The Best Healthy Heart: The Truth About Cardiovascular Diets

Welcome to the show. With us is Dr. Khadeeja Esmail, a cardiovascular specialist with a wealth of knowledge and a love of cardiovascular prevention. I’m so excited you are back to join us. I do not know if you want to give a little intro about yourself.

I have been attending now at UF for about five years, and my focus is really on prevention as well as cardio-obstetrics and women's health in general. I’m excited to be here for another episode. 

I cannot wait. We are getting into the best diets for cardiovascular health, which I love about this topic, because I think a lot of people get a little overwhelmed about what they should do in terms of heart health and what options there are. When people hear a heart-healthy diet, what does that actually mean from a cardiologist's perspective?

The big thing in prevention is trying to prevent heart attacks and cardiovascular death. Heart-healthy means a diet that is able to decrease those events. Within the nutrition world, a lot of the data is observational, not the strongest, but some really strong trials have been done in nutrition with cardiovascular event outcomes, and the biggest data support the Mediterranean diet.

Which I am excited for us to talk about. Why would you say diet matters so much for cardiovascular health in comparison to other lifestyle factors? 

With diet, you are able to do a lot of things that will slow down the plaque progression. Plaque progression is really the plaque buildup in the coronary arteries, which eventually can rupture, leading to a heart attack. With diet, you can decrease your LDL, that bad cholesterol that gets into the arteries, causing plaque. With diet, you can decrease inflammation in the body. Inflammation has also been shown to accelerate plaque development. It really helps you decrease those things, which helps decrease cardiac events. Exercise does play a role, more so for mortality benefits and longevity, but in terms of specifically decreasing cardiovascular outcomes, diet has the upper hand.

That is helpful for people to know because I do think, depending on who you listen to, some people really focus all on exercise, and then some people will focus all on diet. Again, looking at the body as a whole, it is important to know that both of these are important for different reasons. They do have a role, but especially for the plaque prevention that you were talking about, eating and everything really does have an effect. We just mentioned the Mediterranean diet. I thought we would maybe get into that a little bit more. It gets mentioned all the time. What is it really? 

First, I do want to go over the data behind the Mediterranean diet because it is actually pretty strong. The PREDIMED is a randomized controlled trial that was done for the Mediterranean diet, comparing it with a low-fat diet. It was published in 2018. It had over 7,000 patients. Basically, it showed that there is a 30% reduction in heart attack, stroke, and cardiovascular mortality. 

That is huge. 

Yes. This is a big trial with a lot of patients. Strong data for the Mediterranean diet. What exactly is it? It is a plant-forward diet, essentially focusing on vegetables and fruits. It also includes your animal protein. More so, focusing on chicken and fish, red meat, limiting that to once a week. Focusing on nuts, focusing on fibers, especially soluble fibers. Those are the main things that make up this diet, especially good fats, meaning olive oil and fats that you find in fruit and vegetables, avocados especially. 

Knowing how to use these things is also important. With regards to the olive oil, it needs to be at a low temperature or just right out of the bottle. Once you start heating up the olive oil, it does lose some of those beneficial properties. The recommendation is about 2 to 3 tablespoons a day. The best way to do it is over your vegetables, over the salads. Some people even just take it straight out of the bottle. Those are the main things that make up the Mediterranean diet. 

That is really important to touch on for the olive oil because I think a lot of people do not realize that as you get into those higher heats, it degrades, it becomes more rancid, so then you actually are not having healthy benefits with it. What a lot of people do not think of is that a lot of times, you could steam your vegetables without oil, and then afterwards, once they have cooled down, you can easily drizzle olive oil over them. Instead of a lot of other vegetable oils that are used to be used and all that stuff, it is an easy way to decrease that, but then increase one, you are eating more vegetables, and then you are also getting olive oil. You are not getting the risk of it getting overheated and everything.

With regard to those specific things mentioned with regard to the nuts, people say, "Which nuts?" Walnuts, especially, are high in omega-3s. Hazelnuts, almonds, those are your best options. You also do not want to overdo it with nuts because the calories are a little bit dense in them as well. It is a bit of a balance, but that is something that you really should be eating every day. With regards to fruits, the blueberries especially have a lot of antioxidant properties. Soluble fiber, we are talking about a lot of apples, pears, as well as berries. Those are really important to do. You want to aim for at least three to four servings a day. With every meal, you should be having fruit and vegetables, really. 

Which, unfortunately, I think that in our diet today is not as common. It is a lot easier for people to get more starches and more meat. They think, "If I have one vegetable, that is enough." Even if you think about a regular breakfast, it is rare for people to have veggies on the side with their breakfast. Really, probably what we should be doing, though. 

The other thing you can do for breakfast would be oats, because that is high in fiber. What fiber does is it really helps bind the bile acids in the body and helps excrete those. It really does reduce your LDL, your bad cholesterol, as well. In terms of reduction, the Mediterranean diet gives a modest reduction in your LDL, about 10% to 15%. 

That is actually really good. That is better than I would have expected. 

Combining everything, there is that 30% mortality benefit and heart attack reduction. 

That is what I was going to ask. We talked a little bit about the risk reduction, but for the Mediterranean diet, how much does it really decrease your heart attack risk, stroke, and your overall cardiovascular health?

It is about 30%.

It is 30% for all of that. That number is still blowing my mind because it is actually more significant than I even thought. I thought maybe in the 10% to 15% range. I did not realize.

When you give this data to the patients, then they really understand, "I can really decrease my risk of heart attacks and death from cardiac issues." People think it is those really big plaque buildup, significant blockages in the arteries that cause a heart attack, but it is really not. It is those 30%, 40% stenosis in your plaque in the arteries that rupture, causing the heart attack. Even if you go to your doctor and you have a normal stress test, that just means you do not have obstructive coronary disease, but it does not tell you that you have an absence of coronary disease. Once you see that you have even mild disease, you need to start working on these things, even with no disease. As you get older, you definitely need to start working on these preventions. 

Prevention is key. It is way better to prevent a disease from happening than to try to treat the disease later on. That is so empowering for people to know that you can make these sorts of diet changes and for it to have a 30% decrease in your risk. If somebody wanted to start following the Mediterranean diet this week, and they might be a little overwhelmed, what would you say would be the first three changes that you would say they should start with?

I will go over those changes in a second. The other thing I liked about the Mediterranean diet is you can really adapt it to whatever cultural needs you have, so you can accommodate it to whatever it is you like, Indian cuisine, whatever it is, you can really make these changes within that. It is not restrictive, it is easy to follow, and it is sustainable. Those are some other really good things about the diet. I would say the number one thing would be the olive oil, with a low temperature or just right out of the bottle, on your veggies on a salad. In that PREDIMED study, they were having a lot of olive oil. Olive oil, and as we talked about, fruits and vegetables with every meal. Third, I would say it would be the nuts. Start incorporating nuts daily.

Nuts are great too, because a lot of people will say, "I do not have time, I am on the go." Nuts are such an easy on-the-go snack that you can throw in your bag. They do not need to be refrigerated. It is just like a really nice grab-and-go thing where you can still be healthy. 

With the olive oil, there are some specifics about that as well. There are certain harvests. If it is earlier in the harvest or mid-harvest, those are a little bit better. Some have more concentration of the good things that will help your heart. There are some nuances within olive oil itself, as well as in terms of which ones to pick. You cannot just go and pick some random olive oil from your grocery store. Do a little bit of research on what olive oils you have in your grocery store and try to figure out the best, highest quality you can. 

Is that talking about, because I see cold-pressed olive oil all the time, is that talking about that in terms of olive oil choice or not?

Not so much that, but the quantity that it has of hydroxytyrosol in there. You can just Google the brands that you see in your grocery store and see what the concentrations are, and then when they are harvested. Those are the important things.

I did not know that about harvesting. That is cool.

You want to store it in a dry, cool place as well. 

That makes sense. Again, if heat degrades it and everything, that could have an effect. I guess a lot of people hear about the DASH diet for heart health. How would you say the Mediterranean diet compares to the DASH diet?

It all depends on what your goal is. If your goal is blood pressure reduction, then the DASH diet outperforms the Mediterranean because it can decrease your systolic blood pressure by at least 10 millimeters of mercury, so 10 points on your systolic. The more strict you are with sodium, the less than 2 grams of sodium you can even have on your blood pressure. If that is your goal, to try to decrease your blood pressure, maybe not be on any blood pressure medicines, or decrease the amount of blood pressure medicine, then DASH outperforms the Mediterranean for sure. If your goal is to slow down plaque prevention and decrease heart attack risk, then the Mediterranean is a good option for you. 

You would say overall, then, in terms of diet for blood pressure, it would be the DASH diet out of all the diets, the salt. Probably what people should realize is that you can also do the Mediterranean diet with the DASH diet, right?

Correct.

Just limit your salt. If you have high blood pressure, you are more than likely also in the category of your higher risk for cardiovascular events.

A lot of the same things within the Mediterranean are also with the DASH diet, so it is pretty easy to blend them together. As you said, the salt reduction is less than two grams a day. 

What about low-carb diets? I feel like these were all the rage for a while. Atkins, you had your South Beach diet. Now, there is, we will talk about it a little bit, the carnivore diet. Anyway, are these low-carb diets heart-healthy? Do you think it just depends on how they are being done? What are your thoughts there?

It all depends on how you are doing this diet. If the sources of fat and things that you are getting are more saturated fats, then you are definitely going to have a higher risk for coronary disease progression. It really depends on how you do it. If you go with better sources of your protein that do not have as much saturated fat, and you are still able to eat some of your vegetables to offset things, then it can be healthy. It is more so that the low-carb diet is more beneficial to patients who have elevated triglycerides. It does decrease your triglycerides better to reduce insulin resistance. There are some benefits of that low-carb diet, but it just depends on how you do that diet. 

That makes sense because I think more and more studies are starting to show that for a lot of people, and obviously, there are caveats to this, like there are people who have a genetic predisposition to high triglycerides, but for a lot of people, the high triglycerides are like the first signs of this whole insulin resistance pathway. It does make sense that it would help with that, decreasing the triglycerides. How would you look at plant-based diets?

Plant-based diets definitely, like the Mediterranean, do decrease your cardiovascular events for sure. It is definitely a beneficial diet. Some studies even show that there is some mild plaque regression with a very strict plant-based diet. 

Really? That's cool.

Some of the studies with Ornish and some other people did show some plaque regression, but only with a very strict plant-based diet. Same thing, it is how you do it. If there are people who are plant-based and they are not really eating whole foods, they are eating a lot of junk. Those heavily processed foods also affect cardiovascular health, so it all depends on how you are doing this plant-based diet. If you are doing it in a whole food setting, then it definitely benefits. 

I always tell patients, because they will ask about vegetarian or vegan diets, and I am like, "It all depends on how you do it." If you are on a vegan diet where you are having all fresh vegetables and olive oil and all this stuff that is basically in the Mediterranean diet without the fish and the chicken and stuff, it is fantastic. If you are having Oreos, because typically Oreos are vegan, they are so fake that there is no actual real food in that, basically. There is no actual cream. It is great because it is all fake. That is so unhealthy for you. That vegan diet is very bad and not healthy. 

Just like low-carb, it just depends. What are you replacing things with? 

That makes sense. I feel like keto, and people still talk about keto diets for different reasons, one just to lose weight, but then also for some brain issues or different psychiatric issues, sometimes it can help. What do you think about for long periods from a heart standpoint?

The data in terms of what happens with your LDL, it is usually neutral. There is no real concern there. Again, it depends on how much saturated fat you are getting. If you are having a lot of fats with this keto diet, then your LDL is going to go up, so it just depends. That ties into the carnivore diet as well. It depends on how you are doing this keto diet, but long-term, we have not really seen too much impact on LDL.

That's actually reassuring. I was thinking it would be a little bit worse on LDL. I wonder if that is because a lot of people will be on keto for a fairly long amount of time, but I feel like a lot of people are on it for a short period of time. 

It’s because it is very hard to stick with those. That is why we do not really see much change, because I do think that is a diet that is very hard to stick to. Whereas the Mediterranean diet is sustainable, keto, and low-carb, those are all ones that are very restrictive, and patients find a hard time sticking to them. 

Which also means if you are not on it for a long period of time, it is harder to get that long-term data. Beef tallow, I feel like that is all the rage now. It is like people are thinking it is the new natural fat that they should use for everything. It has had this rebranding. From a heart-healthy perspective, what is your issue with that?

It makes me cringe a little bit because beef tallow is very high in saturated fat. It is not something you should be using in your everyday life at all. Fifty percent of it is actually saturated fat. Saturated fat has been proven to increase your LDL. It increases the cholesterol in the liver by a lot of different mechanisms. Your liver downregulates receptors that are supposed to pick up all the LDL from the body. Now you have more LDL in the blood, which makes its way into the arteries. 

Saturated fat really accelerates plaque buildup, and beef tallow is 50% saturated fat. That being said, seed oils. What's the issue with seed oil? Inherently, nothing until you use it in the fast food world, where it is used multiple times over and over, and it is heated at a very high temperature. When that happens, it releases chemicals that are pro-inflammatory, which will speed up plaque progression. 

The issue, too, is what are you eating when you are eating this fast food? It is ultra-processed, really bad food. Already, it is not great. It is fries, it is all that stuff that they are frying, so that is the problem. In that situation, beef tallow, maybe there is some benefit, but rarely if you are going to use it for fast food. Already, you are eating fast food, so it is not great, but then at least you do not have that extra inflammation from the seed oil. It is hard to say, but I do not think either way is bad for you.

That is really the biggest take-home point that I would want people to have, is beef tallow is not a healthy, “This is fantastic for you.” Yes, maybe it is slightly better when you are comparing it to the seed oils and the inflammatory properties, but it is close if you are looking at the data. What I am afraid of with this whole rebranding is that people are like, "Wait, now McDonald's fries, maybe they are changing to beef tallow. That's great. “This bag of chips now has beef tallow. This is great." No, this is still bad for you. You still have to look at this as a bad choice.

It might be a slightly better choice, maybe again, it is neck-and-neck. Time will tell, but it is not a good choice. That is what concerns me about this whole rebranding. Even the other day, I was walking through Costco, and I felt like there were so many more things, but now it is beef tallow. People are thinking that this is a lot healthier than it is. People should be aware, especially of the LDL risks. If you are starting to have beef tallow in everything and you are thinking it is healthy, then instead of the healthy olive oil and all the other stuff, it starts replacing that, and so starts having some issues with your cholesterol. 

Especially if you are a cardiac patient, do not use it in your everyday life for cooking. Definitely not. There was a billboard on the way to my kids' school, and it was for one of the fast food places, and it was just saying, "Now serving beef tallow fries." Every time we drive by, I am like, "Oh my god."

That is the thing, people are now thinking of this as healthy. You are like, "I am going to go to that fast food place now because they have tallow and look at me making this healthy choice." It is fine, again, something in limitation. I just want people to be aware of the risk. 

What it really is is that those companies just realized, "We can sell beef tallow to these fast food chains, and we are going to make more money because we are not wasting this anymore. We are able to sell it to these companies." It has gone through this huge marketing thing, and it is really just mostly about money.

Which, unfortunately, a lot of things are. How would you say beef tallow would compare to olive oil, nuts, and seeds? Other unsaturated fat sources?

Again, it is high in saturated fats, 50%. It does increase your LDL, so it is not a great option. 

Cardiology guidelines obviously emphasize replacing saturated fats with unsaturated fats. Why is that?

Mostly again, it is because saturated fats will increase your LDL, LDL being one of the main things that increases plaque buildup, leading to heart attacks. If we want to minimize that plaque buildup, we have to minimize the saturated fats. 

Again, I mean, that is one of the reasons we always check cholesterol panels. One of the other episodes that we did went all into that, how that is so important. If you can prevent that from even occurring, that is the biggest thing you want to do. The carnivore diet, I feel like it is such a thing on Instagram now, which is wild to me. From a cardiologist's perspective, what concerns would you have with the carnivore diet? 

My in-laws actually were on the carnivore diet for a little bit, and I had to bite my tongue. I told them my concerns about it, which are valid because the issue again comes with saturated fats. That is what it boils down to. Beef is high in saturated fats. There is certain beef that is better than others that are leaner. If it has loin or round in the name, then those ones are leaner. Those ones are a better option with less saturated fats. 

The more marbled the beef is, for example, ribeye has more saturated fats, increases your LDL, leads to more plaque buildup, and more heart attacks. On a carnivore diet, again, it depends. How are you doing it? Also, you are missing a lot of the antioxidants that you get from your fruits and vegetables, which, on a carnivore diet, are not eaten. You are losing out on all the benefits from the fruits and vegetables. You are missing out on all the micronutrients. It is a big problem. It has been shown to increase LDL very dramatically. 

It is kind of wild to me how popular it has gotten online. Also, I feel like it is rebranded. People just make it seem like it should be really healthy for you. It will help you lose all this weight. You will feel great on it, your brain, your energy. They really try to sell it as if it is going to be this cure-all. My concern is that people listen to that, and they get on it, and then they have all these unintended downstream consequences. You are not going to see the plaque build up right away. 

You are not going to start the diet, and next week it will cause a heart attack. It is this progression of plaque as the LDL builds up. People do not realize the risk because it is silent as it starts. It is a little concerning, especially the lack of fiber, because fiber is so important. Even with the whole protein movement, which I think is good that people are prioritizing protein, I do feel like fiber gets pushed to the wayside a lot of times. People forget how important it is for so many things. Your heart, your brain.

Your gut microbiome. It is huge.

Cancer prevention, colon cancer. It is just so important. That leads to the next question. How does fiber play a role in lowering your cardiovascular risk?

There are soluble fibers and insoluble fibers, and it is really the soluble fiber that has that benefit for cardiovascular health. Those main sources, as we alluded to earlier, are apples, pears, berries, and oats. It basically will decrease your LDL. It helps your gut microbiome and decreases inflammation in the body, which again has a beneficial effect on slowing down the plaque progression. It’s super important.

I completely agree. That is something else that people do not quite realize. Inflammation is bad for you in many categories. Inflammation is bad for your heart health. It increases the risk of plaques. It is bad for your brain. It has the same bad effects there. In terms of your risk for autoimmune issues, inflammation begets inflammation. If you can increase that, it is huge, and fiber plays such a huge role in that.

With regards to the LDL again, LDL on its own is not the issue. It is when it gets oxidized. What oxidizes it is really inflammation and all these things that we have been talking about. Certain things can make the LDL size smaller, and those smaller LDL particles are even worse because they get into the artery a lot easier. 

It is a lot easier for them to burrow into that wall. Those are the ones we talked about before, where they can break off and cause those heart attacks and stuff. Salt. We talked about it a little bit for blood pressure. How concerned should people be about salt in their diet?

The average person, if they are not dealing with blood pressure issues, it is not a huge thing that I focus on. I usually talk to my hypertensive about it. The average person without it, if they have other things like coronary disease, it is not something I really stress unless they are hypertensive.

Mostly, once your blood pressure starts to be an issue, then you start talking about the salt. Sugar. Would you say this is a bigger issue for the heart than most people think? A lot of people put sugar in the diabetes category. "I do not have diabetes, so I do not have to worry about my heart." What's your thought on that?

Indirectly, it does increase your cardiovascular mortality because the problem with the sugars is it increases your triglycerides. The triglycerides through the liver, those get broken down to the very low-density lipoproteins and remnants of your lipoproteins, and they go into the arteries and cause plaque. The more triglycerides you have, the more of these remnants you are going to have in your blood from the breakdown of these triglyceride molecules, and then basically plaque buildup. Indirectly, it does affect you if you have coronary disease from that standpoint.

I also think from the inflammation standpoint, too. The more sugar you have, that tends to just drive that whole inflammatory pathway too. What would you say about ultra-processed foods? 

Same thing. Those are things that you really need to limit in your diet. A lot of people are drinking these sugary drinks, which I would say is like the number one thing, one of the things you really need to get rid of if you are having soda, if you are having a lot of juice, sweet tea, especially here in the South, sweet tea, juice. Those sugary drinks from Starbucks, those things. Those are problematic. If you are trying to improve your health, one of the things, if you are drinking these sugary drinks, one of the first things that you need to do is stop drinking these because it is just causing havoc in your body. 

Even energy drinks, which for you probably have like a double hitter for the heart, you have not only all the sugar that's packed into them, but then you have all of these stimulants for the heart that are not great. Eggs. I feel like eggs have gone through a "They are so bad for you, do not have them because of all the cholesterol" phase, back to "They are good for you." Where are we now with eggs? Would you recommend them, or can you just pick a couple? What are your thoughts?

As everything, I wouldn't really go overboard, but definitely we are okay with eggs. The dietary intake of cholesterol has not really been shown to cause too much of an effect on our actual lipid levels. One to two eggs a day, we would say, is fine. It has got protein. Some things in there are good, so we do not really limit the eggs anymore. 

Nice, which is awesome because there is all this choline, and like you said, a lot of nutrients. Good news there. Red meat, we talked about that a little bit. Would you say that for most patients, that needs to be limited? What are your thoughts?

Within the Mediterranean diet, the recommendation is to limit it to once a week. Once a week is what I am telling my patients for red meat. As we talked about, if it has loin or round, those are better options because they're leaner, so less saturated fat. Filet mignon actually is a good option because it really does not have much fat. The ribeyes have quite a bit. Those marbled steaks have more saturated fat, so stick to them once a week. 

That is where we are at with our recommendations for red meat. In terms of processed meat, now this is another big issue. Processed meat, hot dogs, your cold cuts, bacon, salamis, these are a huge problem. Not only do they worsen the plaque buildup, but they are also cancer-causing. They are pretty much as bad, in the same category, as smoking. I tell all my patients, "You guys need to stop with these processed meats. No more processed meats." That, you really need to limit. 

Which I think a lot of people do not realize. A lot of people have a salami sandwich every day for lunch. I feel like it is very common. Even just hot dogs and stuff are just I feel like still a staple for a lot of diets. 

It is a very American thing. I tell them, "If it is the 4th of July, you want to have a hot dog, that is fine.” Aside from that, you really should not be eating this stuff because in those processed meats, there are nitrites, which have been proven to cause cancer." 

That is so important for people to know. We talked a little bit about drinks. Is there anything else in terms of drinks that sticks out to you? Caffeine probably. I do not know if you have any thoughts on caffeine. Coffee has a lot of benefits. 

You should talk about the coffee benefits because this is something that you brought up to me that I had not even heard of. Touching on the caffeine and the LDL stuff is important too. 

Obviously, coffee has a lot of benefits. One, the caffeine in lower doses, obviously. People should not go crazy with having ten cups of coffee, but actually have some dementia prevention. There are a lot of antioxidants. I know that we try to limit plastics, so we were trying to do more of a French press because I could get a stainless steel hot water kettle, and then I could get a stainless steel French press. I was getting no plastics with it. Unknown to me is that the coffee beans have all these oils in them. With that, you are not using the paper filter that filters out the oil.

My LDL went up, and so did my husband's. Once we made the change to a pour-over, again, then it was all glass that had the carafe, but it still has the paper filter on top, so it actually catches those oils, and he had a significant drop in his LDL, which I did not expect with no other changes. It would have been, if we had made a diet change at the same time, then it would have been like, “It is not a diet. I would not have thought that it was all from the coffee.” A significant drop there. That was something that I learned because I had no idea about that.

Something you taught me. I switched over to the same thing because I was getting Americanos before, and Americanos do not go through a paper filter. Now I do the pour-over with the paper filter, and now I am telling all my patients, if we have issues with LDL, I am always asking them, "How are you preparing your coffee?” If you are drinking coffee, make sure it goes through the paper filter, because the chemicals are called diterpenes, and that is what increases your LDL. There are a lot of good things in the coffee bean in terms of improving longevity and stuff. 

That was a pretty interesting one for me. In terms of other benefits, we talked about cutting out all those sugary drinks. I would say that is number one for sure. Alcohol, that is another thing, because for a long time, all the cardiologists were like, "Yes, have that one glass of wine, red wine, and it is going to help you." Alcohol is a toxin. I do not recommend alcohol to any of my patients. There are plenty of other ways you can get the antioxidants and things like that, and we do not need to turn to alcohol for that.

Sadly, now the data is out there and definitive that it is not good. As much as I love a glass of wine, I cannot lie to myself and say that it is good for my heart. It is not really good for anything. 

No. I feel like I am just the bearer of bad news on this episode.

No, but I think it is good for people to know, right? Because it is also, I think, exciting that there are so many changes that can be made that have such a big impact. If our diet could not change some of these outcomes, then it would not really be worth talking about. The fact that it can have such a huge impact, I think, is empowering. People can make a change and a choice, and it can make a big difference, which is cool. Cholesterol, I think we talked about it a little bit, so diet, how much do you usually see it changing your cholesterol numbers?

Not much.

You can do a fair amount with diet, but sometimes you are still going to need the medicine. I especially love that they changed recommendations in terms of screening for people, so now that they actually screen for some of the markers that can show more of a genetic predisposition to cholesterol issues. When people find out if that marker is higher for them, meaning they have a higher genetic predisposition, then that is probably a little bit less likely to change versus somebody who does not have that, and it is more from ultra-processed foods and things like that. Blood pressure, how much does diet really change blood pressure?

With the DASH diet, you can expect a 10 to 15 millimeter of mercury drop.

That is actually pretty good.

At least you can maybe not be on two meds, maybe on one. That combined with weight loss. Weight loss, you can drop another few millimeters of mercury. With all these lifestyle modifications, it is possible to get about a twenty-point drop, just with lifestyle.

It is pretty good. That is also something for people to remember, too. A lot of times, when you lose weight, that is another aspect that sometimes can come along with healthy eating and then exercising. If that, then you are losing weight, which is another way that it helps decrease and control your blood pressure. What would you say a realistic day of a heart-healthy diet looks like? 

For breakfast, like we talked about, oats. Oats would be good. Chia seeds. The night before, if you have a hectic morning, you could prepare this the night before. Just put some oats or chia into one of those mason jars, pour in some milk. You can try different kinds. Almond, oat, or even just regular milk. If it is not a big amount, it is fine to use a little bit of cow's milk. Just let that sit in the fridge. In the morning, throw on some blueberries, some cacao nibs, some nuts, you can drizzle a little bit of honey, and then you have your breakfast there, and maybe with a banana.

There you have your fruit, and you have some nuts, and you have the fiber, so it will keep you full. There are also eggs, and combine that with some fruits and vegetables. Usually, those are my go-tos for breakfast. Lunch, a nice salad, lots of different colors of vegetables. If you are not following a plant-based diet, you can add on your protein with chicken, and drizzle on a good amount of olive oil. The Europeans, their salads are pretty much swimming in olive oil. 

If you get some good quality olive oil and you just drizzle that over your salad or make it swim in that, then you have your vegetables, you have your olive oil, and you have fruit with it too. Dinner, same thing, like chicken with a side of steamed veggies. That is usually what we do. Sweet potato. Sweet potatoes have a lot of benefits, especially the purple ones, which you cannot find everywhere. Japan has a lot of people who live very long, and they study a lot of these people, and they eat these purple sweet potatoes, and they have a lot of benefits in there, a lot of micronutrients and antioxidants.

Fish, with the Mediterranean diet, 2 to 3 times a week, some fish intake. Salmon, if you do not like that, you can do tuna, sardines, or mackerel. Those are the go-to options for fish, a few times a week. If you do not like fish or you are on a plant-based diet, then you can get supplements as well for that. That is pretty much it. you can have grains with the Mediterranean diet. You could do some whole-grain bread here and there, and put some avocado toast. You could do that for a snack or for breakfast. Lots of options, the Mediterranean diet is not really restrictive. 

I always tell people it's like, really, if you think about it, it's more like adding healthy things in. When you are adding all these good things in, you are like, "Wait a minute, I am really not restricted."

Legumes, I do not think we had really touched on legumes, so that is also another important part of fiber, so chickpeas, kidney beans. All these legumes are also really helpful for heart health.

Lentils, all that. As you said, in Europe, when I lived in Spain for a little bit, it was always like I wouldn't mind what they would add olive oil to. I feel like here we add butter to everything, and there they add olive oil, like even bread.

It is a big difference.

Yes. Here, it's as if you're going to have a piece of toast, you're spreading some butter on it, and there it is, all olive oil. I do not know. It's just interesting to me, even like those things, how it's like they just use olive oil.

It is very different. Actually, the PREDIMED study was from Spain. The olive oil is something that's very beneficial, which I think is really underused here in the States.

I know it has changed how we use olive oil here. We will now even add it to our rice and things like that, just like after it's cooked, of course. Just changing that. Even like I think some people do not realize, when you cook the grains like rice and breads and things like that, if they are frozen or cooled off first, the next day they actually change so that there is more soluble fiber in it, which is also helpful because then it will decrease that glycemic index, so the sugar load and everything. It increases the fiber on that, so it is also another way that people can help with that. 

Opt for brown rice if you can. There are also other things, like psyllium. You can just buy that. It is not in food, but it is like psyllium husk. They have the supplements that you can get, and you can get fiber that way as well. You just mix it with water and take it down.

Take it, and inulin is another one too that you can take that helps. I know pretty much everything purple is so good for you. I do like now that when you go to the grocery store, a lot of times, even if you get frozen carrots, a lot of times the medley will include the purple carrots in there. When you are trying to get gut diversity, that is so important. What is nice is even though it could be like three carrots because they are different colors, that actually helps with the diversity because they are different plants, which is so great. 

Trying to eat stuff that has lots of different colors. When you think of the typical American diet, it is pretty beige, just bland. There is not much to it. Just aim to find those different colors, and that is where you are getting all your micronutrients, all the antioxidants. Aim for a colorful plate. 

Tips for busy people who are trying to be healthy for their hearts.

The overnight oats and chia for breakfast, I think, is huge because you just put everything together, pop it in the fridge, and you're good to go. In the morning, you just add some of your toppings, and you're good to go. You can make your eggs ahead of time, boil your eggs, and you can take some of that with you. You have got to just pack some snacks, which I do now. I just have my containers, and I put in walnuts, blueberries, super easy to do. Take apples, bananas, and those that travel pretty well. Oranges. Just pack your stuff the night before and throw in all the fruits you can. That is how I go about it.

I know some people struggle with, "Maybe I cannot have a cooler, or I do not have a fridge, or something." There are a lot of healthy things you can still do even without that. We talked about nuts. Also, you can bring a whole avocado with you, and then just bring a knife. It is good until you open it up.

Bananas, apples, those can stay out for a long time. We do not really have issues with that. Even the berries, I mean, those can stay out for a while. You can have that as your mid-morning snack or something, and you should be good with that.

There are a lot of options out there now for people, which is good. This was awesome. I think that this was a great overview of diets because I think people, again, especially with social media now, can get overwhelmed. You get a lot of conflicting advice and what is trendy versus what has actually been studied. This was awesome for going over what is really beneficial for our hearts.

I was happy to be here, and it was fun talking about this with you.

I am sure we will do another episode soon. Thanks again.

You're welcome.  Bye.

Bye.

Dr. Khadeeja Esmail

UF Health Jacksonville

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