9UNP1214HD_Patrick_McBride_Transcript
University Place:
Cardiovascular Health and Cholesterol
June 17, 2015

- Now, I'd like to move to the part of the presentation with our guest speaker, and that is Professor Patrick McBride from the UW School of Medicine and Public Health. And the title of his talk is Taking Care of Your Heart: Chemistry and Heart Disease. So please join me in welcoming Professor McBride. 
(applause)

Gotta get your slides here. 

- Yeah, we're all set. Well, thank you all very much for welcoming me here. And I'd like to welcome my good colleague and friend. What an honor to be here because he is part of the Wisconsin Idea, and my work has been the Wisconsin Idea as well, one of the great ideas that this state has ever had. So, thank you all very much. He mentioned Galileo and Copernicus, who are some of my heroes.

The greatest course that I ever took on this campus was The History of Science. The great scientists that have come before us are always in my mind. And when I took that course, I was astounded to think that people could use things like a magnifying glass or a microscope to figure out that the world wasn't flat, that it was round and that they could be headed for such a discovery like that because people didn't want to believe that the Earth wasn't the center of the universe, but the Sun was the center of the universe. So, I thank him for bringing up those kinds of things.

In my work, I work in the School of Medicine and Public Health. I work with people with heart disease and I work with people who are trying to prevent heart disease. My goal has been trying to reduce heart disease and other diseases in the state of Wisconsin and in the country. So I have worked in the last 30 years to try to reduce diseases like heart disease, diabetes, and obesity. And I'm going to talk to you about how prevention involves chemistry. So, the work I do involves biochemistry, and I'm going to talk to you about that in plain things, plain language rather than medical terms, as much as I can. So I hope you'll keep me honest about that.

So, I'm going to focus on just two areas. There are a lot of different risks associated with that, but I'm going to focus on cholesterol and how cholesterol is really chemistry. And I'm going to talk also about obesity. And I'm going to talk about the chemistry of obesity and how that's changed in our world and in our country, and it's really becoming a problem in the developing world. And I'll use this example that Dr. Shakhashiri has mentioned together, and I'll talk about how chemistry is really a big part of nutrition. He talked about malnutrition and we have a big problem in this world with both undernutrition and overnutrition and how it would be better if we had a balance of that in our world.

And I'm going to discuss common problems with cholesterol and how chemistry is really metabolism, about how our health is really about metabolism, and talk about how that's really chemistry. So I'm going to talk about the risk factors associated with heart disease, particularly cholesterol and obesity, and how some of those are associated. And I'm going to focus primarily on lifestyle, but I'm also going to talk about medicine because one of the most striking changes in the last 10 years in my career has been the development of the Internet.

And one of the most interesting things about the Internet is that it's a great source of knowledge, but it's also a great source of misknowledge, there's a tremendous amount of misinformation. I had the the incredible experience this past weekend of sharing a stage with a guy named Akira Endo. And Akira Endo is a Japanese researcher who discovered the metabolism of cholesterol and he discovered statins.

And this man is responsible for saving millions and millions, perhaps billions, of lives with the discovery of statins. And I actually got kind of emotional when I first saw him. This was the first time I ever saw him. And he did this by working with fungus. And he studied over 6000 different fungi and realized that fungi metabolized cholesterol. And through that discovered these statins. And he never made a penny off that discovery and the pharmaceutical companies made billions and billions of dollars. He didn't get one penny.

But statins will have saved billions of lives and they're incredible medicines, and yet the Internet has really confused people about those. They're some of the best and safest medicines that have ever been produced, so, I'm gonna talk about that tonight. But first of all, I want you to focus, this is an important slide that talks about two of the most important problems that we face in healthcare.

And I want to point out tonight how both heart disease and cancer really have the same risks. And heart disease and cancer, as you can see, are the leading causes of death and disability that we face in medicine. So, heart disease at all ages is the most common source of problems that we face. And cancer is pretty close behind.

And part of the issue is that we've been able to reduce heart disease so much over the last three decades in this country and other countries, and so cancer's kind of catching up. Less than 85 years, both heart disease and cancer are pretty close, and when you add up stroke and heart disease together, that's where they are. And you can see lung disease, COPD, which is the same as emphysema, is pretty far behind.

And then over there at greater than 85 years, you can see that heart disease even far outstrips Alzheimer's and dementia. So we worry a lot about dementia and Alzheimer's. Most of dementia is actually caused by small vessel blockages, which are actually very attributable to the same risk factors as heart disease and stroke. So some of the same risk factors that we deal with with cancer and heart disease are the same risk factors that we deal with dementia.
So the
The good news is that we've seen dramatic changes in heart disease and stroke over the last 30 years, and that's due to the discovery of a number of the risk factors that have been associated with this, some dramatic changes in tobacco. So when the Surgeon General's report came out in the 60s and it said that tobacco was associated with heart disease and stroke, we've seen heart attacks decrease by 50%.

When Franklin Roosevelt died in 1945 at the end of World War II, he died because he didn't have any treatment for high blood pressure. If he'd had medicine for high blood pressure, we wouldn't have given away Eastern Europe, for example. And so, in the 50s we developed all these great medicines for high blood pressure, so now we have over 300 medicines for high blood pressure. That's been very important to our reduction in stroke, for example.

And now we're seeing major decreases in heart attacks due to these important medicines and these important approaches we're taking in nutrition for reducing cholesterol. So we've seen these important changes. And we're starting to see life expectancy increased because of our important advances in medicine and our important attention. And we estimate that about two-thirds of the changes that we see are the changes that we see in lifestyle. And about a third of this has been attributed to these important medicines.

But something really important is changing. So the great changes that we've seen in the reductions in stroke and heart attacks are starting to take a sudden change for the worse. Now some of this is because of the changes in aging in our populations, but a big part of this is because of the epidemic in obesity and diabetes that we're seeing, not just in this country but all over the developing world.

So because of the great advances that we've seen in productions of food, productions of sugar, high fructose corn syrup, we're seeing major increases in diabetes and obesity. And it's projected that over the next several decades we're gonna see a marked increase in heart disease and stroke again. And I'm hoping we're able to reverse this curve.

So I want to talk to you about what we're really treating when I talk about treating heart disease and stroke. We're talking about a problem called atherosclerosis. That's what some people call blockages or plaques. And I'm going to describe that in more detail for you and I'm gonna talk about the chemistry of heart disease.
So, this
This is a picture of the inside of an artery. It's like you sliced an artery right across it. And then this is a lifetime of a person's arteries and the development of arteries. And it's why we've developed guidelines going all the way back to the health of children. I was on a panel both in 1992 and in 2010 where we talked about the health of children in this country because of the incredible epidemic of overweight and obesity in our children and because most of the kids that start smoking, start smoking before the age of 18. So we really wanted to address how this process starts in childhood.

But what we see is inside the blood vessel, the arteries, we see the accumulation of cholesterol. And it's developed in a process that starts with inflammation. There's irritation and inflammation of the artery, the artery gets irritated. And then through the process of cholesterol entering into the artery, these blockages and plaques slowly build up over a lifetime. That happens through two processes. One is environmental, what we do to ourselves. The other is what we inherit, genetic. So we can inherit genetic issues, like, some of us inherit high blood pressure.

Thanks to my parents, I've inherited high blood pressure. Many of you might have inherited cholesterol problems because they are quite common. People can also acquire these in a lifetime through poor lifestyle habits: poor nutrition, poor exercise or activity habits. We like to joke that America's favorite activity is watching other people exercise. And so you can inherit these both genetically or through the environment. And over the process of a lifetime, that may result in a heart attack or stroke.

Now this is a blood vessel cut the other way, across the blood vessel. And this is from an autopsy of somebody that's had a heart attack, and that artery has ruptured. That's a plaque or a blockage that cracked open. And when the body has that blood vessel crack open, the body tries to repair it by putting a blood clot on it.

So that might have been a blockage that was 30% or 40%. And a lot of times somebody says to me, "Well, my brother had a stress test two weeks ago "and it was normal, "and then two weeks later he had a heart attack. "So your stress test wasn't very good." Well, it's because it was a 30% blockage, and those didn't get picked up. But under some form of stress that cracked open and the body tried to put a blood clot on top of it.

So it went from 30% to 100% in a matter of seconds or a minute and completely blocked off that artery and it may have caused a heart attack if that artery was in the heart, or a stroke if that artery was in the brain. And that could have caused a sudden cardiac arrest or a stroke and caused a death. That's why we have this autopsy picture. And that's one of the reasons we use blood thinners like aspirin or Warfarin, which was discovered on this campus, as a blood thinner for people that are at risk of heart attack or strokes.

So the question is, is this process reversible? And the answer is yes. We've done a lot of that research here on this campus and a lot of places. And we've done a lot of that research ourselves. And it's reversible through two different ways: through changing lifestyle and through medication, if necessary, if a person has enough risk.
So here's
Here's the risk factors for heart disease and stroke, which many of you are aware of, and as I mentioned, I'm going to focus on the ones that I've highlighted in yellow tonight because they're the chemistry, if you will. So, high blood pressure and physical activity, tobacco, diabetes, stress, family history, these are really important. Family history, by the way, is expressed through these other risk factors like blood pressure, cholesterol factors. Inflammation, a lot of times, is a genetic factor, for example.

One of the things that's difficult to do anything about is age because our arteries harden through age, but one of the ways we can reverse that is through regular physical activity. There's no fountain of youth, but I like to tell people the closest thing we have to the fountain of youth is trying to remain physically active. If you want to speed the aging process, sit around. Sit on the couch and watch the "boob tube",
," as my dad used to call it. If you want to reverse the aging process, get active. Get out there and get moving.

But I'm going to focus on high cholesterol, low/good cholesterol, it's called HDL, and I'm going to focus on obesity and how it's related to genetics tonight.

Now there is one way that you can measure your risk, and there's some good risk assessment tools, and I've listed a couple of those tonight right on this slide,
and one. One is called healthdecision, that's one word, healthdecision.org. And there is a lot of really good tools at that site. That's a site we developed here at the University of Wisconsin, healthdecision.org. Great site, where you can graphically look at your risk for the next 10 years or over the lifetime, both for heart disease and stroke.

And the other way that you can look that up is at heart.org. Heart.org is a great website. It's the American Heart Association's website. And so, I always tell people there are good Internet resources and terrible Internet resources. This is a great Internet resource: heart.org. The American Heart Association is a non-profit source that has great sources of good information, new information on heart, good hand-outs, a lot of professional information. It's where our guidelines are. It's where I'd like you to read about nutrition because there's a lot of misinformation about nutrition. So our guidelines on cholesterol and nutrition and stroke are all published there, heart.org.

Now I want to point out that the same risk factors that we have for heart disease are the same risk factors for cancer. One of the things I like to joke about is that when I come through the cafeteria line at the hospital, everybody checks my tray to see what I'm eating. And I go, "Hey, go check the oncologist." Because tobacco, a big risk factor for heart disease, is a primary risk factor for cancer. Genetics is a big risk factor for cancer. High fat intake, a major risk factor for prostate cancer, breast cancer, and even lung cancer, bladder cancer. Low intake of vegetables and fruits.

I can tell you that on food records every patient that comes to our clinic we ask to do a three-day food record. The one thing that we see consistently over and over again is a low intake of fruits and vegetables, and that is a huge issue for cancer and heart disease. Low levels of physical activity. 80% of Americans do not even come close to meeting recommended levels for regular activity. And then lack of appropriate screening. That's true for all Americans around heart disease and cancer. Same risk factors for heart disease, same for cancer.

So when people say, "Oh, ya gotta die of something." That's my favorite answer that I get, when people say, "What about heart disease?" "Oh, ya gotta die ..." Yeah, well, you know what? If you want to prevent cancer and you want to prevent a stroke and you want to prevent a premature heart attack or premature surgery, live a healthy lifestyle. Go to your doctor for regular physical checkups, take your medicine. There's a lot of good research on this, but here's a good example. When women are regularly physically active, there's a lower risk of breast cancer. So you see that women in the regular physical activity group are one-third less likely to have breast cancer than the women that are inactive. And this is true in many, many studies.

So reducing risk of heart disease and stroke, it's the same list that you'd expect to see: regular physical activity, healthy eating, avoiding tobacco, maintaining optimal weight, aspirin, if your doctor recommends it. Some people do this on their own. You shouldn't do that unless you talk to your regular clinician and they recommended it for you. Generally, it's men over 50, women over the age of 65. But you need to make sure it doesn't interfere with other medication you're on or other medical problems that you have. So you need to talk to your clinician first. And then take your medicine. 

There's so many patients that we recommend a medication for, they get on the Internet, I can't tell you how many patients say, "Well, I talked to my neighbor and they said, 
"'Well, I heard this about a medicine and I heard that.'" So six months later they come to see me and they say, "I've been off my medicine for six months," and I go, "Has your neighbor got a degree?" "Has your neighbor been in practice for 30 years? "This is the area that I work in. "This is the area that I do my research." Please talk to your clinician before changing medicines and things like that. These medicines can be life-saving. They're really, really important. There's a lot of research that goes into them.

So reading somebody on the Internet that has no connection to medical care or science or talking to a neighbor over the fence is not the way to do medical care. Find somebody you trust. So let's talk about the chemistry of heart disease and about prevention. So, I want to focus on these three main areas of cholesterol: LDL cholesterol, triglycerides, and HDL cholesterol.

LDL cholesterol is the primary cholesterol, the lipoprotein that travels through the bloodstream, that accumulates in blood vessels, the one that forms that plaque. Triglycerides are another type of blood fat that accumulates because of what we eat and sometimes because of genetics, that also can irritate arteries, damage arteries, and sometimes accumulate in arteries. Those are the two that we call bad cholesterol.

Now I put it in quotation marks because they're not necessarily bad. A small amount are necessary for normal functioning. People always say, "Well, how much?" We're going to talk about that. So, we need a modest amount for normal daily functioning, but the average American has many times more what we really need for our normal daily activity. So, one excuse people make for not changing their lives, they say "I heard it's good for your brain." Well, not at the levels most Americans have it. We don't need very much.

The "good cholesterol", HDL, actually cleans out the system. It travels through the bloodstream and actually removes cholesterol from the blood vessel and from other tissues and it takes it back to the liver. So, it's actually our cleanup crew. It actually removes cholesterol that we don't need and takes it away. So the more of that, generally, the better, and some people are born with very low amounts of that. They inherit low amounts of that. We can raise HDL cholesterol through regular physical activity and losing weight. So HDL cholesterol is very important to us.

Now these are what we consider normal levels of these cholesterols in our bloodstream when we get a blood test. LDL cholesterol, the one that accumulates in the blood vessels, should be less than 130 when we get the measurement, unless someone's had heart disease diagnosed or a prior stroke, then generally much lower than that. Usually less than 100. Triglycerides should be at least below 150, the lower the better. And then good cholesterol, HDL, the higher the better because it's a good cholesterol, it's a cleanup cholesterol. So for men at least above 40, and for women higher than 50 because it's a very important predictor in women.

In fact, HDL cholesterol, the higher it is, the lower the risk of breast cancer in women. It's associated with breast cancer, so HDL cholesterol is an important predictor in females. So it's important that we have a high HDL cholesterol. 

Now, what we do when we try to lower it with both lifestyle and medicine is we determine the amount of reduction based on the person's risk. 

So if somebody has a high LDL cholesterol but they haven't had a diagnosis of heart disease yet, then we generally shoot for about a 30 to 40% reduction. If somebody's already had a diagnosis of heart disease, they've already got blockages, those plaques that I showed you, then we really try to reduce it, because we're trying to reverse those plaques. So it's been shown that if you get more than a 50% reduction in LDL cholesterol, you can actually start shrinking the size of those plaques and flatten them out. And I'll show you some pictures of that. So we go for more than a 50% reduction if somebody's had a prior heart attack or they've had a prior stroke or bypass surgery or they have a history of diabetes, because it's been shown in people with diabetes that more than a 50% reduction in LDL cholesterol reduces the risk of heart attacks. And it's always important to do lifestyle. So one of the things that's been shown in studies is that when people take a medicine to lower cholesterol, they think, "Well, great! 

"Now that I'm taking a medicine I can eat whatever I want." That's not true. The medicine's less effective if a person is eating a high-fat diet. So it's important to both eat healthy food and take their medication. That's really important. 

I was in Washington, DC one time, visiting my brother. And we were sitting at a table, and he's an attorney, and a plate of fettuccine alfredo showed up at the guy next to us. And the guy that he was with said, "Well, wait a minute. "Aren't you on a cholesterol medication?" He said, "Yeah, so I can eat whatever I want." And my brother, who's the attorney, said, "Are you going to say something to him?" I said, "I'm not licensed in this state, so I'm gonna, "I'm not gonna say anything." So let's talk about it. 

Now, this is the way cholesterol works in the body. There are two really primary sources of cholesterol. As I mentioned, one source is what we put into our body, the type of fats that we consume, cholesterol that we assume. And the other source is our own body, so, what our own tissues produce, and that's the genetic source. The liver is the primary factory for this whole process. On the left I show the intestine, and the fats and cholesterol are important. Now you may have read that recently the dietary guidelines said, "Well, we can lighten up on cholesterol." What people heard was "Maybe that means we can eat whatever we want." That's not what they said. What they meant on that was dietary cholesterol. The average American consumes about 200 milligrams of cholesterol. Dr. Shakhashiri was talking about understanding in chemistry amounts. 200 milligrams of cholesterol is roughly about the amount in one egg yolk, one egg yolk. That's the average that a person consumes, and that's about the amount recommended per day. One egg yolk. 

What we consume in dietary fat are grams. That's 100 times what we consume in milligrams. So it's important that you understand that the guidelines are about dietary cholesterol, not fat. So we're still supposed to monitor the types of fat and how much fat we eat on a daily basis. And I'll talk about that. So we are still supposed to know how much fat we put into our guts, into our mouth, and into our stomachs, and our intestines because that's a primary source of cholesterol in our system, and the one that we really can control unless we take a medication. 

So if we really want to reduce our serum cholesterol through our lifestyles, it's how much we consume and how much we burn through physical activity. And then what happens in our body is really determined primarily by our livers, unless we burn it, because our muscles are a factory for burning cholesterol. So if we exercise for 30 or 45 minutes a day, our muscles will burn away triglycerides and make more HDL cholesterol. So, this is also a diagram. It's kind of a cartoon of these types of cholesterol. You can't put fat in water or it will float up to the top. So our body puts it in little particles, and these are the cholesterols. And so when it's produced in the liver, it first comes out as a particle called VLDL, which is high in triglycerides, and then the body converts it through a number of different conversions to this LDL cholesterol. And that's what deposits in the body, and you can enhance this production and clearance by either eating less or burning more. That's really important to understand. You can put less in the system or you can burn away more. That's why we say eat better and do more physical activity, and your liver can only handle so much, your liver has got its limits. And if the liver is overwhelmed, more and more will float through the bloodstream and it's only got one place it can land and that's your blood vessels. And that's how it accumulates in your blood vessels. 

So here are some key facts that you need to understand. Genetics and lifestyle are the key issues for the chemistry for cholesterol. And the major influence is on LDL cholesterol, the type that deposit in your blood vessels, are dietary saturated fats and trans fats, which made the news this week, that I'm going to talk a little bit about and Sue Nitzke's gonna talk a little bit about more in the course. And also genetics. So LDL's both affected by what we put in our body and also our genetics. And the major influences for triglycerides, which travel around the body in this VLDL, are carbohydrates and fats. So the carbohydrates we consume, which I'll talk about, are very important to our triglycerides, and so is alcohol. So carbohydrates are primarily affected by added sugars, the sugars that we consume, as well as how much alcohol we drink. So there has been a message around heart disease that, "Hey, I heard alcohol is good for your heart." Well, in moderation. It's all things in moderation. One drink is one beer, one shot, or three ounces of wine. But what people have done is made, glasses have gotten bigger and bigger, and so, if you say to an American "Hey, I heard alcohol is good for your heart," that means a six-pack. Or, 14 ounces, or a bottle of wine. They don't understand it's one drink, one drink a day. 

So, triglycerides are also affected by our body weight and our fat distribution, which I'm gonna talk about. They're also affected by how much we burn. You can drop your triglycerides in minutes by how much activity you do. And our good cholesterol, as I mentioned, clears cholesterol from the body.

Now the types of fat really fall into these categories. There are really only these fats in our body. Saturated fats are the ones that are fully saturated, and they're the kinds of fats that we find in fatty meats, in whole dairy products. And I want to make one major disclaimer right now, because I'm from Wisconsin. Dairy products are good for you, but what you want to do is use low-fat dairy products, so skim milk, skim milk cheeses, yogurts, and things like that. So we try to get the saturated fat lower in those products ,
because that'll lower your cholesterol.
t
Trans fats are the ones that have been altered. They're not natural fats. These are the ones that are altered, that the FDA this week declared have to be completely removed from food by 2018. Now, most food manufacturers have already started to voluntarily take them out of chips, and crackers, and cookies, and things like that ,
because they've been shown to be associated not only with heart disease and cancer, but also dementia. And so they've already been really removed, but if you look on a package and you see "hydrogenated",
," that's a trans fat. So, you don't want to have trans fats.

Saturated and trans fats are the ones that raise your LDL cholesterol. Monounsaturated fats, the ones that we think about most when we talk about this, is olive oil or canola oil. These fats have been shown to lower LDL cholesterol and raise HDL cholesterol. So these are the ones we try to encourage. That's why we try to encourage the Mediterranean diet. And, I'll show you data that shows that the Mediterranean diet's associated with lower heart disease, mortality, and overall better health.

And then, polyunsaturated fats are things like corn oil, and soybean oil, and things like that, and lower LDL, but are neutral on HDL cholesterol. So we tend to recommend to people substitute monounsaturated fats primarily or polyunsaturated fats for saturated fat in your diet, and you'll lower your cholesterol. That's what we've been saying for 30 years. People always say, "Why do you keep changing 
"the dietary recommendations?" I got news for you: the American Heart Association has not changed the dietary recommendations in 30 years. They really haven't changed. People around them have made changes, but they really haven't changed substantially in 30 years.

So, as I mentioned, saturated and trans fats increase LDL. Polyunsaturates decrease LDL. Monos have the dual benefit of decreasing LDL and raising HDL cholesterol. That's why olive oil is such a good fat to use in substitution for saturated fats. Now all of these are fats, so remember they're high in calories. So they all have the same amount of calories, so you can't just pour them on things. People tend to do that. If you substitute an oil for butter, it's still the same amount of calories, so they're still gonna increase weight. So, you still have to be cautious in the amount of oil you use.

Now these trans-fatty acids, as I mentioned, these are the hydrogenated. They use them because they are stable at room temperature. So what I like to tell medical students and the PA students is "Hey, when you go to the vending machine, "the reason that those crackers, and cookies, "and chips, and everything aren't refrigerated "is because they can leave them in that machine "for a year without refrigerating them, "because they have trans fats in them, "'cause they're stable at room temperature. "That's why they don't have to refrigerate them." That's little scary to me, okay? So, that's why they have trans fats. That's why food makers developed them. That's not natural, okay?

So, they decrease HDL, they raise LDL, and fortunately they're starting to come out of food, and as I mentioned, they're completely gonna be banned. So the natural ways to lower cholesterol, and this is really important because most people in the United States could lower and make their cholesterol normal on their own ,
if they change their lifestyle. These are the ways you could do it. Lower saturated fat in the diet. Increase the soluble fiber through things like oats, and flax, and psyllium.

Fish oil, more omega-3s in the diet. Nuts are a very good way to lower cholesterol, especially almonds and walnuts. As I mentioned, the use of these monounsaturated oils. Soy, tofu, soy nuts, soy milk, and then exercise and weight loss, and there's a very good resource for that at the lifestyle guidelines at heart.org, as I mentioned. And then, just to give you an example, if people added soluble fiber, things like oats and oat bran, in their breakfast in the morning, you can drop your LDL cholesterol five or 10%. Using soy milk or tofu or soy nuts as a snack, for example, you could get another five to 7%. Using these sterols, they're an added ingredient that people could use as a number of different ways of do it. They're found in different margarines. That's another 10 or 15%. Ways to naturally lower LDL cholesterol.

So, there's a lot of different ways to do that. Let me say something about carbohydrates, because they've been massively misunderstood. Number one thing I want to tell you is carbohydrates are good for you, okay? Fruits and vegetables are good for you, okay? So carbohydrates, don't get this idea. Added sugars aren't good for you, okay? That's the carbohydrates we're talking about. Carbohydrates: carrots, celery, apples, bananas, strawberries. Those are carbohydrates. Those are good for you. They're necessary, they're important. So don't try to eliminate all carbohydrates.

Complex grains, oats, flax, those are carbohydrates. They're critical, they're important, they're good for you, okay? So don't get this idea all carbs are bad. But here's what we've done. We've added sugars to our food. Like, here's a 12-ounce soda. There's 10 teaspoons of sugar in this. 10 teaspoons of sugar, okay? So, you look at these kinds of things that we do, and these shakes and, so if a kid is at a fast-food place, and they go and they get a big cup of soda, and they get 37 teaspoons of sugar and they go refill it, they get another 37 teaspoons of sugar. That's enough to bake a cake and put frosting on it, okay? That's what we've done to our kids, okay?

And I'll tell you one of the things that makes me the most angry is the fact that we have a children's menu at restaurants. Starting at the age of two, children are supposed to be eating the same food at a meal that we eat. They're not supposed to have little weenies and macaroni and cheese and PB and J, although I love PB and J. There's not supposed to be meals without vegetables, and we have a kid's menu and it's horrible food. That's inexcusable as a society. I talk to every manager at every restaurant where I see a children's menu and say, "This is inexcusable", okay? It's inappropriate. Kids should be ordering from the same menu that we order from. This is what we've done to our children, is we've tripled obesity in adolescents in this country by doing this. That's what happened. The two factors are soda and television, if you look at the data.

And in the last two decades, we've not only just added television, we've added Game BoysGameboys and computers and video games. 30% of three-year-olds have a television in their bedroom. So if you say to a kid you've been bad go to your room, they turn on their television, all right? So we've really got to change, all right?
alright? So the American Diabetes Association recommends foods containing carbohydrates but from whole grains, fruits, vegetables, and low-fat milk. Carbohydrates are important to the diet. But, the total amount of carbohydrates is what's important and they should come from healthy sources. So, it's added sugar that we're really talking about. And restrictive diets are really only for special circumstances.

Every week I hear about a new diet plan. Healthy eating is what we should be talking about. Not paleo or grapefruit or, you know. Healthy eating for a lifetime is what we should be talking about. So, I want to talk about triglycerides, because this comes up a lot. They're really related to calories, alcohol. I saw two people in clinic today. It was about 15 to 25 drinks a week that was really the issue. You cut that out, their triglycerides would've been normal. Simple carbohydrates. So we try to work with people to do healthy eating, regular physical activity, and moderate alcohol, and we're really okay. So, we want to make sure that people are doing this, and I can tell you this is a rarity on a food record, is that people are eating vegetables. And what we want to do is make sure that people are including foods from all the food groups, and trying to match energy intake to energy output. 

And, if we could just get more people walking. I'm excited when I see Fitbits, and pedometers, and things like that. People don't have to do high intensity. If I had a wish I would take away all the heart rate monitors off every machine. Just walk, walk the dog. Most people's dogs are just staring at them, saying, "Please take me out twice a day." That's all we need. We really need that. So let me talk to you about healthy lifestyle and how it affects chemistry. You can reverse the blockages that people have in their arteries through changing lifestyle. Dean Ornish was one person that did it. He showed a 60% regression in these blockages with changes in lifestyle. It was done in a study called STARS. They found an 85% decrease in progression of these blockages. There was a study we did here at the University of Wisconsin with a professor in the University of Southern California. We were part of this study called CLAS. And we found that this lack of progression was related to a reduction in polyunsaturated fat and an improvement in healthy fats, and fruits and vegetables. So if people increased activity and had a healthier lifestyle, guess what? They had an improved outcome in their arteries. 

Now the Mediterranean diet is what we really tend to talk about. We want to talk about healthy eating, but this Mediterranean approach, I generally not a fan of the word "diet", I like "healthy eating", but, this really focuses actually on complex carbohydrates, nuts, fruits and vegetables, omega-3s, lean meats, olive oil. And two large studies, I mean very large studies, population-based, have shown a reduction in heart disease by 50%. So this is, to me, I look at that and I go, "Man, that sounds pretty good to me, I could eat that." Everything that you want to eat is on that list. If you're a vegetarian or vegan you can work around that as well. So, you can do pretty well with that. This slide doesn't show very well, except if you look at a couple of things. Just look at the lines and notice the separation. Now what this shows is a decrease in mortality in people that went on the Mediterranean diet versus a usual diet in this study. And there's a drop in mortality. And if they added extra virgin olive oil to the diet, they get even a greater drop in the mortality. So, Mediterranean diet is a really healthy way to go. And there's other studies that show this. 

There's a study in Lyon where they took patients with heart attacks, and they showed a marked reduction in heart attacks in patients with heart disease. This is another variant of it. The U.S. News & World Report, and other groups have called the DASH diet approach, which is very similar to the Mediterranean diet. Fruits and vegetables, low sodium, modest alcohol, low-fat dairy products, very important, because they contain calcium and vitamin D, very important to Wisconsin, appropriate calorie intake for bodyweight. You can drop your blood pressure 12/8. That's as good as any blood pressure medicine we have, by using this dietary approach, okay? So lifestyle can really make a difference.

So, the practical approach to eating, just to say this, A lot of times people want to say, "Oh, this food is good for you, this food is," there are no bad foods or good foods. There's just healthy eating, okay? And so we say eat three meals a day ,
because I can't tell you how many people skip breakfast, and have almost nothing for lunch, and then have a big meal at night, then hit the easy chair and watch their favorite show, and (snoring). And then it accumulates right here, okay? So spread the food out.

Watch out for liquid calories ,
because we have a lot of people who say, "I don't eat much at all"," and then they have the mocha-frappuccino-latte-cappucc, and then just, and soda, soda, soda, beer, beer, beer, and boom, boom, boom, okay? So liquid calories can be a real big problem. And eat your vegetables. The seven things your mother told you? Don't do drugs, get plenty of sleep, eat your vegetables, stay out of bars, know who your friends are. Well, she was right, so, (laughing) hate to tell you, but anyway.

Now, I want to talk about medicines ,
because so many of the medicines people misunderstand. We have the safest, most effective medicines in the history of the planet, and people think there's some big conspiracy or something. There is not a conspiracy. Most of our medicines came from plants. Statins came from a fungus. I mean this great researcher in Japan spent years figuring this out. And these medicines are safer than aspirin. There's 5% of people they get muscle aches. There's one in 1000 people that their blood sugar goes up, and that is it, that is it. And they saved millions and millions of lives. And they cost $4 a month. They are incredible, and people get on the Internet and read all kinds of crazy baloney. These are incredible.

I have patients that would have been dead 30 years ago ,
if they weren't on these things. I mean, when I met Akira Endo, this researcher this weekend, I almost cried because of this guy's discovery. He has won so many awards, and he should win the Nobel Prize. And, they are so safe and they are so effective, and they reduce heart attack, strokes, and death by 30 to 45%. So, if your doctor recommends that you should take 'em, you should take 'em, okay? So, don't talk to your neighbor ,
unless they've got an M.D, okay? And they haven't read your chart, okay? They're really incredible. The greater the risk, the greater the benefit. So, please, because this is what they do.

So, this is a picture of what I was talking about. Again, the artery cut this way. And this was published two weeks ago. A researcher at the Cleveland Clinic summarized eight studies of this regression, we call it. These arteries blockages shrinking. Patients not on statins, the arteries progressed, the blockages got bigger. Patients on high-intensity statins, the arteries not only the blockages got smaller, but they actually got firmer and less likely to crack open. They actually sort of scarred, so that they couldn't crack open, and the data is quite clear. There are over 50 studies that have shown this, and we've done threee of them here. So, it's very clear that you can reverse these blockages with aggressive statin therapy. And you can reduce deaths, strokes, and heart attacks. Take your medicine, if your doctor tells you to take your medicine.

This is a study in children that have a genetic form of very high LDL cholesterol, where they measured the early blockage formation in children in their carotid arteries. And the dots above the line are showing blockages progressing in two years in children. The black dots below the line show that you can actually reverse blockages in children in three years by use of statins in children. So we start children at age 10 with genetic cholesterol disorder. I've been using statins in children for 25 years and have yet to see a child with a side effect from 'em. So, they're very important medicines.

So here's a summary of those. Can you reverse these blockages? Yes, significant change in plaques are noted within two years of using these medicines, also with aggressive lifestyle treatment. The combination is really powerful. The placebos groups in these studies show progression in these blockages. So, if you want the blockages to progress, put 'em, don't take medicine. And they diminish the pool of the cholesterol, and they make the fibrous portion, the scar, much more firm. And they are much less likely to rupture. So the way to prevent future heart attacks is take your medicine.

Now I want to talk about the chemistry of obesity and overweight briefly to finish up. So, this is the most recent map from the CDC showing how common overweight and obesity are in the United States. So, sadly, in the states in the US that have the highest rates of poverty, and the highest socio-economic issues, the Southeast, have the highest rates of overweight and obesity.
So, Wisconsin used to be number one, but fortunately we're not there, but no state has anything to brag about. Most of the states are above 25 to 30% rates of obesity. All states in the country are above two-thirds of the population being overweight. What's important is this trend has happened very, very rapidly.

So, first thing I want to say is, I teach our medical students and our PA students, 40% of overweight and obesity is genetic. 40% is genetic. So, a lot of this is it's really difficult for a lot of people to control. But unfortunately, in the last three decades we've seen a huge increase, and a lot of that has to be related to the environmental changes. This change in high fructose corn syrup and inactivity, the Internet, computers, videos, Netflix, and Game of Thrones, and God knows what else. So, you look at this trend of how rapidly overweight and obesity has changed in three decades. It's striking and makes the HIV epidemic look tiny. It's unbelievable, and diabetes has followed right along behind it.

And, what's going to follow right along behind it is stroke, and a rise back again in heart disease. And, sadly, I teach our medical students this is going to dominate everything they do, whether they're a surgeon, or an anesthesiologist, or a pediatrician, this will dominate their entire practice. And, as a country we really have to think about this. Health care costs are going to spiral out of control unless we do something about it. We put more and more people on medicine when the treatment could be healthy eating and regular physical activity. We have taken physical education out of schools, which is a tragedy. It's not about gym class, it's about health education. That's what those classes were. It's a tragedy because overweight and obesity is directly associated with heart disease risk.

So if a female or male has a body mass index above 29, which 1/3 of our country does, their risk is three times someone else their same age. We've seen diabetes increase by 33% since the 90s, and in patients 30 to 39 years of age it's gone up 76%. So the youth are really dramatically affected and obesity and weight gain are it. This is not type I diabetes this is type II diabetes. That's 95% of all diabetes. Two pounds of weight gain translate to a 9% increase risk of developing diabetes. Two pounds. You know how easy that is for all of us to gain? And I do that in a day? So, it's so easy to do that, and so we're really at risk here.

So diabetes leads, of course, to blockages in all kinds of places in our neck. Risk of stroke, risk of heart attack. Blockages particularly in the legs which lead to amputations and sores and all those kinds of things. When I see people losing toes and feet, it's just a tragedy. And it's in my clinic all the time. And so I am always-- And when a person goes from a blood sugar of 118 to a blood sugar of 130, five medicines. 'Cause they need two medicines for their blood pressure, two for their diabetes, and they need to go on a statin. Just like that. And I battle it. We have a diabetes prevention program that I started at our clinic. It's really successful, so when we see people's blood sugar go up, we refer them to this clinic, start working with their nutrition and their activity to try to prevent it. It's really successful, but it's a battle 'cause I don't want to put them on all those medicines, but those medicines are life-saving if they need them. So it's really important.

And I'll tell you what it is: it's the weight gain in the middle. So it's what my dad used to call middle age spread. We can prevent this, if we really do it. But we're genetically determined to put it on here because it's a thing that we used to do as cavemen 2,000 years ago. We used to go out and hunt the animal and kill it and we'd put the fat on here because we would sleep for a day. Then somebody would poke us with a spear and say, "Go get another one. Oh, okay." We get up and go hunt for another animal. But now the animal is in a grocery store in plastic? And we eat it three times a day. People think that's a paleo diet, but we don't go paleo through the woods, okay? This paleo thing is ridiculous because that's not the way we do it anymore. People aren't getting nuts and berries and scavenging for it. They drive in their car and go get the paleo. It's ridiculous, all right?

So here's what happens. When you get weight gain in the middle, you increase your blood sugar and your diabetes risk. All these chemicals, the inflammation chemicals that cause blood pressure and cholesterol go up and you get the chemicals that cause inflammation in the arteries. And this whole process of these blockages start. So when you get this weight gain around the middle, and the measurement at the middle is at your hips, it's the hipbone, not your pants, 'cause I get guys that sag, okay, please don't sag, okay? I get guys that sag. It's the measurement at your belly button. So you take a tape measure and you exhale. It's not the holiday picture where you hold it in to look good in the picture. You exhale and you take a tape measure and you make a measurement at your belly button at the top of the hip bone. If women are over 35 inches or men are over 40 inches, again, this is not your waist that you wear your belt at, this is up here, okay? So it's where your belly is. If you're greater than that, you have this syndrome.

Now it's really common, at least 25% of adults and climbing. And it's much more common in lower socio-economic groups and certain genetic groups. It's very common in Mexican-Americans, African-Americans, Native Americans. At least 50 million adults. There's certain people that in families, you gain it here if you're gonna gain it. You'll see people that have no rear end. Their jeans are falling down, and their bellies are here. That's the people that have this syndrome. High blood sugar, high blood pressure, bad cholesterol levels. That's what it is and it's because the fat right here, turns out, it's a gland. These fat cells are producing chemicals that tell the body where our hormones are supposed to be.

So these fat cells we used to just think were just fat, they're not. They determine our appetite. They're releasing a chemical called leptin that increases our appetite. They release these fats into our bloodstream that cause the blockages. They release chemicals that cause inflammation in the arteries. They release chemicals that raise our blood pressure. And they increase chemicals that cause release of adrenaline and things like that that lead to high blood pressure. So these fat cells are not inert. They're controlling all kinds of changes. They raise our blood pressure, they raise our blood sugar, and they raise our cholesterol. And they lower our good cholesterol and they cause it. So when we gain five and 10 pounds here, boom, the system goes haywire. And that's why we gotta fight the battle of the bulge, okay? That's really important.

Here's what it does when you lose weight: if you lose 10 pounds, the cholesterol goes down 15%, the triglycerides 20%. HDL goes up 15%, blood pressure 12/9, as good as a medicine. The blood glucose goes down, with a weight loss of 5%. So I get a lot of patients and they go, "I want to lose 50 pounds." I go, "Why don't you start with 10? "Let's just go with 10, 'cause that's what you'll get, okay? "And that will improve your life expectancy "and keep you off medicine, okay? "That's what this will do." 10 pounds, okay? 10 pounds. 

What does a pound equal? 10 potato chips, 20 corn chips, a quarter-cup of ice cream, a quarter-cup of pudding, half a cup of frozen yogurt. 

One extra gumdrop a day is a pound in a year. Do you know how easy it is to do that? I have a sweet tooth, if it's at home I'll eat it. So last night I was feeling sorry for myself. I'm saying to my wife, "Where's the chips?" She goes, "I'm not letting you eat them." "Where are the chips?" 

When you get home and you're tired and you're feeling-- I was on call and, so fortunately, she protected me. She gave me a glass of ice water and an apple, sliced apple. Thank you, Kim. 
(laughter)

Otherwise I was going to, when you feel sorry for yourself, right? But that's how easy it is, right there. That's how easy. 

So, what we do in our diabetes prevention program, when we see somebody's blood sugar go 101, 105, 110, so we can keep them off the medicines, hopefully, is we put them in this program. Our goal is 7% weight loss 'cause it leads to all those changes. And this is what happens. Our data shows people can get this. The average waist loss is three inches. That's changing clothes, I mean, I did this, I went into the first group and that's what I got. So I went from a size 36 waist to 34. I had to put all of my pants in the closet. I still got them in there, thinking, in case I ever go back. I couldn't get rid of them. But I went down, I lost 30 pounds? Because I did it with a group. Fasting glucose from 131 to 119, diabetes to no diabetes. They increase their exercise to 120 minutes per week. 90% of people showed up for the class. That's what we found. 

We've had this program for 11 years, those numbers have hung right in there. So, it's really important. So that's what-- People are always looking, right? Move, doesn't matter what you do. If you like square dancing, if you like jump-roping, if you like walking the dog, I don't care. People always say, "What's the best form of exercise?" I don't care, just do it. Forget the heart rate, doesn't matter. 30 to 45 minutes. It doesn't matter if it's three times 15, four times 10. It does not matter. Intensity's not the difference in this. It's the amount of time you spent, okay? That's what it shows. 

So what are the benefits? Here's all the benefits of exercise: you improve your bones, improve your heart, improve your brain, you reduce dementia. That's even bigger effect than heart disease. You improve your cholesterol and your blood sugar, and you improve your psychological well-being. One of the best treatments for depression and anxiety is exercise. That's research from this campus, a lot of research on that from this campus. There's good guidelines on this. So what is the best prescription? Three to six days a week. It's best if you do this, but six days a week with one day of rest. Just do it. 30 to 60 minutes and mix in both endurance and some strength because you not only have to have some flexibility and strength but you also have to have some endurance. All three to be fit.

And it doesn't matter.
If if you're trying to win a 10K or a marathon then you should worry about intensity. I am not trying to win a 10K, so if you are, good for you, but otherwise don't worry about your intensity. 

So in summary, I talked about some of the chemistry of heart disease and stroke and diabetes. The best ways to do this are through good nutrition, healthy eating, variety. Variety is the spice of life. Take care of yourself. Regular physical activity. And if you need medicine, and a lot of us do, take your medicine. These medicines are fantastic and they are safe, so please take your medicine if your doctor recommends it to you. And remember, metabolism is life. Our bodies are chemicals and they're really important. They all interact, so take care of your bodies. Thank you very much for your attention.
(applause)