The Health Curve

Heart Disease in Women: The Deadly Crisis No-One Talks About - with Ritu Thamman, MD at University of Pittsburgh and American College of Cardiology

• Dr. Jason Arora • Season 1 • Episode 2

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Heart disease is the number one cause of death in women globally. It is responsible for 1 in 3 female deaths, or 1 female death every minute.

But, no one talks about it.

We delve into what makes heart disease in women unique, why it is underdiagnosed and undertreated, and what we can all do to help improve heart health in women.

Joining us is Ritu Thamman, MD, a Cardiologist and Associate Professor of Medicine at the University of Pittsburgh, a Fellow and member of the Women in Cardiology Leadership Council for the American College of Cardiology, and a senior collaborator with the American Heart Association.


SPEAKER_00:

Hello and welcome to The Health Curve. I'm your host, Jason Arora. Today we're going to be delving into a topic that doesn't get nearly enough attention. Heart disease in women. Why is this important? Well, did you know that heart disease is the number one cause of death in women worldwide and that it kills more women every year than all cancers combined? Do you also know that heart disease accounts for one in three female deaths globally and that that's the same as one woman every minute? So many people think of heart disease as a man's disease, but that couldn't be further from the truth. Many women don't realize they're at risk. And even more concerning, the medical community has historically fallen short in diagnosing and treating heart disease in women. So today we're going to explore why this is, what makes women's heart health so unique, and what we all need to know so that we can help protect heart health in women. To help us with this, we have an amazing expert guest for you today, Dr. Ritu Thumman. who is a cardiologist and associate professor of medicine at the University of Pittsburgh. She also serves in many leadership roles with the American College of Cardiology, the American Heart Association, and many other organizations. Ritu, thank you so much for being with us. Now, this is a big topic, so let's get into it. Firstly, can you start by explaining what heart disease is or what cardiovascular disease is?

SPEAKER_01:

So cardiovascular disease, particularly in women, pertains to not only the heart, but the vascular juror as well. And so when we think of it as a continuum, I think that is helpful because it is the heart as we know it, but it's also attached to the whole vascular juror of the body. And so it has to be thought of as in conjunction with that. And even as we think of particular disease types such as hypertension, which is the most common cardiovascular risk factor known, it starts in the aorta, but then it comes back and it will also affect the heart. So it's all-encompassing.

SPEAKER_00:

So you'd say it's a cluster of conditions that includes heart attacks, strokes, high blood pressure, heart failure, all these sorts of things. Why is there still a misconception that heart disease is primarily a men's issue? Because I think that's still true, right?

SPEAKER_01:

It is still true. In fact, this has been a truism now for over two decades, at which point the American Heart Association recognized that women were being underrepresented in not only the clinical trials, but just the awareness of And the awareness was that women themselves did not know that they were most at risk for cardiovascular disease. In fact, the prevailing perception, which was echoed by most of the doctors they were seeing as well was that women get breast cancer, women get other sorts of diseases, but cardiovascular disease was never thought of as on the forefront. Plus the US Department of Prevention also didn't really have guidelines to clearly identify and screen those people for cardiovascular disease, like we have set diagnoses or parameters that are set for breast cancer, say you have to go for a mammogram or cervical cancer, you have screenings, but there was no such thing for cardiovascular disease despite the fact that it was, and it still is, the most common, not only disease in terms of prevalence, but the number one cause of death for women

SPEAKER_00:

around

SPEAKER_01:

the world.

SPEAKER_00:

Indeed. And I want us to come back to why women are underdiagnosed and undertreated. But just before we do that, how does heart disease in women differ to that in men, both in terms of the symptoms they might experience and the outcomes? I mean, is it different? And if so, how?

SPEAKER_01:

Well, it is both the same and different. Part of the physiology, obviously, is the same. But the way it manifests is and therefore the pathophysiology will be a little bit different because the environment, the hormonal milieu, and also the size, which again affects all of the fluid mechanics and the basic physics that pertain to the heart and blood flow. So for example, we know that women will have a type of aortic stenosis, a type of valvular heart disease. But the way it manifests and the consequences, the way the heart experiences that sort of narrowing of the aortic valve is different. So the response to the same loading conditions, in that case could be the valve, could be on top of it hypertension, women don't respond the same. They're more apt to get a more of a diffuse fibrosis, for example. And a lot of these kinds of different adaptations are how we recognize the differences amongst women and men. And that has clearly come to the forefront in the last several, I'd say the last decade in particular. Before that, there wasn't that much emphasis placed on this, but now with the newer awareness campaigns, there is a push to have more women studied, enrolled in clinical trials, and also just studied in general, even at a basic science level, to understand these differences that are quite relevant to how we then go on and treat women, which may be different. Not only... because their size is smaller in general. You know, women are smaller, smaller height, and so they manifest differently. And in terms of symptoms, I think this has been a major point of contention because if you in the past ever Googled MI or chest pain, the image of the Hollywood heart attack would come up. on your Google search. And there were only pictures of men and not of women, but women don't necessarily have that classic Hollywood myocardial infarction or chest pain. They, in fact, may have more... They will have chest pain, but they might have it accompanied with shortness of breath or jaw pain or arm pain or fatigue or... associated symptoms, which sometimes can get lost in the shuffle when they present to their physician. If they're not, if their physician is not aware that those may be nonspecific symptoms, but in the context of the high prevalence of cardiovascular disease, it must be investigated just as in depth as you would for a man.

SPEAKER_00:

And I think the General understanding where it does exist is that in women, it may not present as sort of the classic crushing chest pain, which is also true in men. I think when we train as physicians trying to recognize this in our patients, if they have that crushing chest pain, okay, that's a bit clearer. It still may not be a heart attack, but we need to be looking out for more nonspecific symptoms like shortness of breath, nausea, these sorts of things.

SPEAKER_01:

There was a study called the Hermes study. also out of Harvard, that looked at the words we use to describe the pain associated with a myocardial infarction or an MI heart attack. And all of these words were associated with it. So chest pain per se encompasses all these other qualitative descriptive terms based on how somebody is used to articulating that pain and based on their cultural background, how much they're going to express that. So I think it is quite variable. But at the end of the day, you have to just keep in mind, no matter how they're describing the pain, if it's coming from that area, the chest area, that you have to take it seriously. And It's the number one reason why people visit an emergency room in the US, right?

SPEAKER_00:

And so why are women so often underdiagnosed and undertreated? I know we sort of touched on it earlier when we mentioned communication is one thing. The way we do research is another thing. Can you talk a bit more about that?

SPEAKER_01:

So let's talk about why they're underdiagnosed. It's multifactorial. It is not one particular thing. First of all, women generally tend to be caregivers of their families. And when we first started looking at this, one of the surprising things we found out was women didn't want to be calling the ER when they had chest pain. Why? Because they got to take care of their husband, their children, their parents, whoever they're taking care of. And they always would put those people before themselves. So there was a tendency to then just ignore whatever the symptoms were until it got so unbearable or you became hypotensive and passed out or something was so severe that you couldn't just go on doing your things and ignoring it in the context of I'm taking care of my family. And that still persists today. That's one aspect of it. The other reason it's underdiagnosed is then physician recognition is lacking. Like we said, when they look at surveys of physicians, general physicians, some cardiologists, and present to them a case of a female with chest pain, not all of them are even going to recognize that that's the number one likelihood is the fact that that woman might be having cardiovascular disease. So there's not an awareness there, just in general across, you know, what are you going to do in terms of a workup. And then also the way we diagnose women, because A, they may present later because they have not prioritized themselves in terms of coming in. They may not communicate in words and terminology that really reflect is explainable or in a way understood by whoever's taking care of them. And every single parameter that we cardiologists measure is delayed when a woman presents for diagnosis. For example, when they present to the ER for chest pain, their diagnosis is delayed between the time they present and the time they end up in the cath lab. And this is across the board. It's been that way. And while that time difference has certainly shortened as our awareness has grown, it's still not the same. Women are offered less the same procedures. So if some man comes in with a myocardial infarction, they'll be offered a coronary catheterization. Well, women are offered that less. Why that is, you know, is still not clear. It may be some biases. It might be the fact that we just assume that women are, you know, not as high risk and maybe they can be managed medically without all the latest interventions that are possible. And so for this reason, women are not only underdiagnosed, but then undertreated. And the last big part of that undertreatment is the fact that most of the clinical trials have used male participants and enrolled men mostly. And so our knowledge base of what we should be doing, how we diagnose, how we treat, what are the best, what is the best thing to do to get the best outcomes in women is not clear. So we're basing a lot of our treatment modalities based on studies that have been largely done in men.

SPEAKER_00:

And this is a really critical point. For any intervention or medicine or treatment that's offered to people, it has to undergo really rigorous research first. And part of that is to do the research on humans. And for that, you need human participants. And historically, more research has been done on male participants than on female. And so when you're translating those research findings It's more accurate in men because that's who the research was done on more often than on women. And so for heart disease in women, a couple of statistics that I came across that are surprising. One is that a woman experiencing heart attack symptoms will wait on average more than 10 minutes longer than men. man to seek care. We've talked about why that might be, but also that women are twice as likely than men to receive an incorrect initial diagnosis after a heart attack, which speaks to our research failures and our translation failures from research to care. There's definitely this gender bias in the way we do research and in the way we practice medicine, but This is how things are today. I know that there are efforts to improve this. One is, you know, communication. One is improve the diversity in clinical research, get more women involved. But a lot of what we're trying to focus on on this show is how people can advocate better for themselves in the way they navigate their health. So what can women and, you know, of course, also not women, you know, men, others do to advocate for women's heart health, you know, when they maybe feel their symptoms are being dismissed?

SPEAKER_01:

That's an excellent question. And I think it will require a multifaceted, multi-pronged approach. I think that, first of all, if a woman is having symptoms and they're being dismissed, then they should try to seek out another opinion. Now, on the flip side of that is the fact that In cardiology, we've had mostly a flat line in terms of how many female cardiologists there have been in practice. And that's been historically around 13% to 15%. While the numbers of trainees are going up, those numbers in practice, however, remain the same because of the aging population. And so there is... proof to show that if a female patient is being seen by a female physician, they might take their symptoms and their condition more seriously and less apt to just dismiss it. But we need enough of those people to see those types of female patients. So that may not always be the case. One way that men and women can advocate, besides trying to seek out another Second opinion, if you will, is the fact that dollar per dollar, the funding that is being poured into studying diseases is really not equitable of the budget, the NIH budget, which I know now has been frozen. But in the past, it's been about 3% of that dollar amount is going towards cardiovascular disease and women studies. And the vast majority of it is going elsewhere. So while this is the number one problem, it's still receiving the least amount of dollars to really elucidate and figure out what's the reason, what those causalities might be. And in fact, whatever we find out in women patients also helps us diagnose women. in male patients just as much. So if we know that women have a lot of fibrosis, it helps us understand that men, you know, they may reach that same point, but it may not be in the same timeframe, for example. So there's advocacy needed at that level. So there should be like a Title IX, which was for women participating in sports at the collegiate level. We need a Title IX in terms of research allocation should be fairly done. between what we're studying in men and what we're studying in women, certainly. Maybe there'll be a day where that comes.

SPEAKER_00:

3%, it's absolutely shocking, isn't it? But I feel like the conversation is improving, increasing, and it's the reason we're doing a podcast episode on this today. We're going to do lots more on women's health as well, largely to raise awareness of the gap here. Just to keep us going, now we're getting into more of what patients can do for themselves, right? And so if we talk about risk factors in women specifically, so, you know, obviously the female body goes through things that the male body doesn't. Of course, there's menstruation, there's pregnancy, there's menopause. We have things like autoimmune diseases that are more common in women. Can we talk a little bit about the risk factors as they pertain to women? And then perhaps we can get into what we can do about them.

SPEAKER_01:

Yeah, I think that's a really important thing. And that's one area that's been heavily referenced emphasized and studied over the last decade. One is that, yes, women menstruate, they are able to get pregnant when they do get pregnant, if they do. And they get either diabetes, gestational diabetes, for example, and have a low weight infant. That makes them at a higher risk for developing coronary disease down the road. If they develop preeclampsia or hypertension during pregnancy, again, their risk of cardiovascular disease goes up. And these are the types of things that you can't just ignore. So if in your obstetrical history, you've had any of these conditions, you must follow up. And most women just go to their OBs for their care. You know, they go in, they're otherwise healthy, but you have to go in to see their OBs when they're pregnant. And then they may not follow up if they even had diabetes during pregnancy or hypertension during pregnancy. I think those are the two very, very important ones that women should be aware of and make sure that they follow through and assess, make sure that they're not developing other risk factors that will accelerate the atherosclerosis that they're much more prone to. I think that's a That's one area that all women should be aware of and do. Now, if you are not pregnant and you still develop, say, hypertension or you develop diabetes, apart from the pregnancy era, you are at higher risk for not only stroke or an MI than men. And so you have to be aware that even if you versus a man have the same risk diabetes, say, or you're overweight, or you don't exercise and you have low physical activity, all those risk factors are more substantial in women than they are actually in men. And that's something also to keep in mind. So it's not equivalent. And so women have to be extra careful in terms of trying to really be on the ball and focus on preventing those types of some age-related conditions, but other related to life's essential aid in terms of nutrition, in terms of exercise, and all of that.

SPEAKER_00:

And so why is that risk higher in women?

SPEAKER_01:

Yeah, isn't that interesting? So when you look at the Nurses' Health Study and the women's, the Y's, ischemia studies, women ischemia syndrome evaluation studies, they've all shown that that risk is higher. And why that risk is higher is, again, multifactorial, partly because the proportion, say, of women that are overweight or obese is higher in women than it is in men. The number of women that are more physically inactive is greater than it is in men. And that could be a cultural thing. It can be related to the fact that they didn't grow up, you know, playing sports in the same way or they're not interested in it.

SPEAKER_00:

It's very interesting because still many people, when they think about obesity, they think of men. And so this is, it's not just an issue for heart health. It obviously sort of goes, you know, across the board.

SPEAKER_01:

Exactly. And to that point, you know, That's something that women should be advised on, and they should know that if I develop obesity, say, and my BMI is in that range where I'm considered overweight, or my BMI is over 30 and I'm obese, even with the new Lancet criteria that was just released a couple days ago, which says, you know, BMI is not the be-all, end-all. We understand that. It doesn't tell you what percent fat you have. And so you should incorporate other measures like waist circumference. And based on your ethnicity, those numbers change. And women should be aware of that. I feel like it should be on buses. It should be in every grocery store. Those parameters and those awareness campaigns where it's just so ubiquitous that people are not surprised. And they know, oh yeah, I have to do this.

SPEAKER_00:

We'll get back to this conversation in just a moment. But if you're finding this episode helpful, here's a quick ask. Take a second to follow or subscribe to the Health Curve podcast wherever you're listening. And if someone in your life would benefit from this episode or any of the others you've heard, please send it their way. All right, let's get back to it. And so we touched on menstruation earlier. Of course, when people are younger, their risk of heart disease is a lot lower, not sort of non-existent, but much lower. We touched on pregnancy. We talked about gestational diabetes. Of course, there's also preeclampsia. Anything to say on that and heart disease risk and what people need to know?

SPEAKER_01:

Well, if you have preeclampsia or hypertension during pregnancy, first of all, you must be monitored after postpartum, we call it, and be monitored for postpartum hypertension, making sure that you're on blood pressure medicines and that your blood pressure is controlled because your risk goes up significantly for developing cardiovascular disease, especially if your blood pressure is not controlled. And there was... some policy changes that came out of research that was done on that. Because, for example, women who were on Medicaid would come in and have their delivery, and they might be hypertensive while they were in the hospital delivering their child. But then the Medicaid would only cover six weeks of follow-up. And as a result, a lot of these women were going home with hypertension, hypertensive disease, or what we call postpartum hypertension, and they weren't being followed up because they lost their coverage, right? So after six weeks. So then the government, looking at the studies, decided that they would expand that coverage till six months, which was a real positive outcome. And, you know, I think It shows the power of this kind of research to uncover these truths that will ultimately lead to better policy. and better outcomes in women. And that's a clear example. So if you've had any of those conditions, postpartum hypertension or worse, like preeclampsia, that is more significant or gestational diabetes, you're not only at risk for developing, say, diabetes if you had it during pregnancy, but then you're also at risk for developing cardiovascular disease because that is along similar pathways. And you have to be more vigilant in terms of your follow-up and vigilant about knowing your numbers, we call it, right? Blood pressure, what's my LDL cholesterol, what's my weight, what's my blood pressure, what's my sugar and hemoglobin A1C, which is just a parameter, measuring sugar over three months. What are those numbers? Every woman should know what those are. And if they're not right, you have to sort of jump on that grenade before it gets fired. And that's what we're advocating. And that's the best thing a woman can do for herself.

SPEAKER_00:

Right. And just taking another critical life stage, which is the menopause as well, and our understanding that as estrogen levels drop during menopause, heart disease risk may go up. Can you talk a bit about that?

SPEAKER_01:

Yeah. There's been a a lot of information and a lot of misinformation, including what we learned from some of the studies. For a long time, there was this notion that you just do not give hormonal replacement therapy for women, end of story period, right? Because these women are at higher risk for developing blood clots and breast cancer. However, the data has been re-examined and we clearly know now that there is a one, depending on the route of estrogen and progesterone that you give, the dosing, and the timing. When in menopause are you actually giving that medication and for what duration? We know now that it simply is a safe treatment and we use it in menopause. certain cases as needed. And we know that those women that have those vasomotor symptoms are at more high risk for developing CBD. So we want to make sure we treat them. And those are the patients that in the past, even those that say at a young age had a hysterectomy, for example. And even those, there was such a fear of giving hormonal replacement therapy, these women who had surgical menopause because of hysterectomies were not given replacement therapy, even though they were maybe in their 30s, late 30s, early 40s, you know, even before menopause. And they had shown that those outcomes were not as good. So we've come a long ways. And certainly the cardiovascular community in terms of prevention guidelines. I only mentioned a few things, but there have been other collective literatures written about how we proceed. So if a woman does have menopausal symptoms, they should not be ignored. And that they should know that they can be treated with hormonal replacement therapy, depending, like I said, on obviously what your family history or your own history is of breast cancer or pulmonary embolism or blood clots, but also the time. Like, did your menopause, did you just start? You know, it's much easier to give the treatment right early on rather than later on in the course.

SPEAKER_00:

And all of this, of course, it gives patients a lot more fuel, you know, what we're talking about to help with their conversations, you know, encourage them to ask questions, bring heart health into the conversation, whether it's with their OB. or it's with their primary care physician, especially, because this is not a niche problem in women. It's the leading cause of death. I just want to talk about one more set of conditions as sort of an off-ramp for talking about cardiovascular disease or an on-ramp rather, which is autoimmune diseases. So we know, of course, we have this chronic inflammation, this increased risk of heart disease as well. And of course, autoimmune diseases are more common in women than in men. Can you talk a bit about that?

SPEAKER_01:

Sure. So autoimmune disease is considered a, quote, risk enhancer in our latest guidelines, which will probably be revamped soon. And that is an area that is generating a lot of research, and it's developing into its own fields. So we call it cardiorheumatology now, just like we have cardio-oncology. So cardiorheumatology is assessing patients cardiovascular risk in those women that have these autoimmune or rheumatologic diseases, for example, like rheumatoid arthritis or scleroderma. And what we're learning based on our advanced imaging techniques is that the women are presenting earlier and that their risk factors have to be clearly not only delineated but treated and that they're apt to develop cardiovascular disease earlier because of the ongoing inflammation that may be modified with some of the newer drugs that are out there. But imaging is key to part of the risk assessment. And actually, that risk assessment is going on and the research around that is going on as we speak. I mean, there's no set of guidelines per se, but there are two major institutions that are doing the most of the research. One is out of Harvard and one is out of Mayo Clinic. Both those places, I know for sure, have huge imaging programs. And by imaging, I mean CT. So we're looking at CTAs, coronary angiograms done in radiology to assess what do the vessels look like. And there's certain inflammatory markers that are actually imaging inflammatory markers that make the arteries more high risk for future events. And in those patients, we're looking at, well, what sort of prevention should we start? Everyone knows about starting with a statin. even if the LDL may not be elevated. But then there are other anti-inflammatories that are being tested. So it's a widely active and evidence-generating area that is being built as we speak.

SPEAKER_00:

So it seems like the message to our listeners is, look, it's an underdeveloped area, both in terms of research and in terms of what's going to help catch this as early as possible in terms of treatment, diagnosis, screening, etc., And so you've got to ask questions. You've got to bring it up in the conversations with your GP or primary care physician or your OB or whatever. And you've got to start to track and monitor your numbers yourself. Let's talk about prevention and what are the key things every woman needs to monitor or do to stay ahead of their heart disease. We've already talked about ask the questions, have conversations. Heart disease is too big a problem for women's health than for you to wait for it to be brought up with you. We're not trying to over-medicalize this, but of course there is a gap as we sort of started the podcast episode on. But what can women do more in terms of tracking, in terms of prevention, in terms of habits to help themselves whilst we try and bridge this gap on the medical side?

SPEAKER_01:

So we use something called the pooled cohort equation for assessing cardiovascular risk, which is really, does not pick up risk in women as well. Recently, as of 2023, there's an AHA risk prediction called PREVENT, which encompasses a more wider range of factors and has incorporated much larger data sets to come up with a risk calculator. So number one, our listeners should know that there are better risk calculators that can be utilized. And to that end, knowing your numbers, that includes, okay, what were my numbers when I was pregnant? That means my sugar and my blood pressure. Were they elevated when I was pregnant? Did I have any diagnoses? If so, then I have to be super vigilant in the postpartum and for the rest of my life because I'm at higher risk. What is my blood pressure currently? What is my sugar level? What is my cholesterol level, specifically my LDL and ApoB levels? There's lipoprotein A, which is also elevated in about 20% of the population, but most people, we're not sure what to do with that quite yet, although there's a lot of developing ongoing trials looking to see in the future. The real issue comes down to this. So say a woman has a known risk factor of high cholesterol. They're much less apt to be prescribed a statin. They're much less apt to take the statin. They're less apt to even get it filled in the pharmacy and to have their numbers controlled. That's just one example. So the onus comes down to this sort of paternalistic view of healthcare. You know, somebody is going to take care of me. My doctor is just going to tell me what to do. That complacency has to change. It has to be more a proactive and that, hey, you know, I know that these things exist, that there are these biases that are out there, but that doesn't mean that I can't advocate for myself or I can't say, hey, you know, I need my cholesterol checked. One of the things that imaging has helped with is sometimes you look at a number and you think, oh, it's just a number. What does that really mean? But if you see it on an imaging study and a picture of your heart shows, hey, you know, you got all this calcium in your arteries. It makes people more apt to take care of themselves and take the medicine and control their risk factors a little bit better. Sort of like a sign, an impetus. So I have no problems sending people to get a coronary calcium scan to really just see, you know, okay, well, they're good for five years as long as you don't have diabetes. And it tells me what your risk is, you know, in general. So if you're at a zero, then that's good. We call it the power of zero. But if it's more than that, then, you know, you need to do something about it. So that would be probably the strongest message is do not stick your head in the sand like an ostrich. You have to come out, face, and look at the numbers that you have, even if nobody else is doing that. But you have to do it for yourself because if you don't take care of yourself, you can't take care of your family or whoever your loved ones are.

SPEAKER_00:

And so there's the tracking of the numbers, bringing that up with your healthcare provider and saying, you know, I need to know these numbers, I need to monitor them and track them. And this is not over-medicalizing it. Heart disease, like many chronic diseases, or all chronic diseases rather, they develop slowly over time. And if they're not measured, you don't know where you are with your risk or with how close you are to having overt disease. But Then we get into, so we have the tracking and the measuring. We have the bring this up with your physician. Try to speak to someone who's going to be able to talk about heart health with you because it's a big enough problem for women. And then it's the standard stuff that people get lectured on all the time, which is around exercise and healthy eating and good sleep and having social connections and not smoking. Can you talk about that a bit? And I know people hear this all the time and it all comes down to how do I fit this into my lifestyle, habits, et cetera. But from a woman's perspective, how would you frame these kinds of things that might help us be a little bit more insightful and a bit more helpful.

SPEAKER_01:

Most women that you'll talk to will say, I don't have time to do this leisurely exercise because it's considered like a leisurely thing, but it's actually not. Just like food. Food is medicine. Exercise is medicine. Both are. Like you're taking a daily dose. And the good thing is that for exercise, your heart does not care if you do five minutes here, five minutes there, and you add up to 30 minutes in a day, that's okay. Because people will say, I don't have this collective time. And I just can't do it. And most women, if they're taking care of somebody in the house, young children, older people, they can't get out of the house or they come home from work and they're too tired to get out of the house. So that is something that you have to work around. But I think now that people recognize you can just have a workout with some free weights that are not expensive and you don't need any fancy machine, you don't need a fancy equipment or even space. As long as you can squat and you can jump up and down, that's all you need. That's where the digital realm has really made a dent. So you can incorporate that five minutes here, five minutes there. And that's what I tell my patients, the ones that are so extremely busy. And then on the weekends, you can do more. But on the weekdays where it's just packed, that's just five minutes is better than no minutes.

SPEAKER_00:

And I think that's a common misconception around exercise is that if you only do a little bit, it doesn't count. And that's obviously not true.

SPEAKER_01:

Exactly. So start with five minutes if that's all you got. But that's five minutes. And, you know, that does add up. And in terms of food, you know, we are in a food crisis in America because of the nutritional quality. And, of course, both major organizations, ACCHA, have huge initiatives out to try to revamp the thinking around food where food is medicine.

SPEAKER_00:

Our listeners will be pleased to know that we're going to do a few episodes on food and nutrition just because it's such a huge topic, but very sort of relevant here.

SPEAKER_01:

Oh, that's tremendous. It is so very relevant. And so there are parameters, of course, salt. The DASH diet shows that if you have 2.4 grams a day or less, you're going to live longer. Nobody really adheres to that, but it can be done. And you can learn or sort of relearn how to eat. And that's something that all of us in America struggle with because food is ubiquitous for some, but it's mostly unhealthy food. We here at Pitt, I teach a culinary medicine class at a teaching kitchen at Phipps, which is a botanical garden, so we use their kitchen. materials and, you know, teach medical students how to cook, not only for themselves, but then they can teach their patients. You know, it doesn't have to be cumbersome. And in fact, a lot of the immigrants that come from all over the world, they bring their cuisines with them and they cook at home. They mostly will eat simply, however they've been used to preparing things. And it's economical and, you know, it can be done, but you just have to know How? And that's a whole other can of worms. And also, this is so critically important because all our policy around food in America is tied into the Farm Bill. And there's a lot of circulating red tapes. around changing that paradigm and it's gonna take a long, it'll take some time, but now that it's recognized, it's such a critical part of our wellbeing and it is getting the attention that it needs, but of course we can do much more. And again, I think the digital realm and space will help with that because now if you don't know how to cook something low fat or something healthy, you have YouTube, you can go for free and just look up a recipe. But not everyone has access to that. Not everyone has access to fresh fruits and vegetables. Again, those things are changing, but it's going to take a while.

SPEAKER_00:

Indeed. Well, we'll be doing a lot more on sort of the lifestyle variables that can help improve one's overall health, but also especially their heart health and their metabolic health. So we will come back to that. Any last messages for our listeners today? if they have just a couple of things they want to take away from this episode, what's going to be most useful for them?

SPEAKER_01:

I think number one is value yourself. Put yourself first. And I don't mean that in a selfish way. But for you, in order to help somebody else, you have to be able to be healthy yourself. Otherwise, you're not going to be able to do that kind of work that you perhaps are required to do or need to do. You shouldn't feel bad about that. It's not a shameful thing. And I think that that attitude is really important. So as you go into and you delve into what your risk factors may or may not be, you have to go with that mindset. So number one, use that mindset. That's the only way you'll be successful. And then you can get into the nitty gritty of, all right, you know, these are well-known risk factors and I will start with taking small steps because it can feel overwhelming. Like I have to know all these numbers about myself, my blood pressure, my LDL, my sugar, hemoglobin A1C, my weight, you know, all these. Start with one and you can do it incrementally. But, you know, set up a timeline for yourself. Okay, I'm going to check this this week or this month, and then I'm going to go on to the next parameter. And when you start making changes in either your exercise or your diet or what you're eating or how much you're getting out, try again. to remember that Rome's not built in a day, and so it's going to take you some time, and that's okay too. But that even five minutes or one substitution is going to make a difference, and don't minimize that effect. Because over time, small changes are going to be effective, and you'll be able to persist in them rather than not.

SPEAKER_00:

Excellent. Very helpful. Thank you so much, Dr. Ritu Thaman, for joining us on this podcast episode. We hope you found it helpful and thank you very much for listening.

UNKNOWN:

Thank you.