The Farmacy, Prescriptions of the Future

June 2021: My colleague, Dr Malcolm Mackay and I were honoured to have the opportunity to present to the annual Melbourne University Medical School MD Student Conference in June 2021.

June 2021: My colleague, Dr Malcolm Mackay and I were honoured to have the opportunity to present to the annual Melbourne University Medical School MD Student Conference in June 2021.

Transcript of the Conference

all righty hello everyone thank you so much for joining um i would just like to start by acknowledging the traditional custodians of the land on which we are all attending the session from for me thisis the war injury people of the kulin nation i pay my respects to elders past presentand emerging as well as to any aboriginal or torres strait islander audience members here todaypart of today’s conversation will explore common chronic diseases such as ischemic heart disease and type 2diabetes which plague australians today and i would like to acknowledge that chronicdiseases plays a significant burden on first nations people in terms of mortality and disabilityand first nations communities need to be consulted and included in the fight to reduce the huge chronic disease burdenhere in australia so welcome to the pharmacy prescriptions for the future i’m excited to bring youthis session on behalf of the australian holistic health student association asaa group striving to better integrate various health disciplines systems and practices in order to facilitate thedevelopment of holistic health professionals and enable better patient-centered carethank you all so much for joining us we’ve got two fantastic speakers with us today daughter dr peter johnston and drmalcolm makai who will speak on the role of nutrition specifically plant-based nutrition andhealth their short presentations will then be followed by a panel discussion as wellas an audience q a so please submit your questions throughout the session using slidowithout further ado i’d like to introduce our first speaker dr peter johnstonpeter is an accredited practicing dietitian with a masters in nutrition and dietetics and a phd in humangenetics peter is also a fellow of the australasian society of lifestyle medicine and has completed healthcoaching training with wellstart health he has been exclusively plant-based since 1991 after learning of the healthenvironmental and ethical benefits he has expertise in the prevention treatment and reversal of chronicdiseases through the use of whole food plant-based diets and the holistic approach of lifestyle medicine andenjoys empowering people across all life stages to attend attain optimal healthover to you peteruh thank you bethany and good afternoon to everybody and thank you for this opportunity it’s a real privilege to beable to present to this audience so i’ll zip through these i have quite alot of slides and it really is a brief overview the evidence for plant-based nutrition is vast so i’ve tried to coversome of the the key evidence but i’ve had to leave a lot of important studies out but at the end there isa slide with some further learning suggestions so this is about mei’ve done a lot of study bethany went through this so i’ll keep moving i’m also as with malcolm who follows mean advisory council member of dietitians doctors for nutritionso i’ll just move this across a little bit so around 80 of the patients you’ll seewhen you graduate will be seeing you because of what they put in their mouths and these things won’t be unfamiliar toyou we know that these things um have negative health impactsso malcolm and i are lifestyle medicine practitioners so this is a graphic from the american college of lifestylemedicine and they sum it up the six domains um on the right here so eat plants keep moving sleep well bepresent which means not being inebriated or on drugs or addictive substances stay calm and love peopleso these are the domains that we work on to help people attain or regain optimum healthso lifestyle medicine addresses upstream determinants as opposed to treating symptomsthis cartoon was commissioned by dr dean ornish who i’ll mention shortlyhe was expressing frustration with the medical system treating symptomsrather than causes and mopping the floor as an example of this rather than turning off the tap here behind themso an important distinction to make just up front vegan is different to to whole foodplant-based so there we see in our practices some unhealthy vegans andthere’s a lot of unhealthy vegan junk food around which wasn’t there 30 years ago when i started being plant-basedwhole food plant-based is more useful in a more preferred term amongst us practitioners because it describes whatyou what you are doing predominantly or only plants minimal processed foods no oiland minimal or no salt and sugar and the graphic from um physicians committee for responsiblemedicine in the us illustrates that in australia we’re in trouble as thisone illustration shows us this is the rate of increase of obesity in millionsand between these two readings this one came out in 2019 5.8 millionobese australians and that’s almost a million increase in four years so we’re in deep trouble and it’s notlooking like leveling off anytime soon this is just a quick illustration toshow the relative impact of different causes of death and this is from the nhsand britain but we’re not that different here so i’ll look at heart disease for the next part of the talk because that’sour biggest killer by quite a way it’s the leading cause of death aroundthe world accounts for about 18 million deaths a year um 31 of all global deaths and about 50people a day in australia interestingly people in some countries in earlierparts of this century heart disease was pretty much unknown and a fewinsightful practitioners noticed this and asked why in fact my colleague malcolm being oneof them rural china in the 80s the china studypapua new guinea highlanders traditional cultures didn’t have these western diseasesincluding heart disease and so this really opened eyes of some practitioners that well we need to lookat how they’re living and what they’re doing differently vascular disease starts early and a lotof people don’t realize this this is from autopsies of children if they’re on a western diet they willall have early stages of heart disease and we think from other research thatactually begins in utero based on the maternal nutritional stateheart disease is unusual and the first symptom is often sudden death this was on the door of the cardiology lab wherei did my phd at anu in canberra downstairs from my from the humangenetics department and a lot of people don’t appreciate that soit’s quite shocking this study should have changed the world and itgradually is but it’s far too under-appreciated this was the first time in arandomized controlled trial that the ability to actually reverse heart disease was shownquantitatively through angiograms this was led by dr dean ornish who i mentioned earlierthis should have really changed the world a way to reverse our biggest killer should have been front page news onevery newspaper around the world and should have changed medical practice this has been replicated by other peoplebut what ornish did this was a small study 48 patients an experimental group in a control groupthe experimental group will put on a plant-based low-fat diet and look and stress management smokingcessation exercising group support ornish sums this up today is eat better move more stress less love moreafter one year there was significant reversal of coronary artery disease in the in the experimental group whereasthe usual care group had progressed in a year as expectedthis is a later study by ornish a bigger group 85 percent had regressionof atherosclerosis and a 400 improvement in blood flow inthe coronary arteries just enormous changes and these are published in prestigious journals peer-reviewedornish’s program was finally reimbursed by the u.s government in 2011 but it took him 16 years of lobbyingand a key factor in medical practice is that reimbursement determines the natureof the practice we’re trying to establish lifestyle medicine in australia but it’s really hard workwhen it’s not reimbursed even though the evidence is very strong that it workscaldwell esselstyn is another giant in this field he did a study that was published in 2014 with almost 200non-smoking patients with severe coronary artery disease supported them to go on a whole foodplant-based diet with no oil almost four years of that group 89were adherent the outcomes one person had an incidentin that almost four years out of the inherent group out of the non-inherent groupthe adverse cardiac events were 62 of that small group this is incredibly powerfuland this is a picture of the changes in the in the widow maker artery of of oneof the patients and this is typical so the moth eden looking artery on the leftchanged to a healthy normal looking vessel on the right within about three yearsmoving on to some of the risk factors um this is a large study and found thatjust reducing saturated fat by 5 reduced heart disease death by 25so there’s a lot of evidence around saturated fat being a major risk factor for heart diseasealso animal protein diets high in animal protein lead to an increase in all-causemortality increases in cancer five-fold jump in diabetes and igflevels higher and these are a risk for cancer amongst other things animal protein protein versus plantprotein from the nurses health study so animal protein intake was associatedwith higher premature mortality whereas plant protein was associatedwith low mortality and this is repeated in many studies so any amount of replacement of animalprotein by plant protein reduces your risk of premature mortalitythe further you go there’s no endpoint zero animal protein is optimum in inmy opinion and the science suggests that as well this is just a cartoon my onlyconsolation is that eating by eating us they’re killing themselvesanother large study um almost 50 000 men consumption of choline predominant inred meat eggs and milk was associated with 70 increased risk of lethal prostate canceragain these are all prestigious scientific journalsplant-based diet also down regulates the mtor gene which helps prolong lifephysicians health study so the stand those on a standard western diethad 250 percent higher risk of prostate cancer related death and at 67 higher risk of all-causemortality compared to those eating mostly whole food plant-based 36 lower risk ofmortality very powerful and very big contrast in the outcomesthis is some work by dino ornish i’m coming to epigenetics is really important this stuff was pretty muchunknown when i did my phd back in the in the late 80s in human genetics but the key thing fromthis is that genes we realize now are not our destiny for most chronic diseasesit’s said that they they load the gun but lifestyle pulls the triggerso dean ornish did a a landmark study which looked at theimpact of gene expression and the changes in gene expression after three months on his lifestyle medicine programso what they found was that oncogenes down regulated as were genes involved inatherosclerosis inflammation oxidative stress etc really powerfuleven changes to our cognition so eating more fruit and vegetables a day was associated with a 47 percentdecreased risk of cognitive impairment amazing work has been done by thesharesides who are medical doctors and neurologists working out of loma linda in california highlyrecommend this book if you want to learn morethe diet also impacts the it affects the microbiome dramatically this is a landmark study by lawrence david andcolleagues they took ten subjects and they had five days on a plant-based diet and then fiveon an animal-based diet the diets were isocaloric and the microbiome was monitored dailyand you can see the differences here so zero fiber and animal diet versussignificant amounts of fiber big differences in fat and protein[Music] so dramatic changes within 24 hours ofthe diet because we know that bacteria replicate about every 30 minutes so they have 50 life cycles within a dayso these populations in our microbiome change rapidly based on what we pass through our gi tract so the plant-baseddiet led to increased numbers of the beneficial bacteria that confer health benefits and producing byproducts suchas butyrate and acetate which we’re finding are incredibly important for well-being they also help protectagainst a variety of chronic diseases and they increase our insulinsensitivity serotonin production enhance weight loss so all very powerful positive effectsin contrast animal-based diet decreased butyrate increased levels of pathogenic bacteriaetc this was just five days on each diet and the changes were dramaticso what you eat changes the microbiome within 24 hours and can promote either health or diseaseand this is what we tell our patients what you put in your mouth every chance every time you’re choosing to eitherhelp heal yourself or injure yourself and just related to covert this studycame out a couple of weeks ago those eating a plant-based diet had a 73lower risk of moderate to severe covert infection this was almost 3 000frontline health workers in six countries who all who all contracted covertinterestingly those who were on a low carb diet had a 48 higher risk for moderate to severecovert symptoms this is really powerful it was a relatively small study butinteresting early evidence of further power of plant-based eatingwill patients eat this way we can talk some more about this in the panel discussion but umthe key thing that people find is what they gain is much more than what they give upthe benefits are so powerfully reinforcing we find that people go i like feeling good and i prefer that tohaving my bacon for breakfast and this kind of diettreats many conditions that will be filling your waiting rooms when you’re seeing patients once you graduatei’ve seen all of these conditions and seen them all improve i don’t have time in this talk for casestudies but malcolm and i have we could talk about them perhaps in the panel but we’ve seen dramatic turnarounds in many of theseconditions this is also cost saving for health caresystems huge reductions in health care costs um through lifestyle medicine so most ofthe costs are due to the small proportion of people that are getting sick and heart disease is the most expensivecondition although it’s forecast that alzheimer’s and dementia will dramatically overtake that in the nextfew decade or two this is some work again by dean ornishum [Music] they were able to have 80 of their patients who wereneeding bypass surgery or angioplasty avoid it by changing their lifestyleenormous cost savings this is called esselstyn with a quotefrom him so people sometimes think this is an extreme approach buthe makes the very um [Music] sensible proposition thathaving bypass surgeries in many ways a lot more extreme and this is um kim williams who was the president ofthe american college of cardiology in about three years ago there are twotypes of cardiologists vegans and those who haven’t read the datathis is just a couple of slides on the environmental impacts this is humanslivestock is about six percent of all remaining mammalswild animals sorry livestock of the bulk of the mammals on the planet todayand livestock causes more global warming and all forms of transportation combined and produces 18 of our greenhouse gasescompared to transport which produces 13 this is from a landmark paper by um poornemesis came out in 2018 finding with comprehensive analysis offarms 90 of all food production around the world that animal farming takes 83 percent ofour agricultural land which uses produces less than 20 percent of our caloriesshockingly wasteful if everyone on the planet adopted a plant-based diet we could cut farmlanduse by 76 and half greenhouse gasesthis is some further learning i can highly recommend all of these and bethany was happy to share theslides from malcolm and i after the talk so i’ll finish up there that’sall i have for today so thank you for the opportunitythank you so much peter um for that incredibly insightful introduction to and rational behind a whole foodsplant-based lifestyle and we are excited to continue the conversation um in a moment but i would now firstlike to introduce our second speaker so dr malcolm makai is a gp and lifestylemedicine specialist malcolm completed his medical degree at flinders university and has a graduate diploma inhuman nutrition from deakin university he is a board-certified lifestyle medicine physician and fellow of theaustral australasian society of lifestyle medicine he has a special interest in preventing treating andreversing chronic disease with a whole food plant-based diet and other lifestyle interventionsbefore the world went into lockdown malcolm was a regular attendee of the international plant-based nutritionhealthcare conferences in the usa and has engaged with many of the leaders in this field he has presented at manyevents and is a representative of the australasian health charity doctors for nutrition as peter mentioned earlierin addition to in-person consultations and tele-health malcolm and his partner jenny provide introductory seminars andwebinars and run a six day immersion retreat on the surf coast of victoriaso take it away marcum thank you for that introduction bethanymy short presentation will be on prescribing a whole foods plant-baseddiet in clinical practiceso i’m as bethany said i’m a gp i practice in fit swimming melbourne i also provide telehealth to people acrossaustralia and i consider myself a conventional doctori give immunizations i prescribe medications probably far too many medications but i also often recommend awhole foods plant-based diet and other healthy lifestyle behaviors because for many of our chronic diseasesthis is the safest most effective mode of treatment we have and it can be givenin conjunction with conventional treatments i guess my aha moment was back inmedical school at flinders university when the crusty old cardiology lecturertold us about what he said was the inevitable process of atherosclerosisfollowed in the same semester by someone else professor anthony radford who toldus about other peoples in the world like those in highland papua new guinea who never got coronary artery diseaseand that really really got me thinking here’s a group of peoplewithout much education or medical care and they can beat the western world’s leading cause of deathso whenever other topics came up in the medical course be it your breast cancer rheumatoid arthritis diabetes i wasalways interested in is this just a human disease or is this um lifestyle related and time and timeagain the same thing a diet that was having a diet that wouldhave had sugar salt and fat i don’t avoid a fiber so at this point i was in i was going toeat the sort of diet these people ate i was going to have minimal salt fat i wasgoing to eat minimally processed food lots of oats and rice etc and it seemed to work for me within thenext 12 months i ran a 232 marathon that was part of my motivation for changingmy diet and and and got a first place in one of the early triathlonsbut when i finished medical school i realized that i didn’t really know hadn’t learned much about nutrition inmedical school at all so i then enrolled with an off-campus student at deakin university andcompleted a graduate diploma in human nutritionquite many years later i think education is very important and many years later whenlifestyle medicine had become an accepted discipline i undertook a board certificationtraining and gained a fellowship with the australasian society of lifestyle medicineone of the biggest things i learned from this was about how to assess people’s readiness forbehaviour change and to help people to actually change their health behaviorsand i’m still running today and i think if i’d been eating chicken cheese and olive oil for the last 40 years i mightnot have good joints and i might not still be running but the lifestyle medicine conceptincludes i think peter alluded to these domains of health and wellnessbut out of these i consider nutrition to be the keystone i think that if you get the nutritionright often some of the other things will fall into place you know you’ll feel better you’ll sleep better you’llfeel more like moving and peter’s already covered much of thisbut a whole foods plant-based diet is based on whole grains legumes vegetablesfruits and small amounts of nuts and seeds food processing isminimized vegetable oil is excluded along with other hard processed foods and animalproducts are excluded the evidence base which i’m not reallygoing to go into you know it includes a lot of different areas of research from populationstudies through to observational rodent studies interventionslab studies of cellular mechanisms and it is generally consistent with theknown mechanisms of disease there are a few good randomized controlled trialsbut unfortunately very few and very difficult to do because people usually know when they’re eating plants versusprocessed food and animals and but we don’t always need randomizedcontrolled trials for those of you who sort of think well i’m not going to do it if there’s not a randomized controltrial then you’re not going to be able to tell smokers to stop smoking so they don’t need lung cancer or warn sporting peoplethat repeated head injury may lead to dementiaso the general principles of prescribing food as medicine is to treat the causenot just the symptoms or biomarkers and we have on our side the action ofcountless phytonutrients working on multiple mechanisms versus the pharmaceutical which is trying towork on just one process and the treatment has a wide breadth of effectand side benefits rather than side effects our diet prescription here is holisticrather than reductionist we’re not prescribing a herb for each condition or or individual foods we’re prescribingdietary patterns and we may all be special in some way or other but if you’re a veterinarian or afarmer feeding horses you know what horses eat you know that there’s a little bit ofvariation that no horse eats roast chicken and it’s similar the case is similar to humansas patients improve with prescribing food as medicine we d prescribe their medicationssome of these multiple mechanisms these are homeostatic mechanisms that whole plant foodsenhance or put into balance and these include the gut microbiomeinflammation oxidative stress blood lipids vascular health and angiogenesis that is the thegrowing of new capillaries in the pairing off of old capillaries this is a factor in cancer progression for exampleglycemic control and metabolic health hormones and some of those nutrient sensing pathways peter mentioned mtorimmune system balance and the regulation of gene expressionso we’re in clinical practice and we’re given a patient a new diagnosis or aboutto prescribe another medication and the patient says what do i eatwell most of these real world patients will never see a dietitianso we need to be ready to to we need we’re really ethically obliged to informthese patients if there is a safer more effective treatment option availablesuch as whole foods plant-based nutrition and we need a basic understanding therefore of nutrition that’s relevantto our field of practice if we’re a cardiologist we know we need to know what sort of foods will help theirvascular health for example their lipids if we’re a gastroenterologist we need to understand the microbiome and what sortof foods will improve their inflammatory bowel disease and then we have to be ready to providethese patients who will never see a dietitian in most cases with some resources that they can follow up onand that could be a link to a website recommendation for a book or watch thisdocumentary on netflix none of this replaces the role of thedietitian the lifestyle medicine approach however requires patient engagementwe need to assess and the patient has to be ready to make the changesand we we give information that that’s appropriate to their stage of readiness for changeand the patient decides how much they want to change this is a collaboration with a patientrather than than a prescription if you like and we therefore become an educator and we alsobecome a health coach and doctors often think this will be toohard my patients won’t change their diet we often undermise underestimatespatients willingness to change and we definitely overestimatemedication compliance a huge proportion of patients within a few years will not be takingcholesterol-lowering medications for example so when i’m in a consultation i consideri’m sowing the seed that may later grow i’m providing information on dietaryfactors that are relevant to their conditions you know and these suggestions are not always welcomeum it can be quite challenging to overcome patients defensivenessand one strategy i use is to try and not point it straight at them to say youknow there’s quite a few studies that link prostate cancer with dairy consumptionand just leave that with them however however tactful you aresome people will react negatively and i think when that happens you just have to drop the subject and keep your mouthclosed and there’ll even be complaints the patient who i advised about dairy being a risk factor for prostate cancerbecause he was extremely worried about his family history and wanted a prostate test complained to the next doctor that drmackay told me not to eat dairy and i just wanted a prostate test but some patients will surprise you forfuture consultations patients who seem quite negative and unwilling to change quite put out well then come back youknow maybe six months later and say um what sort of plant milk do you recommendso let’s look at a hypothetical case and the gentleman on this picture is not mycase but i actually met this man in uh in japan um when he was sort of three quarters ofthe way through to the to his lean healthy self so the hypothetical case has coronaryheart disease type 2 diabetes obesity and other numerous other diagnosesincluding osteoarthritis renal impairment and so we might look at what sort of dietary approaches could helpall of these well to start with the patient will need to deal with that weightand i introduce here the concept of energy density or calorie density the chartshowing how many calories per weight of food and the concept here is that rather thanhaving portion control you change the quality of the food so that patients can still eat normal size or larger heartymeals and not gain weight and this has been demonstrated in the broad study innew zealand where where they a community intervention where theywhere they assisted people to um eat a low-fat whole foods plant-baseddiet with no restriction on portion sizes no exercise componentgreatest weight loss found in any of this sort of study 11 kilos at 6 months kept off for 12 monthsheart disease as peter pointed out as preventable and largely reversible you’ll be familiar with the standardrisk factors blood pressure cholesterol diabetes obesity smokingbut the non-traditional risk factors can be under under emphasized oxidatives what if oxidative stress andinflammation tmao an artery toxic substance producedby the gut microbiome from the carnitine in red meat and the choline in eggs andother animal products we have no treatment for animal protein itself is a hearttreatment a heart risk factor so when we use when we do cardiovascular risk reductionwe prescribe drugs that partially treat a small number of these factors whereas if we prescribe whole plant foodsthen we’re treating most of these risk factorsand i must add that the most successful heart disease reversal programs or all successful heart diseasereversal programs have used a similar sort of dietary pattern you know low fat or starch basedwhole foods plant-based diet so that has the runs on the board type 2 diabetes you’ll be familiar withbased on insulin resistance which is caused byum intramyocellular lipid or the fat in the muscle cell also the fat in the lipid cell the fat in the iron itselffat where it’s not meant to be fat that comes from well the spillover of body fat but alsothe fat we eat particularly saturated fat you can do a low carb diet fortype 2 diabetes and you’ll reduce the blood glucose but you won’t reverse theunderlying cause you won’t reverse the insulin resistance in fact you might even put more saturated fat into thosecells and make them more resistant so that when that patient eats a potatothey’ll get an inch long spot a glucose spike a whole foods plant-based diet treatsthe cause reduces the fat particularly the saturated fat in the cell helps to reduce the weight reduces other factorslike inflammation as well and of course the number one cause of death in diabetes is iscardiovascular death so any dietary approach for diabetes must also preventheart disease and so that brings us back to a whole foods plant-based diet as the default dietand we need some renal protection and it’s well established that animal protein tmio as wellquite have an adverse effect on kidney function so insulin resistance is reversibleand depending whether there’s yet any damage to the islet cells has occurred type 2 diabetes is reversiblei’ve just got this little slide of looking at food options and how these might impacton some of these mechanisms of disease you know when my patient eats chicken the cholesterol on the chicken will beabsorbed the saturated fat in the chicken will stimulate more cholesterol production so all the proteinif the patient had had a chickpea curry instead of a chicken curry then they’re not getting the cholesterol thesaturated fat there’s no tmao and they’ve got dietary fiber that actuallyhelps to bind cholesterol and bile acids and actually excrete cholesterol andactually lower it as peter mentioned with the gut microbiome you know you could eat ketostyle diet and you’re going to have a terrible inflammatory gut microbiome or you could choose high fiber starchy foodand your gut microbiome will churn out these short chain fatty acids for which we have receptors all over the bodyreceptors that help to regulate blood sugar control vascular health appetite regulationtalking about glycemic control you know some of the low-carb sort of people say hey you knowbacon no carbohydrates in that what could possibly go wrong well processed meats are one of the foods i stronglyassociated with diabetes versus if you’d chosen a whole grainbreakfast such as oats you would actually be giving the body a slow release form of carbohydrate andnot adding to the fat in the muscle cell then looking at antioxidants and thewhole foods question extra virgin olive oil but not most ordinary oil has a fewpolyphenols but orders of magnitude less than you’d findin the blueberries on this bowl of oats and even less than even plain plant foods like whole wheatwhen we’re talking about endothelial health really all of the aboveimpact on that plus the effect of nitrate rich vegetables umnitrates and vegetables give the endothelial cells a shortcut for the production of nitric oxidethe green leafy vegetables are also the sort of number one umconcentrated food for um plant antioxidants in terms of the hormoneswhen you eat animal foods you ingest animal hormones uh we milk pregnant cowsso milk and even worse cheese has cows eastern is in it this is aum and chickens have east kitchen and eggs have estrogen and the chicken estrogensare exactly the same as the human ones and versus soy when you eat soy foodssome of those plant phytoestrogens they actually bind to the beta estrogen receptor anddown regulate eastern eastern resetand then when we consider also fiber the fiber in whole plant foods particularly things like lignans in flaxseedbind the conjugated estrogen that the body’s trying to excrete and and help to lower it and why is this important uh wehave an estrogenic environment and it affects men and women particularly women who are going to have with excessestrogen heavy periods breast disease endometriosis etcso for a hypothetical patient we see the bio markers improve and the medicationsare reduced or even ceased weight comes down to a healthy level future cardiac events are avoided cancerrisk is reduced and but it’s the experience of wellness that really stands outas dean ornish says the experience of wellness reframes the motivation for adherence to a whole foods plant-baseddiet from the fear of disease to the joy of living which is much more sustainableand we i regularly hear reports from patients that they have more energy thatthey feel more like exercising that they have a clearer mind feel less stressed sleep better have a better relationshipwith food and resolution of osteoarthritic andrheumatoid joint pains better digestive health and of course bowel functionbut also some empowerment that gives them some self-efficacy and some control over their umtheir destiny and this is not sort of one-off these results are typical i’ve i’ve seen these heard these reports fromdozens of patients so to sum up um a whole foods plant-based diet has apowerful therapeutic effect but because it has a symphony of nutrients workingon a multitude of mechanisms versus the pharmaceutical inhibiting one process it’s also got a wide breadth of effectin that the same diet i would give you for recommend for diabetes will also be good for preventing cancerfor stopping heart disease and the same diet that can be prescribed to prevent adisease can also be used to treat the disease and in many cases actually reverse thedisease when a patient embraces a whole foods plant-based art we see healthtransformations beyond anything that drugs and procedures will give patients experience true wellnessand these are some of uh resources my own websitea link to the doctors for nutrition health charity the plantricion project in the usa whose conferences i hope toget back to eventually the forks over knives website and appand dr michael greger’s video encyclopedia of nutrition factsthank you bethany thank you so much malcolm for such aninspiring presentation i’m sure you’ve planted you and peter have planted many seeds todaywe will now move on to the panel discussion um which and i have been looking through the q aand so my aim is to weave some of your questions thank you to everyone who sent in questionsum the plan is to try and weave some of those questions into this discussionum but to start off with malcolm you mentioned that patients struggle with adhering to medicationum so how do you suggest we help patients maintain lifestyle changes especially if it’s something they don’texactly find enjoyable such as eating lots of veggies or exercisingoh that’s that’s a big question isn’t it um you know it’s worth doing some health coaching education part of the educationi did with the um board certification and lifestyle medicine was in this areaum i guess we’re first of all we sort of look find out where thepatient’s at find out their openness to change and umyou know what their sort of life situation is for it and then we’ll look for their why andoften it’s good to find the why beneath the y like because i want to live long and be healthy but why do you want to live long and be healthy because it’sreally important for me for my grandchildren or so that i can do this or so that i can do thatparticularly if something you know beyond their personal needs umand then i guess we have to give them the information in a clear and concise wayand keep it fairly simple and it’s often a balance between perfection which will give them reallygood results and and setting the bar a little bitlower so that they don’t kick over the table fall into the ego trap and and give upand it’s really useful if they have a sort of group support jenny and i give these four-partwebinars and we deliberately keep the group to a group of no more than 12. there are some onlinegroups like whole foods plant-based aussies and plant-powered milk melbourne meetups so i think having some groupsupport ongoing is really important as well all right thank you and peter do youhave anything to add to that um you’re on mutei have the luxury of a one-hour first consultation so i like malcolm i dive into their goals andtheir why and the why beneath the why and their motivationand then i’ll look at the benefits of changes they might want to make versus the risks of not makingany change and really highlight where that will take them in five yearsor ten years um [Music] it’s guided by each individual personreally what they’re willing to do and i’ll be honest with them about whati think is the best available diet and lifestyle and then let them know that i’ll support them onany changes they want to make in that direction so generally i don’t get the negativityor resistance because people have generally sussed me out and know that i’m plant-based by the time they come tosee me so they’ve got a sense of what to expect andthey’re fronted up and they’re ready to pay their money umso but i take quite a bit of time setting the scene and talking about what is a natural human diet and why and someevidence for that you know the the historical stuff around horror ancestors eighteven pre-agriculture [Music] and what our species is designed to eatand and take them through that to help them see the broader picture so i find the inherits is pretty goodokay that’s very promising to hear i guess my next question is to you peteron a similar note do you think that the only way to go is a hundred percentplant-based or is there a spectrum is there something in between um what should we be aiming for on a realisticlevel that’s a really key question and i raisethat with everybody i see and there are really big pros and consto going in gradually or going in 100 umand i’ve run workplace health programs which malcolm and jenny helped me with in a local government setting where weinvited volunteers of the staff to to go 100 for three weeks and we bloodtested them pre and post and did qualitative measures as wellwith 100 there are many advantages you’re breaking the old addictive habits of the salty fatty sugary diet and the junkfoods and the animal foods and you’re getting a quicker turnaround of positivefeedback in how you feel with a gradual approach it suits some people but you’re kind ofgetting the worst of both worlds you’re maintaining the habit and taste for the old ways of eating and livingand you’re getting a diluted version of the benefits because you’re still having a diet which is partly injuringyou so i’ll talk about the pros and cons with people when i see them and let themmake that call but for example a chap i saw last week and i’m singing again tomorrow once ilaid that out and he was very unhealthy and had a huge amount of risk factors mid-50s[Music] and i thought he was pretty conservative a businessman i didn’t expect he wouldjump at it but once i laid it out he said no i’ll go 100 i want to start tonighttell me what i can have for dinner this evening and so as malcolm said it can surprise you oncepeople are given a bit of the evidence what they’re willing to do once they see what it can mean and and it’s also aboutbuilding the trust and the relationship with that person so that theyyou they can really sense that you care about them and that you want to help them and that there’s a really a realgenuineness to that um that’s a part of thethe practice of coaching is really building a good rapport so that the person really feels that you care andyou have their best interests at heart and you’re willing to spend that time with them because this is not an easy process it’sit is very different to the typical 15-minute medical consultation wethe immersion retreats that malcolm and jenny do and the lifestyle medicine program we’re developing involves 50 60hours to change someone around and there’s a lot of learning needed so that’s why it needs repeatconsultations and giving people a lot of resources and homeworkon that note so there seems to be a difference i guess in this process between malcolmbeing a gp and having 15 minutes with the patient and peter you having the luxury of an hourso how much crosstalk is there between doctors and dietitians in thisfield and maybe um is this optimal or what would you liketo see that any of you can answer this i think um yeah lifestyle medicine worksbest when there’s a whole team of healthcare providers you know our healthcare systems not allthat well set up in that respect um you know it would be ideal if if i couldtalk to to someone about nutrition diet and they could sort of think yeah i’d like to do that and then i could youknow fit them in with my dietitian and medicare would completely cover it and maybe there could be a fitness coachthere that would be the ideal situation butmany of us in medical practice find ourselves without that much supportwe do network closely bethany with those that we know will support these approaches and cross-referall right um so my next question um isi guess we’ve had a couple of questions about oil specifically so either of you can tackle this one aswell um why is there a recommendation for no oil is this all oil or just addedoils what’s this all about i love this question i have a whole web page on uhcalled no oil first of all let’s just consider thatthe oil is a sort of plant extract andyou know whether it’s olive oil or any other oil it’s extremely high in caloriesand has almost no nutrients look at the look up that we only have to look in the food composition table no iron nocalcium no protein no fiber um this should classify as a junk foodwe’re looking at something like olive oil we say ah but it’s good fats well hang on um there’s actually a moderateamount of saturated fats there and there’s almost no none of those omega-3sso some research research atla trobe university on getting people to eat olive different types of olive oil andwatching their health outcomes when you add oil to your diet one of two things happeneither because it’s so dense and just adds calories to the food you eat more calories and you gain weightor if you compensate and reduce your whole food the food consumption in generalthen you’ll be getting less nutrients so adding oil to your to your diet givesyou more calories less nutrients or a combination of bothall the they’re all for mediterranean diet studies but just remember their dietary pattern studies you know we gotthe subjects to eat less of the other processed food and less meat and more fruit and vegetables and some wholegrains and legumes and those oil in there and they got healthier i don’t think youchallenge you to find studies where they find that adding oil to a healthy diet brings anyimprovement in health outcomes that and and in our clinical experienceyou know the difference between we notice it particularly with um osteoarthritis and some other types ofarthritic joint pain they’re getting the last of that processed oil out of the diet can can make the difference betweenpain resolution and pain we’re not resolving similar thing with weight as well oftenpeople find when they stop that oil they freak out about how can they evercook without oil until they’ve done it for a few weeks and then they find that they’re uh they get past their weightplateau thank you peter do you have anything toadd to that i know malcolm’s covered it really well i think i i like him i consider it ajunk food people will readily say that sugar is a junk food but somehowbecause it’s had the fiber removed it’s energy dense and nutrient depleted but people don’t make the connection thatoil is in the same category so i i treat it as a junk food and it comesas a big shock for many people with there’s so much information out there in invertedcommerce that oil is a health food but with approaching 70 of the population being overweightwhy would you want people to increase consumption of most energy dense food on the planetwhich is displacing the nutrient-dense foods that were many of us are deficient inyeah absolutely all right so we’ve got a question here which is the whole food plant-based diet sounds like it has manyhealth benefits but is there any evidence of it having any adverse health effectsyour toilet paper bill will go up [Music]um i won’t answer that peter we always get caught up in these conversations when we meetyeah look um remember i showed you that energy density chart that it’s quite low in incalories and so um i think that people have to be realized that if they’re going to eatwhole plant foods they’re going to have to eat a lot more and they’re going to have to get used to the idea of eating a lot of starch that is you know eatingmuch bigger serves of things like oats brown rice potatoes beansand the nutrients that are missing from a whole foods plant-based diet is vitamin b12 b12 is a component ofanimals not a component of plants you know if you’re a happy hunter-gatherer i’m sure there’d be enough bacteria if you drank from theyarra river and i dirty potatoes and slimy fruit i think you probably get enough b12 but you’re living in in ourmodern society and you’re eating totally whole plant foods you will need to take a vitamin b12supplement you have adding to that a trap many people make when adjusting adopting this diet is they just don’teat enough and they say they feel tired and hungry you really have to have more on your platebut the beauty of it is that people can eat ad libitum without portion control or calorie countingi really strongly encourage all my patients to throw those concepts out the window and just eat when they’re hungryit’s what they eat though that’s the critical thing if they stick to whole food plant-based with not too many nuts or seeds thenthey’ll lose weight and get healthy it’s it’s really simpleit might be a puzzle we we’ve been i’ll make up my own question here you knowwhat was we’re not that keen on the on the nuts and seeds and you know it’s not that they’re not whole plant foodsum but it’s just that they’re very calorie dense and as peter pointed out most australians even a lot of vegans don’tneed foods that have more concentrated calories and many of the studies that have been doneon you know reversal of heart disease reversal of you know treatment of diabetes etchave utilized a whole foods plant-based diet with more emphasis on the the foods at the more carbohydrate end of thespectrum you know the whole grains and the legumes so that approach really has the runs on the boardbut of course as humans as a sort of savannah animal we’re driven to eatcalorie dense foods so you know people love nuts and nut butters and highcalorie foods in general but if you think back to our evolution 99 of our history was pre-agricultureand nuts are seasonal so we would have found them once a year and if if we were lucky if the othercreatures hadn’t got to them first for example i’ve grown almonds in melbourne and if we don’t net the treewe get zero because the birds the possums the bats they all know they’re rich food and those are hungry animals looking forenergy dense food to survive as we were pre-agricultureso they can be a bit of a pleasure trap food because they’re so rich our brain is likely to want us to overeat themso we use them we eat some but we keep we keep it in moderation and it’s a good practice to not snack on nuts on theirown but to use them in dishes as a condimentyeah i mean as you both mentioned it is really hard for us living in this obesogenic environmentum i want to kind of change track now and i guess look more at the bigger picture sowe’ve got a question here from irene why is hospital food generally so nutritionally poor when diet is soimportant to health outcomes and what can we do about this it’s funny because when i first startedat flinders university and this is going back out a really long time remember the dietitians spoke to us and they made itclear that they weren’t responsible for the hospital food that the flinders medical centerwas sort of supplied by the state food supplier who had the food all packagedup and manufactured and was sort of pretty much the standard sort of you know institutional food you know we’regoing to have a meat and two veg and we’re going to have a sweet dessert andso i think i think that’s the background on it there are some groups that are working quite hard on thisdoctors nutrition some of some of the people working inpolitics in victoria the ama so there are groups working on thisfor example processed meat should not be served in hospitals in any area at all just likebecause it’s a group one carcinogen it’s going to be difficult umyeah the problem with the food in hospitals too is that it sort of tells patients that’s all right to eat thatkind of food and it’s going to be difficult to implementmajor change but there have been there are a number of hospitals in other parts of the world where they have actuallythere’s one i think i can’t remember where it is but have a completely plant-based menu and i think in some places in the usathe hospitals have adopted a policy where they must offer a plant-based option forevery meal and let’s hope that we can go that way eventually in australia in victoriait’s a very challenging area to make change bethany becausefood is deeply cultural and emotional and people like what they’re used to andthere’s a bit of an echo chamber and confirmation bias dr michael greger describes iteloquently as he does on many issues that if you think of a doctor in the 50sin the in their surgery um smoking while they’re seeing the patientso that doctor’s not so likely to tell the patient to quit smoking or to quit animal foods because theylike eating eating animal foods and they like smoking and the science wasgrowing but it wasn’t overwhelming at that stage about smokingthe first surgeon general’s warning about smoking didn’t come out till 1963 in the u.s and even then the americanmedical association opposed it so there’s a lot of inertia with thesethings and the science it’s estimated that the average research findings take about 17 years to get intopractice it’s been longer that we’ve known about reversing heart disease butit there’s in institutional inertia as well in places like hospitals and i don’t think we should notunderestimate the the uh power of uh of the food industry correctum you know organizations like meat and livestock australia and uh and the dairy industryand all the people who they fund and supportsome of it up front some of it where we’re not really aware who’s getting the funding who’s working with themum [Music] and so these groups are sort of threatened byuh plant-based nutrition and they’re fighting back and and they’ve got they’ve got it’s been said that um we have the truthbut they have the money so you know i see advertisements every week in my medical magazines talkingabout well the dairy saturated fat must be right because it’s in the dairy matrixso it would be industry would not let usremove animal products from the hospital menu the best we could hope for is perhaps toremove the most dangerous as in processed meat and to provide plant-based options ithink at this point in history that’s all we can ask forall right thank you both for that and i wanted to ask do either you have any personal experience in trying toadvocate for plant-based nutrition on a broader scaleit’s not really i guess it’s a clinicianand someone that provides our webinars and living events and seminars umit’s not really part of my scope of practice although doctors for nutrition arelobbying here and i have put in a submission for the scope for initial scope finding for thenext dietary guidelines so what about you peter i have actually in the local governmentsetting where we ran those programs um having people test out being whole foodplant-based for three weeks our results were really dramatic like we had an average total cholesterol drop of23 percent in three weeks and this is with people going home and eating from from we don’t know what theyate but we still got dramatic changes the ldl dropped 20 in three weeksand then and a lot of positive changes and engagement and we had a cue forpeople wanting to do those programs once they got rolling i did advocate with management thatgiven the power of what we were seeing that that the council should trial thiswith community members who had chronic disease particularly low sesdisadvantaged cohorts this would be a first for australia but um and we knowit works and we’d seen the evidence with our own staff but it was slapped down or there wasn’tany interest in it [Music] it’s having the right people in leadership who are open to these thingsand willing to trial but if the leaders areinvested in their traditional ways of eating and living then and haven’t experienced the programum then they’re not going to understand the power of it as readily so some of the best changes come when thepeople in leadership have experienced this either through learning from a daughteror son who’s gone plant-based or had some health changes themselves soit’s percolating through the community but it’s many people just don’t understand howpowerful this is i think um there’s an uh the documentary plant purenation uh is sort of based on an example of howhard it is to get things through a local government and and comes to the conclusion that thiswill need to be a grassroots movement and there’s some saying in the u.s thatnever underestimate you know the power of a small group of people to change the nation in fact it’s the only thing thatever has [Music] absolutely i guessand i guess coming off that then as future doctors um there are a hundred of us herelistening to you what are some of the things that we can do to get the ball rolling not in not only in ourindividual clinical practice but also more broadly on a public health scalei think bring the impact of any environmental groups you’re involved inbring it to their attention bring it to their attention about the impact of animal product on the otheranimal agriculture and the environment and just how quickly we can change things umi think also to be curious don’t don’t get to get get umum you know set in the ways you know be curious when you hear about you knowum some of this plant-based information you know look into it consider it umbe a bit curious too when you hear things like um you knowmeat is actually good for heart disease i’m not sure if i’ve heard that yet but we will one day then you also need tosort of um you know consider things a bit deep more deeply go beyond the abstractand i think critically education continue to educate yourselves on on thesubject one thing i was mentioning to bethany before we started was themoving medicine forward movement which is led by dr michael clapper inthe us he’s he’s organized a 12-week uh two hours a week master class sessionwhich you can purchase and participate in for a bit over 200 u.sand it was tremendously well produced very professional and powerful very evidence-basedi’d highly recommend that it’s a very affordable way to get a comprehensive overviewof the power of this for health and that program is expressly designed for health practitionersparticularly medical students and dr clapper will come toany medical school pre-covered in person but now online and presentto the to students if he’s invited um and he has a talk around what i wish i knew when i was aat med school absolutely i’ll definitely keep that inmind and share that information um because as you know we get little to no nutrition training in medical schooldespite it being a big part of especially um a gp’s roleum and malcolm would you say that like significant amounts of lifestylemedicine are part of a gp’s role and then to follow on to that by siloinglifestyle medicine as an area um will it get less attentionyeah i think you know lifestyle medicine is really the future of medicine for chronic diseasemanagement and so the gp certainly has a big role in thisbecause we see a bigger part of the public and we see them incidentally for otherthings and give them their prescriptions but i don’t think it’s strictly just the domain of the uh the gp you couldimagine that you’re a gastroenterologist or a cardiologist or an endocrinologist[Music] and i think for all those other specialties lifestyle medicines very important fortheir chronic disease patients as wellall right and we’ve got a couple minutes left so i’ll just flick back to the audience q a and look at some of theother questions um we’ve got a question about the role of lab-grown meatdo you think that lab-grown meat can be used to counter some of those negatives of diets high in animal proteinwell i’d say no because it is animal protein it’s just grown in a lab insteadyou know i think when you look at all the sort of meat replacement foods um [Music]many of them are not very healthy at all i mean i guess if you have lab grown meat it’s still two min too much of thewrong sort of protein if they’re growing the saturated fats they’re still the saturated fats they’llstill be the tmao produced and when it comes to all the um you knowbeyond burger beyond mints and all the other burgers and thingsthey’re often highly processed foods and certainly you know environmental animalwelfare advantages for people who are going to eat meat to change over to those foods or if we find in the longterm that lab meat takes less resources i guess it’ll reduce the resources usedbut it still won’t have all the the power of whole plant foods you know it won’t have the antioxidants you won’thave the fiber etc there is a fascinating report by usthink tank called rethink x which is forecasting an enormous rise in lab-grown meats which will beas good as or better and much cheaper than farm grown meats and their forecasters that will lead tothe collapse of the animal agriculture industry globally with by the end of this decadeum as malcolm said i don’t think it will be a health food and i certainly wouldn’t eat itbut if it it it’s estimated to have about a 99 smaller environmental footprint thanfarm-grown meat and that’s enormous for the health of our planet as well as enormous for thefor the welfare of the of the um the trillions of animals that areslaughtered every year and many of them have dreadful living conditions in in factory farmspigs and chickens for example mostly farmed indoors and never see the light of dayhave pretty miserable lives so it’s going to be very powerful but it won’t be a health health benefitit will one in one way it will because it won’t have as much bacterial contaminationwell not just bacterial contamination but um viral you know umwe’ve set ourselves up for uh pandemics with the factory farming you know we got swine flu from the north american pigindustry we’ve got sars and thencovered from you know consumption of wild animals and in thefuture we may well have more bird flu type viruses fromindustrial chicken production it’s a time bombit’s very interesting there are so many different facets to consider not just personal health but also planetaryhealth and ethics of course tied to this dietanother question that we have is some plant-based products can be high in cost for patients restricting them fromaccessing it such as oat milk how can we comment how can we combat thiswell i i guess we need to help educate people on uh how they can do things that areinexpensive you know rolled oats are not very expensive um you know you can buy canned beans butif you’re on a really really tight budget you can cook beans you can cook brownrice there’s there’s one author australian author living overseas emma roach who’swritten a book whole foods plant based on five dollars a day andduring the pandemic she passed her time during the pandemic by writing another book that’s only available as an e-bookcalled whole foods plant based on three dollars a day so it is actually you know if you put awayaside the highly processed foods and maybe some of the very expensive fruits etcthen you actually save money by eating a basic whole foods plant-based dietwe would we would consider the plant milk a processed food to be had as a condiment so not as a drink when you’rethirsty so you shouldn’t be going through litres per day so that shouldn’t be too expensivebut you can make oat milk at home with oats and water it’s it’s not difficult but these because you’re taking out thefiber when you make the milk it is a processed food and you’re losing unless you reuse it elsewhereyou’ve lost essentially the most important part of that foodi think yeah i think that is a consideration that a lot of people aren’t aware of that plant foods are generallyum less expensive than animal products if you stick to the basicsum so we’ve come to the end of the session now i just wanted to close by askingeach of you um if you had one short takeaway message for us um to leave uswhat would you give what would that beum my i guess my takeaway message would bebe curious continue to educate yourself in this area and when it comes to patientsuh never prejudge them on who might change and who might notum i would say continue to be curious and learn and and and appreciate the power of nutritionto to malcolm and i this is the future of healthcare in australiais lifestyle medicine with with nutrition as the core of thatall right thank you so much malcolm and peter for taking so much timeout of your day to come and speak to us and join us for this conference i’m sure everyone learned a lot i will becirculating your slides to the participants after this talk and i know that both of you have included resourcepages as well as how to get in touch with you so hopefully this is just the start andwe’ll keep the conversation going thank you so much thank you for the opportunity[Music] thank you bethany

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