998 from his uh randomized clinical trial of five years, the diet composed of complex carbohydrate 75% and the dash diet is really about 50 to 60% maximum. That's a big difference. The protein content pretty much similar honest diet is a plant protein without any high animal protein and that's about 15% and it is a little higher in the dash diet. But what is remarkable is the fat content on his diet is a very low fat diet. 10% of the calories are coming from fat and kelly already elaborated that any other diet that exceeds that. And in the death diet, it's 30% very remarkable. Similarly, the cholesterol is less than 10 g per day and any other diet because the animal components are high in cholesterol. Plants do not have any cholesterol and that is the beauty of this plant. So, analyzing on publication in 1998 on the left side, you see the panel, it is a randomized control trial and the treatment group pulse started with a narrowing, coronary artery narrowing and geographically above close to 40%. And those who followed the honest lifestyle over five years and continued to decline in the regression of the atherosclerosis from 40% or 41% to it is about 37% decline in the diameter of stenosis of coronary arteries. On the other hand, the contralateral group, the control group, they have a consistent increase from 40% to almost 10 11% higher. So, so this is the contrast that we are dealing with in our everyday life, we are taking care of the patients. They are getting sicker and sicker because their dietary habit is not comfortable to what honest prescription is. And on the right side panel, as you can see those who are most at their end to the honest lifestyle. After they graduate from the program, they consistently have done better and continue to regress while those are not compliant, they have a minimal benefit. So diet has a profound impact in regress on and that's where we need to focus on. So coming back to our experience with the Honest program, as I mentioned, the last quarter, we have able to provide it over 500 graduates from the program and of what stands out here, I consistently have seen that our courts are carry about uh 6 to £7 higher compared to the national average. And that is the reflection of the Hampton dose. We deal with a lot of obesity and as a result, diabetes, the hemoglobin A one C is the highest in our cohorts here compared to the national average. Even though in all areas, we have made significant progress just in a matter of nine weeks and the exercise capacity is significantly improved because of the supervised nature. But deeper as I already mentioned, the encouragement the diet, the support all these are help to improve uh to like 4.4 Mets from less than three mets like a sedentary lifestyle to a functional lifestyle. And so the diet exercise, et cetera has contributed to their well being and these are most of the parameters are equal or better compared to the national average. And uh Kelly has already mentioned about the fat content where we design the meal monitor their adherence in a way the fat in their diet at home has decreased over 50% compared to what they have been used to do. And that has helped and similarly, fiber has significantly improved. It's a very important component for the G I tract control of diabetes, improving immunity, improving the brain function. It is t to multiple way by its intra with the microbiome. And uh so this is an important fact of stress. And secondly, that helps to dilute out the calories. So that's how you reduce obesity and indirectly diabetes, reduce cholesterol. So this is an important aspect of this diet plan with high five or low fat. So this is a recent study that kind of uh tracks what we have seen in the honest angiographic data. This is a randomized control study published in 2021 by Angela and their group. And this is evaluated on a best diet and control about CT angiogram and uh those who are not probably familiar with the CT angiogram is qualifies the nature of the plan and it is evaluated by the Hans field units. A calcium or dense calcium scores 351 or great of the harms units. A hydrous plaque is between 100 and 51 to 350 hyper fatty plaque is 31 to 100 and 50 the necrotic core is less than minus 30 to 30. But it means that have the necrotic code in the, it is the early phase of accumulation of oxidized LDL that attracts the inflammatory components and makes it very susceptible to plaque rupture plaque eros and the acute syndrome that presents with the acute coronary syndrome, STN non STL and myocardial infection or simple angina pectoris on account of uh the inflammation that is happening with some systemic effect and how it is monitored. So, these are the high risk plaque. In other words, when it's a high risk, even though the coronary artery stenosis is less than a 50% of the diameter reduction where most of the acute events happen because of the first part of this plaque in modulation. And these are, these are the four categories that lead to acute presentation with the unstable angina acute coronary syndrome. Number one, when the art well is remodeling compared to the normal segment, it is dilated on account of a damage to the elastic and muscular lamina causing out pouching or remodeling. And that is an acute inflation going on, makes it susceptible to have a clinical presentation with the acute coronary syndrome. The second category uh it is by the CT angiogram, it's like a nap I it's a profound uh extensive inflammatory condition and you can measure it by the hand built units. So it will characterize what is the nature of the plan. Then the spotty calcium, that means this is the end stage. But behind in the back when there's no extensive cancer calcification, that means still some inflammatory melo is going on. So it's a marker telling that uh a lot of the inflammation is happening and this artery is susceptible to present as an acute abnormality. And then these low density marks in the rounded figures. It is highlighted are the acute phase of the lipid core. They are not calcified or fibrous yet and are highly susceptible to causing acute syndrome. What is missing from this? The technology has advanced substantially to categorize whose artery is susceptible. So we can able to preemptively do the scan to identify the individuals and treat them aggressively to reduce their chance of having an acute event. At this time. The technology has not advanced enough to characterize the thin uh uh cap uh and it will take another probably technological advance to see the fissures, the erosion, the plat aggregation. And these technologies are going to be advanced in the near future. Uh So based upon this randomized trial and the CT and geographic parameters on the left side I have given at the baseline, the disco trial is the, is the um dash diet that is promoted against the control. And as you could see here from this graph at the end of the study that is after 70 weeks on the site versus the control, there is no improvement of the parameters take into consideration cholesterol, ldlhtl, triglyceride and homocysteine. None of them have significantly better compared to the control except the inflammation that is barely positive, high reactive c reactive protein is better compared to the control. And that's because the diet is not sufficiently close to the honest diet. And I will reemphasize that to educate ourselves. So if you just take out the fibro fatty and the necrotic, which are the susceptible part of the acute presentation, again, you can see disco versus control barely barely improved. There is an improvement in it itself. But when we compare to the control, the PF is barely significant. And if you analyzed the whole plaque, this is on the uh dash diet at the baseline. 2, 70 week later, it increased the plaque from 36.5% to 37.4%. It increased. What are advantages are the necrotic core decreased? But the hydrotic and the calcific part of the store increase. So the diameter is not reduced and it is very much similar to the control. So there is hardly any difference between controlled diet and the dash diet in terms of a coronary artery irritation. And this is the summary of this dash diet compared to the control diet. In this cohort of studies of randomized trial, evaluated with the current CT angiogram, the reduce inflammation marker by just reducing the CRP, reduced plaque volume only happened to the hydro fatty and the lipid core thereby improve the acute inflammation. But in 70 weeks, the whole volume has increased and there is no plaque regression, plaque progression happening just in 70 weeks. Look at what will happen in 10 years. If we are going to give you on a dash diet, you'll end up the same, you just delayed it. Instead of this happening at the age of 65 it'll happen at the age of 70. That's what we are doing. So we're kind of cheating ourselves thinking that we'll be able to solve this problem. It will not happen. Why? Look at this. This is the study done by Tom Cell from uh Cus Rochester. He's the co author of the China study with his father. He has taken a group of patients, those who are ha have adult onset diabetes and are on insulin. So this is the parameter of their dietary fat, protein and carbohydrate. That is similar to you can say that diet or the ordinary diet, less carbohydrate and uh protein and fat. Nearly 30% fat. Ok. So he put them on the dash diet and clearly as you could see the calorie uh content of the diet has decreased and that translated into some weight loss and a reduced need for insulin. There, he changed the same cohort to a whole food plant based diet. There is a dramatic change further improvement compared to the death diet in terms of needing insulin and automatically because of the high complex carbohydrate, the total calorie need has decreased and that is a less protein and less fat. As a result, the demand for insulin also decreased. Then he recalled with the dash diet and it is back to the same or progressing towards the same as you could see. So, so, so this is a very interesting story and here is the insulin requirement where the same group of people from the baseline went to the dash that insulin requirement decreased, but it further decreased with the whole food plant based diet similar to what we are promoting the honest diet. And when we are recalled with the tast insulin is beginning to rise. It's just a matter of weeks, it is not uh years, it is just weeks. So this is what is happening. This is a recent story from Stanford by Christopher Gardner and their group. This is the twin study, whether you have heard about or not. There are 20 sets of twins, they are in their fifties, they were given a vegan diet and their sisters are to other partners. So given the omni dies, say they, they crossed over after two or three weeks. And as you could see, the vegan diet has already have multiple benefits including the cholesterol triglycerides and the TMO, which is derived from fat, from the animal source and protein possible. So, so again, you see the beauty of a whole food plant based diet in a graphic um these are the vegan diet and here is the Omnivore diet. The vegan diet always have improved all the parameters including the TML. So, so what uh these uh experiences are telling again and again, a whole food plant based close to vegan diet is the optimum diet for a best of health which includes it will lessen up coronary atherosclerosis, prevention of diabetes, prevention of obesity. And these are the major factors. We did not go into cancer, but cancer is also will be helpful by the whole food plant based diet. Coming back to the trajectory of the heart disease. As you could see, the green is for 2022 compared to two thou sorry, 20 green is 20,021 compared to 2020. All the parameters are increasing. In spite of all the technology, all the statins powerful statins, blood pressure, blood glucose monitoring, nothing is stopping the progression of heart disease. And we really have to think well and hard. All of us those who are um treating these patients with a bent of scientific mind. What is truly we are doing what we should recommend. And that's where I stress the importance of um whole food plant based diets as a foundation for treating all our chronic diseases, anything less we're not able to overcome the tragedies that is happening in the United States and throughout the world. And I'll conclude here and thank you for your attention.
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