SELF-DEFENSE - Butler Health System ©2014, David Schwartzman, MD SELF-DEFENSE A Primer for Patients with Diseases of the Heart or Blood Vessels

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©2014, David Schwartzman, MD

SELF-DEFENSE

A Primer for Patients with Diseases

of the Heart or Blood Vessels

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DISCLAIMER

The information provided in this document are my personal beliefs (and, where specified,

practices), and are based upon experience and my own interpretation of the relevant science as it is

understood today. The opinions of any one person should never be taken as gospel - please approach this

document while keeping that in mind.

INTRODUCTION

If you are reading this, you or someone you know have been diagnosed with disease(s)

of the heart or blood vessels. Examples of such diseases include high blood pressure, high blood

cholesterol, atrial fibrillation, coronary artery disease, angina, heart attack, stroke, dementia, diabetes,

sleep apnea, gout, arthritis, kidney insufficiency, lung insufficiency, erectile dysfunction, and cancer.

Such diseases require treatment, and optimizing that treatment will depend on you. This is because for

most people diseases of the heart or blood vessels are caused by problems with one or more “lifestyle”

elements. The term lifestyle refers to personal behaviors, and its elements are 1. self-monitoing; 2.

avoidance of unnecessary heartache; 3. Avoidance of tobacco products; 4. regular exercise; 5. adequate

sleep; 6. peace of mind; 7. eating and drinking.

4. regular exercise; 6. adequate sleep; and 7. peace of mind. Optimization of these elements is the

foundation upon which a treatment strategy for any heart or blood vessel disease is based. Just as a

house built on a poor foundation may collapse, so too may the treatment strategy without attention to

lifestyle. Collapse predicts additional diseases, more doctor visits, more hospitalizations, more

medicines and surgeries, higher out of pocket costs, diminished life quality, and frailty at a young age.

As this issue is so crucial and often not addressed, I created this primer to get you thinking about

lifestyle in the same way you think about medicines or surgery.

LIFESTYLE OPTIMIZATION

1. Self-monitoring

It is very important to monitor yourself over your lifetime, in particular once you are

older than 50, as nobody can do a better job. Here are the measurements I would recommend you

perform, write down (with dates), and review with your health care providers. It is best to keep all of

these in a single place, for simplicity as well as to provide clues as to how different issues may be

interacting (examples: 1. blood pressure rising as body weight rises; 2. Body weight rising in the months

after starting a new medicine or supplement):

i. Weight: weigh yourself on your home scale, naked. Do this weekly. If this

measurement is rising over time, this is almost always a bad thing.

ii. Waist: use a tape measure. Start the top of your hip bone, then bring the tape

measure all the way around, level with your belly button. Make sure the tape measure is straight and not

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tight. Do not hold your breath while doing this. Do this monthly. If this measurement is over 35

(women) or 40 (men) inches, this is not a good thing. If this number is rising over time, this is also not a

good thing.

iii. Blood pressure: you may do this with a system which you can purchase for the

home, or at a department store or pharmacy. Measure only when you are at rest. Less important than any

one measurement is the pattern of measurements over time. As a generality, less than 135 on the high

number (“systolic pressure”) and less than 85 on the low number (“diastolic pressure”) should be the

goal. However, due to personal variations, age, gender, and medical conditions, certain people will be

better served by different goals. It is important to discuss your specific goal with your physician.

Measure your blood pressure weekly.

iv. Exercise: keep a record of the type and duration of exercise. You do not need to

make any measurements of intensity, such as heart rate (or calories burned if you have an exercise

machine which provides such information). Simply put down the number of minutes in any given

session in which you were moving constantly.

v. Medicines: keep a record of every pill, liquid, inhaler or potion (apart from food

or drink) that you use. This includes things you need a prescription to get, as well as things that you

don’t. Get into the habit of bringing the packages (eg. pill bottles, powder bags) with you when you

come to your health care provider office, a “medi-quick,” an emergency room, or a hospital.

2. Avoidance of unnecessary heartache

a. Vaccinations: these are a gift from heaven, and you’ll be placing yourself at unnecessary

risk if you miss them without a good reason. Believe it or not, risks include worsening your heart or

blood vessel disease. Vaccinations are available for flu, tetanus/diphtheria/pertussis, varicella, zoster,

measles/mumps/rubella (if born after 1957), pneumococcus, and hepatitis. Please query your primary

care physician as to your status.

b. Seat belts: motor vehicle accidents harm a large number of people each year, and those

with diseases of the heart and blood vessels are at particular risk. Seat belts have been shown to protect.

c. Use of cell phone while driving: we are all aware of the perils of texting or emailing

while driving, but it is clear that any use of a mobile phone while operating a vehicle places you at risk

for accident due to the limited ability of your brain to multitask. Multitasking of this sort also places

considerable stress on your heart and blood vessels.

d. Cancer screening: there are several types of cancer which, depending on your age, gender

and family history, may be worth detecting early because treatments may be available which will impact

you. Late diagnosis makes treatment more difficult among patients with heart or blood vessel disease. It

is important that you discuss the pros and cons of any screening test with your primary care physician.

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3. Avoidance of tobacco products

These products damage you and those around you, plain and simple. They will make

treatment of any heart or blood vessel disease much less likely to be successful. This is true whether you

use them or you are near people who do. You must avoid them completely.

If you are currently using and planning to stop, it is important to know that after stopping your

body will try to put on weight. This is an important reality, and to prevent it close attention to food

choices is required (below).

4. Regular exercise

Exercise is crucial for lifestyle optimization. I define exercise as any activity during

which you are moving constantly. Examples include walking (outdoors or treadmill), elliptical machine,

bicycle, swimming, and rowing. I want you to aim for a daily regimen, which does not need to be the

same thing each day, in which the activity lasts for at least 30 minutes. Duration matters more than

intensity. There should never be pain, you should not exercise in environments at temperature extremes,

and you should not expose yourself to unnecessary injury (for example, slipping on icy or wet

pavement).

Note that although regular exercise is crucial, do not depend on it alone to take weight off or trim

your waistline. I frequently speak with people who are frustrated because they are exercising all the time

yet are unable to lose weight. This is because the body will make adjustments as to maintain your weight

unless you convince it otherwise. That is no small thing, as our bodies have evolved to be expert in

keeping weight stable. It is going to require a focus on food choices (see below).

5. Adequate sleep

During sleep, your body conducts what can be thought of as “repair and maintenance.”

When sleep is disordered, these processes are incomplete, and this can have a damaging effect over

time, in particular targeting heart and blood vessels. People vary in regard to how much sleep they need

on a daily basis – on average 7 to 8 hours. Some tips to promote healthy sleep include: A. go to bed

approximately the same time every night; B. do not eat for at least 2 hours prior to bedtime; C. exercise

every day; D. the sleep space should be cool, dark, and quiet; E. use the bed for sleep or romance only

(eg. no television, computer, books, etc.). If you cannot sleep, do not lay awake

Whether they know it or not, many people with diseases of the heart or blood vessels have

disordered sleep, which requires professional evaluation and management. A common term used for this

problem is “apnea.” Warning signs of sleep apnea include snoring, daytime fatigue or sleepiness, and a

partner who tells you that you “stop breathing” for periods of time while you are sleeping. Sleep apnea

is more common among people who are obese, have increased waistlines (more than 35 inches in

women or 40 inches in men), or have increased neckline (more than 14 inches in women or 18 inches in

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men). As an example of how important sleep is to wellness, if you have disordered sleep you will find it

almost impossible to lose weight.

6. Peace of mind

This may be the most difficult of the lifestyle elements, because “peace of mind” is

personal and thus difficult to define, with many moving parts What we know is that patients with

diseases of the heart/blood vessels who have poor peace of mind do worse, likely because when the

brain is unhappy, it turns on itself as well as other organs and systems of the body, resulting in damage

and the occurrence or worsening of diseases, in particular those of the heart and blood vessels.

Some areas to consider as you put together your own peace of mind puzzle include:

- quality of your relationships with family, friends, co-workers and acquaintances.

- work life: quality, fulfillment, and enjoyment

- faith

- causes

- hobbies

- behavioral counseling

- exercise

- meditation

- yoga

- medications

As a generality, you should create a clear peace of mind strategy and attempt to pursue it, even if for a

few minutes, every day.

7. Eating and drinking

I have saved the best for last. This is, without doubt, the most important of the lifestyle

elements. Your gastrointestinal tract is the dominant interface between your insides and the outside

world, and the quality of your food will have a tremendous impact on your internal workings. It is clear

to us that food choices dictate body weight, and that certain diets are associated with much higher rates

of heart and blood vessel disease, as well as cancer. If you already have heart or blood vessel disease,

the effect is greatly magnified.

To emphasize the importance of eating and drinking, I have included a number of appendices

which you may find helpful. In Appendix 1, I provide a primer on nutrition, which will help you to

“speak the language” as you learn more about food and nutrition. I also want you to read a book entitled

“ALWAYS HUNGRY?” (author David Ludwig, www.drdavidludwig.com). You will find this book

empowering because it gives you a clear understanding of how your body works in regard to food and

weight control. It is essential if you are trying to lose weight. In Appendix 2, I have created a list which

http://www.drdavidludwig.com/

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separates food into those you should and those you should not eat. You may find it helpful to take this to

the grocery store with you. In Appendix 3, I provide a primer on how to read a food label. You would do

well to become familiar with this, so as to become an “educated eater.” In Appendix 4, I include a list of

terms meaning “sugar” which you may see on a food label. I want you to avoid all foods to which sugar

is added by the manufacturer, unless the manufacturer is god. In Appendix 5, I provide a primer on a

“whole food, plant-based” (WFPB) way of eating, which uses only some of the foods from the list in

Appendix 1. Many of my patients ask about my personal way of eating, which is WFPB, because I

believe that it is the best way for me to slow down the aging process and minimize the likelihood that I

will develop a chronic disease along the way. In Appendix 6, I include some thoughts on eating outside

of your home.

FREQUENTLY ASKED QUESTIONS

1. What about caffeine?

Caffeine is a drug which we consider a stimulant. It is commonly found in coffee, tea,

and soft drinks, but elsewhere as well (check the label). As a generality, it is not considered a

danger. You should discuss your situation with your doctor.

2. What about sex?

As noted before, sexual activity is an important element of life quality for many people,

and if so should be encouraged. If you are exercising regularly, it is rare that sexual activity

would be inadvisable. Men or women may experience problems when it comes to sexual activity,

including lack of desire, inability to perform, or pain. It is important to recognize that these are

not normal, and may be associated with foundational elements, disease processes, or prescription

medications. You should not be shy about discussing your situation with your doctor.

3. What about alcohol?

As a generality, as little as possible is best. You should stay away from spirits, and not

exceed 1-2 glasses of wine or beer per day. Keep in mind that alcoholic beverages contain

calories of a type that the body likes to turn into fat.

4. What about dietary “supplements”?

These include vitamins, minerals, herbs, probiotics, oils, powders and other assorted

potions, all of which you can buy in stores or over the internet and without a prescription. It is

important to understand that these substances are largely unregulated by the government, which

give manufacturers broad scope as to what they put in the bottle, can, or bag. For example, recent

reports have demonstrated that certain supplements contain things other than those on the label.

In addition, the vast majority of supplements have never been tested scientifically as to whether

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they may do harm or whether they have any benefit. Finally, we are increasingly aware of

harmful interactions between prescription medicines and supplements – but again, our current

awareness is likely only the tip of the iceberg. For these reasons, as a generality I do not

recommend supplements. However, you should understand that there are certain circumstances

in which a particular supplement will be safe and useful in protecting your health. You should be

sure that you bring the containers of any supplements you are taking with you to all of your

physician visits, and be prepared to discuss the pros and cons of each. If you are considering a

new supplement, discuss this with your physician in advance.

5. What about “artificial” sweeteners?

Since I am telling you to eliminate any foods to which sugar is added, this is an important

question. These are considered to be substitutes for sugar, and include acesulfame potassium

(Sunett®, Sweet One®), aspartame (Equal®, NutraSweet®), saccharin (SugarTwin®, Sweet N’

Low®, NectaSweet®), sucralose (Splenda®), stevia extracts (PureVia®, Truvia®), and tagatose

(Naturlose®). Their attractiveness is based on the fact that they add few calories, and because

they are many times sweeter than sugar, you need only a fraction of the amount to get your

sweetness “fix.” I remain suspicious of these chemicals, for three reasons:

A. They are often used in foods which have been processed to taste good, but in

addition to the artificial sweeteners contain known to be harmful items (including processed

carbohydrates, trans fats, and salt). Thus, as often as not, artificial sweeteners are a marker for

foods that you’d do well to avoid.

B. Although most have been “generally recognized as safe” by the government,

this definition is typically murky and poorly defined.

C. I am concerned that, despite the lack of calories, these chemicals cause the

body (including the brain, which is the central player in how you metabolize foods) to respond in

a way similar to as if you had eaten sugar. The science here not clear and so should be

considered a work in progress, but my feeling is that when it comes to chemicals (“food” or

otherwise) which are not found in nature (and therefore unfamiliar to our bodies), they are guilty

of causing harm until proven innocent.

6. What about salt (sodium)?

As a generality, our diets contain more salt (sodium) than is healthy. Sodium is the active

ingredient in salt that you need to be concerned about. Most of this comes from processed foods.

In addition to avoiding such foods (see appendices), I would recommend that you do not add salt

to your food. Instead, try experimenting with flavorful herbs and spices, including garlic/garlic

powder, lemon juice, flavored vinegar, salt-free herb blends, cumin, nutmeg, cinnamon, fresh

ground pepper, tarragon, and oregano. Salt substitutes should, in general, be avoided. If you are

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going to use a salt substitute, check with your doctor first. You should become adept at reading

food labels (see Appendix 4) to see how much sodium is in the product you are considering. You

should assume that any food that is prepared for you contains too much salt, which is one reason

to limit your eating out frequency (see Appendix 5).

7. I’ve been told that I cannot eat certain foods if I am taking a blood thinner. Is this true?

This is simply not true, regardless of the blood thinner. As is detailed above and in the

appendices, food optimization is a key to your self-defense strategy. Therefore, any drug,

including blood thinners, must take a back seat to the food. However, and in particular if you are

making a change in the way you eat, you should discuss this with the physician who is

prescribing the blood thinner, so that s/he can anticipate changes in the amount you will need.

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APPENDIX 1

A Primer on Nutrition

Eating is one of the great joys of life, as it should be. It is also required, as food (under which I

will also include drink) can be thought of as fuel or energy which your body requires to function. In

addition to energy, food contains compounds or chemicals which the body needs (cannot make them

from scratch). Between energy and materials derived from your food, your body does the following:

1. maintains your tissues.

2. regulates body processes, including circulation, consciousness, breathing and digestion.

3. allows your muscles to work.

4. maintains your body temperature.

When food is digested and absorbed from your gut, the materials are made available for the

body’s use. Food can be grouped into 6 large classes: 1. water; 2. carbohydrates; 3. fats; 4. proteins; 5.

vitamins; 6. minerals. I’ll provide a brief description of each:

1. water: except for air, water is the most essential element for life. We can live for weeks

without food, but only a few days without water. All of the chemical reactions in the body which use

food to create energy and new tissue require water. It is in every cell of your body. About two-thirds of

your body weight is water. Your body loses water on a daily basis, to get rid of wastes (urine) and to

maintain body temperature (sweat). Water is replaced primarily by food (solid or liquid). Just like you,

most foods are mostly water.

2. carbohydrates: these are commonly known as “starches” or “sugars.” Also included

would be “fiber,” (also known as “roughage”) but this is a type of carbohydrate which we are not able to

digest, and so passes through our gut. The main function of carbohydrates is to provide energy.

3. fats: these are commonly known as “lipids.” Also included are oils. Fats may be called

“saturated” (usually derived from animals, including beef, pork, lamb, milk, cheese and eggs. They are

solid at room temperature), “unsaturated” or “polyunsaturated” (usually derived from vegetables or fish.

We call them “oils” because they are liquid at room temperature), and “trans” (these are not natural –

rather, they are created by chemists. They have a number of advantages to food manufacturers, including

taste, texture, and shelf life, but they are not good for you and should always be avoided). Check the

label of your food package (see also Appendix 3). If you see the terms “partially hydrogenated” or

“hydrogenated vegetable oil” or “vegetable shortening” or “shortening,” you can assume that the

product contains trans fats. Fats have many functions in our bodies, in addition to providing energy.

Included are tissue repair, body temperature regulation, protecting internal organs from damage, storing

energy for later use, keeping skin healthy, and as a vehicle for vitamins (see below).

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4. proteins: these are compounds which, unlike carbohydrates and fats, are not generally

used to supply energy. Rather, they are generally used as building blocks to maintain the structure and

function of your tissues. Contrary to what you may believe, protein is found in abundance in vegetables

and grains.

5. vitamins: these are naturally occurring chemicals found in foods, and are necessary in

very small quantities for normal body function. There are about 15 different vitamins. You need only a

very small amount of each, and not necessarily on a daily basis. More than what your body needs

provides no added benefit, and is often gotten rid of quickly. Some are not, and so too much can do

harm. Most foods contain a variety of vitamins, but no one food has all of them. If your diet contains a

variety of foods, it would be rare that all of your vitamin needs will not be met.

6. minerals: these are also naturally occurring chemicals found in foods, and like vitamins

are needed in small quantities for normal body function. Although more than 15 different minerals are

required, all together they make up less than 5% of your body weight. As for certain vitamins, taking in

too much of certain minerals can be harmful. If your diet contains a variety of foods, it would be rare

that all of your mineral needs will not be met. Note that some medications will cause your body to lose

certain minerals, which cannot be replaced completely by food. In these cases your doctor may prescribe

a supplement (examples include potassium and magnesium).

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APPENDIX 2

Grocery Store Shopping List

1. Good: most of your food/drink should come from this section. CHECK THE LABEL - avoid if any

term for added sugar appears – see also Appendices 3 and 4):

A. Breads:

- coarse wheat kernel

- cracked wheat (bulgur)

- coarse barley kernel

- coarse rye kernel (pumpernickle)

- whole grain pumpernickel

- oat bran

- Healthy Choice® 7 grain

- buckwheat

- whole wheat matzo

B. Cereals:

- steel cut (Irish) oats

- rolled oats

- All Bran®

- Muesli

- Kashi®

C. Rice:

- brown rice

- wild rice

D. Pasta:

- whole wheat

- semolina

- rye

E. Grains:

- bulgur wheat

- teff

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- quinoa (really a seed, but we’ll leave it here)

- kaniwa

- farro

- freekeh

- millet

- barley

- wheat berries

- buckwheat

F. Meats/meat substitutes

- fish

- lamb

- turkey

- chicken

- lean ground beef

- veggie/garden burger

- Boca® burger

- tofu

- tempeh

- seitan (whole wheat flour only)

G. Nuts (no more than one half cup per day)

- almonds

- walnuts

- pecans

- brazil nuts

- cedar nuts

H. Seeds (raw or roasted; no added sugar or salt)

- flax

- hemp

- sesame

- sunflower

- pumpkin

- chia

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I. Dairy:

- plain yogurt (low fat)

- string cheese

- cottage cheese (low fat)

- farmer’s cheese

- mozzarella cheese

- queso fresco

J. Beans:

- black

- garbanzo (chickpeas)

- lentil

- kidney

- black-eyed peas

- edamame

- cannellini

K. Fruits (fresh, frozen or canned; if canned, no syrup):

- apple

- avocado

- banana

- cantaloupe

- watermelon

- honey dew

- strawberry

- raspberry

- blueberry

- cherry

- apricot

- guava

- grape

- kiwi

- mango

- mandarin

- orange

- papaya

- peach

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- pear

- pineapple

- plum

- star fruit

- dried apricot

- raisin

- fig

- date

- dried apple

L. Vegetables:

- artichoke

- asparagus

- bean sprout

- beet

- beet green

- celery

- parsley

- chicory

- chinese cabbage

- chives

- collard green

- endive

- jicama

- mustard green

- cabbage

- kohlrabi

- brussels sprout

- dandelion green

- green bean

- pea

- escarole

- fennel

- edimame

- pepper (red, green, orange, yellow, hot)

- bok choi

- carrot

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- lettuce (romaine, red leaf, green leaf)

- cauliflower

- tomato

- cucumber

- eggplant

- mushroom (any kind)

- onion

- radish

- squash

- spinach

- turnip

- zucchini

M. Eggs

- organic

- free range

- pastured

N. Beverages:

- cow’s milk (reduced fat)

- rice milk

- soy milk

- almond milk

- coconut milk

- water

- sparkling water

- club soda

- coffee (black)

- tea (herbal)

- wine

- sugar-free flavored waters

O. Spreads:

- hummus

- salsa

- spreadable whole fruits

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P. Condiments:

- soy

- sweet and sour

- cocktail

- teriyaki

- barbecue

- ketchup

Q. Oils:

- olive

- canola

2. Bad: these items should be avoided:

A. Breads:

- bagel

- white

- corn

- potato

- rice

- doughnut

- hamburger bun

- hot dog bun

- croissant

- roll

- English muffin

- Italian

- baguette

- pita

- tortilla

B. Cereals: anything not listed in section 1

C. Rice:

- basmati

- white

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- jasmine

- Arborio (risotto)

- long grain

D. Pasta:

- white

- noodles

- canned

E. Grains/baked goods:

- pop tart

- cake

- brownie

- chip (any)

- cracker (any)

- pizza (crust)

- rice cake

- instant oatmeal

- waffle

- pancake

- cookie

F. Meat/meat substitutes:

- bacon

- chorizo

- sausage

- hot dog

- lunch meats (any)

- turkey bacon

- steak

- hamburger

- turkey dog

G. Nuts:

- candied

- roasted

- glazed

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H. Dairy:

- yogurt (except plain)

- cheddar cheese

- jack cheese

- American cheese

- Colby cheese

- cream cheese

- ice cream

I. Fruits: canned in syrup

J. Vegetables:

- French fries

- tater tots

- onion rings

- baked beans

- popcorn

K. Beverages:

- soda

- “sports” drinks (Gatorade, Powerade, Propel, G2, etc)

- diet anything

- slurpie

- smoothie

- juice

- flavored milk

- whole milk

- cocoa

- designer coffees (frappucino, macchiato, mocha, latte, etc)

- beer

L. Spreads

- jam

- jelly

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- honey

- peanut butter

- guacamole

- margarine

- butter

M. Condiments:

- lard

- sugar

- cream cheese

- sour cream

- mayonnaise

- salt

- salad dressing (except oil and vinegar)

- honey

N. Oils:

- coconut

- vegetable shortening

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APPENDIX 3

How to Read a Food Label

Packaged foods are required by the government to have labels which tell you about what they

contain. These are entitled “Nutrition Facts.” An example is shown below. Here are the keys to reading

these labels:

1. Serving size: usually given as a volume (the “cup” measure is commonly used) and/or

weight. Understanding serving size is crucial, because people commonly assume that the label

summarizes all that is contained in the package. This is usually not true. It is important, because the

information as to what is inside will be per serving. So, for example, if you eat double the serving size

listed, you must double everything on the list below (calories included).

2. Calories: this is a term for energy contained per serving. The minimum number of

calories you need per day to maintain health varies based on a number of factors, including age, gender,

and body size, but if you are 50 years or older is approximately 1600 for women and 1800 for men. On

the label will also be a term entitled “calories from fat,” which I want you to ignore. As is discussed

elsewhere in this manual, the calorie issue is a tough one. First, it is difficult to count calories accurately,

and even if you could you probably don’t want to be doing this for the rest of your life. Second, it is

difficult to restrict calories adequately over the course of time. I favor a different approach: ignore

calories. My thinking is that, assuming you choose only the right foods, you can eat as much as you

want, not count calories and not gain (and lose if you are overweight) weight.

3. Fat: usually given as total and, underneath this, different types including saturated,

monounsaturated, polyunsaturated, and trans (see Appendix 1). For each is given a weight (grams or g)

as well as a “percentage (%) daily value”. The latter term has to do with what the government believes is

reasonable, based on a diet which contains a total of 2000 or 2500 calories. I want you to ignore the

weight and percentage of total, saturated, monounsaturated and polyunsaturated fat in the product. What

I do not want you to ignore is the presence of trans fats. If you see the term “trans,” I would

recommend that you do not use this product.

4. Cholesterol: this is a type of fat. The amount is usually given as a weight (milligrams

or mg) and % daily value. I want you to ignore this.

5. Sodium: this is a type of mineral (see Appendix 1). The amount is usually given as a

weight and % daily value. It is very commonly added to foods, because we like the taste and because it

prolongs shelf life. As a generality, we eat too much of it, and this may do harm. I would recommend

that you aim to eat no more than 2,000 milligrams per day. In addition to paying attention to labels, this

means that you should get rid of the salt shaker and not add salt to foods when cooking. As is discussed

elsewhere in this manual, there are excellent substitutes for salt from which you can choose.

6. Carbohydrate: given as total and, underneath this, different types (eg. fiber, sugars).

For each is given a weight (grams or g) as well as a “percentage (%) daily value.” I do not want you to

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pay attention to the total carbohydrate data. However, I do want you to pay attention to the different

types. First, look at the fiber. Fiber is a material which only comes from plants (fruits, vegetables,

grains, nuts, seeds) and which cannot be digested by the body. Despite the fact that it is not digested, it is

a crucial element of health. When it comes to fiber, more is better. I want you to aim for a total of at

least 40 grams of fiber per day, every day. If you are eating fruits, vegetables, and (some) nuts and

seeds, there will be no label, so I have provided a table below which gives you a sense of the amount of

fiber in some of these items. Next, look at the sugars. Unfortunately, the current government mandated

food label does not tell you whether the sugar is natural (contained within the food) or added by the

chemists who create the final product which is sold. You will have to also look at the ingredient list

(below). If you see on this list any term for sugar (see Appendix 4), it means it was added and thus I

want you to try to avoid this product.

7. Protein: given as a weight (grams or g) as well as a “percentage (%) daily value.” I

want you to ignore this.

8. Vitamins and minerals: these are listed in the section below protein. On the sample

label shown below, they include vitamin A, vitamin C, calcium, iron, thiamin, vitamin B6, and

phosphorus. Next to each is provide a % daily value. I do not want you to worry about these.

9. At the bottom of the label is a chart which provides government recommendations for

amounts of different items from the sections above. I want you to ignore this.

10. Ingredients: either next to (as in the sample label below) or elsewhere on the package,

you will find the list of all ingredients in the product. As a generality, if there are more than 3

ingredients in this section, the product should be considered as suspicious. There are a couple of specific

ingredients that I want you to look for, and if you see them I would recommend that you avoid using the

product:

A. added sugar. In addition to “sugar,” look for one or more of the terms listed in

Appendix 4. Avoid these foods.

B. trans fats: If you see the terms “partially hydrogenated” or hydrogenated

vegetable oil” or “vegetable shortening” or “shortening,” you can assume that the product contains trans

fats. Avoid these foods.

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23


TABLE. Fiber content in Fruits, Vegetables and Nuts

Food Amount Fiber Content (grams)

Alfalfa sprout 1 cup 0.6

Almond (slivered) 1 tablespoon 0.6

Almond (sliced) 1 cup 9.5

Apple (raw, with skin) 1 3-5

Apricot (raw) 1 0.8

Artichoke (cooked) 1 10.3

Artichoke (canned heart) 1 1.0

Asparagus 1 cup 3.5

Avocado 1 2.8

Banana 1 3.0

Bean (black) 1 cup 19.4

Bean (great northern) 1 cup 16.0

Bean (kidney) 1 cup 19.0

Bean (lima) 1 cup 12.0

Bean (pinto) 1 cup 18.8

Bean (white) 1 cup 16.0

Beet (sliced) 1 cup 5.0

Blackberries 1 cup 8.8

Blueberry 1 cup 3.6

Bok Choi 1 cup 1.7

Brazil nuts 1 1.7

Bread (white) 1 slice 0.8

Bread (whole wheat) 1 slice 3.0

Bread (rye; whole grain) 1 slice 3.0

Bread (seven grain) 1 slice 3.3

Broccoli 1 cup 8.0

Brussel sprout 1 cup 4.0

Bulgur wheat 1 cup 9.6

Cabbage (white or red) 1 cup 3.0

Cantaloupe 1 4.0

Carrots 1 cup 4.6

Cashew 1 cup 2.7

Cauliflower 1 cup 3.0

Celery 1 cup 6.0

Cherry 10 1.2

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Chestnut 1 0.8

Chickpeas (garbanzos) 1 cup 12.0

Coconut 1 tablespoon 3.4

Corn (cob) 1 ear 5.0

Corn (kernels) 1 cup 10.0

Cranberry 1 cup 8.0

Cucumber (with skin) 10 thin slices 1.0

Dates (pitted) 2 1.2

Eggplant 1 cup 2.5

Endive 10 leaves 1.0

Figs 1 2.0

Flax seed 1 tablespoon 2.8

Grapefruit 1 1.6

Grape (any) 20 1.0

Green (snap) pea 1 cup 4.2

Swiss chard 1 cup 8.0

Honeydew melon 3 inch slice 1.5

Kale 1 cup 2.6

Lentil (brown) 1 cup 18.0

Lentil (red) 1 cup 20.0

Lettuce 1 cup 0.8

Mushroom (whole) 5 small 1.4

Mushroom (sliced) 1 cup 8.0

Nectarine 1 cup 2.4

Okra 1 cup 3.2

Olives 6 1.2

Onion 1 cup 3.0

Orange 1 2.4

Peach 1 2.3

Pea (green) 1 cup 18.2

Pea (black eyed) 1 cup 16.0

Pecan 1 cup 2.7

Peppers 1 cup 2.4

Pineapple 1 cup 1.6

Plum 1 cup 2.3

Pomegranite 1 11.3

Potatoe (boiled, with skin) 1 3.5

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Potatoe (mashed) 1 cup 6.0

Prune 1 0.6

Raisins 1 cup 2.4

Raspberry 1 cup 9.2

Rutabega 1 cup 6.4

Sesame seed 1 tablespoon 1.1

Spinach 1 cup 7.0

Squash 1 cup 5.0

Sunflower seed 1 tablespoon 3.1

Sweet potatoe 1 3.8

Zucchini 1 cup 6.0

Strawberry 1 cup 3.0

Sunflower seed 1 tablespoon 0.5

Swiss chard 1 cup 3.7

Tomatoe 1 2.0

Turnip 1 cup 4.8

Walnut 1 1.1

Watermelon 1 thick slice 2.8

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APPENDIX 4

Sugar, by Other Names

Agave nectar

Barley malt

Beet sugar

Brown sugar

Buttered syrup

Cane juice

Cane juice crystals

Cane sugar

Caramel

Carob

Carob syrup

Confectioner’s sugar

Corn syrup

Corn syrup solids

Date sugar

Dextran

Dextrose

Diatase

Diastatic malt

Erythritol

Ethyl maltol

Fructose

Fruit juice

Fruit juice concentrate

Galactose

Glucose

Glucose solids

Golden sugar

Golden syrup

Granulated sugar

Grape sugar

High fructose corn syrup (HFCS)

Honey

Hydrogenated starch hydrolysate

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Invert sugar

Isomalt

Lactitol

Lactose

Malt

Malt syrup

Maltitol

Maltodextrin

Maltose

Mannitol

Maple syrup

Molasses

Raw sugar

Refiner’s syrup

Sorbitol

Sorghum

Sorghum syrup

Sucrose

Turbinado sugar

Xylitol

Yellow sugar

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APPENDIX 5

A Whole Food, Plant-Based Way of Eating

1. Note

Any substantial change in how you eat requires careful consideration and planning. In

addition the understanding the reason to change, the goals, and the types and quantities of food items on

the menu, it is important to consider your environment. This includes family, with whom you should

discuss this in detail before embarking, as well as friends and other people from whom you receive

social support. Many people have told me that partnering with one or more family or friends makes the

transition easier.

You should be aware that you body is quite complex when it comes to how it perceives

and acts upon food. Therefore, although a given way of eating might be better for most people, there are

some for whom it will not work or even potentially cause harm.

You must have patience. In embarking on any way of eating with a particular goal, for

example changing your weight or waistline, you must understand that you are going up against millions

of years of evolution. If nothing else, our bodies have evolved to hold the line, presumably because we

evolved in environments (unlike today which were very unpredictable when it came to essential

elements, such as food and water. Thus, your body will fight back hard against any force you place on it

which threatens the status quo. A change in your way of eating may be just such a force.

You should be aware of the fact that a change in way of eating may well change your

prescription medicine requirements. Reducing the number of medicines you need is an excellent

incentive for adopting a better way of eating. However, whether and how this takes places will vary, and

thus it is very important to keep your doctors aware of what you are up to, as to make changes safely

over time.

2. Introduction

I know this may be difficult to understand, given that if you are like me, you’ve been

brought up to believe in the concept of “calories in, calories out” when it comes to weight. Therefore,

our understanding of the word “diet” has been an endeavor in which you limit calories. In addition to the

torture of constantly trying to figure out how many calories are in this, that, or the other thing – which

can suck the joy out of eating – calorie restriction will inevitably leave you hungry. This is doomed to

fail in the long term. And it is the long term we are interested in, because if you lose weight for only a

brief period of time – say 6 months or a year – then you do not significantly change your health path. So,

sustainability is the key. This is why I call this a “way of eating” rather than a “diet,” because the word

diet makes you think this: “I’ll do this for a while, get my weight where I want it to be, then go back to

what I was doing before.” This is also doomed to fail, or worse, because if you reintroduce old foods to

your body after a period of dieting, the weight and waistline will come back with a vengeance, often

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exceeding where you started. This phenomenon, which some call “yo-yo,” is very common, and it is

demoralizing. Changes in weight and waistline must be sustained over your remaining lifetime in order

for you to receive the full health benefit.

There are several different ways to eat which will induce weight loss, and it is important to

understand that the science in this area is as yet immature. This is why you have and will continue to see

pieces on television and in print about outcomes with certain diets. Conflicting information may leave

you confused and frustrated, thinking that the medical or scientific communities do not know what they

are talking about (sometimes true). For what it is worth, based on my personal evaluation of the science

it is my firm belief that the whole food, plant-based (WFPB) makes the most sense, given what is known

in 2014, for a number of reasons:

i. It will not leave you hungry. Hunger competes with pain to be the most terrible of

sensations, and it is simply not sustainable for a person who has access to food. Assuming that you stick

to the menu (below), you can eat more, certainly enough for you to feel full and not subjected to

constant cravings and food thoughts or fantasies, while losing weight and waistline. The emerging truth

is that the body perceives certain types of food differently than others – effectively, a calories is not a

calorie. There are “good” calories and “bad” calories. The bad calories will tend to make you fat, even if

you restrict them. It is therefore best to avoid them.

ii. You will not have to count calories. If you stay true to the food choices, you can

literally eat as much as you want.

iii. You will be well nourished. Although losing weight, maintaining a healthy

weight, and minimizing your waistline circumference are very important goals, they are not the only

goals. In addition to energy, food contains thousands of compounds which your body tissues use to

maintain themselves. It is my belief that in 2014 these compounds are best provided by a WFPB diet.

iv. You will be able to afford it. Many ways of eating, in particular those attached to

commercial products (eg. Weight Watchers®, Jenny Craig ®, Nutrisystem®), may sell packaged

products which can be very expensive. This is not necessary in WFPB. Be aware however that WFPB is

becoming big business, and some promoters are also selling branded foodstuffs (examples: Fuhrman,

McDougal). Purchasing such products is NOT recommended, as they add unnecessary cost.

In my experience, these elements give you the best chance of adopting this way of eating for the

rest of your life. Note that The nutrient composition in WFPB is approximately 70% carbohydrate, 20%

fat, and 10% protein.

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3. Myths debunked

i. Not enough protein: incorrect – there is plenty of protein in plants. As discussed

above, variation in what you eat is important so that your body gets all different types of protein.

ii. Aren’t carbohydrates bad for you? They can be, which is why the specific choices

are crucial. See the menu below.

iii. I’ve heard that WFPB leaves you with vitamin deficiencies? This is possible, and

should be monitored by your physician, who may prescribe selected supplements including vitamins

B12, K2, and D3, iodine, and a chemical called docosahexaenoic acid (also known as DHA).

4. Changing your food environment

One of the keys to WFPB is stocking your pantry and refrigerator with the right stuff, and

getting rid of the wrong stuff. It is a given that a WFPB pantry will turn over faster than a typical pantry,

so you will need to plan. If you know throughout the week that your ingredients are waiting for you at

home, and that they will not keep, you’ll be less likely to pick up restaurant food. When shopping, come

with a list and become adept at reading labels (Appendix 3). Although early on the supermarket will

seem like a brave new world, once you have a sense of what you enjoy eating and can prepare in the

context of the rest of your day, it will be quick.

You cannot control your food environment outside of your home, and this is a real

problem. So many convenience foods are available and within eyeshot, and that can be very tempting if

you are hungry. You will need to plan ahead and take your pantry with you. For example, prepare a bag

with apples, strawberries, raisins, carrots, or almonds. Hummus travels well, and can be used in lieu of

dressing on just about any vegetable. When eating out, you will be challenged. Restaurants make money

by serving food, and it is their nature to seek foodstuffs that have extended shelf lives (which imply

processing and the inclusion of sugar and salt).

5. What’s on the menu?

a. All fruits (see Appendix 1)

b. Leafy or cruciferous vegetables, including lettuce, collard greens, kale, broccoli. Whether

you go for organic or conventional produce, eat an array of colors. Different colors imply different sets

of nutrients, so you want to be all over the board. You can eat these raw, of course, but you’ll also want

to experiment with mixing things up, such as with grilling, baking, or sautéing. See also Appendix 1.

c. Tubers and starchy vegetables, including potatoes, yams , yucca, winter squash, corn and

green peas (see Appendix 1)

d. Grains: “whole” grains have not been refined through a manufacturing process which

removes the bran and germ portions of the plant (these are the most important). You can find whole-

grain versions of all kinds of foods, including bread, rice, and pasta. Look carefully at the label

(Appendix 3): don’t just look for the word “whole”; also read the ingredients to be sure that “whole

31


grain” is first or second on the list. Also, there should be no more than one or two ingredients after that,

nothing that says “refined” or “enriched,” and NO added sugar (Appendix 4). Examples include rolled

oats, brown rice, wild rice, whole wheat, buckwheat, millet, and bulgur. See Appendix 1.

e. Tofu

f. Tempeh

g. Seitan (whole wheat flour only)

h. Legumes: all kinds, including black beans, kidney beans, pinto beans, navy beans,

garbanzo beans (chickpeas), lentils, edamame, and cannellini beans.

i. Hummus

j. Salsa (no added sugar)

k. Nuts (no more than a handful per day): almonds, walnuts, brazil nuts, cedar nuts, and

pecans. Raw or roasted

l. Seeds: flax, hemp, sesame, sunflower, pumpkin, chia and quinoa. Raw or roasted

m. Oils: olive, canola

n. Beverages: water, sparkling water, club soda, soy milk (no added sugar), almond milk

(no added sugar), coffee (black or with almond/soy milk; no added sugar); tea (no added sugar), wine.

6. Helpful references

There are an almost unlimited number of resources which will help you adapt to a WFPB

way of eating. I list a few representative sites below. You will need to teach yourself – this is time well

spent.

1. Books:

The Complete Idiots Guide to Plant-Based Nutrition (Julieanna Hever)

Eat to Live (Joel Fuhrman)

Eat more, weigh less (Dean Ornish)

The Prevent and Reverse Heart Disease Cookbook (Ann Crile Esselstyn)

The Whole Foods Plant Based Diet – A Beginner’s Guide (Gary Roles)

2. Web sites:

http://myplantbasedfamily.com

http://www.forksoverknives.com

http://plantpoweredkitchen.com

APPENDIX 6

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Tips for Eating Outside the Home

1. Eat “out” as infrequently as you can. In general, restaurant food contains “bad stuff,” in

particular sugar and salt, because these things improve the taste and prolong shelf life – both are

good things if you are a restaurant owner. You will likely never know what is in the food, and

you should not assume that your server has any clue. If you are going to eat out and have the

opportunity to plan, research the menu first to get a sense of whether there are decent options.

2. NEVER eat at or get delivery from a “fast food” restaurant, including: Arbies, Baskin-Robbins,

Blimpies, Buffalo Wild Wings, Burger King, Cal’s Jr., Chick-fil-A, Dairy Queen, Dunkin

Donuts, Hardee’s, Jimmy John’s, Krispy Kreme, Kentucky Fried Chicken, McDonalds, Pizza

(any), Popeyes, Roy Rodgers, Sonic, Steak ‘n Shake, Taco Bell, Wendy’s, White Castle,

Wingstreet.

3. Sit-down restaurants with very limited healthy choices include: Applebees, Bob Evans, Chili’s,

Cracker Barrel, Denny’s, Eat n Park, Five Guys, Golden Corral, IHOP, Olive Garden, Pizza Hut,

Red Lobster, TGI Friday’s.

4. When in restaurants:

A. drink a full glass of water first. NO soda or juice. Limit wine or beer to 2 glasses.

B. do not eat bread from basket - ask to have it not delivered or taken away.

C. order a large salad as an appetizer; dressing on the side (use it to dip), no croutons.

D. do not be afraid to “negotiate” with the server for things not exactly on the menu.

Many restaurants which make food to order are willing to make alterations, such as switching

sauces or side dishes

E. try to say NO to dessert.

Documents

SELF-DEFENSE - Butler Health System ©2014, David Schwartzman, MD SELF-DEFENSE A Primer for Patients with Diseases of the Heart or Blood Vessels