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Last week, we presented a case of a 54-year-old hypertensive patient and asked for your CulinaryRx. Now, Mike Roizen, MD, of the Cleveland Clinic, and Robert Lustig, MD, of the University of California San Francisco (UCSF), discuss their optimal eating plans for the patient with John La Puma, MD.
A lightly edited transcript of the Google Hangout is below, along with additional references for works cited during the talk. Also, La Puma lists that have some evidence supporting their potential effects in hypertension.
Citations and Additional Resources:
CulinaryRx Google Hangout Transcript
John La Puma, MD: Hi, I'm Dr. of Chef Clinic and Chef MD in Santa Barbara, Calif., and welcome to Culinary Rx from 鶹ý. CulinaryRx is our 8-minute primer on prescribing the right foods, and avoiding the wrong foods, for a specific patient and his case. And I'm so happy to have with me this morning two experts in culinary medicine: , an internist and a physiologist and chief wellness officer of the Cleveland Clinic and , a pediatric endocrinologist at UCSF and a professor of pediatrics there.
Good morning to both of you, thanks so much for being here, it's really a pleasure.
Michael Roizen, MD: John, the privilege is ours, I'm sure.
La Puma: Dr. Lustig, it's really great. I admire your work.
Robert Lustig, MD: Thank you for having me and especially as a pediatrician commenting on 54-year-olds, you know, I'm really out of my element here.
La Puma: It will take a little bit of a stretch but I know you're capable of it. In fact, you're being too modest since you have done work in this area before.
So here today we'll try to help a specific patient with high blood pressure and you both read the case, which I posted on 鶹ý under CulinaryRx, where we had about 10 comments of what to tell this patient. Readers from Australia, from all over the U.S., from South America; bariatric specialists, lots of people had ideas about what to tell this patient to eat and what to tell this patient to avoid. Ranging from to the Mediterranean diet to not drinking beer, which I think is probably an error, but, in any case, here is the case and we'll hear what you guys have to say. So I'm just going to recount it for our audience.
A 54-year-old Caucasian man who is asymptomatic presents for a checkup. He doesn't have medical problems but he's been told in the past that his blood pressure is a little high. He doesn't take medications, he tries to eat healthy, he doesn't salt his food -- which is important -- and he walks his dog every Sunday ... he has a waist circumference of 41 inches and a body mass index (BMI) of 38.2 kg/m2 and a blood pressure of 168/96 in his left arm measured twice, 5 minutes apart, sitting down like you're supposed to do it. He takes multivitamins when he remembers; he doesn't take prescription medication; and his lab's cholesterol, blood sugar, blood count are all within normal limits. He's prepared to take an ACE inhibitor as part of a medication course ... for hypertension and begin a more vigorous exercise program. But he really wants to optimize his diet.
So you have about a minute and a minute and a half each. Dr, Lustig, I'm going to give you the first shot. What eating plan would you recommend, what foods and beverages should he specifically avoid, and what should he consume? And if you know it, how much should he consume of the foods that are good for him?
Lustig: Well, the first thing I would say is that if this guy is only walking his dog on Sunday, we'd better take the dog's blood pressure first. Clearly what this guy has in ten words or less is metabolic syndrome -- and you can tell from his waist circumference, you can tell from his BMI, and you can tell from his blood pressure. Even though we don't have the triglycerides, even though we don't have the glucose tolerance, we can be pretty sure that this guy manifests metabolic syndrome. The question is, how do you treat metabolic syndrome?
Now this guy says he tries to adhere to a healthy diet. I don't even know what that means. You know, he says that his wife does the shopping. But what is it that she buys? We need to know a whole lot more in order to be able to make a rational, accurate prescription. If he is consuming processed food, the fact that he doesn't salt his food is sort of irrelevant because he is salting his food whether he recognizes it or not. The other issue, of course, is the beer; the 12-oz beer that he's consuming is not helping matters because it is helping contribute to metabolic syndrome as well. The likelihood is that he is getting a tremendous amount of extra sugar in his diet if he is consuming processed food, and that in and of itself raises blood pressure. It's been referred to as the "other white crystals."
So it's not all just about salt. The bottom line: I would tell this guy that if he is eating processed food, stop and eat real food. And what kind of real food ... is very much up to him and his wife; what they can ultimately agree on, as long as it doesn't come from a freezer or from a take-out menu. I think it's a good start.
La Puma: Okay. Is there an eating plan that's specific that you would recommend?
Lustig: I think that there are several eating plans that would probably work in this venue. Certainly the Mediterranean diet could. I think the Paleo diet could work in this instance. Probably the only diet that has been shown to be effective for metabolic syndrome, but that I would not advocate for in this patient, would be a traditional Japanese diet because of the high salt content. But other than that, if it's real food; if we're talking low sugar, high fiber, if we're talking about foods that get your insulin resistance down, your insulin sensitivity up, I think it would probably do the trick.
La Puma: Okay, I understand that as a general approach. Let's try Dr. Roizen, and then we can come back to you and you guys can discuss the differing ideas. Dr. Roizen, which eating plan would you recommend, which foods should he avoid, and which foods should he specifically consume?
Roizen: Well, the worst part, John, is that I agree with Robert entirely. But I think that I would actually say ... we know 10,000 steps a day breaks down insulin resistance, he has to get in another habit. And then you want to analyze is he addicted to some of these foods, and which foods it is, and then get him off whatever foods he is addicted to.
So for that goal, I avoid the five food felons in virtually everyone: simple sugars, added syrups, any grain that isn't a 100% whole grain, saturated fat, and trans fat. So I think those are totally out for anyone at risk or who has metabolic syndrome. And that obviously includes those things that cause inflammation such as red meat, egg yolks, and other things that cause inflammation.
And I think it's important to find out ... if he has stress, then help him manage that. You want to go on a Mediterranean or DASH diet ... but it can't be done without physical activity. If he's going to lose the weight, it can't be done without helping him manage stress.
So in those categories I would do that, and I would tell him to split his multivitamin in half; take half in the morning, half in the evening. Add some vitamin D; make sure he's getting DHA. And then talk to him [and] find out if he is in a risk group that's appropriate for two aspirin a day with water. But it's a regular wellness program, I don't think it's just a diet alone. So those are my thoughts.
La Puma: OK, so you both recommend a more comprehensive approach. But when you're sitting with him, which foods do you tell him to eat now to lower his blood pressure?
Lustig: Well, the first thing I would say is: What foods drive metabolic syndrome? And the short answer to that is refined carbohydrate and sugar. Refined carbohydrate because it drives insulin secretion, which drives weight gain, and sugar because it drives hepatic insulin resistance. Both generate hyperinsulinemia, drive energy into fat, and ultimately lead to that inflammatory response that Dr. Roizen talked about.
Now, this guy says that he eats healthfully. I don't know that anybody in America eats healthfully today. The bottom line is we need to know a whole lot more about what he does eat. If he is consuming a significant amount of processed food, he is getting enormous amounts of sugar and salt that he doesn't even know about. He may be doing it under the guise of low fat since so many people are on a 'low-fat diet' and that is likely actually driving his metabolic syndrome rather than helping it.
So I would say before we jump into a specific type of dietary plan -- which is so hard for people to stay on; -- let's just get him onto some real foods, see how well that does, and then we can tailor and tweak that diet as necessary based on the response that he demonstrates.
La Puma: So you might want a dietary history from him.
Lustig: Number one.
La Puma: In order to be able to say 'Change this, don't change that.'
Lustig: Right, absolutely. Number one: find out what it is they're eating because I'll tell you right now, it's not that 12 oz of beer that did it. The 12 oz of beer is a marker for his general dietary nonrestraint.
La Puma: Or maybe just his taste in .
Lustig: For sure.
La Puma: Dr. Roizen, what would you tell him to eat or avoid very specifically [while] he's in front of you. I know you've done this with hundreds of executives.
Roizen: Again, what you have to do is find out what does he specifically eat ... and you go through it, the dietary history. And I do that with most patients ... I take longer than most [doctors] but I go through it. If you don't have the time, you have a dietitian do it. You find out specifically what he eats, what has sugar in it, what has simple sugars in it, and you avoid those things. I also am strong about avoiding those things with carotene, lecithin, and choline in it. Find things he loves to eat and spices he loves to do. You taught me that you can do this with spices, John. And so you're the one who is a real pro at getting people to love life. You want him to love life and maybe he should walk to the grocery store with his wife so that they get some exercise in daily.
But I think that 10,000 steps a day -- you make sure he's got a pedometer and you make sure he starts walking at the same time because you're not going to cure this with food choices alone.
Lustig: I'm with you.
La Puma: Alright, let me throw in a few foods and then we're going to wrap up. Because we're trying to keep this short and pragmatic. I know both of you know that ... two or three small studies have shown that beets, because they're nitrates and it's converted to nitric oxide which allows arteries to expand, improves blood flow and actually . But beets and beet juice, does that have a role?
Lustig: I have nothing against beets. I actually didn't know anything about the effect of the nitrates and nitric oxide. In general, we tend to tell people to avoid nitrates for the cancer-causing properties that they have. But if this patient has a specific problem with hypertension and we can do something to cause vascular dilatation to lower systolic pressure, I'm certainly not against it.
My concern is that most of these patients, especially those with metabolic syndrome, have very high uric acid levels. And uric acid as you know is the endogenous inhibitor of nitrite-oxide synthesis. So I would say that before you start adding beets, let's get rid of the sugar.
La Puma: Fair enough.
Roizen: And the worry I have with beets is that they do have a lot of sugar within them. And so I don't know the trade-off between those. I haven't limited beets in any of the patient populations but haven't advocated it. So John, you've got ... a short-term food for a long-term bad; are the beets going to hook them on the sugars again? I just don't know the answer to that. So I don't specifically advocate that, if they like beets as a vegetable choice, I don't inhibit it.
Lustig: Better to have a vegetable than not.
La Puma: Really good answers by the way, terrific answers. Dr. Lustig ... the sodium nitrate is what's converted with heat to nitrite and nitrate in beets. So that's different from the organic nitrate that occurs within beets. It's a different chemical compound. But generally you're right, preserved foods have often nitrate and nitrite.
There is actually very good data for hibiscus tea; you may have read about hibiscus tea which is used in the Middle East and in South America and in Mexico as well. It's also called Jamaica -- which is spelled like [the country] Jamaica. And it's the seed pools of a hibiscus that are dried and are in . What has been shown is that 1.25 g of hibiscus simmered for 20 minutes, and drunk in 8-oz of water, actually has ... in some people in two ... in part because the anthocyanins, which are color compounds, appear to act like ACE inhibitors, like captopril does.
Roizen: John, I'd like to say what we really need to do is get someone who will coach this guy daily, or every other day, to walk and eat healthier as well as manage stress, and then make a deal with him. I'd say 'If your weight's coming down and your blood pressure is coming down, then we won't start an ACE inhibitor and you won't have to go to the specific foods. But if it isn't, then we'll go to on an ACE inhibitor or specific foods that will take the place of it.'
So I try and make a contract with patients so that they know where the endpoint is, and the endpoint for this guy is losing weight. It's probably as important as getting rid of the blood pressure initially. So that's the main goal, to lose that 5% of weight initially... because he's aging a great deal; his arteries are aging a great deal just by his waist size. So you want to get his waist down below 39 inches and you want to get his weight down the 8 to 12 lbs that the 5% will represent.
La Puma: Fair enough. And, of course, the reason we want to treat high blood pressure is to reduce the risk of cardiovascular and other arthroscopic events.
So in closing, what I hear from both of you is that you would like much more detail about what it is he's currently eating, and you would like to make sure that his sugar levels -- both in food and in processed foods -- decline. Because that seems to be key towards exacerbating both insulin resistance and inflammation and leading towards aging, particularly arterial aging. [Also], you would focus on knowing more in detail what he's eating, so that you could tweak it and allow him to make better, more whole-food choices. Is that an accurate summary?
Lustig: I think that's pretty accurate. What I would say is that he doesn't even know what he's eating; if he's eating anything that even resembles a standard American diet. And while he thinks he's eating healthfully -- because the health claims on packaging say he's eating healthfully -- I can pretty much guarantee you he's not because he's got a BMI of 38.2 and he's got a blood pressure of 168. So we already know he's not eating healthfully. And he's certainly not exercising healthfully either.
Roizen: And I totally agree because I learned from John La Puma -- and by the way John, I think your background in there, the background of the office that is as disheveled as all of us have it, you've captured the office perfectly.
La Puma: It's where I live. Last question: Our commenters said Mediterranean diet and DASH diet. Three or four of them said one or the other. Up or down for the Mediterranean or DASH diet for this guy, or do you not know enough yet?
Lustig: I think that the DASH diet certainly works for hypertension. I think the Mediterranean diet works for metabolic syndrome, I think a lot of diets work for both of them. I'm not for or against any one individual diet. I think your biochemical profile, your proteomics probably dictate what diet works best for you. And without knowing more about this patient, it's really hard to prescribe a specific diet. I would rather know his biochemistry than his nutrition. But you know, we don't have that information. What I do know is that processed food causes metabolic syndrome and real food is the way out. That's what I know.
La Puma: Awesome. Dr. Roizen: Mediterranean, DASH?
Roizen: Either is fine...it's a greater avoidance of saturated fat and red meat and things that change your microbiome is all I would do differently than either of those. And I would get a little more specific on it so I avoid cheese, I avoid red meat totally and yolks totally. So that's the only change or modification I would make because I think the science has advanced past if you will DASH or Mediterranean.
La Puma: Really great. So smart, so well-informed, so focused, thank you very much.
Roizen: Thank you.
La Puma: No, it's great. We have a couple of different approaches that have a unifying theme, about how to use lifestyle and food to approach treatment of hypertension. For more information please read our transcript and check out the reference links below with citation both from Dr. Lustig and from Dr. Roizen and some additional links about high blood pressure and food and lifestyle.
And if you like, send us your own patient stories so we can write a CulinaryRx for you. Just go to 鶹ý and we could feature it in an upcoming segment. Please share it with your friends and colleagues and try to get a CulinaryRx from your doctor today.
From CulinaryRx and 鶹ý, Dr. Robert Lustig, Dr. Michael Roizen, thanks so much, and I'm John La Puma. Take care.