#106: Dr. Robert Ostfeld - Miracle at Montefiore
We’re calling this episode, “Miracle at Montefiore” in honor of the herculean work Dr. Robert Ostfeld is doing at this Bronx hospital to move the needle on the life-saving benefits of a whole food plant-based diet, especially for cardiac patients.
Inspired by the legacy of his two young brothers who lost their lives to incurable diseases, Ostfeld attended medical school at Yale and went on to get his Masters of Science in Epidemiology at Harvard. Today, he’s a plantstrong non-invasive cardiologist and Director and Founder of Preventive Cardiology at Montefiore.
Knowing that whole food, plant-based nutrition really is the most powerful form of medicine, Dr. Ostfeld was instrumental in getting Montefiore to start offering plant-based meals for people recovering from heart procedures. The documentary, Forks over Knives, is also made available for viewing to any and all patients, thanks to his efforts.
Dr. Ostfeld also discusses his upcoming research studies on the parallels between lifestyle and erectile dysfunction and why erectile dysfunction is often “the canary in the coalmine” and a surprising predictor for heart disease.
As he says, his work at Montefiore is “a labor of love wrapped in a pit bull,” but with doctors like Dr. Ostfeld on the front lines, we are optimistic that real change can and will happen in our healthcare system.
Episode Resources
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About Robert J. Ostfeld, MD, MS
Robert J. Ostfeld, MD, MSc, FACC, is the Director of Preventive Cardiology at Montefiore Health System and a Professor of Medicine at the Albert Einstein College of Medicine. Dr. Ostfeld treats patients with adult cardiovascular disease, including coronary artery disease, hypertension, hyperlipidemia, and erectile dysfunction with a focus on prevention and treatment through lifestyle change. He works closely with his patients to help them adopt a plant-based diet.
Dr. Ostfeld received his Bachelor of Arts in the Biologic Basis of Behavior from the University of Pennsylvania, graduating Summa Cum Laude and Phi Beta Kappa and his Doctor of Medicine from Yale University School of Medicine. He then did his Medical Internship and Residency at the Massachusetts General Hospital and his Cardiology Fellowship and Research Fellowship in Preventive Medicine at Brigham and Women’s Hospital, both teaching hospitals of Harvard Medical School. During his Cardiology Fellowship, he earned a Master’s of Science in Epidemiology from the Harvard School of Public Health.
Dr. Ostfeld’s research focus is on cardiovascular disease prevention and reversal through lifestyle modification. Ongoing topics he investigates include the impact of plant-based nutrition on erectile function, coronary artery disease, angina, and heart failure. His work has been published in peer-reviewed journals, books, articles, and clinical statements and has been presented nationally.
Dr. Ostfeld is board certified in Cardiovascular Disease and Echocardiography and he is a member of numerous professional societies, including the Physician’s Committee for Responsible Medicine and the American College of Cardiology.
Full Transcript
Dr. Robert Ostfeld:
But we were seeing people have their blood pressures come down very quickly with this new habit, more typical omnivorous diet, and they would switch to almost exclusively or exclusively plant-based, and their blood pressures; their high blood pressure would come down. In fact, oftentimes two weeks after they would start eating this way, I would get a phone call, a message that patient so-and-so is lightheaded now. And what that was, was that they were healing themselves so much, they didn't need as many blood pressure lowering pills. So we started peeling off blood pressure lowering pills.
Rip Esselstyn:
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Rip Esselstyn:
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Rip Esselstyn:
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Rip Esselstyn:
Hey, everyone, welcome to another episode of the plantstrong podcast. I'm your host Rip Esselstyn. And I'm going to call this episode with Dr. Ostfeld who's a cardiologist at Montefiore Hospital in the Bronx. I'm going to call this the miracle at Montefiore, because what he has done at Montefiore and the example that he is setting there is truly, it is miraculous. He is the director and the founder of the Preventive Medicine Cardiac Wellness program at Montefiore. He went into medicine because he didn't want to make little changes in people's health, he wanted to make radical transformative changes in people's health. And he realized that the approach and the paradigm that he had learned was doing just that; was making little, little, little gains.
Rip Esselstyn:
And when he stumbled on plant-based nutrition, tried it out for himself, he realized that this was the answer that he was looking for with his patients as well, and the results speak for themselves. He was also able to get the hospital to serve plant-based food for people recovering from a heart procedure, which is absolutely phenomenal. This is a man who is the real deal through and through. He has got his MD from Yale University, Master's of Science and Epidemiology at Harvard, and then went on to get his degree in his specialty of cardiology. But this man is fascinating. What he's doing is spectacular, and I can't wait for you to hear all the great things that Dr. Robert Ostfeld is doing at Montefiore. Let's take it away.
Rip Esselstyn:
So, Doctor Robert Ostfeld, it is so fantastic to have you on the PLANTSTRONG Podcast. I can't believe that it's taken three years to get you on, but here we are. Are you in New York right now?
Dr. Robert Ostfeld:
I am in New York City. It's great and it is such an incredible honor to be here with you and your audience. I love, love the work that you're doing, your family's doing. It's just an incredible inspiration. It's terrific to be here.
Rip Esselstyn:
Well, thank you, Robert. So I want to talk to you about the miracle that you have worked at Montefiore. Am I pronouncing that right? Is it Montefiore?
Dr. Robert Ostfeld:
Yeah, that's great. Montefiore. Perfect.
Rip Esselstyn:
Okay. All right. Montefiore, because to me, you have worked miracles. Before we talk about the miracles that you've worked there, I want to backtrack for sec, and I think it's important, and you've been a speaker at our Plant-Stock event in the past. And to me, you have a really compelling and riveting journey that launched you into medicine. And I'd love if you could share with our audience what inspired the first of all, the journey into medicine and then secondarily, and I want to pepper you with some questions, but then why your interest in plant-based.
Dr. Robert Ostfeld:
Got it.
Rip Esselstyn:
Yeah.
Dr. Robert Ostfeld:
Well, so thank you. And the reason that I got interested in medicine is because when I was a young kid, I had two brothers who died from an incurable disease. And so ever since I was a young kid, I'd been interested in medicine and health, and that is what led me to become a physician. From the time I even, I think it was in high school, I was pretty much on that path.
Rip Esselstyn:
Do you know what were the incurable diseases that your brother's got? Is it something that's well known or very rare?
Dr. Robert Ostfeld:
It's pretty well-known. It's called Tay-Sachs and it is not uncommon in French-Canadian populations and in Ashkenazi-Jewish populations, and I'm an Ashkenazi Jew. And so there, to my knowledge, remains no cure for it, but there's all kinds of research going on in the area, and so there's growing hope. And basically you're missing an enzyme, and my understanding of it is probably too simplistic, but you have an enzyme that controls fatty tissue, the amount of it in your brain, and we all need a certain amount, but you're missing an enzyme in Tay-Sachs, and that fatty tissue just grows and grows and slowly takes over the brain. There's no cure for it. You slip into a coma and you die. And my brother, Daniel, died when I was seven.
Dr. Robert Ostfeld:
He was about a little under four, and definitely some of the memories I'd have, I don't know if they're stories that I heard or pictures, and some of them are definitely on my own personal memories. And my brother, Michael, lived a much shorter period of time. I don't have memories of him, but I have memories of my brother, Daniel, and I look at their part of what I get to do with preventive cardiology and plant-based nutrition as part of their legacy and our program as part of their legacy to try to help people be healthier, and their lives are an inspiration to me. And we used to have a conference, which we had for about three years on preventive cardiology plant-based nutrition based at Montefiore that your father spoke at, and we were honored to host him.
Dr. Robert Ostfeld:
And it's been a whole now because of COVID, but we had a Daniel-Michael Ostfeld memorial lecture as part of that conference. So I look at our work, which is very much inspired by your family, your father, you, as part of the legacy of my brothers.
Rip Esselstyn:
Do you have any other siblings?
Dr. Robert Ostfeld:
I do. I have a younger brother, Scott, who is doing really well, has three kids and he's plant-based. And I remember many, many years ago I brought over like almond milk or something to his home and he gave me look and laughed a little bit, and now he is plant-based. So it was a cool evolution.
Rip Esselstyn:
Good. Good, good, good. Okay. All right, so your brothers really inspired you to go into medicine, and it's amazing the legacy that you're doing for them. So let's talk for a second about your interest in plant-based, but before we do, I really want to share with people your education, because I think that that's really important. So your undergraduate work was at University of Pennsylvania, right? Then you went to Yale for your degree in medicine, and then you went to Harvard, if I'm not mistaken, to get your Master of Science in epidemiology. Is that correct?
Dr. Robert Ostfeld:
Yes.
Rip Esselstyn:
Right, right. And then at some point you decided you were going to go into cardiology. Why cardiology?
Dr. Robert Ostfeld:
Well, I'd always been interested in the physical exam and a heart. I kind of like an anatomy class and in medical school, I just seemed like the heart interests me the most of the different body parts but, and so I'd always have that in the back of my mind. And then when I went up to Boston to do my residency in general internal medicine, during that time, it's like a three-year period of time, you decide if you want to do a subspecialty. Like an internist is like a general pediatrician for adults. And sometimes an internist will then specialize in the kidney or in organs such as the kidney, the lung, the heart. So the heart's doctors are cardiologists. So during the residency is when you have to apply for fellowship and formalize it. And so I'd always had an interest in the area.
Dr. Robert Ostfeld:
And I remember I was doing this elective because I was ultimately deciding between endocrinology, being like a hormone doctor or thyroid and testosterone, things like that, and cardiology, because both of them really intrigued me. And so I'm doing the endocrinology elective and I walk into a patient's room and suddenly the patient flips into an abnormal heart rhythm. And I'm the only one there. So of course I'm dealing with it. And I realized that I enjoyed taking care of the abnormal heart rhythm more than I enjoy taking care of the hormone issue.
Rip Esselstyn:
Right.
Dr. Robert Ostfeld:
Well, that's a sign, that means something. So one thing led to another, and I became a cardiologist.
Rip Esselstyn:
Yes, you did. And did you immediately come out as a cardiologist at Montefiore?
Dr. Robert Ostfeld:
So I did all my training up in Boston, and then when I finished all of that, my family is in the greater New York area, and I always knew that I wanted to come back closer to home. So I luckily found a position at Montefiore, which is in the Bronx. And one of the things about Montefiore that was really appealing to me is that there's a lot of medical need in the area. I think New York state has something like 50 counties, and Bronx, in terms of health, is last 50 of them. It's not even close to like 49. Might be the least healthful inner city in the whole US. It's a title no one wants.
Dr. Robert Ostfeld:
It depends on how you define things, but there's a lot of medical need there. And there's a very large indigent patient population. And I wanted to use my training, the legacy of my brothers to help people in need. And so I wound up at Montefiore to work as a cardiologist. So in 2003, finished up fellowship, moved down to New York City and started working.
Rip Esselstyn:
So you're a cardiologist there, and what kind of cardiologist are you there? Because there's a lot of different cardiologists, correct?
Dr. Robert Ostfeld:
You're absolutely right. There's all kinds of ways to slice and dice it and make it extra complicated sounding. So you can be a non-invasive cardiologist, which is what I am. And that generally means you see patients in clinic, you see patients in the hospital, you read ultrasound pictures of the heart, maybe stress tests. There are electrophysiologists, another kind of cardiologists that do heart rhythm disorders, pacemakers, defibrillators. There are invasive cardiologists that put in stents and other things. Now there's a whole other area in cardiology now like structural cardiologists that do fancy valve procedures, where they go in through an artery and replace valves without open heart surgery.
Dr. Robert Ostfeld:
It's really unbelievable the advances that are happening. It's incredible. So I personally am a non-invasive cardiologist, and about 80% of my time is seeing patients and about 20% of my time with various academic pursuits, whether it's teaching, doing research, starting initiatives programs. So that's my role at Montefiore?
Rip Esselstyn:
Well, your role at Montefiore is you're the founder and director of the Preventive Medicine, right, or cardiology, which... Let's backtrack for a sec? So you're a non-invasive cardiologist at Montefiore, but I'm assuming when you started in 2003, that you didn't know anything about a plant-based diet. Is that right?
Dr. Robert Ostfeld:
You're 100% correct. I was always really interested in prevention and I did a year of preventive research during my fellowship, and I got to work with great people, but I really learned almost nothing about diet, almost nothing about nutrition. When I was done, I knew that a Mediterranean style diet was pretty good, but I couldn't really define it, and that was really it when it came to diet. And so when I came down to Montefiore, that's when I kind of knew, and then I would encourage patients see eat more of a Mediterranean style diet, and do procedures and medications and things as necessary. And then people got a little bit better, but there wasn't any kind of... there wasn't transformational change. And so I was little bummed about that. I'm like, I didn't go into medicine just to move the needle a teeny bit.
Rip Esselstyn:
Right.
Dr. Robert Ostfeld:
So that was a real bummer for me. And I remember one, it was like one weekend early on, I'm on call, and I'm sitting in the hospital, it was a Sunday or something. And I'm like, it just seems like the only people in our division who are really saving people are the invasive cardiologists who put in stents at three in the morning for a giant heart attack. Yeah, it's wonderful that they can do that, but I'm like, there's got to be more. There has to be other ways to prevent this stuff. And certainly the medications and the minimal degree of lifestyle change that I was espousing then is helpful, but it wasn't really... People just the progression to additional disease, another standard heart failure, another admission to the hospital for heart disease just kept on going. So I was getting like this illusion.
Rip Esselstyn:
Yeah. Okay. And so who introduced you to plant-based?
Dr. Robert Ostfeld:
Yeah, so a friend of mine, she handed me a Colin Campbell's book, The China Study. And so at the same time I was also running cardiology grand rounds at Montefiore, and that's kind of like a big weekly academic talk that the whole division goes to. It's an important lecture, and you invite all kinds of leading academicians. So she hands me this book, The China Study, and she's like, you're going to like this. I'm like, okay. So I'm a myopic cardiologist and there's a small section in the middle, it's about cardiology. So of course I just go there at first. And I started reading about the plant-based side and the work of your dad and wow, this is really amazing. The degree-
Rip Esselstyn:
So you didn't immediately [poopoo 00:18:35] it. You were like, there might be something to this.
Dr. Robert Ostfeld:
Yeah. Yeah. I definitely did not immediately poopoo it at all. Like, wow, this is super impressive. And I had to learn more about it obviously, but I just hadn't, those kinds of patient turnarounds, I had not seen, and so... And that was very much aligned with my proclivity toward prevention. So, wow, this seems great. And I was fortunate at the time to be running the cardiology grand rounds. So I had the opportunity to invite all kinds of speakers in this space in. So, we were honored to host your dad, and Dr. Campbell and other people in this space as well.
Dr. Robert Ostfeld:
I think we had Dr. Willett. And anyway, so there was also... I had a double-edged another motivation was to hammer into the cardiology faculty as well. So I got to learn more and then I got to expose all of our faculty, our fellows, and the various other trainees coming through cardiology to this information.
Rip Esselstyn:
Which is brilliant on your part because otherwise they're hearing it just from you and I would imagine that an invasive cardiologist is not going to be too receptive to this information.
Dr. Robert Ostfeld:
Yeah. It remains an uphill climb in some portions of medicine, but I'm sure you see it for yourself, but it's become an easier and easier sell, certainly as society has changed, that helps move the needle. The American College of Cardiology Guidelines, which we can get into a little more, have definitely moved the needle way more toward plant-based nutrition. So it's an easier sell now. But back then, this we're talking like 2006, 2007 maybe.
Rip Esselstyn:
Oh, yeah.
Dr. Robert Ostfeld:
It was harder. So I'll fast forward and we'll back up a second, like some had become plant-based cardiologists around then, and we could talk about that a little bit, but I'm looking around New York city, right? Nine million people. And I obviously I don't know everybody, but I didn't know a single other plant-based physician in all of New York City. It's like nine million people, the closest one was your dad. The closest physician doing it was your dad in Cleveland. I'm like, this can't possibly be. And of course, very soon after that, I got to know Dr. Michelle McMacken. But, and now there's a whole plant posse, all kinds of plant-based people.
Rip Esselstyn:
There is. Well, you got in during basically the medieval times for the most part. Yeah, when it really wasn't a thing. It's nutty now. We all know of Dr. Kim Williams at Rush, and what he's done there as the president of the American College of Cardiologists. And what I think that I've read that on his staff of cardiologists, there are 23 or 24 are now plant-based
Dr. Robert Ostfeld:
Yeah, something amazing. He's done a great work. His words are more influential than mine. I don't have 95% plant-based faculty.
Rip Esselstyn:
Right. But, and then I love his quote, which is something like, there's two types of cardiologists, right? Those who are vegan and those who have yet to read the data.
Dr. Robert Ostfeld:
It's a great quote.
Rip Esselstyn:
Yeah. Yeah. So, I'd love for you to share with our audience. You've said that this is probably the most powerful form of medicine that you know of outside of some sort of an acute injury that needs to be [healed 00:22:27] like a gunshot wound or something like that. Can you speak to that? You eat this way to heal your heart and what happens as... What are some of the bonuses that happen when you start eating this way?
Dr. Robert Ostfeld:
Sure. So, yeah, the kinds of benefits that we see are tremendous. And so we became plant-based, and I started to eat this way myself as well because I'm like, well, if it's going to be good for patients, presumably it will be good for me also. So I'm like, why not do that? But for our patients, the first it was anecdotal because we were just starting out and getting our feet wet, but we were seeing patients who... Now mind you, these were also using medications and procedures when necessary. Those things are also important. It's really all of the above to protect people. But we were seeing people have their blood pressures come down very quickly. It was new habit, more typical omnivorous diet.
Dr. Robert Ostfeld:
And they would switch to almost exclusively or exclusively plant-based and their blood pressures, their high blood pressure, would come down. And in fact, oftentimes two weeks after they would start eating this way, I would get a phone call, a message that's patient so-and-so is lightheaded now. And what that was was that they were healing themselves so much they didn't need as many blood pressure lowering pills. So we started peeling off blood pressure lowering pills. And actually sometimes if they call the primary care doctor who may not know as much, at the time, about plant-based nutrition, they would tell the patient to go back to eating how they were before to have more salt.
Dr. Robert Ostfeld:
It was like 180 -and I'm like, oh mygod. Anyway, so we would see that; we would see cholesterol fall a lot. And I usually wouldn't recheck it for like three months, because I wouldn't see them or wouldn't check in like a week later. But after like three months, we would see [LDL 00:24:32], bad cholesterol, not uncommonly come down 20, 30% in people, which is great. And that's like the same level that you would see with a low dose statin. And there's randomized control data to support that; Dr. Jenkins portfolio diet study, where he took people and had them on a high fiber plant-based diet and also on low dose of a statin and the LDL cholesterol fell to a similar degree. And also, I should say, in terms of high blood pressure, there's randomized controlled data, the DASH; the Dietary Approaches to Stop Hypertension data, which is basically a typical Western diet, versus almost a fully plant-based diet, not completely, but way, way more plant-based.
Dr. Robert Ostfeld:
And there were significant drops in blood pressure there. So the anecdotes that I was seeing are backed up by much more robust information. We would see patients who had angina or chest pain or chest pressure, for example, because of cholesterol blockages in the blood vessels that feed their heart with blood. As a cardiologist, unfortunately, we see a lot of that. But over a couple of weeks, their symptoms would start to improve. And sometimes it could take months before it might fully resolve and sometimes patients did require procedures, but we would begin to see turnarounds very quickly in that kind of symptom.
Dr. Robert Ostfeld:
Typically, and certainly, there is data to support that some of Dr Ornish's work, where he would in randomized control studies would have patients have over time less angina improvements in stress test findings as well, which supported our anecdotal findings. Also, we, in men, I would start... People would tell me that their erectile function would improve. And I had one patient who said that now he is a rockstar in the bedroom. I don't know what his wife thinks, but that's what he thinks. There's randomized control data to support that too with a Mediterranean style diet, not fully plant-based, but more plant-based.
Rip Esselstyn:
Well, you've actually... I think it's you that has this quote and that is, the way to a man's heart is through his penis.
Dr. Robert Ostfeld:
I wish I could take credit for that quote. It's a good quote, but yeah, I mean...
Rip Esselstyn:
Yeah, but I think that you, if I'm not mistaken, haven't you started a research study.
Dr. Robert Ostfeld:
Yeah, so thank you for asking. So it hasn't started. Right now we're targeting December. We hit a lot of pickups and hurdles because of COVID. So we were geared up to go and then COVID hit and everything. So, we are going to look at the impact of dietary pattern on erectile function in young, healthy men. So we're going to randomize young, healthy men between 18 and 30 years of age to either a couple days of plant-based diet or a couple days of animal-based diet, and then cross them over to the other arm and measure their erectile function with the RigiScan device in a rigorous way, and we'll see what happens. We hypothesize that it will improve with a plant-based diet, but we don't know until we do it.
Rip Esselstyn:
So how much of this research study was inspired by the game changers and what Dr. Aaron Spitz did with those collegiate athletes with the RigiScan?
Dr. Robert Ostfeld:
It's definitely a part of it, for sure. And it was sort of like a whole bunch of moving parts came together at the same time. We were separately having conversations before I even knew about that scene, and I was having conversations with other people. So all kinds of planets aligned, like Halley's Comet came around or something, and boom, it all just came together. And we're very fortunate that Dr. Spitz is going to be one of the coauthors on our study. I work with him and we text about it regularly. He's been an incredible source of health and information.
Rip Esselstyn:
Yeah. Yeah. Well, he is a rockstar in that department. No doubt about it.
Dr. Robert Ostfeld:
Absolutely.
Rip Esselstyn:
Truly. All right, gang, want to share an Instagram message that I just got. This is from a gentleman. His name is [George Legos 00:28:55]. And before I do, I want to just share a little side note here. He just happened to be the first customer to spot our new plantstrong broths, chili's and stews inside his local whole food market store. It's in Wheaton, Illinois. And he did it, he found it after visiting both downtown Chicago stores to try and find the new products. So he was persevering. He was on the hunt for the new plantstrong products, and really appreciate that George. He went on to share that he's been plantstrong since 2019 when he saw my book, my first book; The Engine 2 Diet that was being sold at his local whole foods store. And at the time, he was in fantastic shape. He was working out six days a week.
Rip Esselstyn:
He weighed a trim, lean and mean 165 pounds. But guess what? His cholesterol was a staggering 330. And one of the things that I tell people is it doesn't matter how hot your engine burns, you don't burn away cholesterol. It doesn't work that way. Right? You want to bring down the cholesterol, you got to bring down the saturated fat, the dietary cholesterol, the animal protein, and you want to be like hammering it with all the fantastic substances, the phytonutrients, the antioxidants that you get in whole plant-based foods. Now, since reading The Engine 2 Diet, he's gone all in, and he said that he's not had a drop of oil since he started, and his cholesterol is now right as rain, and he's never felt better. And that to me is not surprising. And I want to appreciate and thank George for sharing his story and huge congrats on his success.
Rip Esselstyn:
Now, everybody that's listening. I want you to hear this. This is a participatory lifestyle. This is a participatory sport, meaning anyone that's out there listening, you can achieve these results not by listening to podcasts and not by reading books, although it's helpful, but by engaging with the lifestyle. You literally have to stick a fork in it and dig in. We want you up to your knees, waist, chest in this lifestyle, and I promise you, you won't regret it. So, "kale yeah" to George and keep it plantstrong. Thanks.
Rip Esselstyn:
And just so people understand, as a cardiologist, and again, I don't know if this is your quote, but it's like the Canary in the coal mine, right, is ED. Can you expand on that?
Dr. Robert Ostfeld:
Yeah. So we look at erectile dysfunction as the Canary in the coal mine for heart disease. Now, the way people get an erection is there's a psychological or neurological or physical stimulation, and then people can get an erection. And what happens is there's blood flow to the penis and the artery to the penis where the blood flows in is pretty small. And so by the time there's a blockage in that artery that may limit blood flow into the penis and cause some erectile dysfunction, there are many reasons to have erectile dysfunction, that's one of them, but that's the most common one.
Dr. Robert Ostfeld:
By the time there's a blockage there, it is extremely likely that you have a blockage in the blood vessels in the heart that just has not clinically manifest yet because those arteries are a little bit bigger. And typically erectile dysfunction presents around three to five years before overt cardiovascular disease. So really is a Canary in the coal mine and a great opportunity for us to intervene with risk factors and lifestyle change.
Rip Esselstyn:
That's fascinating. I never heard that before that it usually precedes the heart disease by three to five years, which in some ways actually to me now that I'm hearing this for the first time makes sense because those coronary arteries are about five times bigger than the artery to the penis.
Dr. Robert Ostfeld:
Yeah, that's exactly right. We wrote a review article in the American Journal of Medicine and Dr. Spitz is one of the coauthors on it all about lifestyle and erectile function, and we get into why it happens and the impact of various lifestyle changes on erectile function.
Rip Esselstyn:
Yeah. Well, I'm going to have you and Aaron back after you guys have done this study. How long will it take to do this study?
Dr. Robert Ostfeld:
It probably up to two years. It could be one year. We're going to look at the data after we have 38 people enrolled.
Rip Esselstyn:
Yeah.
Dr. Robert Ostfeld:
And we bake that into the statistics. So if we see a significant difference, then we can stop, and that might take us a year or so. But if we don't see a significant difference, then we'll extend it up to about 72 people. And so I don't know. We'll see how well we do with recruitment and enrollment.
Rip Esselstyn:
That's fascinating right there. Can't wait to see the results of that.
Dr. Robert Ostfeld:
Me too.
Rip Esselstyn:
Let me ask you this. What are some of the youngest patients that you see coming in to Montefiore that actually have confirmed heart disease. Do you see anybody as a teenager with that?
Dr. Robert Ostfeld:
So as an adult cardiologist, I typically don't really get exposed to people until around the years 18 to 21. There's a vague line when does childhood start and adulthood begin. But we certainly see diabetes and high cholesterol even in teenagers or younger with obesity now. That is not uncommon at all, which is terrible because we can look at a number of these disease processes as area under the curve, like how long are you exposed to diabetes? How long are you exposed to high cholesterol? How long are you exposed to high blood pressure? And these things add up over time, it's a disaster. And so you have problems way earlier in life. And so the youngest person that I've seen with a heart attack that hadn't been… sometimes people use drugs or other substances that can trigger these things. But the youngest person that I've seen with a garden variety heart attack without a genetic predisposition, without any illicit use, very early 20s, and-
Rip Esselstyn:
Is that a male or female?
Dr. Robert Ostfeld:
It was a male. But typically, our typical patients are in their 50s, 60s and 70s, but the seeds for the problem had been growing for a long time. Maybe they've been obese for a while and their blood pressure has been too high for a while and their cholesterol has been too high for a while. Maybe not the most ideal lifestyle. And this is definitely not patient blaming at all. Society is not built to make the healthy choice, the easy choice, and certainly there are genetic contributions and social determinants of health and all are very complicated milleu, but the seeds of the problem as you know, start very, very early.
Rip Esselstyn:
So in doing my research for this, I saw you mentioned in one of your interviews in Johannesburg, South Africa, over a 10 year period, just to, where they I think eat predominantly plant based to see what kind of heart disease do they have there in this one hospital going back 10 years, roughly 40,000 visits a year, or 40,000 patients. So a total of 400,000. And I want you to say it, how many people have those 400,000 over 10 years had heart disease written down?
Dr. Robert Ostfeld:
Yeah. So that’s good memory. I had forgot about the study by Dr. Birkin. And this was about 40,000 patients a year. It was a more indigenous population, not a westernized population of people and they are having their physically active plant-based diet. I think there may have been 30.
Rip Esselstyn:
30. That's the number. It was 30. 30 out of 400,000.
Dr. Robert Ostfeld:
Yep. Exactly. Over 10 years. And then as you know, you could go to the Cleveland clinic right now, or your dad, you can go to Montefiore where I am, and there are more than 30 heart patients on the floor this very second. Yeah. So, and then it's so interesting, there is this wonderful study, the Tsimane people that was published in Lancet in 2017 and they're an indigenous population out of Bolivia. And they eat mostly a plant-based diet. I think 72% of their calories is carbs, 14% animal protein, 14% fat, they’re very physically active and they have the lowest rates of heart disease ever recorded in the medical literature.
Rip Esselstyn:
How low? How can you get lower than that?
Dr. Robert Ostfeld:
Well, yeah, that's true. I should say because they had CT scans. So it was very rigorously assessed as opposed to maybe somebody just wrote a chart. So more rigorously assessed with CT scans and their vascular age is felt to be about 20, 25 years younger than typical Western. And their diet is largely plant-based. It's obviously uncomplicated, they're not exposed to pollution. They're living much more of an indigenous lifestyle, but it just highlights how powerfully lifestyle can impact cardiovascular disease.
Rip Esselstyn:
And for you as somebody that is trained and has a degree in epidemiology, this is just, you must go, come on, what more do we need? Right? This is so powerful.
Dr. Robert Ostfeld:
Exactly. It's disappointing and invigorating at the same time because you see all the potential opportunity and then you see all the headwinds. And there's all kinds of data that even if people make modest changes, have a few more servings of fruits and vegetables, eat a little less junk food, a little fewer animal products that they see all kinds of benefits. So on epidemiologic level, we don't have to have perfection be the enemy of good. And if you look at, there's all these dietary studies where if they look at the way people eat, and they say, okay, we're going to define a perfect diet. It's not perfect. It's like a handful of fruits and vegetables a day, low salt, low sugar, some whole grains, and some of these studies will say a little bit of fish.
Dr. Robert Ostfeld:
And if you have the perfect diet, you will have five levels. And if you're in the highest quintile, that's considered more ideal. And in one of the studies 0.7% of the US achieved the ideal diets as defined by that. And 58% was in the lowest category to find by that. We are not even within 100 miles eating reasonably optimally in the US. There's a really cool study out of Framingham, the Framingham heart study, which got cholesterol and risk factors on the map. And they looked at ultra-processed food, junk food, like sugar cereals, chips, stuff like that. And shocker, the more you ate, the worse you did. But the thing to me that was super interesting about the study is, there were 3000 people in this, the average person had seven and a half servings a day of ultra-processed foods.
Dr. Robert Ostfeld:
It's like, when do you have time to eat? How can you do anything else? It's like, we're so far away from ideal, that there are some serious headwinds. No one is seeing it in their hospital, people. I talked to some of the cardiology fellows and I'm like, Hey, when is the last time you saw someone just with lifestyle change, their angina improved, they lose 25 pounds, their cholesterol falls or diabetes goes away. They're like, never. We don't see it. But we see it regularly, of course, with a plant-based diet.
Rip Esselstyn:
So let's talk about the food for a sec. So when I say, or somebody asked you, so, Dr. Ostfeld what does a whole food plant-based diet mean? Give me your reader's digest version of what that means.
Dr. Robert Ostfeld:
To me, it's a minimally processed or smartly processed plant-based diet. And so, sugar cookies can be plant based, can be vegan, but they're not healthy. No one thinks that they're healthy. So to me, a smartly or minimally processed plant-based diet is tons of green, leafy vegetables, fruits, other vegetables, herbs and spices, beans, lentils, chickpeas, teas, tofu, baked potatoes, for many patients avocado and raw nuts, and getting rid of the ultra-processed foods and getting rid of the animal-based foods, particularly processed and red meat in particular. And if someone is going to go down that path, we certainly want them to supplement vitamin B12.
Dr. Robert Ostfeld:
And I'll also often ask patients to supplement Omega-three as well, not necessarily for heart health but for brain health, because although you might be able to get ALA, alpha-linolenic acid from hemp seeds, chia seeds, ground flax seed meal, not everybody converts that all that well into other Omega-threes. So I will often belt and suspender that with an Omega-three supplement. So to me it's a minimally or smartly process plant-based diet, brown rice and beans, a big salad, got lots of wonderful options, literally anything that's in your cookbook.
Rip Esselstyn:
Yeah. Yeah. Got it. So to me, one of the miracles that you have pulled off at Montefiore, and you correct me if I'm wrong here, but I think you were the first to make this happen is you now offer your cardiac patients a wholefood plant-based meal option as they're recovering, is that correct?
Dr. Robert Ostfeld:
Yeah. It was a really interesting adventure. I don't know for sure if we were the first, we were definitely the first or at least I think we were the first, to have Forks over Knives playing for free for patients on one of the inpatient channels. You could watch something else and we’d also have it on the inpatient TVs and it has Spanish subtitles, which is very important for our patient population and in a place just on continuous loop, which is great. So the story with that is, at that time we already had our outpatient program where you see patients in clinic going strong. We would help them become more plant-based, we had the Saturday morning sessions modeled after your father's sessions, where patients would come with a friend or significant other.
Dr. Robert Ostfeld:
And we take a deep dive into how and why plant-based nutrition, and work with the nutritionist, Lauren Graf, and RD Lauren Graf on that a lot. And we wouldn't charge patients for it. We would fund it all through donations. It was a very large indigent patient population where I am. And so we wanted to democratize this information. So our outpatient program is going strong, but I would also round in the hospital, for patients who were admitted after a heart attack or for whatever reason, they're in the hospital. And I would mention plant-based nutrition and go raw plants. And then I leave the room and 10 minutes later, dinner is served and it's chicken or something. It's totally undercut, it's not working. So we work with food services and really it was wonderful collaborative effort with nutrition and food services and multiple chefs throughout our system to make ethnically relevant meals. And we built a plant-based menu. It's not five star Michelin, but it is decent.
Rip Esselstyn:
And how long did it take from, when you hatched that idea to where you're actually serving it to the patients? Is that a two year journey?
Dr. Robert Ostfeld:
Yeah. 18 to 24 months. And that sentence took a long time to materialize. I remember we would sit down like, okay, would love to have, let's have some hummus and this or that. And then they'd be like, okay, that's beyond our ability, it's too costly, so we'd have to revamp it. So a lot of trial and error, and then getting it into the medical records system and all this stuff. But finally it worked and it's been there for a long time now, many years, and it is in, we have an electronic medical record and you can just go in and click, and boom, can border cardiac plant-based diet, which is great. And it's supposed to, it doesn't always, but it's supposed to come with a handout and you can also watch Forks over Knives on the TV. So now I can walk into a patient's room, go raw-raw plants. We order the meals, you get the handout hopefully, and you can put on Forks over Knives. So now I have my plant-based posse with me.
Rip Esselstyn:
So are you able to keep track of the data? So just for example, let's say over the month of June, you had 100 cardiac patients, how many of those 100 are picking the plant-based option?
Dr. Robert Ostfeld:
Well, so I don't have that data. I would love to. But the good news is that at Montefiore, the physicians, or the physician assistants order the meals. And it's not like a patient gets a menu. It's just how it works in our systems. So they order the meals. And I keep on pushing to have it be used more and more throughout the system. Right now, the plant-based meals I think are offered in three of our hospitals, that's got to be like 12, 1500 beds. And not everybody's getting it, it's like herding cats, people come, people go. And we're actually, I've been pushing for this for a while, it hasn't happened yet, but I want to make it the default meal on one of our cardiology floors and have it grow and grow.
Dr. Robert Ostfeld:
And the person who runs clinical cardiology is definitely aligned with that. So I'm very hopeful that it will happen. But it's been a great adventure. It's a wonderful resource for us. And it has led to all other kinds of initiatives, for example, I make our cardiology fellows have, there's a little question in their consult note templates, if they ever see a consult in the hospital, they have to ask, does the patient consume at least five servings of fruits and vegetables a day? And the answer is, yes, no, differ if you're intubated and can't speak, it's deferred obviously. And we put that right over the assessment and plan. So for people who read medical notes they'll know that that's good [real estate 00:49:33], so you'll see it. So the point of that is to drill it home, and it's a simple intervention, to drill it home to the fellows that it's important, to drill it home to anyone who reads the cardiology consult note that cardiology thinks it's important.
Dr. Robert Ostfeld:
And to drill it home to the patient that their physician thinks it's important. And hopefully, as the years go by and people graduate, and they go to different places, it spreads throughout the medical system slowly. And it's totally, non-controversial like the American Heart Association, World Health Organization, they recommend four to five servings of fruits and vegetables a day. Not controversial.
Rip Esselstyn:
Yeah. Yeah. So do you know, following your lead, is this happening all over New York, for example?
Dr. Robert Ostfeld:
Well, yeah, this is not our doing, but through PCRN and we certainly were sharing them on in other groups, Eric Adams, the incredible Brooklyn borough president will be the democratic nominee for mayor of New York City. I believe, yes, it's mandated in New York state that the hospitals at least offer a plant-based meal for inpatients, that doesn't mean the patient has to get it, but they at least have to be able to offer it. And PCRN was involved with that. And they did something similar in California. So the needle is shifting and of course, Eric Adams has been very involved with the city hospital system with Dr. McMacken doing wonderful things at Bellevue. And if he is to become mayor, presumably it'll get a lot more attention, a lot more funding and resources.
Rip Esselstyn:
Can you imagine? Yeah, we had Eric on the podcast two seasons ago and he has a saying that I love, and he says, how goes Brooklyn, goes New York, goes the USA, goes the world. And with the help of Eric, I think we'll be able to really, really move that needle. It'll be really cool. To me, that is so miraculous, so Herculean that you were able to make that happen. I think it must be a Testament to not only your fortitude, but also the passion and the results that you're getting there. So kudos to you on being such a trailblazer like that.
Dr. Robert Ostfeld:
Well, thank you. It's very generous of you to say. It was really a labor of love, wrapped in a pit bull.
Rip Esselstyn:
I love that.
Dr. Robert Ostfeld:
Yeah, so, well, thank you. And we were super psyched about our conference and stuff, and other educational research initiatives too, but some of that stuff got stalled by COVID, understandably.
Rip Esselstyn:
Yeah. Yeah. What do you think, what do you see with your patients as being the number one stumbling block, or does it vary person to person?
Dr. Robert Ostfeld:
It definitely varies, but you've hit on the key thing, behavior change. We all know that eating more kale is good for us, but getting ourselves to do it is often a problem. And I think the biggest thing is it's just not baked into society. We're not geared to be healthy. [Out of the supposed 00:17:50] food bill, somebody else supports to billions and billions of dollars, not necessarily healthy items and agribusiness. There's tons of fast food restaurants all over the place. There are bodegas that don't necessarily have the healthiest foods. The people around us because of this system we live in, are not eating healthily.
Dr. Robert Ostfeld:
And so, we may talk about it with patients and then they go home and it's just harder. The activation energy is hard because society is not geared like that. It's harder to find all the fresh vegetables and then maybe you live in a food desert, maybe you don't feel safe walking to the supermarket that's an extra five blocks away. Just all kinds of hurdles are in the way of that happening. And that's why we really pushed that we don't want to have perfection be the enemy of good. And even if patients are having to make some changes, we're super excited about that. But I think the biggest hurdle is that society needs change.
Rip Esselstyn:
Yeah. So, and that really to me resonates with Dan Buettner's work with the blue zones. And as you said earlier in the podcast, we got to figure out a way really as a society to make the healthy choice the easy choice. Right? So it's not a huge lift. Yeah.
Dr. Robert Ostfeld:
I totally agree. That's the key. And you can, I don't necessarily get into this in the medical world, but clearly animal agribusiness creates more greenhouse gases than all transportation combined, which of course includes cars. And who cares how healthy you are if there's no planet. No planet, no health. So it all aligns.
Rip Esselstyn:
It's so true. There's a study that came out. I just got it two weeks ago. I don't know if you know who Sailesh Rao is, but he started a nonprofit called Climate Healers. And this study it's in part Stanford and another organization shows that, the global greenhouse gas emissions emitted by animal agriculture are 15%, which is basically what all forms of transportation are. Aren't 51% as the World Health Organization or the World Bank commissioned a report in 2009 called Livestock's Long Shadow. And that showed it was 51%. This latest report shows it's 87%. It's mind blowing. Yeah. So again, it's like, as you just said, we got to collectively get behind this and get behind this in a hurry. Otherwise, we're doomed.
Dr. Robert Ostfeld:
Yeah. Yeah. New York City will be underwater pretty soon.
Rip Esselstyn:
Yeah. Not pretty, not pretty.
Dr. Robert Ostfeld:
Yeah. Terrible.
Rip Esselstyn:
Yeah. But in the meantime, the miracle at Montefiore, you got to do a book.
Dr. Robert Ostfeld:
Well maybe after the erectile function study, I don't know, every now and again I think about it, but I don't have… heart isn't there, a passion isn't there for that. It's fun. I like giving the talks and writing articles and teaching the residents and fellows and, uh, right now, my passion's there. Maybe after the erectile function study is done, I think I'll revisit the idea of a book. And we actually even just launched a podcast called Cardio Nutrition through the American College of Cardiology geared toward cardiologists about diet. And so we're hoping to move the needle there.
Rip Esselstyn:
Is that something that you're hosting?
Dr. Robert Ostfeld:
Yeah.
Rip Esselstyn:
Wow. When did you start it?
Dr. Robert Ostfeld:
Honestly it launched yesterday.
Rip Esselstyn:
Great! Good, good. Well and is that open to everybody to listen to?
Dr. Robert Ostfeld:
It is open to everybody. They are bite sized. They're like 10 to 20 minute interviews. So they’re real quick, and it's about whole grains and about fats and about protein and about dietary patterns and the guidelines. So it's really meant to be bite sized, friendly approach to diet that will hopefully be helpful for patients and cardiologists.
Rip Esselstyn:
That's smart. That's smart. Yeah. Well, I'd love to have you back on and we can talk about TMAO and Hemiron and all those things that basically contribute to heart disease. But I want you to get it back to Montefiore and all the wonderful things you're doing there, but I really appreciate you taking time out of your day to join us on the PLANTSTRONG podcast. And I wish you all the best by PLANTSTRONG brother.
Dr. Robert Ostfeld:
Oh, well, thank you. The work you guys are doing, a total inspiration. Your father's work is the inspiration for our program and all the ripple effects there. So thank you. Thank your family. Thank you for this opportunity. And it's great to connect.
Rip Esselstyn:
Thank you. Hey, sign off with me. Ready? Peace.
Dr. Robert Ostfeld:
Peace.
Rip Esselstyn:
Engine two.
Dr. Robert Ostfeld:
Engine two.
Rip Esselstyn:
Keep it plantstrong.
Dr. Robert Ostfeld:
Plantstrong. Alright.
Rip Esselstyn:
Yeah. I find doctors like Dr. Robert Ostfeld to be absolutely so refreshing. And with doctors like him on the front lines, I am optimistic that real change can and will happen in our healthcare system. But the key is, we're going to have to pivot from the current focus which is on sickness back to health where it all belongs. It's about prevention, prevention, prevention. For more information on today's show, simply visit the episode page at plantstrongpodcast.com and next week get ready because I speak to the most authentic and compassionate guest that I've ever had the privilege of speaking to. I'm sure that it will leave a huge imprint on you, just like it did me, and you do not want to miss it. I'll see you then. Thanks.
Rip Esselstyn:
Thank you for this listening to the PLANTSTRONG podcast, you can support the show by taking a quick minute to follow us wherever you listen to your favorite podcasts, leaving us a positive review and sharing the show with your network is another great way to help us reach as many people as possible with the exciting news about plants. Thank you in advance for your support. It means everything. Have you had your own Galileo moment that you'd like to share? What happened when you stepped into the arena and shed the beliefs that you thought to be true? I'd love to hear about it. Visit plantstrongpodcast.com to submit your story and to learn more about today's guests and sponsors. The PLANTSTRONG podcast team includes Carrie Barrett, Laurie Kortowich, Ami Mackey, Patrick Gavin and Wade Clark. This season is dedicated to all of those courageous truth seekers, who weren't afraid to look through the lens with clear vision and hold firm to a higher truth. Most notably my parents, Dr. Caldwell B. Esselstyn, Jr. and Ann Crile Esselstyn. Thanks for listening.
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