Prevention Does Work: A Guide to a Healthy Heart

iUniverse, Inc.

Contents

Preface..............................................................viiIntroduction.........................................................ixDefinitions..........................................................2Concepts: Cholesterol Risks and Treatment............................8Concepts: Nutrition in Preventing Heart Disease......................10Diets for Heart Health...............................................12Diets for Losing Weight..............................................15Nutrition Issues Regarding Certain Foods.............................17Nutrition Issues Regarding Food Supplements..........................21Dietary Tips.........................................................25Other Prevention Issues..............................................27Special Patient Populations..........................................30Drug Therapy In Prevention: Focus On Cholesterol.....................35Introduction.........................................................44The Pantry...........................................................45Index................................................................93References...........................................................95

Chapter One

By Paul Goldfinger, MD, FACC. Cardiologist

Definitions

A cute myocardial infarction ("heart attack" or "M.I.") is a serious and sudden event that results in injury and possibly permanent damage to heart muscle. An "M.I." occurs when a fatty plaque within the inner lining of a coronary artery becomes acutely disrupted. This results in clotting and obstruction of blood flow. It may have taken many years for the plaque to develop, and the narrowing often isn't severe prior to the event, but the acute injury to the plaque is what sets off a cascade of events within the artery which results in total blockage. There are impressive therapies available now for the treatment of acute myocardial infarction

Arteries are blood vessels that carry oxygen rich blood from the heart to organs and tissues throughout the body.

Atherosclerosis is a condition in which fatty deposits (plaque) build up inside the lining of arteries. The plaque deposits are complex and consist not only of fat, but also of scar tissue, calcium, inflammatory cells, and muscle tissue. The risk of acute complications, such as heart attack, is particularly great if the plaque consists of soft mushy fat deposits. If the buildup is severe enough to cause obstruction to blood flow, then symptoms will often develop. Atherosclerosis can involve the coronary arteries (causing heart attack or angina), the carotid arteries in the neck (causing stroke), or the leg arteries (causing pain with walking, i.e. claudication). Atherosclerosis can occur in other areas as well, such as the arteries to the kidneys or the intestines, causing kidney failure or abdominal pains. It takes many years for plaque to develop, and the earliest sign (the fatty streak) can be found in children as young as 10 years old. Plaque usually develops slowly and silently (i.e. without any symptoms), but early detection is often possible.

ATPIII is the Adult Treatment Panel of the National Cholesterol Education Program which provides guidelines for cholesterol management.

BMI (body mass index) is a number that tells you if you are overweight, obese or normal. It is obtained from a chart that utilizes your height and weight. These charts can be found on the internet ( http://www. nhlbisupport.com/bmi/ ) Your doctor should have a copy of this chart. Twenty seven or less is a normal BMI. (NEJM 10/7/99). The lowest risk regarding weight is associated with a BMI of twenty five or less.

Cardiovascular refers to the entire system of heart and blood vessels (arteries and veins).

Cardiovascular disease (CVD) occurs when atherosclerosis compromises arterial blood flow and can involve the heart, brain, kidneys, legs and/or other vital areas of the body.

Cholesterol is a fatty substance found in all animal products, and the level in a person's blood relates to the amount of cholesterol ingested as well as to the body's ability to manufacture the substance in the liver. Genetic and dietary factors determine how much cholesterol is produced in the body. Vegetables do not contain cholesterol.

Coronary risk factors are the characteristics which make a person prone to develop coronary heart disease (CHD) and related cardiovascular disorders. They include high fat diets, high blood pressure, smoking, obesity, heredity, lack of exercise, diabetes, and abnormal blood cholesterol levels (especially high LDL and low HDL).

Coronary artery disease/coronary heart disease/atherosclerotic heart disease (CHD, CAD, or ASHD): This disease occurs when the coronary arteries (the arteries that supply the heart with oxygen) become partially or completely blocked by atherosclerotic plaque. A person with CHD may develop chest pains (angina), "heart attack" (myocardial infarction) or other complications, but it is also possible to feel fine and still have this condition (i.e. "silent" heart disease).

Complex carbohydrates are found in whole wheat flour, brown rice, potatoes, bran, legumes, soy, fruits and vegetables. These are "good carbs" because these foods contain substances that protect against cancer and heart disease.

CRP (C reactive protein). This blood protein is a "marker" for inflammation in the body. A blood test is available to measure CRP (high sensitivity CRP blood test), and a high reading has been correlated with risk for coronary disease. Increased risk is associated with levels above 2-3 mg/L. A level less than 1 mg/L is considered to be low risk.

HDL cholesterol (high density lipoprotein) is the "good cholesterol." This protein particle is responsible for "reverse transport" of cholesterol, which means that the cholesterol is carried away from the arteries and back to the liver for metabolism and removal from the body. This is the only lipid number that should be higher rather than lower. Levels that are low (i.e. under 40 mg/dl) are associated with increased heart attack risk, even if total cholesterol levels are normal.

Hyperlipidemia refers to elevations in blood lipids, such as hypercholesterolemia, which refers to high cholesterol levels, or hypertriglyceridema, which refers to high triglyceride levels.

Hypertension is a disease where the pressure in the arteries is too high (i.e. high blood pressure). The top number is the systolic, while the bottom is the diastolic.

Inflammation and/or infection in the body may be a risk factor, such as occurs with periodontal disease.

LDL cholesterol (low density lipoprotein) is the "bad cholesterol." LDL cholesterol becomes oxidized in the bloodstream, which means that it is chemically converted to a form that can stick to the interior lining of arteries and form plaque. It is the most important number in terms of risk, and that risk correlates with the degree of elevation. High levels relate mostly to dietary and genetic factors.

Lipids refer to the fatty components in the blood. If your doctor orders a "lipid panel" blood test, he will get total cholesterol, HDL, LDL, triglycerides and a risk ratio number. These results provide the basic information regarding lipid related risk. The test should be done with a 12-14 hour fast, although a simple cholesterol measurement does not have to be done fasting. The protein particles that carry fatty materials in the blood are called lipoproteins.

Metabolic Syndrome is a disorder which consists of a combination of characteristics that are associated with increased risk of cardiovascular problems. The syndrome includes abdominal obesity, abnormal lipids, high blood pressure, and diabetes/elevated insulin levels. The metabolic syndrome is associated with impaired lung function, mostly related to abdominal obesity. A French study found this condition to be more common in men with waist size of over 37 inches and, for women, 31 inches.

Monounsaturated fats (MUFA) such as olive oil and canola oil do not raise the levels of LDL cholesterol and may actually have some additional protective value. These fats, along with polyunsaturated fats, are often called "good fats."

Omega-3 fatty acids are polyunsaturated fats found in fish (i.e. fish oils). Fatty fish such as salmon, tuna and halibut are rich in these oils. There also are plant sources of omega-3's found in canola oil, nuts and many other plant sources. Feeding chickens high flax or algae diets has resulted in eggs rich in omega-3 fatty acids. Fish oils are also available in capsule form and in some margarine. Some processed foods, such as breads, are available fortified with omega-3 fatty acids.

Polyunsaturated fats (PUFA) are found in liquid vegetable oils including sunflower, cottonseed, safflower, corn, and soybean oils. These fats may be beneficial ("good fats") when used in modest amounts as part of a low fat diet. Unsaturated fatty acids do not raise LDL cholesterol levels.

Primary prevention refers to preventing disease in apparently healthy individuals.

Saturated fats are dietary fats, usually solid or semi-solid, derived mostly from animal sources such as red meats and dairy products, although some are derived from vegetable sources such as coconut and palm oil. The term "saturated" refers to the chemical composition of the fats. Saturated fats raise the levels of LDL cholesterol in the blood and are associated with increased risk for cardiovascular disease as well as being linked to colon, breast and prostate cancer.

Secondary prevention refers to reducing progression of disease in those who already are affected.

Simple carbohydrates such as sugar, alcohol, white flour, and white rice, are "bad carbs" that promote weight gain, conversion to fat and increased insulin levels.

Social issues seem to be associated with increased risk including low income, social isolation, low level of education, and stress/anxiety/ depression.

Statins are drugs which reduce blood cholesterol levels by influencing the production of cholesterol within the liver.

Stroke is a general term (also called "CVA", or cerebrovascular accident) that describes brain injury resulting from either occluded brain arteries (usually due to atherosclerosis with thrombosis) or from brain hemorrhage. The risk of stroke correlates with the same "risk factors" as those associated with coronary heart disease, including hypertension, high cholesterol and smoking.

Thrombosis is clotting within a blood vessel. Thrombosis, occurring suddenly on top of atherosclerotic plaque in an artery, can cause acute complications such as heart attack or stroke.

Total cholesterol is the total concentration of cholesterol in the blood and consists of mostly LDL ("bad") cholesterol. The total also includes HDL ("good") cholesterol and a small amount that is carried with the triglycerides in the blood. The levels of total cholesterol correlate with risk of heart disease. In general, levels under 200 mg. are considered normal.

Trans-fats are artery clogging fats that form when liquid vegetable oils are converted into hard margarines. It also happens when vegetable oils are used for deep-frying. Trans-fats are found in stick margarines, doughnuts, French fries, shortenings, cookies, chips and crackers. Ingestion of trans-fats raises cholesterol and LDL levels and lowers HDL levels. Food manufacturers are now required to put trans-fats on their labels.

Triglycerides When elevated, these fatty particles are known to increase the risk of cardiovascular disease. Normal levels are under 130 mg. Individuals with very high levels (e.g. 500-2000 mg.) are also at risk for inflammation of the pancreas. Elevated triglycerides levels often occur with low HDL levels, and this combination is associated with a particularly high risk. Excess intake of carbohydrates, fats and alcohol contribute to high triglyceride levels.

Vascular refers to the blood vessels, particularly the arteries, which carry oxygen rich blood throughout the body. The functions of vital organs, including the heart and brain, depend on a good arterial blood flow. When arterial blood flow is inadequate due to narrowing of arteries, reduced tissue oxygen results. The medical term for this is ischemia. If arterial flow is completely obstructed, then tissue damage (infarction) may occur. The usual cause of such flow restriction is atherosclerosis (see below).

Concepts: Cholesterol Risks and Treatment

It has been known for many years that elevated blood levels of cholesterol correlate with the risk of coronary heart disease (CHD). About 75% of patients with CHD have some type of lipid abnormality and most of these have elevated total and LDL cholesterol levels. The Framingham Heart Study showed that the risk of CHD was 3-5 times higher in men and women with total cholesterol levels of 300 mg. compared to 200 mg. Even for levels from 150-200 mg., the risk varies according to the degree of elevation.

Typical Americans have total cholesterol levels between 200-240 mg. and, although such levels are "normal" in the US, they are certainly not ideal and are high compared to many other parts of the world. In countries with average total cholesterol levels that are around 150 mg., heart attacks are rarely seen.

Most of the cholesterol in blood is found in the LDL cholesterol (low density lipoprotein) component of total cholesterol. The level of LDL cholesterol is the single most important number in assessing risk of atherosclerosis, because it is the component that promotes atherosclerotic buildup in arteries. The number relates to genetic and dietary factors. Diets that are high in saturated fats result in elevated LDL cholesterol levels.

There is strong evidence that low HDL cholesterol levels (less than 40 mg.) increase CHD risk, and that high (over 60 mg.) levels result in a reduced risk. Every 1 percent decrease in blood HDL is associated with a 2-3 percent increase in risk.

CHD can occur in people with "normal" cholesterol levels. The most common level among patients with coronary heart disease is 225 mg (Castelli. JACC. 1998). Since this number is fairly typical of many Americans, looking only at total cholesterol levels in "healthy" people is not enough to assess risk. We now know that measuring both LDL and HDL cholesterol levels together can more accurately evaluate risk. If one divides the total cholesterol by the HDL you get a risk ratio, which is, according to the Framingham Heart Study, the "best predictor of coronary artery disease". High triglycerides also pose a risk, especially if coupled with a low HDL level.

Normalizing abnormal cholesterol levels can improve risk. (See later sections on therapy). LDL levels can be lowered dramatically with diet and drugs. The most difficult therapeutic task in lipid therapy is raising the HDL level. HDL cholesterol increases of only 6% have been associated with significant reductions in coronary morbidity and mortality in patients with low HDL levels. (Rader, Medscape 6/04). For raising HDL levels, regular aerobic exercise can help, as can stopping smoking and losing weight. Fish oils have been reported to raise HDL levels by about 8%. Drug therapy for treating low HDL is discussed later.

Research is ongoing as to how cholesterol lowering actually works. It appears that much of the benefit has to do with alterations in the fatty deposits that build up inside arteries. Aggressive lowering of serum cholesterol helps to remove these fatty deposits within the plaque, thus creating a more stable situation within the artery, even if the degree of narrowing remains unchanged. Some of the benefits occur soon after starting cholesterol drugs and seem to be related to mechanisms such as altered blood clotting and reduced arterial spasm. Such early benefits are independent of cholesterol lowering, and physicians have begun initiating cholesterol-lowering medications very early during an acute event, such as starting statin drugs in the coronary care unit after a heart attack.

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Excerpted from Prevention Does Work: A Guide to a Healthy Heartby Paul Goldfinger Eileen Goldfinger Copyright © 2011 by Paul Goldfinger, MD, FACC, and Eileen Goldfinger. Excerpted by permission of iUniverse, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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