South Asians and Heart Disease – Creative Solutions with Therapeutic Lifestyle Changes

South Asians and Heart Disease – Creative Solutions with Therapeutic Lifestyle Changes


>> SAINT CLAIRE: To you the co-founders of the
South Asian Heart Center in Mountain View, Doctor Cesar Molina and Ashish Mathur. Doctor
Molina is Medical Director of the South Asian Heart Center. He has a medical degree from
Yale University and completed his medical, clinical pharmacology and cardiology training
at Stanford where he was a Robert Wood Johnson scholar. In 1990, Doctor Molina established
his cardiology practice at El Camino Hospital. Ashish Mathur is the Executive Director of
the South Asian Heart Center and is actively involved in promoting awareness of this epidemic
within the community. Prior to his work with the center, Ashish worked for over 25 years
in the software industry. He’s been a board member, entrepreneur and an executive at many
technology companies. Ashish holds a BS in Electrical Engineering from the Indian Institute
of Technology, Bombay and an MS in Computer Science from University of Southern California.
Please help me in welcoming Mr. Mathur and Doctor Molina who are going to discuss and
further elucidate this apparent paradox.>>MATHUR: Thank you Doctor Saint Claire.
Can you hear me? Okay? Alright. And the members of the Google team who have been kind enough
to have us here to talk about this issue. Just before I get started, how many of you
know about the South Asian Heart Center already? Guess a few. And have you been to the program
already or you’d–okay. So, you know, I, as Doctor Saint Claire introduced, I’m not a
medical doctor but I took part at El Camino Hospital to start this effort because I suffered
from a heart attack myself. And so since then I’ve been looking for ways to prevent the
second one and as part of that search we have been able to put together this program as
a non-profit organization at El Camino Hospital. And so, we talked about the epidemic and how
severe this epidemic is in South Asians compared to other populations. I’ll give you a brief
overview of what we do at the center and how you might be able to avail of our services
there. Doctor Molina will then talk about therapeutic lifestyle changes, which is what
our program is really based on. And he’ll present to you kind of the evidence behind
it. And then finally, we’ll talk about what you can do to help prevent a heart attack
and help have better heart health. So, one thing that I just wanted to point out was
that South Asia consists of the Indian subcontinent countries like India, Pakistan, Bangladesh,
Sri Lanka, and Nepal. It constitutes about 17% of the world population, 2.5 million South
Asians in the U.S. and they carry 60% of the disease burden, the global disease burden.
What we see is that seemingly healthy, young South Asians presents themselves with a MI
or a heart attack at early ages. Fifty percent of the heart attacks occur before the age
of 55 in this population and 25% of the heart attacks before the age of 40. At El Camino
Hospital, where I’m at, when we started looking at this issue, while only 3% of the district
population was South Asian, 6% of the cases that were reported in the emergency room with
heart attacks were South Asian. We did a recent survey in 2009 and we found that 17% of the
cases that were reported with MI, 41 out of 217 cases were South Asians. So, that’s a
disproportionately large amount of people suffering heart attacks. In the last three
months, I personally know of three people within my family and friends circle that have
had heart attacks and one of them passed away as well and I hear this constantly. I’m called
into emergency when a 35 year old or a 30 year old shows up with an MI and they don’t
know what happened and they don’t know why it happened to them. So, we are looking at
this very, very closely at the South Asian Heart Center. And some of the statistics around
that are really so severe. Twice the amount of mortality compared to other populations
when you have a heart attack, three times the chance of having a secondary heart attack,
four times the risk of disease compared to general population, six times compared to
the Chinese. And so the question always comes up, why is there this greater risk for heart
disease? And there are really three reasons that we can talk about. The first one is that
there is early onset of the traditional risk factors and this has been shown by multiple
studies, the most famous one of them being INTERHEART and Doctor Molina will take you
through some of the numbers corresponding to that, diabetes and cholesterol levels.
The second one is the shortage of protective risk factors, again a thing that INTERHEART
study pointed out. That we have a vegetarian population that is not vegetable eating but
grain eating, no fruits and vegetables in the diet, and a very sedentary lifestyle.
And the third aspect is the genetic predisposition. There are many other risk markers and factors
that are typically not looked at that present themselves in the South Asian population.
So, the South Asian Heart Center was formed with the mission to reduce this high incidence
of heart disease through a program that raises awareness, to a program that actually prevents
by evaluating risks of different people, and then facilitating lifestyle changes and coaching
them through it. So, we are at El Camino Hospital, which is right here at Mountain View. And
it is really the first program that was started in the Silicon Valley to address this need.
Our program has some guiding principles we usually–we call our participants, participants
not patients. We are preventing them from becoming heart patients. And it’s really a
three-way collaboration between you, the participants, us the South Asian Heart Center, and your
physician. We are not a medical facility. We do not provide any medications. You have
to work with your doctor on that but we work collaboratively with your doctor on that.
And we work on the lifestyle aspects that can really dramatically change your profile,
specifically as it relates to nutrition, the coaching that we do to help you on your exercise
programs and stress management. So, we have created a methodology which is more comprehensive
that you might find at your physician’s office which consist of a very detailed heart health
risk assessment followed by a physical exam, a laboratory test that includes the lipid
panel which you might get at the physician’s office but also some of the genetic factors
that we have started looking at and some of the risk markers that are emerging as part
of the risk factors for this disease. And we’re also introducing now the ability to
actually detect the disease. You know we can find risk factors but it would be really nice
to know whether you have the disease or not and then you could start working more aggressively
on managing it. So, once we are done with the assessment, we identify your level of
risk and then we start working with you on lifestyle changes. And we do that through
a series of consultations. All of these are actually provided to you, all the consultations
at no cost at the center. We go over the risks and that’s the consultation, we create a plan
with you. We do a nutrition consultation and maybe one or more depending on how much need
that you have. We do an exercise consultation and we do a stress management consultation.
To kind of tell you the total picture on how you can benefit by getting on to those lifestyle
changes. I’m sorry, this slide is actually going to be covered by Doctor Molina so I’m
going to skip it. But this is what our program looks like. So, there are a series of consultations
like I told you. The only cost to the program is the blood tests that we have to get you
to do first and that has been subsidized for South Asian Heart Center participants so that
is only $73 out of pocket for you. The rest of the cost is borne by insurance companies
as well as the lab provider. And with that, I’m going to let Doctor Molina continue his
talk.>>MOLINA: So, today we are talking about
prevention of cardiovascular disease. Everything that we discuss here today refers to prevention
of coronary artery disease can be also said about the prevention of cancer and the enhancement
on longevity, as well as diabetes mellitus. This is actually a very important topic, at
least important to us, but I think it should be important to all of us because actually
health is a vital principle of bliss. So, we can have this and that but if we don’t
have health we actually have nothing. You can actually go around the world, you can
run–go around this country and look at these great medical centers. Many of their big buildings
have names of individuals who have been very successful, who have ended up being patients
there, are no longer around but their name sort of graces a building. So, today we’ll
be talking about Therapeutic Lifestyle Changes (TLC). This is a lifestyle methodology for
the prevention of cardiovascular disease. This is actually a combination of our program,
the South Asian Heart Center as well as the American Heart Association. If you need to
remember anything after this talk, please remember the number 12. If you were to take
a quiz, the number 12 is actually a very important number because this is how much you can add
or subtract to your life expectancy on the basis of how you live. You can actually live
12 years less or you can enhance your longevity by 12 years depending on how you live. And
also that brings up the point about how many nuts to eat. We’ll be talking about nuts in
a little while, 12 nuts, 12 years. You need a pneumonic for that one. So, we are going
to discuss the possible factors responsible for the increased risk of cardiovascular disease
among South Asians. We’re going to discuss the risk factors and lifestyle associated
with successful aging and longevity. We’re going to review the American Heart Association
and the South Asian Heart Center TLC program. We’re going to define successful aging and
the importance of daily regular routine. We’re going to talk about dietary strategies for
improving cardiovascular and overall health. We’re going to discuss the role of fitness
on health and longevity. We’re going to define stress and stress reduction and its health
implications and we’re supposed to do this in about 40 minutes. So, I hope you can stay
awake. So, Ashish showed this slide. This slide is actually an interesting slide because
you ask yourself, well why? Why do South Asians who are expected to have a lower incidence
of cardiovascular disease? In this country vegetarians tend to actually live longer than
non-vegetarians. But South Asians, many of them are lifelong vegetarians, do not have
protective effect from their vegetarian lifestyle. And they’re actually–these are sort of some
of the reasons why there is excess burden of conventional and metabolic risk factors.
That is when compared to the world population, looking at individuals having a heart attack,
that is in the 50 South Asian individuals with a heart attack versus 50 South Asians
without a heart attack, looking throughout the whole world, actually we see that the
incidence of diabetes among South Asians is a little higher than that of the general population.
The ratio of LDL, bad cholesterol to good cholesterol in South Asians tends to be skewed.
So, there is actually a higher ratio of bad to good cholesterol among South Asians. And
they tend to have an earlier onset of coronary artery disease by actually by six years. There’s
actually a shortage of protective inherital factors. For example, exercise tends not to
be a prominent component of the South Asian lifestyle. Only 6% of South Asians exercise
versus 21% of the average population. They have a grain-based vegetarian diet that is
a non-vegetable, non-fruit containing diet. That is the consumption of just one vegetable
or fruit per day is 26% in South Asians versus 45% in the rest of the population. And they
also have a lower alcohol consumption per week, one drink per week, 11% versus 27%.
The other thing is that alcohol seems not to be protective among South Asian and the
reason is that it’s thought that the way South Asian drinks alcohol, there is more of a binge
drinking rather than a regular daily drinking. And we know that excessive once in a while
warrior, you know, weekend warrior drinker is associated with increased risk of bad things
happening to you. You just have to hang around the emergency room on a Saturday morning and
you’ll realize that. And then there are also some unrecognized risk factors. Now we call
them unrecognized because they are usually not measured in the typical physician visit.
So, what are those? Well, there is actually abnormalities in impaired cholesterol transport,
that is there are abnormalities in the active moiety of HDL cholesterol, the good cholesterol
that takes the cholesterol out of your blood vessels back into your circulation. And that’s
the HDL to be. There are elevated and is a genetic marker of Lipoprotein(a). This Lipoprotein(a)
is also known as the deadly cholesterol. So, we know of bad cholesterol, LDL, we know of
good cholesterol, HDL, and we also know this Lp(a) or deadly cholesterol. High Lp(a) is
higher among South Asians and also Northern Europeans. The Scots, for example, also have
a high risk of cardiovascular disease and they also have a high incidence of high Lp(a)
levels. Then there are other things like inflammatory markers, metabolic abnormalities such as homocysteinemia
and diabetes metabolic syndrome, and abnormalities in the LDL profiles. And I would just go over
that very briefly with you. And this is actually from the INTERHEART trial. Go ahead.
>>On the risk factors, there’s a couple of others that some studies mentioned, one of
them is genetic predisposition having narrow arteries. Then the other one will be behavioral
factors, [INDISTINCT] oxidated fats like [INDISTINCT], what’s your opinion of those?
>>MOLINA: Well actually the crux of the question is, what is the role of South Asians having
smaller coronary arteries? And the–when we started this program five years ago, as a
cardiologist naīve to this data and to the literature, from my experience in the cath
lab, an interventional cardiologist, I was under the impression that South Asians have
smaller coronary arteries. The fact is South Asians do not have any smaller coronary arteries
than the general population for the, you know, volume size. So, that actually is not a real–is
not a real finding. The issue though brings out that when South Asian–a South Asian has
coronary artery disease, they tend to have diffused diabetic looking vessels, diffuse
arteriosclerosis, and then you get the impression that the coronary arteries are smaller but
that is not the case. Then the other question is, well how about the consumption of Trans
fats? And that actually it is true if you have a ref–you know, if you are refrying
and refrying on the same oil, as you refry in the oil, you’re producing all kinds of
toxins in that oil, you’re producing Trans fats and then you’re consuming that. The fact
is that decreased fear that fried carbohydrate, the more Trans fat there is. And in the American
baking industry, you know, if you want to make a nice, crisp, a flaky crust, then actually
that is where the Trans fats and that, you know, Crisco and all those veg, you know,
so called vegetable shortenings were very rich in Trans fat. The highest incidence of
Trans fat in our food supply is actually the stick margarine. And I would advise you to
stay away from Vegetarian Gee, which is high in Trans fat and also stick margarine. So,
I’m glad you’re asking the questions because that will give me an excuse not to finish
in 40 minutes. But go ahead last question, we’ll continue.
>>Why do we need the ratio [INDISTINCT]?>>MOLINA: Why the ratio? The question is,
what is this, why the abnormal LDL to HDL ratio? There could be a genetic component
to that which we don’t understand yet or it also could be driven by diet. The diet being
a high carbohydrate, low protein diet drives lower HDL and higher triglycerides levels
and higher insulin levels. So, those actually–the diet may be driving that and if it is genetically
mediated, this is a beautiful example in which you can actually turn on and turn off the
gene by your behavior. So, hopefully that sort of answers your question. Now going to
the INTERHEART trial, which is sort of the basis of many of the points that have been
discussed so far. You can actually see the data here in red where South Asians tend to
be at a disadvantage. Higher Apo B to Apo A-1 ratio, that is LDL to HDL ratio, high
incidence of diabetes. But look there’s a lower incidence of hypertension, there’s a
lower incidence of smoking. There’s actually a lower incidence of obesity when you compare
South Asians [INDISTINCT] you can just to go, to go to great American you can see how
obese Americans tend to be. Now the negatives, behavioral ones, there is actually a decreased
activity, decreased physical activity versus the general population. There is half of the
consumption of fruits and vegetables. There is half or more than half, a third of the
consumption of alcohol and there is actually appears to be less stress than in the general
population. Now, we talked a little bit about emerging or non-conventional risk factors,
things that are not usually measured at the doctor’s office. And here we go to the red
and that is triglyceride levels tend to be actually no South Asians tend to have higher
triglycerides than South Asians. LDL doesn’t seem to be a problem. There’s no difference
in the bad cholesterol between other populations and South Asians. The HDL level, the good
cholesterol level, seems not to be any different, statistically speaking between other populations
and South Asians. So, what is going on? Well we need to look a little deeper and you can
see that the level of the HDL to be, the good protective HDL cholesterol, that 92% of South
Asians tend to have abnormal HDL to be versus in this study population, 76% had abnormal
HDL to be. The presence of Lipoprotein(a), it tends to be higher among South Asians than
non-South Asians. And homocysteinemia, representative of poor vegetable intake, actually is twice
higher in South Asians than the non-South Asians. So, in summary we can say that there’s
not an LDL problem but there appears to be a reverse cholesterol transport problem, there
tends to be an issue with glucose metabolism and increased risk of diabetes, there tends
to be a genetically mediated higher level of Lipoprotein(a). This is actually an Autosomal
Dominant condition. We all have Lp(a), but the high levels of Lp(a) are genetically mediated.
So, these are actually all drivers of recommendation. These are the things that we looked at. We
look at problems of the HDL cholesterol, we look at problems of Lp(a), we look at abnormalities
of glucose and insulin metabolism, we’re looking at inflammation, and we also look at disorders
of the LDL cholesterol. And on that basis, we then give life to recommendations and suggestions
to discuss with the physicians regarding a pharmacotherapy. And this is actually how
we approach the laboratory findings in the participants that come through the South Asian
Heart Center. Not included here is our interview and that is we do a complete life to health
assessment, family history and we do some biometrics looking at your abdominal waist,
your height, your weight, and your blood pressure. So, let’s just sort of talk about how to sort
of live longer. And I’m not going to mention much about tobacco here. I’m just going to
show you the real reason why dinosaurs became extinct. The fact is that if you smoke and
you have a family history of coronary artery disease, you decrease your longevity by 15
years. So, if you want to live 15 years less than your peers and you have a family history
of heart disease, the best thing to do is to start smoking. And that will guarantee
you that you won’t get your Social Security money back. Now, let’s talk a little bit about
successful aging. And what do we mean by successful aging? And successful aging is actually really
important because if you’re alive or a dead or when you die you don’t really–well I think
some people, most people don’t feel it or we think we don’t feel it but the issue here
is do we want to be a successful ager because a successful ager, number one, has to be alive,
number two, has to be self-sufficient and independent. And one of the things that the
human cherishes the most is self sufficiency and autonomy. When you lose your autonomy
here at work or at home or in the nursing home, that tends to be a source of a great
suffering and a great stress to the individual. So, in order to maintain self-sufficiency
and autonomy, it is actually a good–actually that it what defines successful aging. So,
actually this study was done here in Northern California in Alameda County and they looked
at seven South Asian individuals and they followed them for 25 years. So, a sort of
interesting, the investigators had to be young so that they could sort of take the court–the
25 year course of the study and be able to write the paper at the end, which was written
in the 1980s. So, what they found was that there were seven factors that were associated
with enhancement of longevity and were associated with successful aging. Those seven factors
are, adequate sleep, seven to eight hour per night, regular vigorous activity, maintaining
recommended weight, no smoking, none or moderate alcohol consumption, eating breakfast daily,
and eating meals regularly and no snacking. If you think about it, out of the seven, five
of them have to do with your mouth. Now, if you are a 45 year old person and you have
three or fewer of these healthy habits, you’re expected to live to the age of 67, this is
in 1980. If you have four to five habits, you are expected to live to the age of 73.
If you have six to seven of those habits, you are expected to live to the age of 78.
Now I told you about the 12 year mark where there’s only 11 year difference but if the
question doesn’t have a number 11, 12 years is a good guess. So there you are, that has
an 11 year difference just by adding these seven regular routines to your life, to your
daily living. This actually has been–the “Alameda 7” has been replicated in multiple
studies. Now the question is, boy I am a–you know, I am a disaged–now I’m in middle life,
is there any way to go back? Am I all done? Did I sort of like, I screwed it up and I
can not enhance my longevity? Well actually that question has been asked and has been
answered and it was published in 2007. Can we turn back the clock? So, they look at a
population of 16,000 subjects, they were representative of the American population and they asked
them, they questioned them about some four simple factors, the consumption of five or
more fruit and vegetables per day, regular physical activity, not being obese, that is
not being–not having a BMI greater than 30, if you have a BMI of 27, you’re F-A-T, well
you’re not considered to be obese, and actually I’m F-A-T, and not having a current–and not
smoking currently. So, unfortunately in America, and this actually has been replicate–also
replicated in Europe, only about 8.4%, 8.5% of the population actually fulfills these
four simple markers or factors. So, then actually what they did is they tried to change, they
tried to convert the other individuals who actually were not following this sort of four
simple factors. And they were able to convert 8.4%. So, then what happened? Within four
years, there was a 40% reduction in overall mortality in individuals who were able to
incorporate, that is, they were able to stop smoking, not become obese, have regular daily
exercise, and to eat fruits and vegetables. All those individuals who were able to do
that, who were not doing that before, they enhanced their longevity by 40% and their
cardiovascular enhancement was about 35%. In fact most of the benefit, there was a greater
benefit in the onset of cancer than in cardiovascular protection. Now, this is actually what Hippocrates
said. He said “Eating alone will not keep a man well, he must also exercise.” So, we
are now going to talk a little bit about the evidence behind the recommendations to exercise.
You know you go to the doctor’s office they always say you should exercise, you should
eat fruits and–well many times, you know, even though you do eat some vegetables but
they, you know, the usual thing is, you should have a well-balanced diet. So let’s look at
the data behind exercise. So, this actually was the first experiment that was done that
demonstrated the health benefits of exercise or physical activity. And this actually, this
double-decker bus was the site of the experiment. This was in United Kingdom and it was published
in 1953. It was published in the Lancet. What they did is, they looked at 31,000 London
transport workers. And they actually looked at the driver versus the conductor, so this
is a perfect experiment. These individuals had more or less the same level of education,
lived more or less in the same neighborhood, and were more or less of the same age. One
drove and the other one collected the tickets, going up and down the ladder that you can
not see over here. There’s a stair here, going up and down collecting. So what happened to
them? In the–in the green here are the conductors. This is the incidence of coronary heart attacks
versus the drivers. They actually, by going–by–they’re just going up and down. They decreased their
risk of a heart attack by more than fifty–more than 50%. Now what happens to their longevity,
that is if they have a heart attack, do they tend to live longer? Yes. They survive. The
conductors had a 50% improvement in survival versus the drivers. This was one of their
first studies demonstrating the health benefit, the longevity–the longevity benefit of being
physically active. Now this actually in a different population, we’re sort of dropping
everything over here. Next thing will be my pants. But, this is actually a study on 17,000
Harvard graduates and they were studied for 16 years and this was published in the New
England Journal of Medicine in 1986. There was also a follow-up study that was done also
in Oakland among the stevedores in the docks in Oakland, when dock workers had to really
work really hard. And this is what they found, if the Harvard graduate exercise or walk three
to eight miles per week, he reduced or she reduced his chances of dying by 15%, only
three to eight miles per week. One to two hours of light sport per week reduced the
chances of dying by 24%. One to two hours of vigorous sport activity per week reduced
the chances of dying by 35%. And the effect was most evident over the age of 60. Such
that if you are over the age of 70 and you burned 2,000 extra calories per week, you
decreased your mortality by 49%, right off the bat. If you actually burned 2,000 calories
a week, you enhanced your longevity by 51%, if you are over the age of 70. So, the older
you are, the more benefit you get from exercise. So, when you’re 20 years old, you’re just
practicing so that you can also do it at 70.>>Question from the [INDISTINCT].
>>MOLINA: Is that for me? Go ahead.>>Can you give us an example of a light sport
and a vigorous sport?>>MOLINA: Alright. So, actually a vigorous
sport is playing squash. A light sport is playing double table tennis.
>>Okay.>>MOLINA: Excuse me?
>>Golf.>>MOLINA: Or golf, check. Now with golf,
if you walk, you probably are walking more than three miles but there you go. If you,
yes. You just actually you know the only thing–you know, you’re getting the social experience,
which is really good, you’re relaxing hopefully, some people had to go to see a therapist so
that they don’t get the geebeegeebees. But it can be–it also can get you some sun and
actually, sun exposure is actually–now we know that sun is good for you. So, there is
actually some benefit to that. I have a friend who actually had to go to therapy for his
geebeegeebee. So, the question then is how about the weekend warrior? Well the weekend
warrior, that is someone who just exercises on the weekend, you know, the usual thing
is, “Hi doc, yes I go off the PG on each and I play out once a week. They do benefit but
they benefited, they’re a low risk individual. If they are a high risk individual, then they
don’t benefit. In fact, they put themselves at risk when they’re going up and doing their
sort of like weekend warrior activities. Now how about changing? That is, if you are–you
know, if you are not fit, what happens if you become fit? So, this study was done in
Texas at the Cooper–at the Cooper Institute, what they found was they actually looked at
10,000 men and they brought them in and they exercised them on a Bruce protocol. And they
separated them as fit, on fit, and unfit. And then they actually brought them back five
years later and they exercised again. And they actually found that the people who were
fit on both testing actually had the lowest incidence of heart attacks. The people who
were unfit on both testing had the highest incidence of heart attack. But that the individuals
who actually were initially unfit and subsequently turned and became fit, they had a significant
drop in their mortality rate. And in fact, from this day that they were able to calculate
that per every one minute that you increase in your Bruce protocol exercise stress test,
you enhance your longevity by 8%. So, if you actually can exercise a minute longer on a
Bruce protocol, you are actually biologically 8% younger. And that should pretty impress
us, pretty great benefit. In fact, the level of fitness is the most important predictor
on how well you’re going to live and how long you’re going to live. You have a question?
>>Yes. If you control the [INDISTINCT] sense that great training help [INDISTINCT].
>>MOLINA: This is actually mainly for aerobic exercise. Now, the question is they have looked
at–they have looked at other things such as, which is a better exercise, aerobic exercise,
weight training exercise, or stretching exercise? But not in this context. It has been done
in the context of cognitive capacity and brain mass. With MRI, they have been able to sort
of measure brain, brain growth. And of the three exercises, aerobic exercise is the only
one associated with enhancement of your brain mass, probably also cognitive capacity. And
I don’t want to insult anyone here but, you know, as a typical example is, is the bouncer
sort of, you know, big, huge, bulky, dumb guy at the entrance of the bar. And then compared
to the sort of like the bright, sort of marathon runner. Now the next question is, if you’re
physically active, that is good, but can you actually inhibit the benefit from being physically
active? And this study actually was done in India. And what they did, actually they separated
people who were physically active, but also had different levels of sedentary activity.
In this study, sedentary activity was defined as sitting in front of a TV for three hours,
which in the Silicon Valley would mean sitting in front of a computer monitor for three hours.
And what you can see here is that being physically active and then sitting in front of a television
monitor or a computer monitor for three hours cuts in half the benefit of being physically
active. You still have some great benefit. Here it is being physically active and not
and spending less than 90 minutes in front of a TV set and you actually have a significant,
almost 60% drop in cardiac events. Here is being sedentary and also not and but and also
exercising. And you can see how you compared to non-exerciser and being sedentary. So,
there is actually–you can diminish by half being sedentary as well when you are also
being physically active. So the game plan is, when you are sending an email, you send
the email, you stand up, you go to the person you sent the email to and you tell them, “Hey,
you know, I just sent you an email.” Yes, go ahead.
>>This kind of relates to that. Is the sedentary analysis, [INDISTINCT], so like if every hour
for five minutes you’ve walked around and you got some water and you came back. Does
that change the [INDISTINCT].>>MOLINA: [INDISTINCT]. The question is how
linear is this? can you sort of come up with a predict, you know, a sort of, can you put
it into a mathematical formula and the answer is, on the basis of this study, no. You just
can’t, you just can’t. But could you do a study? Probably. And you can sort of separate
it further but in this study that was not done. But it does make sense. And in fact,
it goes back to this issue about what do you mean by physical activity and how is it that
we should prescribe physical activity and this comes to this next slide. And item number
one, which is sort of a little bit difficult to read says, home based exercise is more
effective than gym based exercise programs for greater exercise adherence and weight
loss. That is, if your physician or whoever or your spouse recommends to you to be physically
active at home or at work versus someone gives you the recommendation to go to the gym. The
individual who is receiving the recommendation would be more physically active and will lose
more weight if he enters and gets a recommendation for a home base or work base exercise program.
So, you actually tend to exercise more and you tend to lose more weight. And the more
important thing is that, you know, it’s always–it’s easier to lose weight than to keep it off.
And actually individuals who are prescribed an exercise program at home or at work tend
to actually be better at keeping their weight off than in their prescribed gym based program.
And now this is also another thing and that is what to do about timing, timing of exercise.
And there was a study that was just recently published. They put individuals on a high
fat calorie intensive diet and they have three groups. Individuals who actually were on their
control here have nice, you know, Burger King and that’s it, we’ll follow how much weight
you gain. Another group they actually said, “Okay, here is your high fat, high caloric
diet. Let’s take you to the gym. We’ll have you exercise but we’ll give you some carbohydrates,
you know, we’ll sort of pump you up with Gatorade and sugar water and stuff like that while
you exercise.” And the other group, they had to exercise on an empty stomach. The fact
then, what they found was, that individuals who exercised on an empty stomach did not
gain any weight. Individuals, who actually had no exercise in their study arm gained
the most weight. But there was some weight gain of about 1.8 kilograms in individuals
who actually went to exercise on a fed stomach. So, if you’re going to exercise, have a big
glass of water and just, you know, start, you know, exercising on an empty stomach and
then you have your meal. The other issue is about skipping breakfast. Remember one of
the first slides looking at skipping breakfast and that is the longer you wait to eat after
you wake up, your higher the risk of gaining weight. So, it appears that exercise tends–actually
that eating before–too long. No skipping breakfast is associated with a decreased risk
of obesity. And then lastly, and this is the issue about fish oils. The consumption of
six grams of tuna oil is associated with an unexercised program is associated with increased
body mass as compared to sunflower oil. So, if you actually want to take this into your
life, then you can either have fish oils or you can actually have–you can have a salmon
or a smoked salmon sandwich for breakfast. There is more fish oil in a salmon sandwich
for breakfast than there is in any pill that you can buy at Costco. Go ahead.
>>Is there any alternate source for that fish oil because most of us are vegetarians,
right?>>MOLINA: Excellent. That’s actually a very
good question. And the question is what is the–are there any non-vegetarian–a vegetarian
sources of fish oil. And there is. You can actually get algae, marine algae base fish
oil. You can buy it online, you can search for it. It’s available on amazon.com. I’m
sure you can Google it. And you can ingest it that way. Or you can actually look at krill
oil. Krill is a plankton so this is–you need to decide if plankton is animal or vegetable,
but there you go. Now this is, we’re running out of time but, you know, I just told you
that exercise is associated with enhanced longevity. Well, it affects your genes, this
is actually telomere length. Telomeres are at the end of chromosomes and they actually
are–they mark the apoptosis of the cell. As long as you have long telomeres that cell
would continue to live and replicate. As the telomeres get clipped, as you are not able
to maintain the telomeres, the telomerase becomes inactive. Your telomeres become smaller
and then you become older and you can then and that’s sort of–it’s sort of a programmed
death of many organisms. Look at telomere length on heavy exercise versus little exercise
and you can see that these individuals tend to have longer telomeres. The same can’t be
said about stress. And stressed individuals tend to have shorter telomeres than non-stressed
individuals. And last we hear about exercise, if you actually want to maintain your cognitive
capacity, there’s nothing worst than, you know, being demented. Physical activity, these
are self-reported, these are individuals who are cognitively normal at the age of 65 and
who reported being physically active three times per week versus less than–less than
three times per week and this is the onset of dementia. And there was a 38% decrease
risk in dementia in people who were physically active three or more times per week. So, there’s–there
you go, not only do you live longer but, you know, you can keep your marbles and you know
where they are. Any questions regarding this? Go ahead.
>>So, I’m from South India. If I look at my–both my parents, mother’s and father’s
side, my grandparents, never went to the gym. Never even passed that age. So, and diet is
pretty normal, aside from maybe [INDISTINCT], I don’t think they were doing anything special,
right? Yet they all lived to the 90s, right. And my dad had a heart attack at about 65,
66 and I’m just wondering what is changing all the [INDISTINCT].
>>MOLINA: Well you can think of it, you know, you can think of [INDISTINCT], meaning that
is, your ancestors used to walk. They used to walk–work for their food. They had probably
a lower carbohydrate, more made possibly more dairy based, vegetable based diet. They were
actually–maybe eating less, you know, [INDISTINCT] and there maybe a lower level of stress. And,
you know, here we go again about that–you know, our behavior and particularly with this
abnormalities of diabetes, HDL to LDL ratios. They actually tend to be genetic but they
can be turned on and off by your behavior, by what you eat, how you live, how much you
sleep, your extended family, the support of your family. And that is an important and
those are very important factors. The incidence of coronary artery disease in India has changed.
And in present in India, there’s a big epidemic of coronary artery disease that wasn’t there
before. And you know India is the best place to be a busy heart interventional cardiologist.
I mean it’s just in and out, in and out, you know, those hospitals are extremely busy,
they account for 60% of heart disease in the world. So you can imagine. Go ahead. Any other
question regarding this? Go ahead.>>[INDISTINCT] question. [INDISTINCT]. Extremely
low level [INDISTINCT] I mean about that and also [INDISTINCT] traditionally wait till
40. Can you do it earlier?>>MOLINA: No. So we actually had developed
a protocol for coronary calcium scoring. And you have to be–for a male you have to be
over 40 and you have to have at least one clinical–significant clinical factor for
us to recommend a calcium scoring. For a woman, we recommend that over 45, because over 45
the age bearing, you know, that is, you know, thinking of having a baby significantly and
the chances of getting pregnant significantly go low–down. We are worried about the use
of radiation so we are selecting individuals because there is some radiation exposure and
there’s no real safe amount of radiation. In the old days, we had an immitron and we
could do an electron beam tomography which we use less radiation than going to the dentist
to get some dental X-rays. But unfortunately a big company bought them and took them out
of business so they could sell their expensive 64-slice scanners. So we don’t have that available
at this time. Now there’s another question and the question is about vitamin D and we
talked about going out to play golf and being out in the sun. Vitamin D is sort of an interesting
thing because those of us who had been around for the Vitamin E story, we thought that everything
could be treated with vitamin E and multiple people took multiple vitamin E doses and there
were multiple initial study showing how great it was and subsequently a multiple sort of
meta analysis of the data, that consumption of vitamin E in a pill form is of no benefit
to anything. And in fact if you’re taking cholesterol lowering medications such as -niacin
and statin, the consumption of vitamin E and vitamin C cuts in half the benefit and the
reduction of arteriosclerosis and the reduction in cardiovascular events provided by the pharmacotherapy.
So, taking antioxidants and vitamin E in a pill form is not recommended in individuals
who are taking niacin and statin. And in fact, they probably should not be recommended to
anyone. Now the story about vitamin D is sort of interesting because we know that people
who have vitamin D levels over 30 tend to have fewer problems than people who have vitamin
levels, vitamin D levels below 30. So, there’s lower incidence of heart disease, hypertension,
multiple sclerosis, and almost anything that we look at. This tends to be lower in people
who have higher vitamin D levels versus those who have lower vitamin Ds. The question is,
is it the vitamin D or is the behavior that leads to higher vitamin D? Because those studies–those
[INDISTINCT] studies have not been done. And that is if you’re outside playing tennis,
jogging, gardening on the weekend, having some nice, you know, great healthy diet that
is dairy containing, then you have higher vitamin D levels. If you’re eating junk food,
sitting at home watching TV, playing videogames, or in a cubicle all day long, not taking any
sun exposure, you will have lower vitamin Ds and also you will have a higher incidence
of bad things happening to you, so we don’t know. However, if you have vitamin D levels
below 10, you actually–that’s the number that is associated with the increased risk
of rickets. And we have had cases described in the pediatric literature of children with
rickets in New York City from playing videogames, which is more or less like sitting in front
of my computer. So, if you have vitamin D levels below 15, it is definitely recommended
that you take a vitamin D supplement and then you get, you know, to meet the sun. Do you
have levels of vitamin D of 29? Presently the Institute of Medicine suggest no therapy.
But now commonly out in the population anyone who would have a vitamin D level below 30
is recommended a vitamin D supplement. Now, I have found in my practice that South Asians
tend to have lower vitamin D than my other patients. And most of the time that I see
a vitamin D level below 10 is usually on South Asians. And there is actually in this valley
there are mainly three reasons. One is the fact that as your skin gets darker the more
sun exposure you need. So, it’s recommended that in the tropics, the individuals get any–you
know, any individual get 15 minutes of sun exposure per day. In this area here, in this
latitude, it’s recommended that be doubled to 20 to 30 minutes per day. But if you are
dark skinned you need to have more sun exposure. But in this population, where most of the
South Asians are engineers or people who are working in places like this and as you’re
playing out volleyball outside during your lunch hour, there is actually less sun exposure.
And then you see, you know, you see this problem. And it’s also that the vegetarian diet, the
ideal vegetarian diet should be a dairy, a non-fat dairy base vegetarian diet, high in
fantastic protein, minerals and if it is actually non-fat, because milk consumption throughout
humanity’s age has always been non-fat until recently when we learned how to band the fat
into the milk and sell it as homogenized full flat–you know, full fat milk. Actually that
is actually a very, very good diet. It’s a full complete protein and it taste really
good. Any other questions?>>One last question. I’m just curious with
[INDISTINCT] based on the factors and the Heart Center [INDISTINCT].
>>MOLINA: The question, this actually a very good question and that is, there–before we
came up with this and when I went to medical school and when any student goes to medical
school in any place in the world, they teach them about the Framingham risk factor formula,
where you can actually look at the habits of the individual, the tobacco, hypertension,
HDL cholesterol, presence or absence of diabetes. And you can calculate, what is the 10 year
risk of having a heart attack, low risk below 10%, intermediate, between 10% and 20%, and
greater than 20%. When you look at certain populations and you apply this formula to
Japanese, where the incident–or Chinese for that matter. Where the incidence of coronary
artery disease is lower, the Framingham formula will often overestimate the risk of coronary
artery disease events. When you apply that formula to South Asians, we will underestimate.
So, we have done a couple of things, we actually will either add one factor and we’ll take
the LDL and subtract 30 and then use the formula or we have not used the formula at all. And
what we have elected to do at the South Asian Heart Center is not to try to predict what
your 10 year risk is. We just number the number of risk factors. The more risk factors you
are–you have, the higher your risk. And then the fewer risk factors you have, your lower
the risk. And that’s how we have decided to proceed rather than to give you a number,
which in fact is actually not–when you look at the NCP, ATP3 recommendations that incorporate
the Framingham factors. They actually failed to sort of predict those who are going to
be having heart attacks in almost 60% of the cases so we tend not to use that formula at
the South Asian Heart Center. Last, over there at the back.
>>Since there are many [INDISTINCT] for individual so I think that [INDISTINCT] risk factor.
>>MOLINA: You know I can’t–I can’t hear you. But there’s a microphone right here.
So by the way, if you can not find a way to exercise, you should get a dog. Dog owners
tend to actually exercise more than non-dog owners, there’s a Canadian study. Now the
question is what breed? Well this study did not incorporate the breed but I have been
an owner of a terrier and terriers make your life miserable until you take them for a walk.
So, I would recommend you buy a terrier, the smaller the terrier, the better. They are
the–have the highest nuisance level and they bark like a baby, you know, a crying baby
and then you enhance your capacity to exercise. Go ahead.
>>Yes. So, I guess I’ll just summarize my question. Do you think doctors in the Bay
Area in general are aware of the fact that South Asians are at a greater of heart diseases
and should [INDISTINCT] be intervention regarding what kind of–which positions do we choose
for that?>>MOLINA: The question is how about the knowledge
in the population, how about the knowledge in the medical population. And there goes
the phone again. The mission of the South Asian Heart Center is not only to bring awareness
among South Asians but also to educate the physicians. And as a result to that, we actually
had done yearly continue medical education seminars to educate physicians of the increased
risk of cardiovascular disease among the population. If you ask me overall, what is the knowledge
base of the physicians in the Bay Area? I think that it has significantly improved over
the last five years. Most cardiologists are aware of this because they see it. And you
see it in–there’s–you never forget to see–when you meet a 34 year old engineer, with a spouse
and two kids, in the waiting room with a heart attack. That’s unforgettable and then having
to go and tell them what’s going on. So, cardiologists know about it. Now they may not know what
the underlying factors are and we are actually trying to sort of bring this up to their attention,
these non-conventional risk factors. But there is an increased risk of cardiovascular disease
and that is actually relatively well known among the cardiologist specialists among others,
but then not so much. This actually started at El Camino Hospital because a gynecologist
who was delivering a lot of babies, a South Asian gynecologist and, you know, many, you
know, she was seeing that the husbands of their–her young patients were having cardiovascular
disease. And they–she brought this up to our attention and this was actually the origin
of the South Asian Heart Center. Go ahead.>>[INDISTINCT] all these home remedy kind
of solutions? Some [INDISTINCT] would actually give it as supplements and you know a pharmacy
like [INDISTINCT] supplement aid or [INDISTINCT].>>MOLINA: So, the question, you know, the
question is actually how about supplements in cardiovascular disease? How about supplements
on longevity? There is no data showing that supplements will enhance your longevity or
would decrease your risk of cardiovascular disease. If you think of fish oils as a supplement,
there have been actually a few trials, the GC trial, for example, showing that the consumption
of Omega 3s in individuals who have had a heart attack, of about 850 milligrams of Omega
3s per day significantly decreases the recurrence of cardiovascular events. But, if you look
at changing the diet and if you look at individuals who are prescribed a Mediterranean type diet
versus a conventional American Heart Association recommended diet, those individuals who have
a 53% drop in the risk of cardiovascular disease, just by incorporating a Mediterranean diet.
So, I would pay less attention to over the counter home remedies and I would pay more
attention to what is in front of your plate, in front of you, as you sit at the table,
and your physical activity. You know, we actually have run out of time, you know, this is like
it’s taken us a long time. You’re welcome to stay here but the next part of the talk
was about diet and the importance of fruit and vegetables, and then also of about stress
reduction. So I’m just going to give you a summary, I’m not going to show you many slides
about–any slide about that–maybe I will at the end, but what to do. Nutritionally
speaking, you actually–it is recommended that you have two cups of fresh, freshly cooked
vegetables per day. So who walks around with a cup? Nobody knows what a cup is, for the
most part, but everybody has a fist. So you look at your fist and you’re supposed to have
two fists of vegetables per day. Now a vegetable is not a fruit, a vegetable is a vegetable.
Because when you ask people, how many vegetables? You would say, “Oh doc I eat a banana everyday.”
That’s not a vegetable, that’s a fruit. Okay? So, it’s important about that. So, two cups
of vegetables per day. That would decrease your risk of stroke by 24%, right off the
bat. Okay? Now, how about fruit? A cup and a half of fruit would actually have a significant
benefit in your longevity and blood pressure. Okay? So, it’s two cups of vegetables, a cup
and a half of fruit per day. Oily fish twice a week, if you are not vegetarian, otherwise
then you can actually have the Omega 3s in another form or not have them. And then lastly,
you should have 12 nuts per day. So, we’re talking about tree nuts. Now they say, “How
about macadamia nuts?” Well, macadamias do not grow in a tree. They grow in a palm. So,
that’s not a tree nut. And they’re very high in saturated fat. So, the recommendation would
be 12 nuts per day, a cup and a half of fresh fruit per day, not from a can, and two cups
of cooked–freshly prepared vegetables per day. Exercise 10,000 steps per day because
10,000 steps is almost three miles per day, you multiply that by seven, that’s 21 miles
per day. Because your body, your physiology, even though–will know if you’re a sprinter
or a marathon runner, you can go to the Olympics and see the body of the sprinter versus the
body of the marathon manner. Their physiology will adapt to that kind of behavior. But regarding
your cholesterol and your blood pressure and all that, your body cares for bulk amount,
not intensity. So, 21 miles of physical activity per day, just you know park really far away
and walk into your office, ride a bike or walk to the next building next, you know,
two blocks away. Go up and down the stairs. They all add up. And you have a benefit from
that. And then lastly, this issue about stress and stress reduction, in the INTERHEART trial,
there was actually the incidence of heart attack in these young individuals, stress,
psychosocial stress accounted for about 28% for the increased risk of cardiovascular events.
And the issue is what is stress? Well most of the time is stress is when you have a deadline,
that is you have no control, so the loss of autonomy is very stressful on self-sufficiency.
But stress is defined in this–in this context as that which actually–stress results from
the inability of the physiology to maintain a steady state or homeostasis. And I’m sure
you all study biology and you know what homeostasis, that’s the steady state. And psychological
stress results from the lack of creativity, to actually address a challenge. So, there’s
a challenge and you know the way out of it, if you know the answer, it’s not stressful.
If you lack–if you have the creativity, it’s a joy, not stressful. If you lack that creativity,
if you lack the cognitive capacity, if you lack the intelligence or the education, you
then accumulate psychosocial stress that way and then you experience this. We actually
don’t have enough time to go over this but there is a lot of beautiful data looking at
a form of yoga called transcendental meditation which is in fact associated with decreased
psychosocial and physiologic stress and is associated with high risk people with coronary
artery disease with a 43% reduction in heart attacks, stroke, and mortality in a recent
study that was presented at American Heart Association. So, anyhow this is sort of like
the gist of the talk. You have a question?>>I have too many questions so I’ll hold
back. Instead I will ask, how do we follow up with you after this talk, to ask you our
questions?>>MOLINA: Well there’s actually the best
way to do it, is you go back to your computer and you are going to southasianheartcenter.org.
And then, there you can register for the South Asian Heart Center. You can make an appointment
online. You can actually have an appoint–an appointment to go through the 250 question
questionnaire, that we ask. Then we bring you into the South Asian Heart Center, we
start to do some biometric measurements. You get this comprehensive test that usually cost
about $1,000 and you get it for $73. Then you have a chance to–you will be talking
to a health educator, a clinical educator. You will be talking to an exercise physiologist
and you’ll be talking to a yoga teacher. That’s all part of the program. And then after that,
if you are found to have multiple risk factors, all these free of charge to you, you will
be assigned a heart health coach who will be going so you will relieve your spouse from
nagging and this heart health coach will be helping you to, sort of, fulfill the recommendations
of nutritional recommendation, stress reduction recommendations and exercise recommendations.
So, this is actually how you do it. And if you have any questions after that then you
can also ask the health educator and he’ll give me a call, send me an email and I will
sort of respond to your question. So actually, another thing is that back there, in that
corner, Pia has actually our brochures so if you want to pick one of our brochures and
give you all this information of how to–how to reach us and how to enroll in the South
Asian Heart Center. Go ahead.>>So, when you talked about the [INDISTINCT].
>>MOLINA: Actually that–you know, beans can protect you better. But so the question
is, do you count legumes, do you count the dhal. Well, the problem with the dhal is that
if you take a quarter cup of dhal that makes soup for four people. But you’re only having
a quarter cup of dhal being distributed among four people. So, that is actually why it does
count some, but it actually doesn’t count for all. And now someone asked a question
about supplements and this issue about fenugreek and other spices. In Ayurveda, which is the
national medicine of India, there are actually routines that are prescribed for the prevention
and treatment of cardiovascular disease. One of the main text of Ayurveda is actually written
by Charaka. And Charaka was actually the first ophthalmologist and he’s known as Charaka
Samhita. And in his text he says that eating vegetables that grow from the vine is associated
with an improvement in cardiovascular health. So, what are those vegetables that grow from
the vine and how then do we married science to this Charaka Samhita? Well, we didn’t have
a chance to go over the diet part but if you’ll invite us, we’ll come back and we’ll talk
about that. It is recommended that you have 25 grams a day, at least 25 gram a day of
soluble fiber. So, where do you find soluble fiber in vegetables? Well, soluble fiber is
found in vegetables that grow in the vine, such as eggplant, grows in the vine, okra,
grows in the vine, squashes, they grow in a vine. You want to push it further and think
about the wine country, the fruits, grapes actually are also–and, you know, wine, red
wine and it’s associated with increased cardiovascular health. So, you actually will find in those
text information that then you can actually marry with the science. And this is actually
as part of our–a mission statement that Ashish read at the beginning. We are actually, the
South Asian Heart Center, is determined to address this epidemic of cardiovascular disease
using a culturally appropriate lifestyle recommendations. And we actually–you can think of this as
providing evidence based Ayurvedic medicine. Recommending lifestyle, which is the cornerstone
of Ayurveda, how you exercise, how you eat. In Ayurveda, with appropriate diet you don’t
need the medication because food is–just like Hippocrates, food is actually medicine.
Any other–any other questions? Well, thanks for coming and I hope to see you at the South
Asian Heart Center.