This transcript has been edited for clarity.
Michelle L. O’Donoghue, MD, MPH: Hi. I’m Dr Michelle O’Donoghue reporting for Medscape. Joining me today is Dr Rob Ostfeld, who has been a leader in the field of plant-based nutrition and implementing change within his own hospital system in regard to the food that’s delivered. You were also a discussant for one of the late-breaking clinical trials looking at a grocery-based type of intervention.
I think that it lends itself to just a natural topic of conversation, which is not so much necessarily what is the right diet for our patients — because I know that there are different viewpoints — but ultimately, it comes down to how we as physicians are often confused on the subject. There’s very little training in medical school, as we know, and the headlines are contradictory each and every day as to which is the best diet to follow. Ultimately, how do we get the education not only for ourselves, but also to our patients? Where do you see that going in general?
Minimally Processed Diets Beneficial
Robert J. Ostfeld, MD: Thank you so much for having me. It’s an honor to be here with you.
You’re absolutely right: Dietary intervention or dietary change is so critically important for our health and for our patients’ health, but maybe the attention or educational time spent teaching us about that is somewhat limited. Actually, the leading cause of disease is an unhealthful diet, so making dietary changes is critically important.
The American College of Cardiology guidelines are very much aligned around eating more plant-based foods, more vegetables, more fruits, more whole grains, beans and lentils, and of course, also incorporating some fatty fish. This is backed up by multiple basic science studies, test tube studies, observational studies, and randomized controlled trials.
I know there’s a lot of noise and confusion, but eating a smartly or minimally processed, predominantly plant-based diet is quite helpful. There is a really interesting analysis by Dr Bundy published in the Journal of the American Heart Association in 2021. They first tried to estimate the dietary quality in the US, and not surprisingly, it was quite poor.
They looked at five healthy lifestyle diet measures. One is consumption of at least 4.5 servings of fruits and vegetables a day, at least three servings of whole grains a day, low salt consumption, low sugar-sweetened beverage consumption, and fatty fish at least twice a week. If you had four or five of those, you had an ideal dietary pattern; however, 0.7% of the US had an ideal dietary pattern, and about 75% had a poor dietary pattern. They estimated that if everyone switched to an ideal dietary pattern, after 1 year cardiovascular event rates would fall by a little more than 40%.
There is so much we can do when it’s all of the above to help our patients every single day. There are sometimes procedures that are helpful; there are medications that are helpful, and lifestyle, too. It is all of the above to help people, and of course, it is completely consistent with our American College of Cardiology guidelines.
Hospitalization an Opportunity for Behavior Change
O’Donoghue: The importance of lifestyle should be underscored. I think that many cardiologists understand conceptually that that is something that they need to be recommending to their patients. Honestly, it often is just them saying, “Think about your healthy lifestyle.”
How do we really effect change? I led off by saying that at your hospital system, Montefiore, you had been a proponent of really changing the menu there. Is that a teachable moment when we think about how to get our patients to start eating more plant-based foods? If they’re being hospitalized for their myocardial infarction, might that be the golden opportunity that we’re looking for?
Ostfeld: I think you’ve hit on the key issue: How do we make the healthy choice the easy choice? There are all kinds of ways to hopefully come at it. It’s a steep lift. We’re not good at that, and we’re not good at behavior change.
I think you’re right. When patients come in, hopefully we can use that as a teachable moment. It’s one thing that we’ve had the opportunity to do at Montefiore, where now we have something called the cardiac plant-based diet that you can order through our electronic medical record (EMR) system, and the patient can get a plant-based diet. We can also give them a handout explaining why it might be helpful. We also have a documentary film playing on continuous loop on one of the inpatient TVs, talking about a healthier diet, with Spanish subtitles, for free for patients to help outsource some of the education, because no one has time.
That’s a wonderful teachable moment, and it can be reinforced by the medical system by the interventional cardiologist who’s very busy putting in a stent for the myocardial infarction. They could say, “We had wonderful results with the stent. Here’s some medications you are going to need to take. We really need you to eat healthily to help protect your heart.” The nurse on the floor can reinforce it, and the PA on the floor, and the cardiologist rounding in the next day. All the little bits.
We know that you don’t have to go all the way with dietary change to see improvements in outcome. In fact, in a wonderful study by Dr Song, they showed that if you just replace 3% of your calories from animal-based protein with 3% of calories from plant-based protein, that’s associated with living longer. Every little bit counts.
I think our intervention at Montefiore has been helpful to at least be a teachable moment and plant the seed in patients. Fortunately, they also serve this food in our cafeterias in a number of the hospitals, and the director of food services tells me that it’s profitable. That’s really wonderful and great that we can have that for our staff and the people who are coming through.
NYC Mayor and Plant-Based Diets
As you mentioned earlier, of course, there’s quite a sea change in New York City now. Our mayor, Eric Adams, follows a plant-based diet, and he’s had a wonderful health turnaround because of that. He is a very strong advocate for nutrition and has helped through the NYC Health + Hospitals system, which is Bellevue, Jacobi, and other big hospitals in New York City, to develop a health and lifestyle program that is quite robust, with Dr McMacken at the helm of that. They have created plant-based or vegan Fridays in schools, so it gets the conversation going. It gets people talking about it. It’s just another bite at the apple, in the Big Apple, of us being able to bend the curve
O’Donoghue: I think people become overwhelmed when you say “plant-based diet.” They say, “Wow, I can never do that.” It is so important to put the food in front of them. Put that menu choice in front of kids or have that option at the hospital and help them see that it is actually a very easy diet to follow once you have that mindset and you’re willing to make the change.
Ostfeld: I totally agree. With anything, there’s a bit of a learning curve. You know, if you go to work at a new hospital, you have to figure out where the bathrooms are and where you park. There’s a little bit of a learning curve when you change your diet as well. But society is changing, and there are a lot more plant-based options. There are thousands of recipe books, many options in the supermarket, in the produce section, wonderful types of food that you can eat. The activation energy is getting lower and lower.
Quite frankly, in our program in the Bronx, 12 years ago, I would mention plant-based nutrition to some patients and they would look at me like I was from Mars. They’ve never heard about it. One borough south in Manhattan, many people are having smoothies and green juices and things, but it might as well have been different planets. Now, 10 or 12 years later, they don’t look at me like I’m from Mars. They’ve heard about it. Society is changing.
O’Donoghue: I think really the opportunity we’ve been hoping for is getting better supports in place. You talked about the hospital-based changes that are being made.
You were the discussant for a trial that was led by Dr Dylan Steen, where he partnered with a grocery chain. What I liked about it is that they were looking at adherence to diet after different forms of teaching.
One of those interventions was actually going through the grocery store aisles with people and helping them make the right choices. I think that’s ultimately what we need to be moving toward. All the money we spend on pharmaceutical products, when insurers really could be shifting some of those dollars into grocery-based interventions that can have a profound effect as well.
Ostfeld: It’s helpful for health reasons, and as you say, it’s incredibly important for fiscal reasons. We spend so much of the GDP on healthcare — 80% of it on chronic conditions, many of them that are preventable or improvable with a more healthful dietary pattern. Creative initiatives like Dr Steen’s are ways to help get us there.
We are up against headwinds. There are vested interests in place that want to have us eat things that may not be so healthful. It’s important to continue to build momentum, to continue to build data, and to continue to pursue a variety of interventions. Dr Steen has really been at the forefront of that wonderful and very interesting study, leveraging a connection between research and retail.
O’Donoghue: Thank you so much for the work that you’re doing in this area. I continue to eagerly watch to see what’s going to be done next, and I’m trying to make changes at our own hospital as well. Thank you.
Ostfeld: Thank you.
O’Donoghue: Signing off for Medscape, this is Dr Michelle O’Donoghue.
Michelle O’Donoghue is a cardiologist at Brigham and Women’s Hospital and senior investigator with the TIMI Study Group. A strong believer in evidence-based medicine, she relishes discussions about the published literature. A native Canadian, Michelle loves spending time outdoors with her family but admits with shame that she’s never strapped on hockey skates.
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