#287: Robert Ostfeld, MD - Can Plant-Based Diets Boost Heart Health and Your Bedroom Performance?
Over the course of his 20-year career at Montefiore in New York, Dr. Robert Ostfeld has been instrumental in moving medicine forward by implementing innovative dietary programs that not only provide plant-based meal options for patients but also educate healthcare professionals about the importance of nutrition in preventing heart disease.
Today, he catches us up on the amazing initiatives at this forward thinking hospital and shares updates on their innovative cardiac wellness program, which now encompasses various clinical trials examining the effects of dietary choices on erectile function and overall heart health, particularly highlighting a groundbreaking study that compares plant-based diets with animal-based diets regarding their impact on erectile function.
Dr. Ostfeld also answers audiences’ burning questions about cholesterol management, the nuances of coronary calcium scoring, and the implications of emerging research on lipoprotein(a) and lipoprotein B. Dr. Osfeld emphasizes that lifestyle changes, including adopting a plant-based diet, exercising, and managing stress, are crucial for heart health, especially in high-risk populations and post-menopausal women.
This episode not only celebrates advancements in preventive cardiology but also aims to empower listeners with the knowledge and tools they need to take charge of their heart health. The mission is clear: a commitment to spreading the good news about plant-based eating as a powerful means to improve health outcomes, particularly concerning matters of the heart.
Episode Highlights
Innovations in Preventive Cardiology at Montefiore
Educating Health Care Professionals on the Power of Plant-Based Nutrition
Studying the Impact of Dietary Pattern on Erectile Function
Bring on the Audience Questions!
Understanding Lipoprotein and Cholesterol
The Risks and Benefits of Statins
Evaluating Calcium Coronary Scores
Endurance Exercise and Heart Health
Is High LDL still a Risk Factor?
Atrial Fibrillation Insights
Considerations for Post-Menopausal Women
Want to Participate in Future Research
About Robert Ostfeld, MD
Robert Ostfeld, MD MSc FACC, a cardiologist, is the Director of Preventive Cardiology, and the Founder and Director of the Cardiac Wellness Program, at Montefiore Health System, and an Associate Professor of Clinical Medicine at Albert Einstein College of Medicine. He received his Masters of Science in Epidemiology from Harvard School of Public Health, and his MD from Yale University School of Medicine, and he is Board Certified in Internal Medicine, Cardiovascular Disease and Echocardiography.
Call to see if you qualify to participate
Episode Resources
Details on the Erectile Function Study 1 (Participants must live within commuting distance of the Bronx as there are multiple study visits)
Details on the Erectile Function Study 2 (Participants must live within commuting distance of the Bronx as there are multiple study visits)
Learn More about the Montefiore Cardiac Wellness Program in Manhattan
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Full Episode Transcription via Transcription Service
I'm Rip Esselstyn, and you're listening to the PLANTSTRONG Podcast.
Get ready to shower your heart with love
[0:04] Get ready to shower your heart with love. February is National Heart Health Month, and I'm bringing you a special series all month long, packed with expert advice, inspiring stories, and practical tips for a stronger, healthier heart. Today, I proudly welcome Dr. Rob Ostfeld back to the podcast. Dr. Ostfeld is the founder of Preventive Cardiology at Montefiore in New York City. And today he shares some of the groundbreaking initiatives and research that they have been doing in preventive cardiology, particularly the integration of plant-based nutrition within the hospital setting. And he also answers a slew of your burning questions about heart health right after these words from PLANTSTRONG.
[0:58] Over the course of his 20-year career at Montefiore, Dr. Robert Ostfeld has been instrumental in moving medicine forward by implementing innovative dietary programs that not only provide plant-based meal options for patients, but also educate healthcare professionals about the importance of nutrition in preventing heart disease. Today, he catches us up on the amazing initiatives at this forward-thinking hospital, and he even provides ways for you to potentially participate in some of their current studies. You're not going to believe some of the innovative research that they're doing in the Bronx. And while I had him, I had to pepper him with some of your questions on heart health regarding statin therapies, cholesterol management, coronary calcium scores, the effect of endurance training on the heart, lipoprotein little a, that is all the rage right now, heart health in post-menopausal women, and much, much more. Dr. Ostfeld's dedication to his work and his passion for advancing preventive cardiology shine through today. Let's get right to it.
[2:14] All right, PLANTSTRONG crew, welcome to another episode of the PLANTSTRONG podcast. Today, especially as we're kind of setting off the new year, I am honored to have Dr. Robert Ostfeld, I'm going to call you Rob, from Montefiore, which is, if I'm not mistaken, Rob, is that in the Bronx? Yes, it is. So you have been there for 20 years. That's crazy. So when you say you've been there for 20 years. You've been with Montefiore for 20 years. Yeah. Yeah. I got a pin.
[2:52] You got a pin. I know. Yeah, baby. Actually, I started here in July of 2023. Right after I finished my fellowship, I came down here and I've been here ever since. 2003.
[3:06] And just so So everybody knows, and if you want to do a deep dive into Rob and his background, I would encourage you, listen to episode 106 of the PLANTSTRONG podcast. I had you on, it was probably two and a half years ago now, Rob. And that was called Miracle at Montefiore because of all the incredible work that you're doing there. But you are a non-invasive cardiologist, and you're also the director and founder of Preventive Cardiology at Montefiore. Has anything changed since we last spoke as far as your position and your title? My title is the same, Director of Preventive Cardiology and founder of the Cardiac Wellness Program here at Montefiore. So those are the same, but we're up to all kinds of great plant, stuff-plant activities. And you know, it all started, of course, inspired by your father,
Innovations in Preventive Cardiology
[4:10] the incredible work of your family, and Dr. Campbell as well. And actually, I just noticed if you look behind me, I'm going to get the left and right all mixed up. Yeah, yeah.
[4:24] This has been hanging on my wall for, I don't even know. It's got to be 15 years, and it's a note. I don't even know if the sticky will work anymore. I'm going to have to take it back up. But it's a note from your dad, you know, saying great work with the cardiac wellness program when we first started, inspired by him. So I've kept this up here as an inspiration to me for at least 15 years. I'm amazed that the stickiness still works.
[4:56] Today is the last day of the stickiness and it's time for two. Yes, yes. Now that you've removed it from the wall, I'll have a hard time going back. Well, so I'd love for you to, give us a little update on what you, what is going on with plants as part of preventive cardiology there at Montefiore. Cause it, you know, my understanding is that you really are doing some breakthrough work. I mean, as we talked about the last time you were on the podcast, you were actually able to get Montefiore to service patients that had just had some sort of a procedure, a plant-based food option while they're in the hospital, which is like Herculean. Well, thank you. And along those lines, we're still doing that. We have the plant-based meals that you can order in multiple hospitals in the Montefiore system. Montefiore has something like 11 or 12 hospitals or related facilities like rehab institutes. And so through many of those, you have the option to order plant-based meals for inpatients. And those meals are also served in the cafeterias for staff or visitors.
[6:20] And you can order, you don't have to order the plant-based meals, but you can. And you can also order like a, quote, flexitarian version where it's a fully plant-based breakfast and lunch and then some animal food at night. So there are variations to try to meet people where they are, because although, you know, I'm sure all of us would want people to be fully plant-based, to some degree, we have to meet them where they are,
The Impact of Plant-Based Nutrition
[6:44] particularly if they haven't heard much about plant-based nutrition before. But at any rate, that's going strong. We keep on revamping the recipes to try to keep them tasty and ethnically relevant. But along those lines, one intervention that I'm really excited about is the.
[7:06] Is that we're in the process. So this is a little bit stay tuned, not fully etched in stone. But actually, about a year ago, there was a White House challenge to promote nutrition and end hunger. And many of us here at Montefiore put together an application because Montefiore does incredible things in the health, wellness, prevention space. And a multi-system application went through and we were very fortunate to be accepted into that White House challenge. And one part that I put into it was that we would create a video that all associates at Montefiore would watch through their credentialing and recredentialing process that comes up every two years, teaching them about the benefits of plant-based nutrition and also quite practically how to order it through our electronic medical record system. And to my knowledge, if this crosses the finish line, and we're going to be starting to film at the end of this month, and right now it's January of 2025.
[8:12] If this crosses the finish line, to my knowledge, we would be the first hospital system in the US to have such a required video. So there's a little bit between here and there, but that's what we're well on the path for, and it's part of our White House challenge. So, and the kind of, in my mind, the beauty of it is, you know, people come and go from hospital systems, Montefiore employs something like 30,000 people across the Bronx and actually stretches into Westchester and Nyack and dips into Manhattan.
[8:44] And so it's kind of like herding cats to try to track people down and teach them about it. And there's constant turnover. But if there's at least a point every couple of years where they're, quote, required to watch this video, then we're capturing them and getting the
Groundbreaking Research and Studies
[9:01] word out and starting conversations and starting discussions. So I'm very excited that this may happen and, you know, to see what the ripple effects thereof may be. And so stay tuned.
[9:18] We've also got a number of other initiatives going. So we have the cardiac wellness program here that we started maybe 13, 14 years ago. And there's a clinical arm, a research arm, and an educational arm. And under the research arm, we started two randomized controlled trials looking at the impact of dietary pattern on erectile function in young, healthy men with normal erectile function. A little bit like the Game Changers documentary. And actually, Dr. Aaron Spitz, who is in the Game Changers, is one of the co-investigators on our study. And so the larger one, we're going to be enrolling 46 people. These are young, healthy men with normal erectile function. they're being randomized to either a number of plant-based meals or a number of animal-based meals. And then we measure their erectile function. Then they cross over to the other arm, either plant to animal or animal to plant. And we measure their erectile function again.
[10:27] Then with this device called Rigiscan, which you actually wear on your penis overnight and measures erections, and it's FDA approved and been used for a variety of other erectile function studies. So our hypothesis is that a plant-based diet will improve erectile function more than an animal-based diet. And we'll see what we see. We don't know. We have 19 subjects who have completed the protocol, and we have to get to 46. So we're well on our way, but still some distance to go. And actually, if people are interested in being a part of the study, which would be amazing, I'm just pulling up one of our flyers here, which I could send you later. But there's a phone number that you can call. And if you complete the study for the larger one, subjects get $350. And the smaller one, I think, is $250.
[11:26] And so the phone number, 917-692-2260, 917-692-2260, and Dr. Weython, our research coordinator and director, will get back to you. And it's for people who are basically 18 to 35 years of age with normal erectile function and who are otherwise healthy.
Heart Health and Young Men
[11:51] So we'll see what it shows. And I kind of think, you know, if our hypothesis is supported, meaning that a plant-based diet is helpful, I kind of look at it as a behavior change study, to be honest, because, you know, I can tell a healthy 25-year-old to eat more plants so that maybe you won't get high blood pressure when you're 40. And, you know, they may or may not listen to me. But if I can tell a 25-year-old that eat more plants and you'll have a better erection tonight, they may listen. So I look at it as a behavior change study, depending on what we find. So we've got two of those. The second one is very similar. I was going to just say, so wait, is the second one also related to the RIDGIS scan? Yes the second also there's they use a rigid scan and we have just a slightly different meal profile but otherwise very similar and um you know you mentioned that you know maybe you got some inspiration from the game changers and what james wilkes and aaron spitz did there with those three young college athletes and as as we saw there i mean it was incredible what happened with the the length the uh and the and the girth if you want to call it of of the erections.
[13:17] Immediately yeah right um and you know you and i the last time i saw you was last year in new york city we were doing a live podcast with the exam room with neil barnard and chuck carroll, and we were on the panel and you said.
[13:34] One of the most brilliant things. And you said, you know, the standard American diet is basically, it's the, it's the erectile dysfunction starter kit.
[13:43] And that got a big roar from the audience, but it's really true, isn't it? It is. I appreciate your generous description of what I said. And yeah, I mean, there's clear data that eating more animal-based foods, more junk food, you know, being less cardiometabolically healthy overall, in addition to promoting cardiovascular disease, stroke, high blood pressure also promotes erectile dysfunction. And it makes a lot of sense. The exact same risk factors that lead to heart disease and stroke, you know, basically also lead to erectile dysfunction of a vasculogenic or arterial etiology. Now, erectile dysfunction, and I have a cool case report to tell you about with this too, But erectile dysfunction is the inability to achieve or maintain an erection satisfactory for sexual performance. It's quite common. 70% of men in their 70s have it. You know, 15 plus percent of men between 40 and into their 50s have it. But I honestly think it's more common than that. And the reason is, is like, you know, people don't like to talk about it. They're embarrassed about it. And I just think it's underreported. And the frequency with which I see it in my clinic, which is indeed enriched for cardiovascular disease, makes me think that it's much more common than is commonly reported.
[15:11] But so erectile dysfunction could happen for a variety of reasons. It could be medications can do it. And so there are psychological causes. And there are trauma can do it. But vasculogenic, or disease of the artery that feeds the penis with blood, is the most common in the Western world. And high cholesterol, high blood pressure, inflammation worsens blood vessel function and can worsen erectile function. And we call erectile dysfunction, or ED, the canary in the coal mine for heart disease because typically it presents about three to five years before heart disease overtly manifests. And why might that be? Well, you know, the artery to the penis is smaller than the arteries to the heart. And so by the time you have disease and blockage in the artery to the penis that is causing poor blood flow and causing erectile dysfunction, it's very likely you also have the same kind of disease in the blood vessels in the arteries in your heart, but that have just not yet clinically manifest.
[16:24] So erectile dysfunction really is the canary in the coal mine for heart disease. And it's a good opportunity if someone notices it to see your doctor, get worked up, make sure we're protecting you as much as possible. And the good news is, in addition, of course, to well-known medications that can help improve it, there are all kinds of lifestyle changes that also can help improve erectile dysfunction and improve all kinds of other health aspects as well, as you and your listeners well know. There's clearly randomized controlled trials that a Mediterranean-style diet, which in its truest form is largely plant-based, exercise, weight loss, compared to more Western-style diets, can improve erectile function. So we're optimistic. No one's ever looked at a fully plant-based diet versus animal-based diet, at least in erectile function. And so we're very interested
Audience Questions Begin
[17:23] to see, you know, what our study shows. So I have a grab bag of questions for you that I would love for you to answer. These come directly from the PLANTSTRONG audience.
[17:39] Before I entertain you with their questions, though, and I want you to know, literally, we put the word out that we were having Dr. Robert Ostfeld from the Miracle at Montefiore cardiologist. We got over 120 questions that were sent. Oh my God. I'm poorly with the artery size one so much.
[18:03] So I've narrowed it down to about 20 questions, but first I have a question for you because I hear so much these days, Rob, about get a heart scan, lipoprotein, little a, lipoprotein, little b. This was not part of the vocabulary five, six years ago. And I want to know from your shoes, from where you sit.
[18:31] Like, how important is it for people to know lipoprotein little A, lipoprotein little B?
[18:39] Is LDL like a thing of the past? Is it like, you know, is that in the rearview mirror? Or like, where are we with all this? These are all important questions. I want to, if I can, I want to mention a couple of other things we have going on at Montetur than dive right in. Please, please. So we've got those two randomized trials ongoing. And the second one has six out of 30 people. That one more recently started. Yeah. But so we also got to present this case at the American Society for Preventive Cardiology from our clinic of a patient inspired by your dad's work.
Understanding Lipoprotein and Cholesterol
[19:15] And your dad is a co-author on the abstract. And it's a guy in his 50s who had vasculogenic or erectile dysfunction due to atherosclerosis. And long story short, He went large. He had a kind of maybe a Western-ish style diet and had moderate erectile dysfunction and then went to plant-based with three servings of greens a day and improved his erectile dysfunction substantially over about nine months and then went whole food plant-based with six servings of greens a day and over the next six to nine months completely resolved his erectile dysfunction, normal erectile function. And to our knowledge, that is the first case ever reported of erectile dysfunction resolving with plant-based nutrition.
[20:07] Wow. And how long did that take? It took some time. It took probably 18 months. Right. And remind me what you said as far as he was doing the three servings of green leafy for how long? And then when did he decide to ramp it up to six? So he got a stent. Someone put a stent in one of his coronary arteries. So he had a good bit of atherosclerosis. And he then decided he wanted to be healthier right after that and found your dad's book and went whole food plant-based with three servings of greens. Fast forward nine months, his erectile function meaningfully improved, but wasn't fully normal.
[20:46] And then he somehow heard that eating six servings of greens a day might be better than three, switched to that, and then fast forward, I think it was about eight months, completely normal.
[21:00] Wow. And so do you, from your vantage point, what is it about the green leafies that has the ability to help really accelerate the increased, I guess, production of blood flow into the penis? Well, I mean, they're so helpful. They're so able to, they so enable the body. Oh, and he puts vinegar on it as well, which hypothetically could ramp up the nitric oxide production of the endothelial cells. But they really are so helpful for endothelial cells ramping up their ability to produce nitric oxide or NO, which can help arteries dilate. They also have antioxidant, anti-inflammatory properties, great, good bit of fiber, which can feed the healthy microbiome, further leading to anti-inflammatory effects. And then, you know, if you're eating six servings of greens each day, you know, just have less room for the junk. So it's also like, what are you not eating? So it's a complicated physiologic milieu, but I think it's impact on those many things, as Colin Campbell has said, improving the symphony of health.
[22:17] I love it. Anything else you got going on you want to share? I do. So we relatively recently, a little over a year ago, opened a new clinic that's completely a plant-based cardiology clinic in Manhattan. Montefiore wanted to create a footprint there. And so I'm there now once a week. And where it's, you know, we encourage people to, it's a preventive cardiology clinic where we encourage people to embrace a plant-based diet. And it's been going great. And it's right next to Moynihan Station in Manhattan West. And if people want to come, we have more openings there than we do in the Bronx because it's a newer clinic. And it's 212-324-4222, 212-324-4222. It's growing quickly, and we're very excited about it. Wait, when did the doors open for that? That opened, I think it's June of 2023. Wow. And were you, how much were you behind that initiative?
[23:28] Well, I wasn't behind the initiative. It's a big clinic. It's beautiful. It's a big clinic. I wasn't behind the initiative for Montefiore to have a footprint in Manhattan. But once they decided to have that footprint, I was honored. They came to me and asked me. They have orthopedics is there and GYN is there and primary care is there. But they also asked me to open up a preventive clinic there that's plant-based because they thought, you know, that there may be people in that region. It's right by a train station that may want to come, but I was honored by it because they felt, you know, that shows that they value the work that we're doing here. Big time. I mean, what a compliment to you and everything that you've been able to do over the last. Well, whenever you started in this direction, which I think was it what was it? Two thousand. I don't know. It was it was after you read the China study. You got really inspired. It was like 2009-ish when we kind of formally opened the wellness program. I don't have a stamp in the ground of it. It's sort of, it's just been an organic evolution.
New Developments in Plant-Based Clinics
[24:37] Yeah. Growth over the years. And I can touch base on some smaller things that actually might be helpful for people in the medical field later that we've been doing here, but I think can be helpful. But along the lines of your question. Yes. So lipoprotein little a.
[24:55] Is a cholesterol particle that is a particularly bad actor. It promotes atherosclerosis. It can promote clotting. It can promote aortic stenosis, which is a type of valve disease. And lipoprotein little a has been around forever. But what is new is our understanding about it, about what it does and its impact on cardiovascular health. And so what we've more recently learned is, first, it's largely genetically mediated. So although the level can fluctuate a little bit, your genes largely dictate the level. There's a couple of smaller studies that lifestyle can change it some, but it seems to fall mostly in the genetic camp right now. Interesting. And do you know, I have no idea because I'm just not familiar with it. What's a range of numbers you would get back if you had your lipoprotein little a checked? Do you know? Well, it can go from quite low, from less than 10, to well into the hundreds. And I have some patients with 500 or 600 lipoprotein little a.
[26:20] And typically, less than 75 is considered, quote, optimal. But it seems like it's limbo. The lower and lower is better. There's a move afoot to lower that to less than even 50.
[26:35] And it does seem that lower is indeed better. And so we know across multiple populations that higher levels of lipoprotein little A can promote heart attacks, cardiovascular disease. What we do not know yet for sure is whether lowering it does anything. Right. There are medications that specifically lower lipoprotein little A exceptionally effectively that look like from risk factors and things that look like they're going to be helpful. But this year in 2025, a large randomized trial where they gave the medication or didn't in people with high lipoprotein little a levels will be reporting, at least we think, and then we should really have a much more definitive answer. So we're at the precipice of knowing much more about whether this is a risk factor we can do anything about with your levels high right now what we do is we first of all want to be sure all other risk factors are optimized like cholesterol blood pressure weight lifestyle because this is one currently we can't really do anything about Yeah. And so that's what we use it to modify lifestyle.
[28:02] And for some people, we use it as a, quote, risk modifier. Say if you're on the fence about starting a statin for someone, you know, like by all other measures, it's not really clear because there's a gray zone. We can check a lipoprotein little a. And if it's high, the light protein little a is high, that would be an impetus to help to make someone want to start a statin to further optimize your risk. And LDL is still a thing. LDL cholesterol promotes heart and blood vessel disease, promotes heart attacks. We want to have that very low.
[28:42] It's also like limbo. The lower and lower, the better. It seems like our thresholds from before of 70 or 100 in people with heart disease are too high. There's a move afoot to get it less than 55 or even 40 in people. Wow. Oh, yeah. And it's all of the above to protect people. It's lifestyle, the healthy plant-based diet, exercise, but also medications, too. One thing that I sadly see, not all that uncommonly in the plant-based world, is a lot of statin skepticism, which is really unfortunate. Because for someone who actually needs it with heart disease and an LDL that's, you know, maybe more than 55 or so, depending on number of things that people can talk to their doctor specifically about that, it's exquisitely effective.
[29:34] Obviously, medications have side effects, but for someone who needs it, the benefits far outweigh the risk. And there's this kind of conspiracy-minded, oh, you know, the puppet master of whatever drug company is controlling it. All sorts of fringe things that have no basis in reality. And so it's really disappointing. And I'll often have to spend 30 or 40 minutes debunking these things when the time could have been used more optimally for other things. Um, but so, so we can use lipoprotein little a to help us think about a statin and LDL still is a thing. We want it to be quite low. And some of these injectable cholesterol lowering medications, the PCSK9 inhibitors can push LDL even less than 10 or 20. Like they're unbelievably effective. And of course it's all of the above with the cornerstone being lifestyle change unequivocally because, yeah, we can lower LDL. The lifestyle is great for so many other things, including LDL. But when they get that low in these studies, they're still accruing benefits and they're not having side effects. So do you ever see anybody that has a LDL, let's just say it's 40, but you've got a lipoprotein little a that's 200?
[30:58] Yes? Yes, absolutely. They're not necessarily related. So they're not at all. Okay. Okay. Interesting. And I think, you know, you mentioned the skepticism with the statin drugs. I mean, I'd love for you to help me understand because everything that I've heard is that, you know, there's a number called the numbers needed to treat, right? How many people need to be taking a medication for somebody to get a positive result from taking that? And I've heard that with statins, and again, this is old, like probably 5, 10 years old, that you had to have 100 people taking a statin drug for a year for one person to get a positive result. Now, I will say, Rob, that's for people that have not had a prior cardiovascular event. With people that have had, the numbers were like, it helps 30% of those people. But again, I am not privy to the latest research on the statins and all the benefits that they have, just the people that are trying to get off them because they don't, as you said, they just don't like the side effects that they get from these statin drugs. So I should say, definitely all medications have potential side effects, but it's a risk-benefit calculus, of course.
[32:10] And so for someone who needs it, There's really no controversy in the cardiovascular world that statins are helpful. And, you know, the patient's the boss. If they don't want to take it, they don't want to take it.
Statins and Their Importance
[32:22] But a number of these, a number needed to treat trials, these are studies that maybe look at people for not all that long of a period of time, three and a half, four years. Let's say there's someone who's 55, they've had a heart attack, and we want to get their cholesterol low. And now they're on a stat and maybe a variety of other medications and hopefully having a plant-based diet. But these studies that are deriving the number needed to treat, they're like three to five years long. Like you want people to live 30 to 40 years, you know. So, I mean, you could, and there's this theme of now called LDL years, where the more LDL cholesterol you've been exposed to over time increases your risk of cardiovascular disease. Wow, yeah. So, you know, of course, not all that surprisingly. And these are very much rule of thumb numbers, rule of thumb. I mean, there's wide variability. But a number of 5,000 is felt to be when subtle cardiovascular disease develops, although we know from your father's discussions and work, you know, can present much, much earlier. And over 7,000 is when you could have over cardiovascular events. These are rules of thumb. But if you think about it, if someone's 50 and they have an LDL of 100 their whole life.
[33:48] Well, by the time they're 50, that's a score of 5,000. They have slow atherosclerosis. And a lot of people have LDLs much higher than that for many years. And people are born with mutations in the PCSK9 molecule where they're walking around with LDLs of 20 to 40 their whole life. And they do much better from a cardiovascular perspective as an interesting comparison. Um so the number needed to treat question it's difficult because it doesn't extend out to the 40 years that we want someone necessarily to live after uh the heart attack and the benefits of a low ldl continue to accrue year after a year so talk about it with your cardiologist and have an open mind and that's really all we can ask yeah yeah thank you thank you for that answer a coronary calcium score, which is kind of a newer kid on the block as well, is also very helpful.
[34:45] And there's some controversy over exactly when to use it. But one very common time is when also we're on the fence about whether to or not to use a statin. And a coronary calcium score, it's a really, really quick CAT scan. It's not like a long one. And so it's lower radiation. And it tells you calcium in your coronary arteries, yes or no. And if you have calcium in your coronary arteries, you have atherosclerosis and you get a score and it's like golf, lower is better, zero is best and that's none. So that's awesome. And it can go up into the thousands, but anything over three or 400 is considered pretty high. But you can have a coronary calcium score of zero, but still have some cholesterol plaque that hasn't calcified. It can't see the soft, non-calcified plaque.
[35:38] But if you have a zero coronary calcium score, your five-year risk of a cardiac event is quite low. So it's quite helpful prognostically, and it can be helpful for behavior change. Like if someone sees that they have coronary calcium and we didn't otherwise know, then we go, oh, my gosh, I really want to push, you know, dial up a healthy lifestyle. And it can open the door to a statin-type medication. And these calcium heart scan, am I correct? do they cost like a hundred bucks? Yeah, about that. If someone's charging you more than like one 50, you're going to, you'll be able to find a place that's less expensive. Right.
[36:18] Interesting. So I know that some of the questions that I have in the grab bag are related to that. Before, before we go to the grab bag.
[36:30] What about lipoprotein little B? Well, I think you're talking about ApoB or apoprotein B. Yes, yes, yes. So that is every LDL particle has an ApoB attached to it, as do some other cholesterol particles like triglycerides that also promote heart and blood vessel disease. So there's a growing understanding that I don't mean to sound like in a pejorative way, but apoprotein little b is probably a better mousetrap than LDL because it captures the LDL particles, but it also captures other atherogenic particles. Um, so there's a move afoot to begin to shift to checking apoprotein B levels, um, perhaps rather than LDL, although there's a little back and forth. Um, but, uh, so that's what it better captures the atherogenic cholesterol profile milieu that, uh, someone has. And is that ApoB reflective, is it reflected at all in your LDL score?
[37:50] Yes, yes, they are correlated, but LDL has ApoB on it, but ApoB is also on other kinds of cholesterol particles that are atherogenic. Okay. All right.
[38:09] Thank you for helping us straighten that out. All right. You ready to jump into some questions? You bet. All right. Great. So the first question I have, you know, we have a lot of women that are in the PLANTSTRONG audience. What, Dr. Ostfeld, are your most important recommendations for post-menopausal women in order to maintain heart health?
[38:34] So my most important recommendations would be, of course, to be sure you see your primary care doctor where traditional risk factors can be looked for, like cholesterol, blood pressure, diabetes, can check your weight, and have a thorough medical evaluation. That's critically important. And then on top of that, as you might imagine, I think a healthy lifestyle, much like before menopause, would be critically important. Now, post-menopause, cardiovascular health seems to deteriorate a bit more quickly in women. So it's extra important to have as healthy a lifestyle as possible. And from my perspective, that is, of course, eating a plant-based diet with multiple servings of greens each day. And I would refer everyone to their physician because there are some people where that may not be the optimal course for them. So I can't give out specific medical advice. But in general, it's a whole food plant-based diet with multiple servings of green leafy vegetables, beans, lentils, fruits each day. Regular exercise for sure, including weight-bearing exercise for bone health and bone protection.
[39:56] And then the other pillars of a healthy lifestyle being screening for diabetes, blood pressure, cholesterol. How is your sleep? How is your stress? And, you know, there are some things, you know, like crazy traffic to work and stuff, but, you know, it's a difficult job. You know, there are some sources of stress that I don't know exactly how we change. But in terms of sleep, you know, sleep apnea is much more common than is often recognized. So being screened for that, because if you have that and you treat that, you can, you know, have all kinds of cardiometabolic benefits.
[40:37] All right. So this is really related to what we were talking about earlier with the calcium scores, but does a cardiac CT calcium score ever decrease or is that damage permanent? This particular person, they've fought using statins for years. Their CT score yielded a score of 800 plus.
[41:00] They're now on five milligrams of statin and 25 milligrams of metroprolol. Yeah, metoprolol, it's a tongue. Thank you. Thank you. I would love to not be on these drugs. Coronary calcium scores can fluctuate around 10% from test to test. So little changes are not unexpected.
[41:20] But it's basically felt that, no, you're not going to reverse your coronary calcium. But by eating more healthfully, living more healthfully, and getting your cholesterol very low, you can improve the health of your soft plaque, which may not be seen on the coronary calcium score. There is a coronary CT angio, which is a similar kind of CAT scan, but it's a full CAT scan with contrast, and we can see soft plaque and degrees of blockage, which you can't see with just a coronary calcium score. But the healthier lifestyle, getting the LDL very low can improve the health of your arteries, make your plaques more stable, improve the thickness of the thin fibrous cap, make you less prone to having a heart attack or a cardiovascular event. And what you can extrapolate from the wonderful work of your father, Dr. Esselstyn, and how his patients did so incredibly well with the healthier lifestyle, and many of them had coronary artery disease and presumably elevated coronary calcium levels. And you can extrapolate for people who have heart disease and who are on statins and do better over time. So it's really not either or.
[42:41] It's all of the above. And if this were my particular patient, and I don't know any of the details, but I would unequivocally want to have their LDL down to the floor, ideally at least less than a 55. And, you know, you want to be sure all the other risk factors are pursued, are optimized. And oftentimes with a coronary calcium score more than three or 400, we very seriously consider an aspirin, although the evidence for that isn't ironclad. But the reason we do that is when the coronary calcium score, excuse me, is more than three to 400, it's epidemiologically considered the same future attack as someone who's had a heart attack before. So we can add an aspirin in that situation. Okay, good stuff.
[43:33] So this particular person wants to know what you think of calcium supplementation. They've heard that several people say that their cardiologist suggests not to take calcium supplements because more of the calcium can potentially wind up in the arteries than in the bones. And this particular person is working on getting all their calcium from their food.
[43:56] Yeah, I mean, if they're meeting their calcium needs from their food, then that's great. And I will defer to the endocrinologists on this one because they are more knowledgeable about bone health than myself. But where I've sort of fallen down from a 500-foot view on this literature is calcium is obviously important. My understanding of the literature, which I haven't reviewed in detail recently, but is that low level of calcium supplementation up to about 600 milligrams a day doesn't seem to promote coronary calcium but when you get to much higher levels that may now there may be newer data that i'm not aware of but calcium is important and it is slightly harder to get it on a plant-based diet you definitely can there's all kinds of sources on it but if you're not thinking about it. Sometimes you may not get it. So for my patients who have bone-related issues, I am very comfortable with them being on up to 600 milligrams of calcium a day. Got it. Good stuff.
[45:06] What's your opinion of the screening tests that consist of an ultrasound of people's carotid and abdominal aorta and the reflection of their overall heart health,
Evaluating Calcium Scores
[45:19] or does this miss the mark on giving indications of potential heart disease? It's a matter of some controversy, the carotid Doppler. Now, there was a very recent study that not surprisingly showed if you do that, you can see subclinical atherosclerosis, which may impact therapy down the line.
[45:42] It's not, to my understanding, it's not a screening one, is not routinely recommended at all, but I do think there's going to be a shift away from that some in the wake of this newer data. Now, if you hear, you know, someone had a stroke or you hear what sounds like a blockage, that's a whole different story. But for screening, it had not really been recommended, but I think there's a shift away from it. And you can see, like when you, if you do it, you can see soft plaque here, pretty, it's just right there, the carotid artery.
[46:14] So I do think it's reasonable. I've shifted now with newer data coming out that it's not wrong to do that. Now, you may not need it to impact your therapy if you have enough already to say you want to start a stat and deal with other risk factors. But it also could be helpful for someone on the fence. So it's not unreasonable. The ultrasound of the abdomen, that is recommended for men around, I think it's 65 to 75, I forgot the exact age cutoff, who have previously smoked to screen for aneurysms. Because smoking, obviously, is a disaster, but it can promote aneurysm formation because it can be detrimental to blood vessels. So there is a window there where it is actually recommended for that kind of screen. Okay, moving on.
[47:14] What in the world does Dr. Ostfeld eat for breakfast every day?
[47:21] Well, it fluctuates. But what I've been into lately is pretty simple. I will. I've been taking those. I don't know if there's a I don't want to say any brand name, but like these little brand high, high, high fiber Bud cereal. Uh so lately i've been doing that with some plant-based milk and i toss uh some fruit on it and then on top of that i'll take like a tablespoon or two of chia seeds i'll put some cacao on it for uh flavor and yeah and sometimes i'll toss like a scoop of beets like the powdered beets on as well uh maybe that's health healthy maybe not but that's uh that's what i do so you're not an oatmeal guy? I used to have oatmeal forever and I'll shift. So I've shifted away from oatmeal over the last few months, but actually I was just on vacation and had this delicious bowl of oatmeal for breakfast the other day.
[48:27] But that's what I've been doing lately. I've been having really busy mornings as of late. So I've been doing the old overnight oats in a mason jar and i layer it with you know frozen blueberries mangoes raspberries with the oats in there with some plant strong millican it's divine the next the next morning so you mentioned chia seeds uh that you you put on there and one of the questions is can an excessive amount of flax and or chia seeds elevate your LDL cholesterol levels to a point where it's not worth it? I don't know. I've never seen a study like that. I mean, the alpha linoleic acid that's in chia flaxseed meal has anti-inflammatory properties. It can reduce cardiovascular risk. I don't know of a study looking at like, you know, 10 tablespoons versus one. I mean, I recommend that my patients have two tablespoons of chia or hemp seeds or ground flaxseed meal each day to get the alpha linoleic acid, a type of omega-3 fatty acid. But I don't know. I have to ask Dr. Kuhl. Well, I would imagine that, you know, don't have more than a tablespoon of each and you should be fine.
[49:53] I can't imagine that that's a problem and I guess if you haven't proved it eventually the calories will catch up to you I just haven't actually encountered someone who had more than two yeah so here's a question Rob that, Ah, this seems to be swirling around a lot. And so this particular question is, they've got an aging parent that says that their doctor says that cholesterol, even if it's in the 3, 4, 500, doesn't matter.
[50:23] And, you know, and of course, you hear this from a lot of the carnivore people, you know, that it doesn't matter. It's almost like a rite of passage to have a high cholesterol now in these carnivore diet people. So how do you respond to that? Well, I mean, it's unfortunate to me. And if there's new data that comes out, like I'm not particularly wedded to one or the other. I just go where the data is. And so you don't even have to take my word for it. Like if you step back, you could take the American College of Cardiologies, the American Heart Association, the Canadian Cardiovascular Society, the American Society for Preventive Cardiology, the National Lipid Association, the European Society of Cardiology, the Indian Society for Cardiology all recommend much, much lower LDL cholesterols, particularly in people with heart disease. And these are evidence-based organizations across the globe. And LDL cholesterol promotes atherosclerosis.
[51:27] Uh, and obviously not in everyone, uh, it's not like, you know, suddenly your LDL level crosses a certain level and then you have a bullet to your head. It's a continuum, but like, and so we all know someone who did everything wrong and smoked and whatever, and they lived to 102, but like, if you're playing the odds, you know, you know, the odds aren't in your favor, uh, if you do that. So, um, it's unfortunate to me, high LDL cholesterol, high APL B levels, uh, promote quote, atherosclerosis. So and we even know treating people who are, quote, older in their 70s, et cetera, beyond with cholesterol lowering medications for the appropriate person can be helpful. So I don't currently agree with that thinking. You know, so I just. Yeah.
[52:20] All right. Good. Good to know. So this question, this person once heard you refer to a place in an interview that was your favorite place to eat when you lived in New York City, which obviously you still do. And that place is, I think it was El Violino. It's an Italian restaurant. And their question is, what is your favorite plant-based dish when you go there? Well, I'm going to have to modify a little bit because, gosh, what is – I haven't been to Il Violino –, since before the pandemic wow yeah yeah i mean i've walked by it much time like we would go there every night uh like our well a lot i shouldn't say we would go there um and uh so well when i was there i would they had this whole wheat pasta with marinara sauce and i'd get like steamed um um.
[53:21] Uh, steamed vegetables, uh, with it. And, uh, yeah. So like you did have, you get steamed, uh, uh, spinach and steamed broccoli. And that's, that's what I would get. And oftentimes I would have a, maybe a half glass of wine. Yeah. All right. I've never, I've never been there, but, um, it looked very cute. I looked it up online. It looked like a cute little restaurant they're lovely it's just wow that's that's great it's good memory and blast from the past haven't been there in years yeah uh do you keep up with any data on endurance exercise this person wants to know you know whether it's marathon running or triathlon if they have an increased risk for heart disease or other cardiac pathology i do some um the the majority of my patients are not in that category.
[54:14] But pound for pound, it's felt that exercising more is more helpful for your cardiovascular health. So all in all, it's helpful. There is a slight uptick in sudden death risk during these large, these very intensive, long races like marathons and triathlons. But on the whole, it appears that risk goes down. And when you look at exercise, the real bang for the buck is going from very little to some, and there's still a bang for the buck, although less so from some to more. Now, there does seem to be a slight increased risk of atrial fibrillation and abnormal heart rhythm when people exercise a whole lot for many, many years. And that may be because of increased blood flow, the atrium stretch a little bit. Maybe there are times when there's poor blood flow to the atrium, extremes of exercise. And so that may, we know that atrium stretching in and of itself can promote atrial fibrillation. So that can uptick.
[55:25] There is also a question with extremes of exercise of promoting coronary calcium more. And people hand-waved the explanation of there's more rheologic stress on the blood vessels as it's expanding more vigorously than it might otherwise without super intense exercise. But whether that coronary calcium is harmful or not is somewhat more of a matter of debate. So basically, the way I come down on it is if it's safe for the person, and safe we could get into how that's broadly defined. And I think on that, there's a quality of life component to it that people love. And I think on that, there is a health improvement that people will see, even marathon runners and Ironman triathletes. Right. For anybody that wants to do a little deeper dive into that subject, tune into the interview that I had with Brad Kearns.
The Risks of Endurance Exercise
[56:25] It's a new book that he wrote called Born to Walk, and really recommending walking as opposed to running for a myriad of reasons that I'm not going to touch upon right now.
[56:37] What do you think about AFib? There's a lot of people that I run into that seem to be suffering from AFib, and can this be prevented or helped with diet, or what have you seen? Atrial fibrillation is unfortunately quite common, and it increases as we get older. The highest risk factor is age, but high blood pressure, diabetes, obesity, sleep apnea, or other risk factors for atrial fibrillation. Atrial fibrillation is an abnormal type of heart rhythm where the atrium or the two top chambers of the heart, instead of squeezing in an organized way like this, jiggle. Who cares? Well, there's a number of reasons why this may be harmful. The most concerning is that when they jiggle, as opposed to squeezing in an organized way, blood can collect, then break off and go to your brain and cause a stroke. And the strokes from atrial fibrillation tend to be pretty severe. So when that happens for the right person, we will put them on a blood thinner. Coumadin is one, and there are other newer ones, more novel, and direct oral anticoagulants. And I just don't want to say any brand names or things.
[58:00] So we give you blood thinners for that. A question that comes up is, well, gosh, I'm already on a plant-based diet. Do I need to take a blood thinner? And so there is a little bit of data that a plant-based diet can improve coagulation factors, particularly factor seven, but we have no data whatsoever at all that a plant-based diet.
[58:23] Is going to obviate the need for a powerful anticoagulant when you have atrial fibrillation and you're the right person for that. So I would want people to have to consume a plant-based diet when they have atrial fibrillation, but in addition to the blood thinner when appropriate for them. So it does not obviate the need for it. It does not take away the stroke risk, just the plant-based diet. Now, your lifestyle, not being obese, treating sleep apnea, if you have it, keeping your blood pressure under control, all of those things can reduce your risk for developing atrial fibrillation.
[59:03] Whether having a healthy lifestyle can, if you already have atrial fibrillation, can reduce its frequency, it might. I can't unequivocally tell you that. Now, there's one study out of Australia where they took people who had atrial fibrillation and they did an ablation procedure where they weighed and zapped some of that electrical tissue in the atrium meant to stop the atrial fibrillation. But it's not a perfect procedure. It works 70, 80% of the time. And they found that people who lost at least 10% of their weight after that, however they got there, had less recurrence of atrial fibrillation. And we know that eating more a healthy plant-based diet can reduce weight. And there's other hypothetical reasons that eating more plant-based, lowering blood pressure, improving blood vessel function, anti-inflammatory effects. So there are hypothetical reasons to think that it may reduce the frequency of atrial fibrillation, but we do not know for sure at all about whether it
Atrial Fibrillation Insights
[1:00:00] absolutely can reduce it, and we certainly know if it can reverse it. So please do eat plant-based, but please also take conventional medical therapy, when appropriate, if you have atrial fibrillation.
[1:00:12] Thanks. What's your opinion about niacin therapy to lower LDL? I don't recommend it. But there's a lot of side effects with it. Typically, in addition to lifestyle, the front line for lowering LDL cholesterol is indeed statins. And then there are other kinds of medications like ezetimibe or PCSK9 inhibitors and others that we can use to lower LDL that are really much more first, second, and third line than niacin. There are multiple randomized controlled trials that show when you add niacin to a statin, that there's no incremental benefit and possibly even they do a little worse. So I don't use niacin. If one of my patients is on a low dose and they're tolerating it just fine and they're very attached to it, I don't think it's something that I need to go to the mat over to stop.
[1:01:18] But I don't use it. I don't recommend it. One of the reasons that people use it is it may reduce lipoprotein levels a little bit or some, but we don't know yet if that's even beneficial. And there will be medications that can more directly and meaningfully lower lipoprotein little a. And if someone wants to lower the lipoprotein little a of note, the injectable PCSK9 inhibitors also can lower lipoprotein little a levels by about 25%. And whether their benefit is due to the LDL lowering or incrementally from the lipoprotein little A lowering. We don't know about the lipoprotein little A part yet. So there are a number of ways to lower it otherwise if one wishes to with their doctor, but I don't use niacin.
Closing Thoughts and Future Initiatives
[1:02:10] Man, you know your stuff. So I got one more question in the goodie bag for you here, and then I'm going to let you get back to business. But that is, this is a person, they're on a whole food plant-based diet, they don't have any weight issues, but they're wondering if, in your opinion, like having an avocado a day would be okay, or would that, in your opinion, affect their cholesterol levels to a point where it would be unhealthy? In my opinion, it's okay. And for a number of reasons. One, it can improve compliance, I think, with, this is more anecdotal, but improve compliance with eating more healthfully. And like, you know, the whole food plant-based diet, it's, It's something we would want someone to eat for 30 years, not 30 days. Like pretty much anybody can do something for 30 days, but 30 years is a lot harder. And so this is going to help someone be more compliant with it long-term. Please have at it. Avocados have lots of healthful fats in them.
[1:03:19] They're fiber. There's, I believe, it's been a while since I looked at it, but as I recall, there's a randomized trial, short-term randomized trial showing it can lower LDL cholesterol levels some. So from my perspective, if they want to do it, they're otherwise eating healthfully, it's going to help them stay on it. There is going to be incremental health benefit, in my opinion. So please have at it.
[1:03:41] What if that person told you that they had had two heart attacks? Well, so your dad's work is absolutely an inspiration for me and is one of the main reasons we started our clinic here. But I remain okay with it, even if they have heart disease. And I have some patients, it's not like I'm not trying to force them to eat avocado. Yeah. If they don't want to, that's fine. But from my perspective, as I recall, the LDL lowering study, the healthful fats, the long-term compliance, I'm quite comfortable having patients eat avocado after hard times. Good. Good. Good stuff. Well, you're continuing to do miraculous work at Montefiore. As you said in our last conversation, Rob, it's a labor of love wrapped in a pit bull.
[1:04:42] I keep pushing ahead. There's so many great initiatives to be had. You know, now that you're reminding me, one small thing that we're doing are two small things that we're doing. If there's any, anyone with, you know, has attached or can get to a fellowship program or a residency program or rounds in the hospital rights in the electronic medical record, there's two things that I've been doing. We've been, quote, making our fellows put in their consult notes the phrase, does the patient consume at least five servings of fruits and vegetables a day? Yes, no, deferred. And if you're intubated and you can't talk, like obviously they can't answer. But the reason, and we put that in a good real estate part of the note, just above assessment and planning. Anyone who reads many medical notes knows exactly what I'm talking about, about real estate in notes. So we put it right above it and we do that. So, A, the patient will know their heart doctor thinks it's important. B, our cardiology fellows will know that we think it's important. And then anyone who reads the cardiology note will know that cardiology thinks it's important. So we're hopeful that it'll have ripple effects, a very simple intervention like that. And the second thing is, for docs out there, they're probably familiar with the term guideline-directed medical therapy, or GDMT, for heart failure. And that means, you know, starting the heart failure medications when someone's heart beats more weekly than normal.
[1:06:06] And I thought, well, you know, we have a lot of guidelines for nutrition therapy. Why should they just keep it all for themselves? So I started putting GDNT or guideline directed nutrition therapy.
[1:06:21] So I have this little smart phrase that you adopt GDNT. And it's like, please encourage the patient to consume guideline direct nutrition therapy, including, you know, that I get into fruits, vegetables, like a little bit more specifically. And I'll write, please order our cardiac plant-based diet in my consult though. So I'm like, well, why don't we have the, we have the impretaur of guidelines. Let's use it. Might as well flaunt it. When did that start? I've been doing that on and off for at least the last year.
[1:06:55] Beautiful. Well, Rob, I can't tell you how good it is to see you, how much I appreciate you coming back on the PLANTSTRONG podcast, sharing all the great initiatives you have going on at Montefiore, answering the grab bag of questions that our audience threw at you. You did handsomely well, my man. I appreciate you. Thank you. Well, Rip, it's an honor to be here with you. I'm so grateful for your incredible work, your team's incredible work, your family's inspirational and incredible work. So thank you. I'm forever in your debt and your family's debt. So thank you. Oh, man. Thank you, my PlantStrong brother. Can you give me a virtual PLANTSTRONG fist bump on the way out? Boom. All right, Rob. Rob, have a great one in the Bronx and Montefiore in 2025. Thank you. Likewise.
[1:07:50] Thank you, Dr. Ostfeld, for your time and your passion around the research, education, and prevention of the leading cause of death in this country, heart disease. If you'd like to learn more about the research studies that Rob mentioned, we've got all the details in the show notes for you to see if you're a potential candidate. it. Next week, we're going to get a little selfish in a very good way, of course, with board certified interventional cardiologist, Dr. Columbus Batiste. Do me a favor. If you know of any loved ones who may benefit from these episodes, please share them and continue to spread the good news about plants. And from my heart to yours, thank you. And remember to always, always keep it plant strong. The PLANTSTRONG podcast team includes Carrie Barrett, Laurie Kortowich, and Ami Mackey. If you like what you hear, do us a favor and share the show with your friends and loved ones. You can always leave a five-star rating and review on Apple Podcasts or Spotify. And while you're there, make sure to hit that follow button so that you never miss an episode. As always, this and every episode is dedicated to my parents, Dr. Caldwell B. Esselstyn Jr. And Anne Crilr Esselstyn. Thanks so much for listening.
