Back in Action!

I took some time off from serious training. It was something I needed to do, to take a break from structured fitness, and to try to accomplish a few things in my personal life.

But now I'm back.  I love having a goal, and what better goal than to succeed in a race, right?  I'm training for a half marathon, the Santa to the Sea half marathon on December 11.  Here's how I'm getting back to it:

Set an Attainable Goal

I ran a 5k race in early October, and that was a big wake-up call that my race pace was not where it once was -- that said, it wasn't entirely terrible because I was the third fastest woman overall.  While I could run a 1:48 half marathon when I was in peak shape, that's not realistic right now.  With five weeks to train, my goal is 1:56, which is just under nine minutes per mile. 

Running

I run four days a week, no more than that.  One run is at a tempo pace, or about 15 seconds slower per mile than my projected half marathon time.  One run is a long run, ranging from 8-12 miles. 

A lot of running happens on trails.  Trails are gentler on the joints, provide far better scenery, and include hills and uneven surfaces for challenging muscles more than the repetitive footstrike of a flat surface.  This picture is courtesy of Gerardo Barrios of Fortius Coaching, taken on the trails of Malibu Creek State park.

Strength training

Interval training and weights have always helped me achieve my goals.  My friend Deirdre Hamilton opened up Hamboody Strong, her own group training playground in her backyard.

Exercises include box jumps (shown above) or box step-ups, kettle bell swings, battle ropes, planks, mountain climbers, or whatever Deirdre imagines for the workout of the day.  If you're local to Lake Balboa, it's a great workout for anyone who wants to build strength and fitness, even beginners!  

Swimming

I still swim twice a week with Golden Road Aquatics.  Swimming keeps me limber and stretched out, and is a great way to start a morning.

Rest Days

I rest at least once a week.  During the first couple weeks of half marathon training, I rested two days a week,

I am hoping my training leads to a successful half marathon, and will keep you posted on how that goes!

Marijuana

With the approval of Proposition 64 here in California, recreational use of marijuana is now legal.  But, what about marijuana from a medical point of view?

To start, for full disclosure -- I am no expert on medical marijuana use, and I do not prescribe marijuana.  This is simply my perspective as a cardiologist.

I have smoked marijuana once in my life, and that was while in medical school.  I choose not to smoke marijuana, simply because I have no interest.  However, I believe people should have the right to choose to purchase and smoke marijuana if they so desire.

I see a lot of patients who admit that they use marijuana.  There are probably many more who use it and don't disclose to me or their other medical medical providers.

Source: istockphoto

There are reasonable medical uses for medical marijuana.  Nausea caused by chemotherapy, poor appetite and weight loss due to chronic illnesses, and muscle spasms from multiple sclerosis are among recommended uses for marijuana.

Often I see patients who are using marijuana to "treat" various aches and pains that in many cases they have never sought care for from a physician in the first place.  I see patients who use marijuana to treat their anxiety and stress, or self-treat other psychiatric illnesses.

There are some possible harms from chronic marijuana use, whether for recreational or medicinal purpose.  Like any substance, or any medication, there are side effects.

First, of course are the "munchies".  Most of my patients are overweight or obese.  The side effect of hunger from smoking marijuana does not help people make good food choices to facilitate their health.

Marijuana is not benign when it comes to the heart, either.  There isn't much research, because marijuana was illegal for so long, so we have no information about what it does to the blood vessels, or even the brain for that matter.  However, it is known to lead to high heart rate and fluctuations in blood pressure.  And, some emerging research suggests that marijuana increases the risk of a heart attack.

If you smoke marijuana regularly, whether for recreational or medicinal purposes, it's probably a good idea to discuss with your physician.

Retired Triathlete at One Year

What happens when you go from a full schedule of races and hours of endurance training to a more relaxed exercise regimen?

Without endurance-race goals, and without a coach to give me workouts, I'm in charge of my fitness.  For me, that means I work out six days a week, one or two workouts per day, with one day a week for rest.

• I swim with a masters group Golden Road Aquatics 3-4 times a week, usually in the morning before work
• One "long" run of 5-7 miles on my own
• Barry's Bootcamp treadmill/strength hour-long sessions once or twice a week
• November Project LAX, a Wednesday morning workout at the Hollywood Bowl, consisting of running and bodyweight strength training
• Other random workouts that sound like fun at the time -- outdoor cycling or open water swimming, a spin class, lifting weights at the gym, yoga.  

Less exercise has led to change in my body and fitness.  While I toed the start line at Ironman Boulder 2015 at 147 pounds, I am carrying ten more pounds on my 5'10" frame.  At a BMI of 23, I am still a healthy, normal-sized person.  And, while I may swim a bit faster, and can competently swim butterfly and backstroke which I couldn't do a year ago, my running and cycling are certainly not as fast as they were, and my endurance in any of the three sports is less.

Barefoot running on the sand, a fun workout I would have never done while training for an event.

I've also learned how to listen to my body.  I no longer have a coach looking at the metrics and heart rate graph from my workouts to tell me that I should go harder or need to rest.  I've found that about five or six days into daily workouts that I need to take a day off to recover.

And then there are my recent labs, during peak training, and now.  This for me is the most startling finding.  While my non-fasting cholesterol numbers look nearly identical, my hs-CRP, a marker of inflammation, which was quite high during training, is completely normal now.

August 2015

And now:

So what's the significance of the elevated high-sensitivity c-reactive protein (HS-CRP)?  It is a marker of inflammation.  The number in studies correlates with increased cardiovascular risk.  I don't think that it in my case it would indicate an increase in my risk of a heart attack or stroke, given my other parameters of no family history of heart disease, a healthy plant-based diet, no hypertension, no diabetes, and the lipid numbers above.

And yet, we know endurance athletes have a five-times increased risk of atrial fibrillation, One study of runners who participated in the Minneapolis Marathon for several years in a row demonstrated increased calcified coronary plaque in the arteries compared to non-marathoner controls.

There is said to be a "U-shaped curve" for exercise -- at one end, there is not enough exercise, which is where most Americans sit.  On the other end, for a very small and growing minority, is too much exercise, and potential consequences of excessive exercise.  There is still much we do not know about exercising this much for years at a time.

My own take-home message -- there's something about Ironman endurance training, for me, that leads to objective evidence of inflammation, and decrease in that inflammation with scaled-back exercise.  It would suggest that, for me, training for long hours year-round is not a good idea.  But, I will race again, maybe even complete another Ironman in a few years.

Plant-Based Diets are Catching On!

I have to admit, at times being a vegan has been a lonely situation.

When I adopted a plant-based diet in 2005 during my cardiology fellowship training in Rochester New York, most people had no idea what vegan meant, most mainstream health care practitioners were unaware of the health benefits of a plant-based diet.  Were it not for the Rochester Area Vegan Society and their monthly potlucks, I would have been entirely lost.

Now in 2016.... vegan diets have become more mainstream.  Documentaries like Forks Over Knives have made people more aware of the power of what they eat.  After watching Forks Over Knives, I know of two cardiologists in the San Fernando Valley who have started recommending plant-based diets to their patients.  And, in turn, patients are more receptive to learning about plant-based diets.

And I was entirely surprised to hear that Dr. Chad Teeters, the chief of cardiology at Rochester's Highland Hospital, who I knew when we were both training at the University of Rochester's Strong Memorial Hospital, has adopted a plant-based diet after hearing Dr. Caldwell Esselstyn speak at the American College of Cardiology conference.

You can hear briefly about how Dr. Teeters made the transition here.  I had the opportunity to listen to Dr. Teeters speak during this podcast, about the worries that he's had about his own health, and how he's lost 60 pounds in six months on a plant-based diet.  Having known him many years ago, I was very surprised that he took this step, but I am so thrilled for him, not just for the benefit that he'll get to his own health, but that he'll be able to impart this advice to his patients as well.

If you're looking for a plant-based doctor, look here.

Listen to my conversation with Kirk Hamilton PA-C

I had the opportunity to talk to Kirk Hamilton PA-C, who is working hard to spread the message of how potent lifestyle and diet are in preventing illness.

Listen to the podcast here.

Weight Loss -- What Doesn't Work

Obesity leads to increased risk of heart disease, decreased mobility, and shortens life.  Many of my patients are overweight or obese.  Most want to lose weight, and as a doctor, I want to help.

I've seen patients who are successful at losing.  Unfortunately, I see more lack of success.

Here are some well-meaning ideas that may sound like they would work for losing weight, but unfortunately don't.

Juicing
Joe Cross of "Fat, Sick, and Nearly Dead" fame went on a 60-day juice fast, making his own juices from fresh fruits and vegetables.  He lost 100 pounds and was able to come off all his medications.  Unfortunately, in practice, none of my patients who have started juicing have lost weight -- in fact, most have gained weight.

How do you gain weight while drinking juice?  There are a few reasons that might be the case.  Juice as a liquid may not be very filling, without the fiber that comes with the fruits and vegetables.  Also, one might use the excuse of "juicing" to justify dietary splurges..

Garcinia Cambogia
Dr. Oz featured it on his show.  Lots of people bought it.  Many of my patients took it.  None of them lost weight.  Then Dr. Oz got sued.

Big Goals and No Plan
One patient, who weighed in over 300 pounds, told me he had a plan to lose 100 pounds before his next visit in six months.  I asked him how, and he told me that he was determined and he would just do it.  At his return visit, he was 20 pounds heavier.

10,000 Steps
These days, everyone has a fitness tracker, which makes it easier to set an activity goal for the day.  However, those counted steps can inappropriately justify bad food choices, and may not be done at an intensity to build fitness and improve metabolism.

The Subway Diet
Jared Fogle became a celebrity back in 2000 after he lost 225 pounds by eating almost exclusively from the Subway restaurant near his home.  Somehow, eating at Subway is still believed by some to lead to magical weight loss.  Jared lost his weight by eating a six-inch sub for lunch with a bag of chips, and a footlong sub, no snacks, no cheat meals.  There's nothing mystical about Subway's food -- Jared just ate less.

So, what works?  The old tried and true standard -- a healthy diet with plenty of fruits and vegetables and regular exercise.

Bringing Vegan Food to LA Unified School District

Lila Copeland, a 14-year old who is about to start high school next year, wants LA Unified School District to provide healthy vegan food options to kids.  I was honored when Lila, the founder of Earth Peace Foundation, invited me to join her and others to speak to the school board.

We waited a couple hours, as we were literally the last agenda item for the meeting.  But, when your group is led into a room with Pamela Anderson, you get attention.

You'll see me at four minutes into this video.

I had the opportunity to make my case for offering healthy vegan options to children.  I made the point that the majority of the diseases that I treat are prevented by a healthy lifestyle, including good food choices.  Healthy habits start in childhood, so a school providing vegan food options can help children live longer and healthier.

Other speakers included Dr. Michael Klaper, journalist Jane Velez-Mitchell, bodybuilder Torre Washington, author Kawani Brown, nutritionist Sharon Palmer, and nutrition educator Lisa Karlan.

As the last speakers of a day-long meeting, we had an uphill battle ahead of us to get the attention of the school board.  I think we got our point across.  One of the board members at the end remarked that his own diet wasn't very good, but we certainly gave him some things to think about and maybe even he could change how he eats.  I am hopeful for Lila's Healthy Freedom campaign to provide healthy vegan lunch options to LAUSD's students.

Forks Over Knives Article

My story has been featured on the Forks Over Knives site!  Check it out.

Passover Seder 2016

Every year, I host a Passover seder at my home on the first night.  This year was particularly special, now that my parents live in Southern California, our entire family was together for Passover for the first time in ten years.  In addition, I had several friends, and in total there were 25 of us at the table.

We read from the "30 Minute Seder" hagaddah, sang a few Passover songs, and then had a terrific dinner.

 Our seder plate -- a beet in the place of the shankbone, and a flower in place of the egg.  The beet represents the blood spilled in the slaying of the firstborn, and the flower represents life and Spring.

Big crowd for seder!

Matzah Balls for soup

Matzo Gratin

 Eggplant Casserole.  

Creamy Pesto Quiona

Sweet Potato, Carrot, and Apple Kugel

Chocolate chip cookies and chocolate brownies

Chocolate Matzo Loaf

ACC 16 Conference

I just returned from the ACC.16, the American College of Cardiology's annual conference, in Chicago.

The last time I attended was back in 2007, when I was an interventional cardiology fellow.  With the incentive of $99 for registration (as opposed to the usual pricetag of hundreds) as a first-time attendee as a practicing physician, I decided, why not!

The conference opened with remarks from the current president of the ACC, Dr. Kim Williams, who happens to be a vegan, and proponent of plant-based diets for heart health.  His opening remarks had a lot of focus on prevention.  It's refreshing to hear talk of prevention at such conferences, because that's where we're lacking.  He talked about traditional diets within some cultures which increase heart risk -- "Don't let your culture hold your heart hostage."  

How refreshing to see a focus on prevention!

I saw Dr. Caldwell Esselstyn -- author of Prevent and Reverse Heart disease.  He's one of my heroes.  His research has demonstrated the reversal of even the most severe of coronary disease with a plant-based diet.  On the first morning of the conference, I came running on over to him, like a rock star groupie, introduced myself, and of course took a selfie.  

I could have asked for his autograph too.

More on prevention.  In fact there was an entire session, with a packed room, all chairs taken, on prevention.  Maybe the title was catchy: "Lifestyle Medicine: A Little Less Drug, A Little More Sex, and a Lot More Rock and Roll."  On stage were Dr. Esselstyn, Dr. Williams, Dr. Arthur Agatston of the South Beach Diet fame, and Dr. Emilio Ros, proponent of the Mediterranean Diet.  

The conversation was good, but I have to say, and maybe I'm a wee bit biased, but Esselstyn hit it out of the park!  He spoke convincingly about the strong benefits of a plant-based diet.  His results demonstrate far greater improvement in cardiac health than South Beach or Mediterranean diets could ever claim.  And, he did his usual, "Eat bok choy Swiss chard kale...." song of vegetables that we should eat, though didn't get as much applause with that as he does at the more vegan-oriented conferences.

Again, rather than the bravado of placing stents through fancy techniques, we talked more about prevention.  Loved it. 

Another awesome focus -- women in cardiology.  There was a Women in Cardiology lounge, a great place to network with other women cardiologists, and to refill my coffee.  Did you know that only ten percent of cardiologists are women?  And, of interventional cardiologists, what I do for a living, only four percent of women?  I attended a few sessions here, one on how to use social media to your advantage (psst... follow me on Twitter, I'm @veganheartdoc).

There was even a session on work-life balance.  Being a woman cardiologist has its own unique challenges, from gender bias to making choices regarding family.  I loved these ladies' perspective.

Some important clinical trials were presented.  We now know from the HOPE-3 trial that blood pressure medicines don't benefit intermediate risk patients, but a statin just might.  There is more evidence for use of trans-catheter aortic valve replacement in patients who are not high risk.  Beta-blockers at the time of a heart attack may not be as important as they were in the pre-angioplasty era.  Those patients with a mutation for familial hypercholesterolemia have a much greater risk of heart attack than someone with the same cholesterol level without a mutation.  Rhythm control of atrial fibrillation after cardiothoracic surgery is no better than rate control. 

And much more.  It's exciting to be present for the debut of important information that will shape clinical practice for years to come.

I ran into some familiar faces.

Dr. Akshay Khandelwal, the incoming president president of the Michigan chapter of the ACC.  But I knew him way back when we were interns, and I've been bowling with him before he became really important.

Dr. Shobashalini Chokkalingam, my senior resident from Henry Ford Hospital, smart and funny cardiologist who helped shape my mind as a physician.

And, it's not a trip unless I go running.  I took advantage on the one warm 68 degree day of the trip:

Change

I'm absolutely fascinated with how people change, how they make lifestyle changes that they can stick with.

In what I do as a cardiologist, motivating people to change is absolutely key.  My goal is to help everyone reduce their risk of cardiovascular disease, whether they've never had a heart problem or they've had bypasses, stents, and heart attacks.

One thing I know, from my own personal life experiences, and from observing my patients -- complete change doesn't happen overnight.  A patient isn't going to leave my office and quit smoking, eat fruits and vegetables, quit eating meat, dairy, and eggs, AND walk an hour a day when these were not prior habits.

My strategy -- I try to focus on the one or two changes that I think will make the most impact on my patient's life.  Some examples, maintaining anonymity of these patients:

--An obese woman in her 50's with diabetes, high blood pressure, heart attack 10 years ago, and a bypass surgery two years ago.  She doesn't exercise, eats a lot of fried meats and white rice, and refuses to eat vegetables because she does not like the taste.  While she clearly has many habits that could improve, I've started by asking her to try new vegetables and incorporate them into her meals, and to walk more.

--A man with atrial fibrillation, sleep apnea, and obesity, who at 6'3" and 270 lbs feels frustrated that he cannot lose weight even though he walks for exercise and tries to make healthy choices at meals.  As it turns out, his meals are mostly at restaurants because his wife is disabled and no longer cooks for them.  We discuss the perils of relying on restaurant food, and he decides he's willing to start cooking for him and his wife, which will hopefully help him burst through his weight loss plateau.

--A man with atrial fibrillation and diabetes, who has successfully lost seven pounds in two months since his initial consultation with me, after eating smaller portions and more fruits and vegetables.  However, he is not exercising because he is afraid to make his heart beat too fast.  After reassuring him that walking for exercise will not be too taxing on his heart, he agrees to start a walking program.

--An obese woman in her 30's sees me because of chest pain that is likely due to reflux.  She has hypertension, is pre-diabetic, and abnormal cholesterol levels.  She exercises by walking on a treadmill or uses an elliptical for 30 minutes a couple of times a week.  She eats a lot of sugary snacks, so we talk about replacing those snacks with fruit, portioned trail mix bags, and Larabars (which are packaged bars made with fruit and nuts and no added sugars or processed ingredients) and eating more meals at home.  The next change for her might be to change the intensity of her workouts to challenge herself more, or to add weights.

We start with making one change successfully, and then move on to the next, with the plan of making these positive changes permanent.

A Cardiologist's Breakfast

After opening up my refrigerator in my last post, I've been asked to share what I eat for breakfast.

Most weekdays, I'm up at 5 am to get ready for 6 am swim practice.  To wake me up, I drink a soy latte.  I mix about 8 oz of brewed coffee with 4 oz of steamed vanilla soy milk (organic/non-GMO of course!)   And here's where the magic happens, with my Breville machine.  This little toy makes a latte to rival any coffee chain, and at a fraction of the price.

Latte magic!

To fuel me for my swim, I drink a big green smoothie.  It takes me about five minutes to whip this up in the Vitamix, a high-powered blender:

My smoothie fruits and vegetables, before they go for a whirl

I blend a cup of unsweetened almond milk, a big handful of green veggies, which could be kale, spinach, swiss chard, or whatever is on hand, a stalk of celery, a handful of carrots, a banana, a pinch of spirulina powder, half a tablespoon of chia seeds (omega-3 power!), and about 5 cubes of ice.  Sometimes, I'll add some apple, a medjool date, or even a couple cubes of sweet potato, all of which add a unique flavor.

It's green and it's delicious!

I pour this into a big cup, drink about 2/3 of it in my car on the way to swim, and have the other third right after I get out of the pool.

If you're new to green smoothies, it might be a good idea to use more fruit and less greens to start, and as you get accustomed to the taste, then add more greens.

Typically, I go straight from the pool to work, arriving around 7:30 am.  I might round on a couple patients, or do a bit of work, and I'll get my second breakfast around 8-8:30 am in the doctors' dining room.

Delicious, healthy oatmeal, and stuff that's not so healthy.  All ready to consume in the doctor's dining room

You can see that there are many options available in the doctors' dining room.  I can't say that they're all good choices, and in fact some cause the diseases that I treat.  I choose the oatmeal.  I fill a bowl with cut up fruit, melons, pineapple, strawberries, pour oatmeal on top, and add a few walnuts (more omega-3's).

That's my typical breakfast, and that will fuel me until lunchtime, around 12:30.

The Doctor's Fridge

In my daily practice, I advise my patients to make healthy food choices.  Today, I'm going to let you peer into my kitchen.

You'll notice lots of veggies.  I shop the Sherman Oaks Farmers Market every Tuesday evening after work.  That's where I get the majority of my vegetables.  However, you'll notice the big bag of carrots, from Costco, which carries organic carrots and organic bulk greens, among other good bulk produce options.  I have a few baked sweet potatoes ready to go as well, some from the farmers market, and some organic sweet potatoes bought in bulk from Costco.

In addition to my produce, I do have a few processed items, like the soy milk that I add to my morning latte, and the almond milk for my morning smoothies.  I have some hummus from the farmers market, which is great to dip veggies in for snacks.  I have a few protein options, tofu, lentils, a lentil curry that I bought at the farmers market, and tempha which is a fermented brown rice protein from Dave's Korean, another farmers market vendor.  There are a couple of Suja juices, which are delicious to drink on the go.  And, finally, a container of pickled daikon radish from Vinh Loi Tofu, to add to my salads.

There's the inside door.  I have plenty of salad dressings, including my favorite, a miso dressing from Dave's Korean with no oil, coconut oil, tahini, almond butter, macadamia butter, a few jams, salsa, sriracha, and a couple of alcoholic ciders for an occasional celebration.

No meal that I prepare for myself takes more than ten minutes.  That's why I say that when I prepare meals, I "assemble" them, I don't cook.  Here's all my ingredients for my favorite salad:  lettuce, heirloom tomatoes, basil, cabbage, butternut squash, sweet potato, tempha (brown rice protein from Dave's Korean), carrots, avocado, daikon, and kimchi.

This is the final product, my favorite salad.  Mixed up in a big bowl, filling, colorful, delicious, and lots of nutrients.

Another evening's dinner.  I grabbed a few ingredients from the fridge, threw them in a bowl, and this creation came to be in just five minutes:  purple cabbage, extra firm tofu, sweet potato, pureed cauliflower, nutritional yeast, and soy sauce.

So there you are.  My refrigerator is an open door.  This is how I eat healthfully living on my own, working full time, with easy to prepare food.

Retired Triathlete

I've spent 10 years training and competing.  Now I'm taking a break.

My mind isn't in the endurance or the competition right now.  And I am not signed up for any races this year.  While training, I thrived on the structure of planned workouts, logging my miles and feeding back to my coach.  Now, I exercise when I want; I love that I no longer need to adhere to a schedule.

I joined Golden Road Aquatics master swim program, and you'll find me in the pool most mornings of the week.  It's great cardiovascular exercise, gentle on the joints, and it's only a mile from my Burbank office. 

I'm learning so much, improving my backstroke and breast stroke.  I can even do a reasonable butterfly stroke and not feel like a dying fish!  I have even swam in a meet.  I wasn't fast, but it was fun to dive off the blocks.

My focus right now is swimming.  But, when I'm not swimming, I'm often at Barry's Bootcamp for their hourlong workouts consisting of treadmill and floor exercises. I am there about three times a week, and that's about the extent of my running these days.  I'm also doing a little bit of yoga, and a bit of spinning, and every so often a strength training session.

My bikes and my trail shoes are gathering dust from lack of use.  And that's okay.

So, that's where I'm at -- trying to become a swimmer, and exercising for the sake of exercise.  It's awfully relaxing.  I might sign up for a triathlon in a year from now, or a road race, but for now I'm content..