Learn why heart disease is a major issue and what you can do to prevent and reverse the number one killer of American's today. Review extensive science and studies demonstrating the effect of nutrient dense foods, exercise and mental health on heart health. Establish your own personal heart health program today.

1. Healthy Living Lecture Series
Stephan Esser MD, USPTA

2. TR Story
• 58 y/o male with a history of high blood
pressure and high cholesterol very well
controlled on medications
• April 29, 2008: “Normal” Stress Test
• 1:30 pm June 13, 2008 while at work he had a
massive heart attack and died

3. JF Story
• 52 y/o male avid runner
• July 20, 1984 found on the side of the road
dead in nothing but his running shoes and
shorts
• Autopsy showed he had blocked one coronary
artery 95%, a second 85%, and a third 70%

4. • Every 40 Seconds someone dies of a
Heart Attack in the US

5. “Heart disease is a
paper tiger
that need not exist”
Caldwell Esselstyne MD
Director of Preventive Cardiology at Cleveland Clinic

6. How To Prevent and Reverse
Heart Disease

7. Goals
• Educate:
– Why Heart Disease matters
– How your body works
– The power of lifestyle: Review the Science
• Empower:
– Develop a personalized Health Plan

8. Tonight
• Is
– Introduction/Review
– Inspiration
• Is Not
– Personalized Recommendations for medication or
intervention for your heart problem

9. Outline
Go to “Mini-Med School”
Learn just how much of a problem this disease is
Review basic anatomy of the heart and cardiovascular
system
Find out what really causes “Heart Disease”
Visit the Market
Learn a few basics about healthy nutrition
Learn how good nutrition can help keep your heart
healthy
Put it all together
Tips to take home

10. Mini Med-School

11. What is Heart Disease?
• Heart Disease
– Broad term for problems with your
“Cardiovascular System” (ie: Heart and Blood
Vessels)
– Including:
– Heart Attacks: Coronary Artery Disease
– Heart Arrythmias (Abnormal Heart rhythms)
– Heart Valve Problems
– ……and others

13. Top Ten Causes of Death for Men in the United States

14. Spending on Heart Disease
• $440 billion (2010 CDC)

15. Basic Facts
• Heart Disease is the #1 Cause of Death in the
US
• Heart Disease is a major cause of health care
spending
Let’s learn more

16. Your Heart

17. Your Circulation
• Blood travels:
• Heart to Lungs where it gets “Oxygenated”
• Back to Heart
• Out to the Body via Arteries
to bring oxygen and nutrition
• Back to the heart via Veins

18. Coronary Artery Anatomy

19. The Arteries
• Endothelium:

20. Review
• The Heart is the bodies “pump”
• Propels Oxygen and Nutrition and carries
away cell waste products via the “highways”
of the arteries and veins
• The vessels are “ Alive”

21. Transition

22. Your Risks
• Non-Modifiable Risks: Not in your control
– Male gender
– Age >55
– Family history of heart disease
– Personal history of heart disease
– Post-menopausal
– Race (African Americans, American Indians, and
Mexican Americans are more likely to have heart
disease than Caucasians)

23. Your Risks
• Modifiable Risks: In Your Control
– Smoking
– High Total Cholesterol, High LDL, Low HDL
– Uncontrolled Hypertension (High Blood Pressure)
– Obesity
– Uncontrolled Diabetes
– Exercise
– Nutrition
– Stress

24. 2 of 32 of 3

25. Associated Pathology
• CVD:
– Hypertension
– Congestive Heart Failure
– PVD
– Impotence
– Claudication
• Endocrine:
– Diabetes
– PCOS
– Hypothyroidism
– Infertility
• Orthopedics:
– Osteoarthritis
– AVN
• Hepatic:
– #1 cause of liver dz in US
• Obstetrics:
– Gestational DM
– Macrosomia
– Inc. C Section rate
– Inc. Perinatal Morbidity
– Inc. Pre/Eclampsia
• Cancer:
– Prostate
– Colon
– Breast
– Endometrial
– Renal Cell
– Gallbladder
– Esophageal Adeno.
• Other:
• Hyperuricemia, Pancreatitis,
Gallstones, Sleep Apnea, Alzheimer’s,
Dyslipidemia, Metabolic Syndrome

27. The Problem
1:9 adults1:9 adults

28. The Problem
• High Blood Pressure:
– 1 in 3 adults
1:3 adults1:3 adults

29. 1:6 adults1:6 adults

32. Smoking
Men: 20.5 (23.9)
Women: 15.8(18.1)
Men: 20.5 (23.9)
Women: 15.8(18.1)

33. Smoking
• Mechanisms of Injury:
– Injury to the Endothelium
– Oxidation at the Cellular Level
– Potent Vaso-Constrictor

34. Cholesterol
• Waxy Fat Like Substance
• Precursor Molecule
– Hormones ( Estrogen, Testosterone, Cortisol)
• Building Block for Cell Membranes

35. Cholesterol
• Lipoproteins:
– Proteins which bind to cholesterol in your blood
stream and act as carrier molecules
– LDL ( Low-Density Lipoprotein)
• Increases deposits of cholesterol in your artery wall
– HDL ( High Density Lipoprotein)
• Reduces deposits of cholesterol in your artery wall
• Triglycerides: Excess calories in meal
converted to these

36. Cholesterol
Goals
• Total Cholesterol < 200
• LDL < 100
• HDL > 40 for men and > 60 for women
• Triglycerides < 150

38. Food Portion Cholesterol/mg
Vegetables Unlimited 0
Fruits “ “ 0
Nuts “ “ 0
Seed “ “ 0
Grains “ “ 0
Milk (non-fat) 100g 2
Milk (whole) 100g 10
Butter 1 Tbs 31
Beef 100g 61
Salmon 100g 55
Chicken 100g 65
Shrimp 100g 126
Lobster 100g 127
Egg 100g 372
http://www.nal.usda.gov/fnic/foodcomp/search/

39. Cholesterol Production
• Increased when you eat
– Saturated Fats, Trans Fats

40. High Blood Pressure
Goal: < 140/90 or < 130/80 if other risks

41. Obesity
• Do you know your BMI? (Body Mass Index)
• If you fall in the “Obese” Category you have
increased risk for:
– Heart Disease, High Blood Pressure, Stroke,
Diabetes and many Cancers
• 1 in 3 Americans are in the Obese category

42. What about “Atherosclerosis”?
• Most of us think of:
– Atherosclerosis: Fatty build up in the blood
vessels

43. Atherosclerosis Development
• Hemodynamic disturbances
– High Blood Pressure
• Hypercholesterolemia
– High Cholesterol
• Inflammation

46. Cholesterol
• Not one or the other: Health vs Disease
• If you have eaten the Standard American Diet
( SAD)
• Then you HAVE Coronary Artery Disease

49. Review
• Atherosclerosis begins early in life
• Progresses with habits and age
• Is the “heart” of disease
• If you have eaten the Standard American Diet
you have atherosclerosis
• We can “nurture” nature

50. Diabetes
• Are you Pre-Diabetic?
• Do you have Diabetes?
– Do you know your Hemoglobin A-1-C number?
• Diabetes Increases Heart Disease Risk:
– Damages blood vessels
– Increases blood pressure
– Weakens your heart
• Good control of your blood sugars is essential

51. Exercise
• National Recommendations for all adults
– 150 minutes of moderate intensity exercise each
week
– 2 days a week of “strength training”

52. Exercise
• Physical Activity/Exercise = Heart Disease
Risk
• How?
– Decreases Blood Pressure
– Improves Heart and Blood Vessel Health
– Lowers Body Mass Index
– Increases “Good” HDL Cholesterol
– Improves Blood Sugars
– Other Benefits

53. Nutrition
• American Heart Association:
– Fruits and vegetables
– Fiber-rich whole grains
– Sodium
– Sugar-sweetened beverages

54. Fruits and Veggies
At least 4.5 cups a day
Primarily Whole
Minimally
Processed “Plants”
Primarily Whole
Minimally
Processed “Plants”

55. Nuts, Legumes, Seeds
At least 4 servings a week

56. Whole Grains
At least three
1-ounce-equivalent
servings a day

57. Salt (Sodium)
Less than 1,500 mg a day

58. Chips: 170mgChips: 170mg
1 Slice of Bread: 150mg1 Slice of Bread: 150mg
Prego Traditional ½ cup: 480mgPrego Traditional ½ cup: 480mg

59. Sodium < 1500 mg
Cholesterol < 200mg
Sodium < 1500 mg
Cholesterol < 200mg

60. Sodium < 1500 mg
Cholesterol < 200mg
Sodium < 1500 mg
Cholesterol < 200mg

63. Review
• Eat MORE
– Fruits, Veggies, Whole Grains, Beans, Seeds,
Unprocessed foods
• Eat less
– High fat, cholesterol, high salt, high sugar, highly
processed foods
Or
“Avoid, boxes, bags, cans and crinkly bags.” 

64. Stress
• Elevates Blood Pressure
• Increases heart rate
• Increases production of inflammatory
hormones

65. Review
• Lifestyle factors powerfully influence our
health
• How powerfully, which one the most?

66. Review
• Universal
• Readily Modifiable
• Multimodal effects
Nutrition

67. Nutritional Factors
• Reduce or Eliminate Cholesterol
• Reduce Saturated, Eliminate Trans fats
• Increase Fiber and micronutrients
• Reduce Sodium

69. Nutrition and Heart Disease
• Can Plant-Based Nutrition prevent or reverse
Heart Disease?

70. Risks
• High Blood Pressure
• High Cholesterol
• Obesity
• Diabetes
• Inflammation

72. Healthy living is the best revenge: findings from
the European Prospective Investigation Into
Cancer and Nutrition-Potsdam study 2009
• 23,153 participants (35 to 65yr) for about 8 years
• Rates of type 2 diabetes mellitus, myocardial
infarction, stroke, and cancer
• 4 Variables:
– Never smoking
– BMI<30
– 3.5 h/wk or more of physical activity
– healthy dietary principles (high intake of fruits,
vegetables, and whole-grain bread and low meat
consumption).
If you had all 4 factors at baseline you had
• 78% lower risk of developing a chronic disease
•
• 93% lower risk of diabetes
•81% lower risk of myocardial infarction
•50% lower risk of stroke, and
•36% lower risk of cancer
If you had all 4 factors at baseline you had
• 78% lower risk of developing a chronic disease
•
• 93% lower risk of diabetes
•81% lower risk of myocardial infarction
•50% lower risk of stroke, and
•36% lower risk of cancer

73. Dietary habits and mortality in 11 000 vegetarians and
health conscious people: results of a 17 year follow up
BMJ 1996; 313 : 775 (Published 28 September 1996)
Results: 2064 (19%) subjects smoked, 4627 (43%) were
vegetarian, 6699 (62%) ate wholemeal bread daily, 2948
(27%) ate bran cereals daily, 4091 (38%) ate nuts or dried fruit
daily, 8304 (77%) ate fresh fruit daily, and 4105 (38%) ate raw
salad daily. After a mean of 16.8 years follow up there were
1343 deaths before age 80. Overall the cohort had a
mortality about half that of the general population.
Within the cohort, daily consumption of fresh fruit was
associated with significantly reduced mortality from
ischaemic heart disease (rate ratio adjusted for smoking 0.76
(95% confidence interval 0.60 to 0.97)), cerebrovascular
disease (0.68 (0.47 to 0.98)), and for all causes combined
(0.79 (0.70 to 0.90)).

74. Vegetarian diets: what do we know of their
effects on common chronic diseases?
Am J Clin Nutr May 2009 vol. 89 no. 5 1607S-1612S
There is convincing evidence that vegetarians
have lower rates of coronary heart disease,
largely explained by low LDL cholesterol,
probable lower rates of hypertension and
diabetes mellitus, and lower prevalence of
obesity. Overall, their cancer rates appear to
be moderately lower than others living in the
same communities, and life expectancy
appears to be greater.

75. BLOOD-PRESSURE-LOWERING EFFECT OF A
VEGETARIAN DIET: CONTROLLED TRIAL IN
NORMOTENSIVE SUBJECTS
The Lancet, Volume 321, Issue 8314, Pages 5-10I.Rouse
59 healthy, omnivorous subjects aged 25-63 years were randomly allocated to a
control group, which ate an omnivorous diet for 14 weeks, or to one of two
experimental groups, whose members ate an omnivorous diet for the first 2
weeks and a lacto-ovo-vegetarian diet for one of two 6-week experimental
periods. Mean systolic and diastolic blood pressures did not change in the
control group but fell significantly in both experimental groups
during the vegetarian diet and rose significantly in the
experimental group which reverted to the omnivorous diet.
Adjustment of the blood-pressure changes for age, obesity, heart rate, weight
change, and blood pressure before dietary change indicated a diet-related fall
of some 5-6 mm Hg systolic and 2-3 mm Hg diastolic. Although the
nutrient(s) causing these blood-pressure changes are unknown, the effects
were apparently not mediated by changes in sodium or potassium intake

76. • BLOOD PRESSURE IN VEGETARIANS
– Am. J. Epidemiol. (1974) 100 (5): 390-398.
• Vegetarian diet in mild hypertension: a
randomised controlled trial.
– 58 subjects aged 30-64 with mild untreated hypertension were allocated either to a
control group eating a typical omnivorous diet or to one of two groups eating an
ovolactovegetarian diet for one of two six week periods. A fall in systolic blood
pressure of the order of 5 mm Hg occurred during the vegetarian
diet periods, with a corresponding rise on resuming a meat diet.

77. Rapid reduction of serum cholesterol and
blood pressure by a twelve-day, very low fat,
strictly vegetarian diet.
J Am Coll Nutr. 1995 Oct;14(5):491-6.
During this short time period, cardiac risk factors
improved: there was an average reduction of total
serum cholesterol of 11% (p < 0.001), of blood
pressure of 6% (p < 0.001) and a weight loss of 2.5 kg
for men and 1 kg for women.

79. The calorically restricted low-fat nutrient-dense diet in Biosphere 2
significantly lowers blood glucose, total leukocyte count, cholesterol,
and blood pressure in humans
PNAS December 1, 1992 vol. 89 no. 23 11533-11537
• Biosphere 2 is a 3.15-acre space containing an ecosystem that is energetically open (sunlight, electric
power, and heat) but materially closed, with air, water, and organic material being recycled. Since
September 1991, eight subjects (four women and four men) have been sealed inside, living on food crops
grown within. Their diet, low in calories (average, 1780 kcal/day; 1 kcal = 4.184 kJ), low in fat
(10% of calories), and nutrient-dense, conforms to that which in numerous animal experiments has
promoted health, retarded aging, and extended maximum life span. We report here medical data on the
eight subjects, comparing preclosure data with data through 6 months of closure. Significant changes
included: (i) weight, 74 to 62 kg (men) and 61 to 54 kg (women); (ii) mean
systolic/diastolic blood pressure (eight subjects), 109/74 to 89/58 mmHg (1 mmHg
= 133 Pa); (iii) total serum cholesterol, from 191 +/- 11 to 123 +/- 9 mg/dl (mean +/- SD;
36% mean reduction), and high density lipoprotein, from 62 +/- 8 to 38 +/- 5 (risk ratio
unchanged); (iv) triglyceride, 139 to 96 mg/dl (men) and 114 to 78 mg/dl (women); (v)
fasting glucose, 92 to 74 mg/dl; (vi) leukocyte count, 6.7 to 4.7 x 10(9) cells per liter. We
conclude that drastic reductions in cholesterol and blood pressure may be
instituted in normal individuals in Western countries by application of a
carefully chosen diet and that a low-calorie nutrient-dense regime shows
physiologic features in humans similar to those in other animal species.

80. Unhealthy Nutrition
• Know the Science:
– Single HF meal
• Alters Endothelial function up to 4 hours after
– Effect of a single high-fat meal on endothelial function in healthy subjects.Vogel RA, Corretti MC, Plotnick GDAm J Cardiol. 1997 Feb 1;
79(3):350-4.

81. The Answer……….

82. Alter Risk
• Change Behaviors
• Bigger Changes = Bigger Results
• Bigger Results = Lower Risk

84. Dean Ornish MD
“Can Lifestyle Changes Reverse Coronary Heart Disease?”Lancet 1990
Regression of Atherosclerotic plaques
“Intensive Lifestyle Changes for Reversal of Coronary Heart Disease”
JAMA 1998
5 yr f/u showed continued atherosclerotic regression and ½ the rate of
cardiac events
“Angina Pectoris and Atherosclerotic Risk Factors in the Multisite Cardiac
Lifestyle Intervention Program” AM J Card 2008
By 12 weeks 74% were angina free
“The effectiveness and efficacy of an intensive cardiac rehabilitation program
in 24 sites” Am J Health Promotion 2010
Significant reductions in BMI/SBP/DBP/A1C/Tchol/LDL/Trig
$30,000 per patient in the first year$30,000 per patient in the first year
Reduced total health-care costs in those with
coronary heart disease by 50 percent after only
one year
Reduced total health-care costs in those with
coronary heart disease by 50 percent after only
one year

85. Dean Ornish MD
• High Mark BCBS : 2 years f/u post 1 year
intervention
• MI’s: 87 %  in Ornish group, 48%  for the
control group.
• Angioplasty: 84% in OG
• Bypass Surgery:  80% in OG
• Catheterizations:  64% in OG

86. Pritikin Program
• Effects of a high-complex-carbohydrate, low-
fat, low-cholesterol diet on levels of serum
lipids and estradiol American Journal of Medicine 1985
• 26 day program
– Total Cholesterol dropped from 229-181
– Triglycerides dropped from 301-151

87. Pritikin Program
• Effects of Life-style Modification on Serum
Lipids JAMA 1991
– 4587 people in a 3 week program
– High-complex-carbohydrate, high-fiber, low-fat,
and low-cholesterol diet combined with daily
aerobic exercise, primarily walking
– 23% reduction in Total Cholesterol
– 23% reduction in LDL
– 33% reduction in Triglycerides
– 5% reduction in weight

88. Pritikin Program
• Effects of a High-Complex-Carbohydrate Diet
and Daily Walking on Blood Pressure and
Medication Status of Hypertensive Patients
Journal of Cardiac Rehabilitation, 3: 839, 1983
• 216 adults on 3 week program
• 83% were able to discontinue BP medx and
had normal BP’s
• 17% had their pill dosages substantially
reduced

89. Pritikin Program
• Pritikin et al Long-Term Use of a High-Complex-Carbohydrate,
High-Fiber, Low-Fat Diet and Exercise in the Treatment of NIDDM
Patients Diabetes Care 1983
– 26 day inpatient stay, 77% off Oral Hypoglycemics, 25%  in TC
• Effect of Short-Term Pritikin Diet Therapy on the Metabolic
Syndrome Journal of Cardio-Metabolic Disease 2006
– 12-15 day stays, BMI 3%, SBP, SG, LDL  10-15%
– 37% no longer met criteria for Metabolic Syndrome

96. Defining Success
• Preventing Heart Disease
• Reversing Heart Disease
• Reducing Medication needs
• Stopping the progression/avoid complications
• Improve Quality of life/energy/clarity

97. What we know
• We can prevent/reverse/eliminate most Heart
Disease
• This takes work………
but it is all worth it!!!!!!

98. Now What?

99. Stages of Change
(Prochaska and DiClemente)
1: Pre-contemplation
2: Contemplation
3: Preparation/planning
4: Action
5: Maintenance
6: Permanent Maintenance (Termination)

100. GROW
• Goals
• Reality today
• Options
• Will

101. Setting Goals
•Specific
•Measureable
•Achievable
•Realistic
•Timely

102. Break Out: 2 minutes
• Set YOURSELF a SMART Goal for heart helth
and share it with your neighbor!
• Specific
• Measureable
• Achievable
• Realistic
• Timely
Exercise
Nutrition
Toxins
Sleep
Emotional
Poise(Stress)
Exercise
Nutrition
Toxins
Sleep
Emotional
Poise(Stress)

103. Conclusion
• Personal Choices are powerful Medicine
• Assess YOUR Heart Health Today
• Identify your heart health goals
• Keep Learning
• Develop a support team
• Take charge of your heart health!

104. Thank You!
Stephan Esser MD, USPTA