Health@Google: "Women, Stress, and Heart Disease" with Dr. Atul Sharma

>>Dr. Atul Sharma: For all conditions, if you look at men and women, if they have diabetes,
they are three times more likely to die from heart disease, no matter what they do. The
only piece of good news is this study done in The New England Journal in 2002 that looked
at people who were at risk of developing diabetes, and they randomized these people to three
different groups. They gave one group of people a sugar pill, one group they gave a diabetes
medicine that has been shown to prevent diabetes, and in the third group they said 'here's your
diet, we want you to exercise 30 minutes four times a week'. And they followed them for
four years and you can see that the rate of developing diabetes if you did nothing is
58 percent in this group. If you took the medication, the rate of developing diabetes
is 31 percent. And if you adhered just to lifestyle changes and didn't take medication,
the rate of developing diabetes was 19 percent. So diabetes can be prevented, which is probably
the single most important thing that we need to know from this slide.
I'm going to talk a little about stress and heart disease and stress and women and heart
disease. This is the first report of a cardiomyopathy, a weakening of the heart muscle, provoked
by stress in women in the United States is published in the Journal of Circulation. And
this is what it looks like, it's called, you may have heard of it, it's called "Broken
Heart" syndrome or sad heart syndrome or the real name is stress-induced cardiomyopathy
or Takotsubo's Cardiomyopathy. But this is a picture of the main pumping chamber of the
heart, and there's a catheter in here that you really can't see very clearly. The catheter
is injecting dye into the main pumping chamber. And this is before the heart beats and this
is when the heart beats. So you can see in this instance that this is the base of the
heart and this is the apex of the heart. The base of the heart is squeezing normally and
the rest of the heart is just ballooning out. The other name for this syndrome is called
'apical ballooning syndrome'. And this is purely a response to some sort of severe emotional
stress. Fatal at times and seen almost exclusively in women. This is an example of just an MRI
sequence. These are relaxation of the heart pictures in people with stress-induced cardiomyopathy
and then in normal patients and then when the heart beats, you can see the muscle here
compared to here thickens in normal people. And in people with stress-induced cardiomyopathy,
it actually doesn't thicken and bows outward.
>>female #1: What kinds of stress [inaudible]?
>>Dr. Atul Sharma: Yeah, that's a great question. Let me get to it, right here. So this is,
this is actually the first group of patients characterized in The New England Journal immediately
after that circulation article. Neurohormonal features of myocardial stunting due to sudden
emotional stress, The New England Journal, famous journal. Another same picture and you
can see that in people with stress-induced cardiomyopathies, this is an MRI sequence,
there is no scar, this is all muscle looks like on MRI, it looks the same kind of gray
density. In people with heart attacks, there is a very bright scar. This is scarring and
permanent damage of the heart muscle. In the cardiomyopathies, you don't have permanent
damage, you have transient damage that goes away as the stressor goes away. So this is
the list of 19 patients that have this condition and you can see the patients are numbered
here. Their age is given here and they range anywhere from 27 to 77 and you can see they're
almost all women. There is one man in this group, alright? And if you look a little further
you look at the emotional stressors.
>>female #2: [inaudible] [audience laughs]
>>Dr. Atul Sharma: Exactly. Exactly right. That is why that my wife will never have a
surprise party as long as she lives, and that's my excuse.
[laughter]
>>Dr. Atul Sharma: Yeah, so one surprise party and some other, some other [inaudible]. But
most of them are deaths.
>>female #3: [inaudible]
>>Atul Sharma: I'm sorry.
>>female #3: [inaudible]
>>Dr. Atul Sharma: Sure, sure. Mother's death, car accident, surprise reunion, [audience
laughs] surprise party, father's death, husband's death, friend's death, father's death, mother's
death, fear of procedure, which is an interesting one. [audience murmurs] Fierce argument, friend's
death, court appearance, fear of choking, public speaking.
[laughter]
>>Dr. Atul Sharma: Yeah, exactly. Husband's death, armed robbery, son's death, and tragic
news. So usually some sort of
>>female #4: [inaudible] When someone asks a question, do you mind just repeating it
into the mic so that [inaudible].
>>Dr. Atul Sharma: Oh sure, that you, yes, I should do that, thank you, I forgot to do
that. So that's one link to stress and heart disease that is not coronary artery disease.
Most of the data on psychological stress and psycho-social stress comes from a number of
European studies and this is the biggest one. Eleven thousand patients and thirteen thousand
controls. They took people that were matched for age, for sex, for gender, for occupation
and matched them as best they could and they asked them to classify their stressors. Whether
they were work stress, home stress, financial stress or major life issues. And they just
followed these people for years. And they found that people who classified themselves
as having one or more stressors were four times more likely to have heart disease and
have heart events, whether it's a stress-induced cardiomyopathy, sudden death, other conditions,
other cardiomyopathies that are unexplained or heart attacks. Another case, cardiovascular
events during the World Cup. This is actually true of the Super Bowl, too. Viewing a stressful
soccer match more than doubles the risk of acute cardiovascular event. In fact, in this
article the authors actually said that they need to have preventive measures, I don't
know what those preventive measures would be, but they need to take preventive measures
when the World Cup is on. [laughter] I don't even know what they would do, but something
like that, right? Overtime work. Overtime work associated with an increased risk of
developing heart disease. Being on call 24 hours, as a doctor, associated with an increased
risk of heart disease. In fact, this is one of the reasons that the laws have changed
for physician work hours in Australia and in the U.K. way before they changed here,
but they finally changed here, too. That people were developing stress-induced cardiomyopathies
and heart disease working 24-hour shifts. Now, we don't really know why this happens,
but stress leads to direct biological effects, physical strain, hormonal changes, it leads
to maladaptive coping behaviors, such as smoking or eating excessively, drinking excessive,
alcohol. And then there are emotional immediate effects on diet and activity levels and they
all lead to increased risk of disease. The body's response to stress is usually one of
three, a set of three different phases. The first phase is an acute alarm phase, where
you kind of everyone knows what it feels like when you feel stressed, you get dry mouth,
your hands get sweaty, you feel your heart racing. Over time as you get used to the same
stressor, your body develops a kind of a tolerance and a, and an acceptance of that level of
stress. And that's where most people are. They're in high states of psycho-social stress
and they've kind of learned to resist those effects on their body because they couldn't
have that same kind of effect for an extended period of time. Eventually over time, the
theory is that the energy sources become depleted and the ability to resist stressors goes down.
So psycho-social stress and heart disease is very important because there are many different
kind of impacts on psycho-social stress. Psycho-social stress in and of itself is a predictor for
heart disease. It is highly preventative and people know it, but they won't go and seek
the care they need to because usually the stress is preventing them from going and doing
something else. Stress in and of itself causes a barrier to medical interventions and commonly
masquerades as heart symptoms. I see 10 to 15 patients a week who come see me for chest
pains and palpitations [inaudible]. Let's talk a little more about psycho-social stress
and what I mean about it. It's grouped into two big categories, one are emotional factors,
the other are chronic stressors. We'll talk about emotional factors first. The first is
depression. This is a study looking at people who had a heart attack and they classified
themselves into four different categories based on a depression index. The higher the
number, the more they were depressed. And you can see that this is on the Y axis the
survival, the survival and this is days on X axis and for any given increase in quartile
of the depression index they had an increased risk for death. In fact that risk, clinical
depression, if you were actually classified as being clinically depressed, is a higher
risk than diabetes, high cholesterol, smoking or age. Two point nine, two point six nine
percent, sorry two point six nine times more likely to have a second event. Hostility index.
Hostility index is an interesting, I'll tell you an interesting story. One day we were
looking to, I was actually looking to park my car near my apartment . Anyone who drives
in New York knows parking spots are at a premium. I saw a spot, cut across, was ready to park
into my spot and then of course someone else drives in to park in, drive into the spot.
So I'm in front trying to parallel back in, the person in front is trying to go in. So
of course being the Type-A personality and hothead I am, I get out of the car and say,
"What were you doing? This is my spot." Out comes a very big, very tall, very strong looking
man
[laughter]
>>Atul Sharma: Who is not happy that I've gotten out of my car, seemingly threatening
him. He gets out, starts yelling at me, hits the back of my hood, of my trunk, the next
thing you know, the back windshield, broken. Very high hostility index.
[laughter]
>>Dr. Atul Sharma: Needless to say, I lost the parking spot. And that kind of anger,
if you've ever seen anybody , one of those people that walks the street and gets pissed
off if you're walking too slowly, muttering under your breath.
[laughter]
>>Atul Sharma: You know those people? You are classified as having a high hostility
index and if you do or do not have heart disease, you are at more risk for it. Twenty percent
increased risk of heart disease. So even if you're just angry for any reason.
>>female #5: [inaudible] [laughter]
>>Dr. Atul Sharma: Yeah, there is. This is something I find really interesting. Type
A personality and heart disease first described by two doctors, Friedman and Rosenman, described
as a continuous, deeply-ingrained struggle to overcome real and imagined obstacles imposed
by events, other people, and especially time. Initially it was called the Hurry Sickness.
Now I don’t imagine there's a lot of this at Google.
>>female #6: None.
[laughter]
>>Dr. Atul Sharma: This seems like a very relaxed, nice place to work.
[laughter]
>>Dr. Atul Sharma: But where I [laughter] where I work, we're all Type A.
>>female #7: [inaudible] it's almost a requirement.
>>Dr. Atul Sharma: Is that right?
>>female #8: [inaudible] We hire Type A's.
>>Dr. Atul Sharma: Is that right? Well look, they're, they're considered to be impatient,
competitive, easily irritated, hostile.
[laughter]
>>Dr. Atul Sharma: The initial description of Type A, competitive, suspicious and quick
to anger. Obviously they're very highly successful. Those behaviors make them highly successful,
however, they are not highly successful to themselves, which is part of the problem.
So there is one study that looks at Type A personality and the risk of developing heart
disease and they found that there's a 50 percent increase in coronary events over eight years
if you are a Type A. And it is a good predictor of a second event if you already had a first
event. This is confirmed in large-scale population studies, the Framingham study is probably
the biggest large-scale study that looks at heart disease, this was confirmed in that
cohort of patients as well. And I think this is probably the most important thing, you
know obviously, as you know, I have a young daughter and I'm, I'm, I'm so Type A that
when she eats I've got a paper towel in my hand, so I'm always wiping her hands and like
wiping the table and wiping the floor. So now she has taken to grabbing the paper towel
and just start cleaning wherever she is. So, I tried to figure out if Type A personality
was inherited or taught.
>>female #9: Taught.
>>Dr. Atul Sharma: Right, interesting question, right? So, Karen Matthews, the University
of Pittsburgh, noticed a striking parallel between Type A adults and Type A children.
I'm just gonna read the paragraph, I think it's interesting. Type A behavior may develop
as the result of child-rearing practices in which parents and strangers, alike, urge children
to achieve at higher and higher levels, but give them ambiguous standards for evaluating
their performance. The example is, "You're doing fine, but next time try harder." This
leaves a child frustrated, without a sense of belonging, and mistrustful of society.
I think that may be a little much, but. [audience chuckles] Moreover, there seems to be a snowball
effect: Children react to the combination of positive evaluation, "You're doing well"
and urging of improvement, "Next time, try harder" by becoming more competitive. In turn,
competitive, impatient children elicit more positive evaluation and urging. So I find
that to be very interesting. The structure of the American classroom, with its reward
system, its competitiveness and its hourly bells, can be seen to encourage such behavior
in children whose home environment makes them susceptible. So, I'm worried for Zia.
[laughter]
>>Dr. Atul Sharma: This is another thing I find very interesting, it's an area of interest,
an area of research for me now, is chronic stressors as they relate to work stress. So
there are two models for work stress. Now again, this probably doesn't exist at Google,
but it exists a lot at the hospital. There is the job strain model, which is very popular
in the United States, and looked at, looks at job latitude as it relates to job demands.
So if you have very high job demands, but you have high job latitude, you don't have
someone micromanaging you, that's not considered to be something that causes increased stress.
However, if you have have high job demands and low work latitude, that's considered to
cause job strain and increases your risk for physical illness. Makes sense, but it's interesting
that it's been studied. In Europe they, they look much more at a reward-effort model. So
if you look at effort either low or high and job reward low or high. If you're high effort,
high reward, that's not dangerous. But if you've high effort, low reward, that's job
imbalance and again, increases the risk of physical illness. Marital stress. This does
not apply to me.
[laughter]
>>Dr. Atul Sharma: So this is, this is a group of women who were classified in three different
groups, either satisfied and married, unmarried, or not satisfied in their or lowly satisfied
in their marriage. And the Y axis looks at plaque scores within heart arteries. So you
can see that if you are happily married, you are at lower risk than if you are not happily
married. The unmarried people are somewhere in between, but not significantly different
than the married happy people. In addition, the development of further plaques over the
next two years is much more likely to occur if you remain in an unhappy or a low-satisfaction
marriage. Interesting. Ok. We've talked a lot about stress, heart disease, problems.
How do we modify risk? I will stop for a second and take questions if there are any. If not
I'll keep going. Yes.
>>female #10: You showed, you were talking about stress and stress events like your public
speaking and if you're repeatedly exposed to that kind of stress then your physical
reaction will decrease. Does that mean that they're no longer stressed, or that someone
is no longer stressed, or does it just mean that your body can't react [inaudible]?
>>Dr. Atul Sharma: The question was, if someone is repeatedly exposed to a stressor, such
as public speaking, usually they adapt, does that mean they're no longer stressed or have
they adapted? The question, the answer is, people have, adapt, they adapt to their environment
and they no longer perceive that stress in the same way, but they are still as stressed.
Their body is still as taxed, they just don't recognize it. It's like, the example I can
give you is if you were to have a kind of a background kind of ringing noise in your
office, you might find it annoying for the first day, two days, three days, but if it
remained there, it would probably still be annoying to you, but your level of perception
would decrease and you wouldn't notice it as much. So it's similar for that. Yes?
>>female #11: So I looked at all of this and I'm like ok, [inaudible] all day long.
[laughter]
>>female #11: I drink a bottle of wine [inaudible]
[laughter]
>>Dr. Atul Sharma: That's very good for you, I'll get to it.
[laughter]
>>female #11: I have annuals, I have physicals here and there, I mean I'm pretty much clean,
right, very healthy? But I still, after looking at this, I still have this fear of heart disease,
or heart attack at my desk one day or whatever. So are you gonna talk about what we should
do to fix it, if we're worried about these things but we still are, are getting a clean
bill of health from our doctors?
>>Dr. Atul Sharma: It's not part of the talk, but I'm happy to talk to you offline about
it. There are a lot of new, newer techniques, and this is something that you know being
part of a wellness and prevention center we focus on. A lot of newer techniques to sub,
to identify subclinical disease, disease that doesn't give you symptoms, but is there. And
the extent of that disease based on age-match controls will tell you if you are at high
risk or if you have a very low risk [inaudible]. There are ways to kind of see whether or not
you're in that quartile of people that have subclinical disease but don't have symptoms
yet.
>>female #12: [inaudible] What steps are taken if you have a history of heart disease [inaudible].
>>Dr. Atul Sharma: So the question is, "What steps are taken if you have a history of,
a family history of heart disease?" And that's a really good question, because I think that
is one of the flaws in current risk assessment for cardiovascular disease. If you look at
all the mod, and this is not to get too technical, but if you look at all the modeling for cardiovascular
risk, the big studies for women, there's a score called the Reynolds Risk Score, you
can look it up online. It's validated more in women than the Framingham Risk Score, which
is actually based on a population in Framingham, Massachusetts, middle aged white male population
doesn't apply to most of us in this room. So they have these models, but none of them
incorporate family history into the model because it's very hard to model something
so heterogeneous. So in that group of people, the family history group of people, I think
there needs to be, what's happening now is some sort of atherosclerotic imaging, imaging
to look for the precursor of cholesterol buildup and so that's what I usually do. That's, I'm
on the writing committee guidelines that are coming out next year for that as a AHA statement
and that's what will be advocated. It's not advocated yet, but it will be in the next
year. Ok. Yes. I will keep going. Modification of risk. Ok? This is probably
the most important slide. Multifaceted approach to modification of your risk for developing
disease and risk for having some sort of body reaction to stress, not just coronary artery
disease, blocked arteries, but body, physical and mental breakdown from stress is best approached
through a multifaceted way. Whether it's dietary changes, regular moderate physical activity,
smoking cessation for people who smoke, maintaining an optimal weight, or really body mass index,
not weight, moderate alcohol consumption and behavioral modification to reduce stress.
I will go through each one of these quickly and in a little more detail. But this is a
slide looking at the importance of a multifaceted approach. On the X axis here is a number of
protective factors and here are, there's three, four and five if you look at the table on
the left. Three protective factors, sorry, if you didn't smoke, you ate a healthy diet,
whatever that means, and regular exercise, you reduced your risk for developing heart
disease by 50 to 60 percent. If you incorporated a healthy body weight, it dropped to 66 percent,
I'm sorry it increased to 66 percent. And if you incorporated moderate alcohol use,
out of moderate, the key word is moderate, I'll get to what moderate is, your percent
reduction goes to 83 percent. So the more different things you do, yes, yes, yes, I
agree. The more different things you do, the better off you are.
So let's talk a little about diet. So this is a slide that talks about structuring your
meals. Practical advice. If you can either plan your meals or have a single meal replaced
[inaudible] loves to go to this, this juice place on 1st and 1st, what's the name?
>>female #13: [inaudible]
>>Dr. Atul Sharma: Juice [inaudible] And she will often use that as a meal replacement,
a lunch replacement. That has been shown, and this is a study to prove it, that that
works better or as well than if you plan your meals. So if you say I'm gonna eat this this
day, that that day, this that day, you plan your diet out for the week. That's as good
as taking one day or one meal a day and having a meal replacement. It has to be something
reasonable, whether its whatever, it needs to be Slim Fast, but it can be, you know,
juicing, it can be whatever you want it to be as a meal replacement, as long as it is
planned, it is much better than kind of winging it for lunch. If you plan your food, you're
much more likely to lose weight, keep the weight off. This is a slide looking at the
nurses' health clinic, this is the largest cohort of women and it's women because it
started in the 60s where it was 99.4 percent were female nurses. Looking at the nursing
health study and looking at fruit and vegetable intake per day and risk for heart disease.
So obviously we all know that people tell you to eat a lot of fruit and vegetables and
you won't have heart disease. This is where it comes from. This is the group of patients
that go from three to eight servings of fruit and vegetable a day and you can see your risk
for developing heart disease drops about 20 percent. This is a similar slide, same group
of patients, in terms of dietary fiber, whole grain and fiber. The more fiber you eat, the
more your risk of heart disease goes down. What about different diets? There's so many
out there. We all know most of them. Ornish diet, which is made very popular by Dean Ornish,
a very, very low fat diet, it's a vegetarian diet, almost all the protein comes from vegetarian
sources, almost no meat. The Pritikin diet, which is a variant of the Ornish diet. Then
there are the intermediate fat diets, Sugar Busters, Zone, etc. And the low-carb diets
which we all know about, Atkins, South Beach, Slow Carb. And then calorie restriction diets,
right? Weight Watchers. Which one of these is better? Long term, short term? Well here's
the data. Ok? This is one study, 160 patients randomized to four diets. This is kind of
an old study, but I'll get you the more newer studies in a minute. Atkins, Zone, Weight
Watchers and Ornish. So Ornish is low fat. Weight Watchers is a point system based on
calories, which is pretty easy to follow. Zone is moderate carbohydrate. And Atkins
is low carb, high meat, high animal protein source, sorry. And you can see the weight
loss is essentially the same [inaudible] seven pounds and five pounds. The problem is most
people couldn't stay on the diet, which is what we find with most diets, right? So no
real difference, hard to sustain. You can see that 26 out of 40 stay on the diet. These
are people who are enrolled into a study. They are people who are motivated to stay
on diets and even they can't stay on the diet. So if you were to take it to the general population
it'd be less. This is a study looking at high fat, protein or carbs. Either high carb or
low carb diets. High fat or low fat diets. High protein and low protein diets. None of
them make a difference in terms of your weight loss, in terms of change in your waist circumference.
They're all kind of the same, you can see the graphs are exactly the same. There's one
controversial study, this is just the same thing in a different table form, this is carbohydrates
at 65 percent, the square is 55, circle is 45, the diamond is 35. There's really no difference
whether you eat a high carb or low carb diet long term in terms of weight loss, in terms
of waist circumference. This is the single study that throws a wrench into all of that.
This is a study published by the New England Journal in 2008 and it looks at three different
diets, a low-fat diet, a Mediterranean diet, which I'll get to, and a low-carb diet. And
that low-carb diet is a diet where it's less than 30 percent of your calories from carbohydrates,
so you really have to restrict all the carbs you eat. And this is months on the X axis,
so it goes out two years, and this is weight loss. And you can see that for a given time,
you lose more weight with a low-carb diet and you're more likely to keep it off compared
to a low-fat diet. This is the single study that shows it. There's no difference between
low-carb and Mediterranean, but there is a difference between both and a low-fat diet.
So this is where the whole low-carb movement came from. Everyone said, oh, this is the
way to go. This is the study that proves it. This is a very controversial study and the
only study that shows it. [microphone feedback] This is a, in my mind, a more important study.
This is 605 people, it's called the Lyon Diet Heart Study. It's probably the most famous
and most quoted heart diet study. Six hundred five patients who had an event, had a heart
attack, randomized to either Mediterranean or a Western diet. And the people who ate
a Mediterranean diet lived longer. This is the only study to show people lived longer
by eating a certain diet. It's followed over five years. Ok, what is a Mediterranean diet?
This is the Mediterranean diet pyramid. Right? Daily physical activity on the bottom, 30
minutes a day is what they advocate. Whole grains as a base for your food, whether it's
couscous, polenta, wheats, and then large servings of fruits, beans, nuts and vegetables.
Oil, olive oil is the base for your cooking. Cheese and yogurt daily, but in small amounts.
And then less frequently fish, poultry, eggs, sweets and very rarely, red meat. And in this,
wine in moderation, it's about two glasses a day, and six glasses of water. So this is
a, this is a table for it and this is a practical guide to a Mediterranean diet. If you wanted
to have a Mediterranean diet and you wanted to know how to put it into action, this is
a simple way to do it. Base the diet on fruits, vegetables and whole grains. If you need snacks,
either keep nuts or carrots, almonds, apples, bananas. These are things with low sugar index,
so they're better foods to eat, pears also. Breakfast every day. It's part of the Mediterranean
diet. You have to eat a breakfast. Most people in that diet eat yogurt for breakfast, but
you can have eggs. Obviously extra-virgin olive oil or hummus as your, as your spreads,
and then whole grain bread instead of white bread. Grilled fish or poultry if you're gonna
use a protein source that's what they want you to eat. Eating oily fish three times a
week. And then milk, yogurt and cheese daily, but not in large amounts.
Alcohol. This is the only study looking at alcohol and mortality. And I will keep it
short. They grouped people into who never drank and assigned them an index of one. That's
their relative risk. People who drank, but very infrequently, and they defined that as
less than three drinks a week. People who were former drinkers, drank more than 14 drinks
a week in the past. And then they grouped three different groups of people who drink
regularly. So light was less than three drinks a week. Moderate was three to fourteen drinks
for men and three to ten drinks for women. And heavy was more than 14 drinks for men,
more than 10 drinks for women per week. And you can see that the light and moderate group
of people had a 25 percent reduction in all cause mortality, cardiovascular mortality.
If you drink in moderation, you raise your HDL, the good cholesterol, and you live longer.
The heavy drinkers, it was indeterminate, the line crossed over, the line of identity
crossed over, so it was a wide range, so it couldn't tell if heavy drinkers were at high
risk or not at high risk. But the low people who drank light or moderate amounts lived
longer.
>>female #14: Can I ask a question?
>>Dr. Atul Sharma: Yes?
>>female #14: I've heard a lot about the benefits of red wine. Is that, is this beyond red wine
or is this [inaudible].
>>Dr. Atul Sharma: This is beyond red wine. This is, they were not restricted in what
they could and could not drink. The reason to drink red wine, especially if you're, if
you're thinking about it from a Mediterranean diet perspective, is that most mixed drinks
or hard alcohol have, are sugar based, so you have large sugar loads, which increases
your insulin levels, which is not thought to be good long term. And dry wines are not
as sugary. So, so not a Riesling, but you know something dry like a, like a Cab or something
like that.
>>female #15: [inaudible]
>>Dr. Atul Sharma: So, yeah, I'm gonna go over it again. The question is what is how
we define the alcohol usage. Light alcohol was three, three drinks on average a week.
Moderate was three to ten, for women, three to fourteen for men. And heavy was more than
ten for women and more than fourteen for men. Yes.
>>female #16: So back to the red wine. So, what do you tell your clients?
>>Dr. Atul Sharma: Oh, yes, patients.
>>female #16: As far as, you know [inaudible]
>>Dr. Atul Sharma: That's a good question. I tell them to have a glass or two of wine
a day. And I don't think there's any risk for that. A bottle of wine a day I'm not sure.
>>female #17: I'm totally kidding.
>>Dr. Atul Sharma: I know. I'm only joking too.
[laughter]
>>female #18: One more question. Is this really saying that if you are an infrequent drinker
or you don't drink, that you're better off starting to drink?
>>Dr. Atul Sharma: Yes.
>>female #18: Wow.
>>Dr. Atul Sharma: Yes, that's what it says. [laughter]
>>female #19: [inaudible]
>>Dr. Atul Sharma: I will say it again. This is saying that if you are not a drinker, if
you never drank, your risk is X. If you start to drink, and you drink in the specified zones,
your risk goes down by 30 percent, 25 percent. Now that risk, that's a relative risk. Let
me just kind of talk about risk with you here. The numbers seem big. Let's say this is relative
risk, so I'll just give you a definition between relative and absolute risk. Relative risk
is a term that we use that's based off absolute risk. So if your risk is 5 percent and I tell
you that your relative risk reduction is 25 percent. It's 25 percent of 5 percent, so
it goes from 5 percent to 3.8 percent or whatever it is. Right? So you're still at a risk of
[inaudible] percent, but it's, it's based off an absolute risk, whatever your absolute
risk would be. Exercise. So this is a, a group of people
were asked to classify themselves in terms of their fitness, whether they were considered
to be fit or unfit. Unfit was category one [inaudible] and for any given group of fitness,
if you are unfit, men or women, you're more likely to have cardiovascular events, you're
more likely to have your own classification. So how do you become fit? Well, you exercise
obviously and how do you do that? The results will surprise you. If you exercise at home
based on if you join a gym, you're much more likely to A. continue to exercise and B. lose
weight. My [inaudible] Most people join a gym, they go for awhile, they stop going.
If you incorporate exercise into your home, you're more likely to do it although we have
heard of many treadmills as a clothing rack, so. But this is the data. The data is what
the data is. I don't know what to say about it. You lose more weight if you exercise at
home.
>>female #20: [inaudible]
>>Dr. Atul Sharma: Then you can exercise at home. So if you live in a studio apartment,
this is what you do, this is what you do. You are more likely to lose weight and more
likely to be healthy if you engage in short bouts of regular physical activity than if
you plan to do one long 45-minute run. Ok? So, this is the data saying if you exercise
in short bouts, you're likely to do more exercise and likely to lose more weight. So how do
you do that? You make it part of your life. This is something that Googlers do a good
job of. If you program your physical activity into your daily life, for example, [inaudible]
walks to work every day, then you are much more likely to keep the weight off and keep
exercising. So that is a single take home point. Put exercise into your daily routine
so you don't have to go somewhere to exercise. That is probably the most important thing
you can do to continually exercise. Because invariably you have demands from work, home,
friends, whatever, and you can't get to the gym [inaudible]. So you know the, New York
City has talked about a big ad campaign [inaudible] to get off two stops, one or two stops before
their stop and walk the rest of the way, so that's [inaudible].
Behavior modification. Behavior techniques. How do you adjust your behavior? I'm not gonna
spend too much time on it, but there are ways to self-monitor, which I think is very important.
Ways to control your stimuli and ways to channel negative thoughts and problem solve. So behavioral
elements in terms of self-monitoring. Create a food diary and an exercise diary. Use it.
Why do I say that? This is the data. They looked at four different groups of people
who monitored their physical activity and their diet. So either you didn't monitor at
all, monitored a little bit, monitored it sometime, monitored it all the time. And over
time, people who monitored their diet and exercise fastidiously, sorry, lost dramatically
more weight than people who didn't monitor at all. I'm talking 30-35 pounds. This is
an example of a food diary. I showed you one. This is my food diary before I started my
diet. So you can see here before I started this diet, this is my, this is my breakfast,
I ate a lot of crap. [chuckles] Two eggs over easy on a roll with hot sauce, not so good.
Benny's Chicken Pad Thai for lunch, not so good. Candy. I love chocolate, so. Chocolate,
a lot. Or Van Leeuwen ice cream. And then my wife and I used to order out a lot for
food, so either we'd order Indian food or order in Kung Pao Chicken or whatever. And
I thought nobody wanted to hear from a fat cardiologist, [audience laughs] so I thought
I should change what I ate, so this is my after I saw what I was eating, this is one
week of a three-week diary, I decided to change my diet based on a kind of a slow-carb diet
to see what would happen. And this is my food log for the next two weeks, and it's basically,
I'll talk about the diet offline if anyone is interested, but high-protein meal first
thing in the morning and I found I wasn't very hungry. So you can see my, just tracking
what I ate, I ate a lot less and I was able to see it. Some people say write it down,
some people say put it on a Google doc, some people say take a picture of everything you
eat before you eat it. So you can see what you're eating. Exactly right. So in this diet
I wasn't allowed to eat certain things six days a week and so I had a little section
where I had a wish list. And that was my wish list. I wanted ice cream the first day I was
on the diet. I wanted my Kit Kat the next day. I wanted dark chocolate the next day
and then by the fourth day I didn't want anything. And then I had a vice list. A list where I
had, I don't know where my little tab is, my vice list and my vice list is right here.
So I was drinking two large bottles of this every day and when I started this diet I thought
I would cut down to the smaller bottles, didn't really work very well, but I did have my one
vice, which I think is very important. You cannot deny yourself everything that you want,
otherwise every diet is doomed to fail. So on this diet I was able to eat, I was allowed
to eat whatever I wanted to eat on Saturdays. So Saturdays, the first Saturday I had a , a
bagel with jalapeño cream cheese. Yeah, exactly. And then a sandwich, because I wasn't allowed
much bread. And then I had my Kit Kat and my ice cream.
[laughter]
>>Dr. Atul Sharma: And then I had pasta, which I also was not allowed to eat, and potatoes,
which I was also not allowed to eat. So I had my cheat day and that week I lost six
pounds. So the diet works. I don't know. This is two weeks of the diet. But the idea is
that if you monitor everything you eat and make yourself look at it, you're more likely
to kind of be conscious of what you're doing. So that's my story on that.
Stimulus control. I think this has happened at Google I think too. Modifying your environment
to facilitate weight control. So reduce cues for overeating by only eating in one particular
place. So, in our house we don't allow our daughter to eat anywhere but the dining table.
And we don't, well I don't eat anywhere but there either. I can't say that for everybody.
[laughter]
>>Dr. Atul Sharma: If you, if you take stuff and put it away where you can't see it, you're
unlikely to eat it. So I think, I think that's happened here. They've taken all the snacks
that used to be everywhere and moved them to a kitchen, right? I think so. They're not
all right in front of you to eat all the time. If you keep healthy food in those locations,
so let's say you like to watch TV and you like to eat when you watch TV. If you put
almonds, unsalted almonds next to your couch, you're more likely to eat those than to eat
Oreo cookies that are in the other room. And give yourself a reward when you meet your
certain goals. Ok, that's the idea behind my Saturdays, eating whatever I wanted.
I don't know how much time I have left, probably not much. But stress reduction I will talk
a little about it. Stress reduction again, multifaceted approach. The one approach that
has been studied a lot in the medical literature is called the 'relaxation response'. It's
very similar to Transcendental Meditation. It's sitting quietly in a room, closing your
eyes, focusing on a word that generally can or cannot have meaning. The idea is not to
focus on the meaning of the word, but to focus on the word itself and allow your mind to
kind of dive deeper into its recesses [inaudible]. The analogy they give is your mind is like
an ocean and the top layer is choppy, but if you allow yourself to get underneath it,
it seems quite tranquil. So if you allow yourself 20 minutes two times a day, to kind of just
let whatever thought comes to you come to you, by thinking of one word, not pushing
thoughts out, but just letting it come to you, that's been shown to reduce blood pressure,
shown to reduce sugar levels and increase energy levels. This is the study that looks
at behavior therapy and risk for heart disease and I'll just circle the conclusion. A cognitive
behavioral therapy approach reduces the risk of recurrent heart disease in people who have
previous heart attacks. And what did they incorporate? They incorporated group therapy
to discuss common stressors. So if you have something that stresses you out, find a group
of people, your friends most likely, who have those same stresses, very easy to talk about
it. If you build social networks to handle your chronic stress, you're much more likely
to be able to deal with that stress. Improving your interpersonal relationships by being
direct and honest instead of kind of holding on to that irritation and anger, just tell
somebody, "You know, I really, I really didn't like when you did that." It's much better
for you and probably better for your relationship as well. And then incorporating relaxation
techniques. Yoga, Transcendental Meditation, Tai Chi, anything you want. The idea is not
one better than the other. The idea is something to reduce the effects of chronic stress. Behavior
modification is well studied. That is a situation where you sit in a room, a dark room, let's
say you [inaudible] something that really stresses you out, let's say giving talks stresses
you out. Sit in a dark room, you allow yourself to kind of relax your mind, you focus on thinking
about a presentation you might have to give and then try to manage your response to that
stress in your home environment, not actually giving the talk. Biofeedback is another way
to deal with this. Biofeedback is a way where you have continuous kind of either visual
or auditory cues that kind of effect, that kind of tell you how you respond to certain
stress. So let's say you're in that same situation, you're thinking about a presentation you have
to give. You put a little monitor on your finger to monitor your heart rate. You're
thinking about it and you're trying to kind of control your response and you're getting
a feedback based on the beeping of the heart rate monitor. Is it going up? Ok, I have to
kind of control that. It's coming back down, I'm handling it better. Biofeedback is a way
to incorporate behavioral modification. So, take home points before we get to questions:
Heart disease is common in women, is often misdiagnosed and can be fatal. Stress is a
major factor in the development of heart disease, especially in women, due to their multiple
roles in and outside the family. And Type A personalities are more likely to have stress-related
cardiovascular events as are people who have anger issues and people who are depressed.
So simple steps to healthier living. Again, multifaceted approach. Mediterranean diet,
the best diet for long-term health. If you don't like to eat fish or you're a vegetarian,
make sure you take fish or flaxseed oil on a regular basis, provides Omega 3 fatty acids
you don't get elsewhere. Of short-term diets, slow carb, low carb diets may be the most
helpful in achieving desired weight loss, that's based on that one study, but long term
you have to make sure to get enough fiber. Regular physical activity is associated with
improved survival, so incorporate it into your daily activities, the most important
thing to do. Hypertension, diabetes really increases your risk for any cardiovascular
event. Maintain an ideal body mass index. Body mass index calculators are available
online. Just Google BMI calculator, a million of them pop up, there are specific ones for
women. And keep a food diary. The whole salt issue I didn't get to, it's very controversial
whether eating a lot of salt increases your risk for having high blood pressure. Recent
studies suggest it may not be the case. To increase your energy levels, I didn't get
to this either, spend 15 minutes in the sun. Most people have Vitamin D deficiency who
live in New York, not in California, but in New York, especially over the winter, that
leads to increased cardiovascular events and general fatigue. So if you can't be in the
sun take Vitamin D, but I'd say go sit in the sun 15 minutes. Eat lots of garlic. If
you don't like garlic, and you have high cholesterol, take a garlic supplement. Garlique is a brand
of supplement, tastes like nothing, I've tried it. Take a multivitamin, for all the women
in this room, multivitamin, folic acid and selenium every day. Each one has been shown
to reduce cardiovascular events in women. Moderate alcohol, smoking cessation, important,
I've discussed why. And then stress reduction through multifaceted approach is the best
way to reduce heart risk and improve one's sense of happiness. I was gonna play this.
I can't play it. It's the 'Serenity Now' montage from Seinfeld, which I thought it was really
funny.
[laughter]
>>Dr. Atul Sharma: And just a quick note, national Go Red for Women Day, February 3,
2012. Very important. I am a speaker for Go Red for Women. There are guidelines coming
out, reiterated guidelines for evidence-based practice for care of women with risk for heart
disease and who have heart disease. This is very important to everyone in this room. I
want to thank Kristy for all her help, Eileen, all your help, and to the two women in my
life.
>>audience: aahhhh
>>Dr. Atul Sharma: Thank you very much. Questions? Comments? Feel free to e-mail me. You can
call my direct line at work or my cell. I'll open up to questions.
[applause]
>>Dr. Atul Sharma: Yes, in the back.
>>female #21: So I think that [inaudible] and you know I think [inaudible] a lot of
us definitely [inaudible] do exercise and eat right and we have [inaudible] to do that
and exercise options, but stress is kind of unavoidable in certain pieces. So I don't
know who can actually avoid this, but though if you are kind of doing the right things
[inaudible] list is in terms of health and exercise, but yet you know emotionally stress
just keeps coming in. And we're doing relaxation things as well, I mean how much do you think
[inaudible] you know, factor in against each other? You are a healthy person, but [inaudible]
you've got a great BMI, you've got low cholesterol, low blood pressure, but yet you're stressed
a lot [inaudible].
>>Dr. Atul Sharma: Yeah. The question is if you're doing all the right things with diet
and exercise and you're, you're an optimal BMI, but you still feel stress and you're
trying to do things to reduce your stress, what do you do? And the answer is that the
more things you do in a multifaceted approach to reduce your stress, the better off you
are. Now it's hard to quantify, there aren't really many studies that quantify well if
you do Tai Chi you're gonna get a 20 percent reduction in your cardiovascular events, but
if you do Transcendental Meditation you get a 25 percent, etc., etc. So, you're better
off saying, ok, I'm doing the right things diet wise. Exercise helps me with my stress.
I need to do x, y and z to deal with my stress at work, or my stress at home. And again,
those are multifactoral approaches. If you have stress at home, for example, there are
unresolved issues with you and your significant other, direct, open communication are important
to say what it is. I, you know I think there aren't a lot of studies to prove that, it's
very hard to study that. It's very difficult to study, but in the psychology literature,
that has shown at least anecdotally to improve interpersonal relationships. If you have stress
at work, one of the nice things about Google is that, at least my impression of Google
is that, you might have 20 minutes during the day to kind of.
>>female #22: Have a massage.
>>Dr. Atul Sharma: There you go. Have a massage. Meditate while you're having a massage, right?
Go for a walk. Lots of different things you can do. Right? So I think incorporating as
many of those as possible into your daily routine, will make you, not only will it make
you less stressful, it will make you happier. Sorry.
>>female #23: Just to piggyback on that, do you recommend, if you still feel very stressed
and you're taking all of these, doing all of these things that you mentioned, to actually
see a cardiologist just to sort of [inaudible] heart disease?
>>Dr. Atul Sharma: Well, the question is if you still feel stressed, should you see a
cardiologist to rule out heart disease? I think honestly, if you're doing all the things
that you need to do and you still feel stressed, I think you have to take a kind of a hard
look at what your stressors are and if they're at all modifiable. If they're not modifiable
and you're doing everything you can reasonably to reduce your stress, yet you can't reduce
your stress, then it's probably not a cardiologist you need to talk to, you probably need to
talk to your general physician about how to deal with stress and you know there are many
different ways to deal with stress. If you cannot reduce the stressor, then and you cannot
find other alternatives to dealing with stress, then you know, I don't like to recommend pharmacologic
therapy, since I'm not an expert in that area, but there are pharmacologic options to reduce
stress. Ah, yes.
>>female #24: Have there been any studies on caffeine and heart disease?
>>Dr. Atul Sharma: Caffeine and heart disease studies. Yes. Many studies on caffeine and
heart disease. Caffeine does not necessarily promote coronary artery disease, but caffeine
in large amounts does cause skipped beats, extra beats and the feeling of palpitations
and can lead to arrhythmias, unstable heart rhythms or stable heart rhythms from the small
chambers of the heart. So, drinking three of these is not really very good for you.
>>female #25: What is too much caffeine?
>>Dr. Atul Sharma: [sigh] That's a, that's a very difficult question to answer. What
is too much caffeine? Too much caffeine is different for each person. And there aren't
any pre-specified numbers for caffeine like there are for sodium, like there are for sugars.
But if you feel the effects of caffeine, which most people can tell they feel, or more tellingly,
if you don't have caffeine and you have effects, then you're taking too much caffeine. What
I used to tell my patients when they, when they had that is to cut their caffeine intake
by one drink a day for the first month, sorry by one drink a week for the first month. So
if you're drinking, like if I, this is like I don't know nine cups of whatever tea, like
two of these. So I would want to cut it to eight the first week, seven, six and then
five and then sit there. [inaudible] get a 50 percent reduction in you caffeine generally
makes you feel better. Yes?
>>female #26: So, I really liked your slides and I'd love to [inaudible] obviously this
is your, this is your patented information or whatever you call it [inaudible]
>>Dr. Atul Sharma: No, I'll, I'll make it available. I'll leave the PowerPoint for you
guys. I can .pdf it or I can just leave it like this. I don't really have any problem
sharing it. Yes?
>>female #27: I heard about lipoprotein little a for the first time when Eileen, [inaudible]
a lot of doctors don't test for and when I spoke to Dr. [inaudible] he was like, you
know, this is one of the big risk factors for cardiovascular disease and you don't hear
a lot of people talking about it. And when I asked some of the other doctors, they're
like, well, there's nothing you can really do about it. So just curious.
>>Dr. Atul Sharma: Yeah, there are a lot of those. So the question is what about lipoprotein
little a? And there are a whole host of other kind of newer emerging risk factors for heart
disease that are pharmacologic testing, etc. There's lipoprotein little a, there's homocysteine,
[inaudible] These are all there and they're all available. The problem with most of them
is we don't know whether modification of that number, of that factor, leads to long-term
outcome improvement. So it's one thing to say, I have elevated lipoprotein little a.
The best example is homocysteine. People who have high homocysteine levels are at increased
risk for cardiovascular disease. But, and surprisingly, lowering homocysteine levels
to normal with folic acid, does not reduce your cardiovascular events. Alright? So on
one hand there's a link, on the other hand there's not necessarily causality. Alright?
Reducing it doesn't change your events. So that's where we are with lipoprotein little
a. It can be reduced by a medicine called, or a B vitamin called niacin. Alright? So
you can take over-the-counter niacin, which generally causes you to get very flushed,
but you can take it. You can take it as your B complex vitamin to reduce your lipoprotein
little a. But we don't know that reducing LP little a has dramatic effects on cardiovascular
events, so that link is not there yet and that's true with a lot of these newer markers.
So yes, it's a risk factor, no I wouldn't go crazy over it if your, the rest of your
risk profile is low.
>>female #28: But if our parents had like a history of it, should they be telling their
doctors, that they should get this tested as well?
>>Dr. Atul Sharma: Yeah, it's a good question. If they have a history of, history of elevated
LP little a?
>>female #28: Or a history of cardiovascular disease.
>>Dr. Atul Sharma: Um, yes and no, it depends on, it depends on what kind of person you
are. If you're the kind of person who will obsess over, over the result and kind of worry
about not, and have stress from the result of not being able to do anything about it,
no don't check it. But if you're not that kind of person and you want a kind of overall
global risk assessment and you'll modify what you can modify, understanding that you can
never modify your risk to zero, then yes, you can check it and understand that it's
part of a group, it's not taken by itself, it's taken as a, as part of a group of risk
modification. Yes.
>>female #29: [inaudible] your thoughts are on recent [inaudible] sleep [inaudible]
>>Dr. Atul Sharma: I am, I will, as my wife will tell you. The question is about sleep.
As my wife will tell you, I'm a little sleep obsessed. I have been studying sleep and how
to get better sleep and I actually sleep very well. The impact of sleep on cardiovascular
disease is very well known, especially if you don't get regular sleep, if you don't
get to REM sleep, if you don't get at least four hours of sleep a night, and if you, if
you have sleep apnea. All those things increase your risk for cardiovascular events. So, sleep's
very important. I mean, the thing I, the things you read about sleep is don't bring any electronic
gadgets into the bedroom. If you're gonna sleep, sleep. Make the bedroom a place you
know for sleep. Don't put a TV in the bedroom. You know, don't do any of that stuff because
you going to the bed, make it relatively a cool place, a dark place. You're going there
to sleep, so sleep. And don't be distracted by other things. Put your phone somewhere
else.
>>female #30: Yeah, phones, digital devices, blinking devices, your Blackberry.
>>Dr. Atul Sharma: Yeah, that can't be there.
>>female #30: Don't use your computer a few hours before bed so you can change your brain
waves back to kind of human neutral.
>>Dr. Atul Sharma: Right. Don't do it while you're in bed trying to go to sleep. You won't
sleep.
>>female r #31: [inaudible] have periods of time where they don't sleep well, right, and
then you go back to old sleep habits, that has no long-term you know effect on you or
is it once you sleep again then you're good?
>>Dr. Atul Sharma: No, no. Usually if you don't sleep well it's usually from some sort
of outside stressor. And the key is to resolve the outside stressor and then your sleep patterns
were usually were turned back to what they were. And that doesn't have long-term effects.
Other questions. [cell phone rings]
>>female #32: I think we are really [inaudible] about your [inaudible] Thank you for coming
in and talking to us. It's common sense and I think what a lot of us I mean they have
the conditions here at Google to practice wellness all the time. This place is set up
for healthy living, healthy eating. Yes, it's a stressful work environment in general, but
all the conditions for staying healthy are reinforced through our wellness programs,
the kinds of foods that are served, there's the best fish probably in New York [inaudible]
and so we're into the question of mindfulness and respect for your body and taking responsibility
for your wellness instead of waiting to treat illness. So thank you Dr. Sharma for all of
your intelligent insight and for putting up with like an hour and a half of our questions.
We really appreciate it.
[applause]
>>Dr. Atul Sharma: Thank you very much.
>>female #33: I still like butter on my popcorn.
[laughter]
>>Dr. Atul Sharma: And that's ok.
>>female #34: [inaudible] a little butter and a lot of truffle salt.
>>Dr. Atul Sharma: Sounds good.
>>female #35: [inaudible] have gone to [inaudible] questions [inaudible] cardiovascular events
[inaudible]
>>Dr. Atul Sharma: Yes. [sounds of video chat happening]
[computer powering down] >>female #35: All of that stuff is encompassed,
not just coronary artery disease.
>>Dr. Atul Sharma: Right. Cardiovascular events, yes, exactly right, heart disease, atrial
fibrillation, your, oh, a stroke, yeah, I missed the big one, but I missed the big one.
>>female #36: And you mentioned, you mentioned that there's some controversy around salt.
[inaudible] My sister's [inaudible] she's now managing my mother and telling my mother
that she absolutely has to stay away from [inaudible]
>>Dr. Atul Sharma: If you have heart failure, salt is a must to stay away from. Incorporating
as many of those as possible into your daily routine, will make you, not only will it make
you less stressful, it will make you happier. Sorry.
>>female #23: Just to piggyback on that, do you recommend, if you still feel very stressed
and you're taking all of these, doing all of these things that you mentioned, to actually
see a cardiologist just to sort of [inaudible] heart disease?
>>Dr. Atul Sharma: Well, the question is if you still feel stressed, should you see a
cardiologist to rule out heart disease? I think honestly, if you're doing all the things
that you need to do and you still feel stressed, I think you have to take a kind of a hard
look at what your stressors are and if they're at all modifiable. If they're not modifiable
and you're doing everything you can reasonably to reduce your stress, yet you can't reduce
your stress, then it's probably not a cardiologist you need to talk to, you probably need to
talk to your general physician about how to deal with stress and you know there are many
different ways to deal with stress. If you cannot reduce the stressor, then and you cannot
find other alternatives to dealing with stress, then you know, I don't like to recommend pharmacologic
therapy, since I'm not an expert in that area, but there are pharmacologic options to reduce
stress. Ah, yes.
>>female #24: Have there been any studies on caffeine and heart disease?
>>Dr. Atul Sharma: Caffeine and heart disease studies. Yes. Many studies on caffeine and
heart disease. Caffeine does not necessarily promote coronary artery disease, but caffeine
in large amounts does cause skipped beats, extra beats and the feeling of palpitations
and can lead to arrhythmias, unstable heart rhythms or stable heart rhythms from the small
chambers of the heart. So, drinking three of these is not really very good for you.
>>female #25: What is too much caffeine?
>>Dr. Atul Sharma: [sigh] That's a, that's a very difficult question to answer. What
is too much caffeine? Too much caffeine is different for each person. And there aren't
any pre-specified numbers for caffeine like there are for sodium, like there are for sugars.
But if you feel the effects of caffeine, which most people can tell they feel, or more tellingly,
if you don't have caffeine and you have effects, then you're taking too much caffeine. What
I used to tell my patients when they, when they had that is to cut their caffeine intake
by one drink a day for the first month, sorry by one drink a week for the first month. So
if you're drinking, like if I, this is like I don't know nine cups of whatever tea, like
two of these. So I would want to cut it to eight the first week, seven, six and then
five and then sit there. [inaudible] get a 50 percent reduction in you caffeine generally
makes you feel better. Yes?
>>female #26: So, I really liked your slides and I'd love to [inaudible] obviously this
is your, this is your patented information or whatever you call it [inaudible]
>>Dr. Atul Sharma: No, I'll, I'll make it available. I'll leave the PowerPoint for you
guys. I can pdf it or I can just leave it like this. I don't really have any problem
sharing it. Yes?
>>female #27: I heard about lipoprotein little a for the first time when Eileen, [inaudible]
a lot of doctors don't test for and when I spoke to Dr. [inaudible] he was like, you
know, this is one of the big risk factors for cardiovascular disease and you don't hear
a lot of people talking about it. And when I asked some of the other doctors, they're
like, well, there's nothing you can really do about it. So just curious.
>>Dr. Atul Sharma: Yeah, there are a lot of those. So the question is what about lipoprotein
little a? And there are a whole host of other kind of newer emerging risk factors for heart
disease that are pharmacologic testing, etc. There's lipoprotein little a, there's homocysteine,
[inaudible] These are all there and they're all available. The problem with most of them
is we don't know whether modification of that number, of that factor, leads to long-term
outcome improvement. So it's one thing to say, I have elevated lipoprotein little a.
The best example is homocysteine. People who have high homocysteine levels are at increased
risk for cardiovascular disease. But, and surprisingly, lowering homocysteine levels
to normal with folic acid, does not reduce your cardiovascular events. Alright? So on
one hand there's a link, on the other hand there's not necessarily causality. Alright?
Reducing it doesn't change your events. So that's where we are with lipoprotein little
a. It can be reduced by a medicine called, or a B vitamin called niacin. Alright? So
you can take over-the-counter niacin, which generally causes you to get very flushed,
but you can take it. You can take it as your B complex vitamin to reduce your lipoprotein
little a. But we don't know that reducing LP little a has dramatic effects on cardiovascular
events, so that link is not there yet and that's true with a lot of these newer markers.
So yes, it's a risk factor, no I wouldn't go crazy over it if your, the rest of your
risk profile is low.
>>female #28: But if our parents had like a history of it, should they be telling their
doctors, that they should get this tested as well?
>>Dr. Atul Sharma: Yeah, it's a good question. If they have a history of, history of elevated
LP little a?
>>female #28: Or a history of cardiovascular disease.
>>Dr. Atul Sharma: Um, yes and no, it depends on, it depends on what kind of person you
are. [chuckles] If you're the kind of person who will obsess over, over the result and
kind of worry about not, and have stress from the result of not being able to do anything
about it, no don't check it. But if you're not that kind of person and you want a kind
of overall global risk assessment and you'll modify what you can modify, understanding
that you can never modify your risk to zero, then yes, you can check it and understand
that it's part of a group, it's not taken by itself, it's taken as a, as part of a group
of risk modification. Yes.
>>female #29: [inaudible] your thoughts are on recent [inaudible] sleep [inaudible]
>>Dr. Atul Sharma: I am, I will, as my wife will tell you. The question is about sleep.
As my wife will tell you, I'm a little sleep obsessed. I have been studying sleep and how
to get better sleep and I actually sleep very well. The impact of sleep on cardiovascular
disease is very well known, especially if you don't get regular sleep, if you don't
get to REM sleep, if you don't get at least four hours of sleep a night, and if you, if
you have sleep apnea. All those things increase your risk for cardiovascular events. So, sleep's
very important. I mean, the thing I, the things you read about sleep is don't bring any electronic
gadgets into the bedroom. If you're gonna sleep, sleep. Make the bedroom a place you
know for sleep. Don't put a TV in the bedroom. You know, don't do any of that stuff because
you going to the bed, make it relatively a cool place, a dark place. You're going there
to sleep, so sleep. And don't be distracted by other things. Put your phone somewhere
else.
>>female #30: Yeah, phones, digital devices, blinking devices, your Blackberry.
>>Dr. Atul Sharma: Yeah, that can't be there.
>>female #30: Don't use your computer a few hours before bed so you can change your brain
waves back to kind of human neutral.
>>Dr. Atul Sharma: Right. Don't do it while you're in bed trying to go to sleep. You won't
sleep.
>>female #31: [inaudible] have periods of time where they don't sleep well, right, and
then you go back to old sleep habits, that has no long-term you know effect on you or
is it once you sleep again then you're good?
>>Dr. Atul Sharma: No, no. Usually if you don't sleep well it's usually from some sort
of outside stressor. And the key is to resolve the outside stressor and then your sleep patterns
were usually were turned back to what they were. And that doesn't have long-term effects.
Other questions. [cell phone rings]
>>female #32: I think we are really [inaudible] about your [inaudible] Thank you for coming
in and talking to us. It's common sense and I think what a lot of us I mean they have
the conditions here at Google to practice wellness all the time. This place is set up
for healthy living, healthy eating. Yes, it's a stressful work environment in general, but
all the conditions for staying healthy are reinforced through our wellness programs,
the kinds of foods that are served, there's the best fish probably in New York [inaudible]
and so we're into the question of mindfulness and respect for your body and taking responsibility
for your wellness instead of waiting to treat illness. [applause] So thank you Dr. Sharma
for all of your intelligent insight and for putting up with like an hour and a half of
our questions. We really appreciate it.
[applause]
>>Dr. Atul Sharma: Thank you very much.
>>female #33: I still like butter on my popcorn.
[laughter]
>>Dr. Atul Sharma: And that's ok.
>>female #34: [inaudible] a little butter and a lot of truffle salt.
>>Dr. Atul Sharma: Sounds good.
>>female #35: [inaudible] have gone to [inaudible] questions [inaudible] cardiovascular events
[inaudible]
>>Dr. Atul Sharma: Yes. [voices overlap]
>>female #35: All of that stuff is encompassed, not just coronary artery disease.
>>Dr. Atul Sharma: Right. Cardiovascular events, yes, exactly right, heart disease, atrial
fibrillation, your, oh, a stroke, yeah, I missed the big one, but I missed the big one.
>>female #36: And you mentioned, you mentioned that there's some controversy around salt.
[inaudible] My sister's [inaudible] she's now managing my mother and telling my mother
that she absolutely has to stay away from [inaudible]
>>Dr. Atul Sharma: If you have heart failure, salt is a must to stay away from.