Welcome, my name's Dr. Warrick Bishop. I'm a cardiologist, I'm an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand. blood pressure, weight, cholesterol, for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Dr. Oreck Bishop, and welcome to my podcast and videocast station today. I have all the way from the United States, Professor Alan Rozanski, who's Professor of Medicine at Mount Sinai Hospital. in New York. Alan, thanks so much for joining me. Thank you for having me. As we were talking before, your CV, your credentials are enormous, so I'm not going to reel them all off, but just so that the listeners have some idea of really what your depth of experience, your credibility, your experience is, in a nutshell, what's your career? What's your bio? Oh, sure. Well, I've held many different positions over the years. I've been involved in cardiac imaging from the start. Nuclear cardiology, which is imaging the heart during stress testing, has been a big part of my staple. At a certain point, I was director of cardiac rehab at Cedar Sun and Medical Center. And I've held many administrative positions and many teaching positions over the years. So I've been involved in teaching administration and cardiac imaging for a few decades, to say. Well, no question, you're one of the most credentialed people I've had the chance to share with on my podcast. So I do appreciate that. Look, looking through your works, I noticed that you've really started to pivot towards prevention and a real desire to try and keep people as well as possible for as long as possible. I have to say I completely resonate with that. One of the things that I saw linked to your efforts and your works were the six domains of health. Maybe you could explain that to me and those listening, if you wouldn't mind. Sure. I'll try to briefly explain something that I've studied for about four decades. Of course. It all started when I, about 1985, we started to see this data coming out in terms of people having what we call ischemia, which is a lack of blood supply, while they were wearing these ambulatory ECG monitors during daily life activity. And this was a shock to us at the time because the way we thought about chest pain is it's just induced when people are physically active. And here it was occurring at low heart rates compared to when we put them on a treadmill. So I became fascinated with this idea and I said, wait, I can use our imaging techniques to study what may be causing this. So we conceived a protocol where we had patients come into the lab and we're looking at the wall motion of the heart. while they're doing a series of mental tasks. Now, when someone's, let's say, doing exercise and we do a wall motion study, we're looking to see that the walls, you know, contract more vigorously as people exercise. And if a wall stops moving or slows down moving, we know, ah, there has to be obstruction of the coronary vessel supplying that. So the question was, what happens during mental stress? And the way we usually conceived of this was having people like subtract seven from a four-digit number faster than they could and so forth. But when I consulted with the psychologist, they gave me a battery of tests. I said, you have to use a few. And one of them was just have people speak about the personal stress in their life. So the second patient we did was a 59-year-old man. And he was having typical angina. He had some chest pain with exercise. And he starts talking about the fact that he's about to lose his job. We're imaging his heart while he's doing this. And to my utter shock, about half his heart stopped moving. while he's just talking about this, and there's no chest pain. Wow. And then when he stopped talking, this went away, and we exercised him, the same thing happened. So we ended up reproducing this in about half of the patients who had coronary disease. This does not occur in normal people. And that itself has been reproduced in about 20 or 25 studies since that time. So that was my aha moment. It was like, wow, there's this body-mind... you know, relationship I need to study. So I was an imaging cardiologist doing the most technical work in the world. And all of a sudden, I'm thrust into this new world. And one thing led to a next, which led eventually to the six domains of health and vitality. So what I came to realize shortly after that was, hey, the body can testify as to what's healthy and unhealthy. Anything that's going to promote longevity, protect your physiology, and decrease the risk of disease, that's healthy. So we know exercise is healthy. Smoking, for example, does the opposite. So we know it's unhealthy. So as I gravitated from studying acute stress to looking at chronic stressors, this was back, again, still in the 1980s, what attracted me was the idea that at that time we were beginning to look at depression as a risk factor for heart disease. Now, typically, the body accepts it, but back in the 80s, there was a lot of skepticism about it. But I know that there's physiological studies coming out and literally practically all major physiological systems of the body go haywire with depression. And then the data came out later in terms of happiness promoting the opposite. So now you have a second domain. You have your physical domain, which is exercise, resistance training, you know, good diet, healthy sleep. Second domain is the quality of your emotions. Eventually, we looked at these other domains. The third domain was the quality of your thinking. We published a paper in 2021, a meta-analysis. People who are optimistic live longer. They have less heart disease. It was very consistent data. So the quality of your thinking is important. There is the quality of your social relationships. That data goes back to the 1970s. The Alameda County study in 1979 looked at people in that county and found the larger your network, the less your risk. of disease, and the longer you lived. The fifth domain is your sense of life purpose. We did a meta-analysis of that as well. People who live with a strong sense of purpose actually have better health. And the sixth domain is actually how you manage stress. So when you do it successfully, it also is health-producing. So there's your six domains. Give those to me again, if you wouldn't mind, Alan. I've got the last two. Absolutely. You have your physical domain. I always went into four subcategories. Exercise. resistance training, diet and sleep, the quality of your mindsets, you know, your thinking, mental vitality, I call it, then your emotional well-being is your third domain, the quality of your social relationships, sense of purpose, and the sixth domain is how you manage stress. Yeah, beautiful. Look, I think it's the Harvard Longevity Study. I might be wrong. You probably know better than me. They released 80-year data, which I think is like three generations. And my recollection was along the lines of people who had good health and good relationships seemed to have the highest happiness quotient and seemed to live the longest. And when they drilled down on good health and relationships, my understanding was that... good relationships seem to be a strong correlate for good health. So it really underlined that social connection, that emotional connection, that relationship stability. That really reflects exactly what you're talking about, if I'm correct there. Absolutely correct. That's an amazing and still ongoing study. Yeah. They showed that in their data set, that social relationships, that quality of those relationships over the long term was an incredible predictor of health. Yeah, isn't that extraordinary? Yeah, yeah. Alan, for those listening, if they've been gracious enough to listen to any of my previous podcasts, I've touched on a condition called Takotsubo syndrome or broken heart syndrome, which is an emotionally charged episode in someone's life that really looks for all the world like a heart attack. And as you were talking about that amazing research you did back in... the 80s, I was thinking as a man's describing his potential loss of a job, are some of those features you are seeing, are they on the spectrum of that Takotsubo cardiomyopathy or is it a different process? And can you speak to that a little? I think it is a unique... different process. This is where the people developed this intense vasoconstriction and then they developed this apical part of the heart stops bloating out actually as a characteristic pattern. We don't understand it well, you know, and generally thankfully it doesn't recur, but it can occur under periods of tremendous emotional stress that has been described by many. But it's a unique syndrome. I think that the acute stress that we were looking at here was in people with heart disease, where you developed a degree of vasoconstriction with stress. You had acute increase in blood pressure, increase in demand, on top of significant coronary disease. It was causing this kind of abnormalities to occur during acute stress. I know that was very important to bring me into the field, What was much more important was after getting looking at what are the factors on the long term, which if you do right, promote health and vitality and look better as opposed to the opposite. Yeah, no, I understand. So for those listening, this is really talking about that mental stress giving rise to narrowing of arteries like you might if your blood pressure goes up, the arteries get a bit tighter. tightening of the arteries, reducing flow to vulnerable parts of the heart muscle, leading to that lack of blood flow and the muscle not working properly. So quite different to that sort of broken heart syndrome, apical ballooning syndrome. And I can see exactly... For your audience, I just want to add one thing, if I may, because they might think, uh-oh, I have to worry about mental stress and so forth. We were studying this in the 1980s when corn disease actually was more severe than it is today. Ischemia or lack of blood supply during stress testing was more frequent and severe than today. I don't think that's where the money is. I mean, there is a situation where acute stress can... Be important when people have, you know, a lot of underlying heart disease. And the name of the game there is we have ways today to take disease much earlier in time. I know that you talk about that a lot in your podcasts and so forth. Calcium scanning. I do. Recent coronary angiography, very important. I think for the audience, what's important is what are the chronic factors that if I work on these things on a positive end, I'm living more healthily with more vitality. And my good health becomes a byproduct of living a life where I'm having a lot more energy and so forth. So it's about how can I improve my sense of emotional well-being? What are better thinking patterns to have? How to have a better sense of life purpose? And importantly, how to manage stress better. So that's kind of my focus, looking at these ways of living better and understanding that that's part of. You know, a healthy heart living and healthy living in general. So that's what I try to emphasize. And good quality of life, actually, because your emotional well-being is so tied in with the quality of your life. So, yeah, I'm completely on board with you. Look, I was just looking at your six domains, six pillars of health. There's no question that emotional component, the social connection is huge. And we could talk about that, I think, for hours, but I'm not going to do that. In respect of time, what I want to do is come back and just talk about the physical aspects because you were very deliberate in breaking that down to exercise and then strength and then diet and then sleep. Tell me how you came to those to be your four... I guess, fundamentals of the physical component of those six domains? Well, that's a short observation. First of all, I always talk about the physical first. Of course. Because the physical is mental, spiritual, and all of that. But the key question is, why did I break down exercise and resistance trainings to separate areas? And, you know, I think we're very vague to the public. about what you should do in terms of resistance training. If you look at the guidelines in the United States, they say very specifically, you should get 150 minutes of exercise a week. And they're specific about what's modern, vigorous physical activity. And they say, oh, by the way, you should do resistance training twice a week. Do some weights. Yeah, do some weights, but with no instruction, with no time, because we... We're not schooled in that. But the fact is that the resistance training is a whole big different kettle of fish. Because there you need to, you know, there's a book, a great book by Michelle Segura about no sweat. It's called the name of the title. And it's about trying to get people sedentary to move more and to enjoy exercise. And she's got very good points there. And I love the book. And it's about just being more active. But that principle doesn't apply with resistance training. With resistance training, you've got to sweat. You've got to, you know, learn what you have to do. But most people need instruction on how to do a good squat, a good lunge, you know, what to do for the different muscle groups. And they're not enrolled in it. And, you know, usually come later in life when they have, you know, need physical therapy. And so it's a whole area that you need to know about because you also have to avoid injury and so forth. And I don't feel that we are providing. through our current healthcare system, the kind of instruction and encouragement that people need in this area. So I divide that up into exercise and resistance training. And the benefits are complementary, right? Yeah. I was going to say, if I was your patient and I said, thank you, Dr. Rozanski, I understand you want me to do walking, swimming, whatever it might be, cycling, but you want me to do resistance training. What is it that that resistance training is giving me over and above the, if you like, the cardiovascular type exercise? What would you say to me? What's your rationale for those listening? Well, so resistance training, just to be clear for the audience, is important because it builds muscle strength as well as quality. increase your metabolism over time. You're going to have a better set point in terms of basal metabolism. It's going to prevent you from falling with more injury. You'll have better balance over time. So it has all these benefits. So that's the first thing to mention. The second thing is to have in your pocket, okay, what do I have to do for arm strength, leg strength, core strength, and so forth? You know, planks, for example, squats, things like that. But I think people generally need instruction. Yeah. Somebody, I wouldn't just tell them just do this and so forth. I have a sheet that I give to patients. I have an article that I wrote last year that we could put in perhaps your show notes about the whole area. And it's got this whole big diagram of just simple exercises for people to do. And I think that, you know, patients. You know, we underestimate what we can do as physicians just by simple suggestions we can say to patients. So if you say to a patient, by the way, we have this sheet, and these are simple exercises to do, you're sending a very powerful message to patients that you think this is important. So that's why I separate it out and think it's important. Look, the reason I noticed it is it's exactly what I would do as well. And we are on the same page there. I think strength underpins endurance and being flexible is fine. But if you're in a nursing home bed and you're not strong enough to stand, being flexible doesn't help you at all. So I think strength underpins everything. And that completely ties in with building muscle, that loss of muscle over time. A word for those listening is called sarcopenia. Sarcopenia, meaning loss of muscle as we age. And it occurs, as you're probably well aware, Alan, at a rate of about 1% per annum from approximately 50 years of age. And once you start to get your head around that, Alan, we are completely and utterly on the same page. Don't lose your muscles. They are the only anti-frailty device you have. I'm pretty sure there's a muscle-brain axis. I've never seen good research on that, but people who have stronger muscles seem to have a better emotional state as well. I might be taking a reach there, but exactly as you said, Alan, balance, reduction of falls, functional capacity. metabolic improvement. So for those listening at that, I'm really glad you spoke to that. I'm glad you made that distinction. Strong muscles is really valuable. Look, a very quick word on sleep as well. I think it's only been in recent time that we've started to understand sleep is such a big player. So what are the, what are the say three or five? key sleep hygiene points or sleep points that you raise with your own patients? Well, I think one that people overlook is regularity of your sleep pattern. When you're going to sleep early one night, late another night, you know, there's actual data just looking at sleep regularity as a predictor of health. So that's very important. I think that, you know, having a room at night that's quiet, which is relatively cool, which is dark. You know, where, you know, you're not doing other activities before you go to sleep, winding down before you go to sleep, you know, in the last hour and not being on these cell phones, you know, at the late at night, you know, having a relaxing book. I remember how my parents used to go to sleep with a book in their hand, you know, and we've gotten away from that, right? I mean, we're just addicted to our phones, but, you know, pulling away from that. is a good thing to do. So these are like five or six things you can do. And I think that everyone should try it. Well, look, I completely agree with you. I read a book on sleep. I'm trying to remember the name of the author. But I have to say, and I might look it up quickly while we're talking, actually. The book, I think, was called Why We Need Sleep. And it was by... A fellow called Matthew. Matthew. I can't find it immediately. Anyway, the reason I mention it is I wasn't up with the importance of sleep as you were talking about. Every time I read this book, every time I read a chapter or a few pages, I'd learn something new that blew me away in terms of. the importance of sleep, the impact on memory, the impact on clearing proteins out of the brain, reduction of risk of Alzheimer's, the importance of your immune system, and a whole multitude of things that all made perfect sense as you read them. And in fact, the whole book started off with the premise that if sleep weren't important, why would we not have evolved? to get rid of it. There isn't an animal on the planet that doesn't sleep. So it's incredibly powerful. We cannot evolve it away because we clearly, clearly need it. Alan, it's been really an absolute pleasure sharing with you. For those listening, I really hope you've enjoyed it as well. I'm going to wrap it up. But, you know, I get the sense we've got so much to talk about. I would love to have you back on at another time so that we could chat some more. I know you want, you have a... expertise on talk about the evolution of heart therapy and treatments. And because of your interest in preventative cardiology, I'd love to have the opportunity to share with you about that as well. So if you're welcome to, if you'd love to come back, you'd be more than welcome. I would be more than delighted. It'd be my pleasure. For now though, Alan, again, thank you so much. You can say goodbye to everyone. Thank you. Thank you very much. From me, thank you so much, Professor Alan Rosansky. For those listening, as always, I really do appreciate you taking the time to tune in. I know how valuable all our time is. So if you've taken time to listen to this, I really respect that. As always, I hope we've given you something to think about. I know we have today because it's been a great interview. And till next time, I do hope you live as well as possible for as long as possible. Take care and bye for now. 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