Q&A: Examining the Key Drivers of a Healthful Lifestyle

Robert Ostfeld, MD, ScM, director of preventive cardiology at Montefiore Health System and professor of medicine at Albert Einstein College of Medicine in New York sat down with Drug Topics ahead of the American Society for Preventive Cardiology Congress on CVD Prevention to discuss the role that dietary patterns and nutrition decisions play in living a healthful lifestyle.

Drug Topics: What specific nutrients or dietary patterns have been shown to benefit patients with hypertension and diabetes, and how can this information be incorporated into patient counseling?

Robert Ostfeld, MD, ScM: That's a very important question. A healthful diet, of course, can very positively impact cardiometabolic health—including blood pressure, diabetes, [and] lipids—and cardiovascular health and overall health in general.

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Reassuringly, there is broad [alignment] in terms of what defines a healthful dietary pattern. For example, multiple medical societies—like the American Heart Association, the American College of Cardiology, the American Society for Preventive Cardiology, the Canadian Cardiovascular Society, the European Society of Cardiology—are all broadly aligned; consuming more plant-based nutrition, less ultra-processed foods, less red and processed meats, is helpful both cardiometabolically and [for] cardiovascular health overall.

Unfortunately, that recommendation hasn't necessarily percolated down well, at least into the US. There was an interesting recent analysis where from the NHANES database—the National Health and Nutrition Examination Survey database—published in 2021, where they looked at a little over 11,000 people…where they used 5 elements to define diet. One element was consuming at least 4 and a half servings of fruits and vegetables a day, at least 3 servings of whole grains each day, low sugar or sweetened beverage consumption, low salt consumption, and 2 servings of fatty fish each week. If you had 0 or 1 of those, then they felt you had a poor diet; 2 or 3 an intermediate [diet], and 4 or 5, an ideal dietary pattern. About 75% of the US has a poor, 0 to 1 of those [elements] dietary pattern; 25% [have] intermediate, and 0.7% of the US has an ideal dietary pattern.

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There's a huge gap between where we are and where we could. You could ask, “Does it even really matter?” Of course it does. In this study, they modeled if everyone adopted an ideal dietary pattern—so 4 or 5 of those 5 elements—for 1 year, what would happen? Well, it was estimated that cardiovascular event rates would fall by about 42%. The gap matters. There's randomized prospective cohort data that eating a healthful dietary pattern, more plant based [and] aligned with American College of Cardiology and American Heart Association recommendations, can also be helpful for high blood pressure, particularly the DASH [Dietary Approaches to Stop Hypertension] dietary pattern for high cholesterol, the dietary portfolio pattern, which is a high fiber plant based diet, and also, similar recommendations broadly for diabetes.

What I should reinforce is, it's not really that there's 1 diet for high blood pressure, high cholesterol, and diabetes. They're really broadly aligned that consuming more healthful, plant-based foods—fruits, vegetables, whole grains, beans, lentils—less ultra-processed foods and less red and processed meats, is helpful for all of the above: cardiovascular health and cardiometabolic health.

Drug Topics: How can patients be supported in overcoming common barriers to healthy eating, such as budget constraints and limited access to nutritious foods, in the management of hypertension and diabetes?

Ostfeld: Helping the individual patient in the office embrace a more healthful diet can be a challenge. Society does not make...it easy for the healthy choice to be the easy choice. And behavior change, getting someone to change how they eat, how they live, can be very, very difficult. These are big hurdles that we face.

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As an individual practitioner, it can be overwhelming to overcome some of these things; at least we can try and start. As an individual [health care provider], you'll have your team around you who can support you and reinforce your message. Nurses, support staff, and registered dietitians can be incredibly helpful to reinforce and educate about this topic.

In the clinic specifically, I will try to find a specific reason that the patient may be interested in living more healthfully. Maybe they want to lose weight or improve their skin complexion, maybe they want to lower their blood pressure, lower their cholesterol, come off a medication… Whatever the case may be, I try to highlight how consistently eating more healthfully can address that particular issue. I will give them some very specific steps—some simple specific steps, because everyone's busy and there's so much information to take in—that they can hopefully do when they get home to live more healthily. I have a handout that I give them that I try to keep very simple.

Sometimes in clinic, because we're all so busy, I'll just say, “Let's just start with 222.” [That’s] 2 servings of green leafy vegetables a day, 2 servings of fruit each day, 2 servings of other vegetables each day: 222. I'll do that a little bit weirdly, deliberately, so they'll remember it. Then when they go home, depending on where they live, there may be more or [fewer] access or cost issues. [I’ll explain that] for ease, [they] could cook in bulk; we certainly don't have to buy, you know, organic green juices. You can get frozen vegetables, frozen fruits, big sacks of potatoes, oatmeal, and beans, and those things can be much less expensive and more doable.

Another way to help patients adopt a more healthful lifestyle is—there may be the hurdle of costs here—but there are services that can deliver meals, healthful meals, to patients; they may be able to access registered dieticians, and of course there are multiple online resources that are free for patients. The Physicians Committee for Responsible Medicine has a 21-day kickstart for more plant-based nutrition should, the [health care provider] feel that that's appropriate for the patient. There are a variety of resources that people can have access to; some may cost a little bit more, but some are also free. The American College of Lifestyle Medicine also has multiple online resources.

The American Society for Preventive Cardiology Congress on CVD Prevention was held August 2 to August 4 in Salt Lake City, Utah. Click here for more of our coverage.