Heart Disease or Atherosclerosis
Atherosclerosis is a chronic, slowly progressive arterial disease that is the most common cause of death in the western societies. It is characterized by inflammation and the formation of plaques within blood vessel walls that contain cholesterol, lipids, and calcium. This can lead to narrowing of the blood vessels and eventually heart attack or stroke. A heart attack is a blockage of blood flow to the heart caused by plaque. A stroke is a blockage of blood flow to the brain caused by dislodged plaque fragment.
The endothelium is the thin layer of cells that line blood vessels. Injury of the blood vessel or endothelial injury leads to a cascade of negative events including vascular inflammation, activation of platelets, proliferation of arterial smooth muscle, and deposition of foam cells which are macrophages full of low density (LDL) cholesterol.
Oxidized LDL is one of the main contributors of endothelial injury. Other factors that promote injury include cigarette smoke and other toxic substances, lipid peroxides, high blood sugar, high homocysteine and possibly autoimmune attack of blood vessels.
Risk factors for development of Atherosclerosis include high cholesterol or lipids, hypertension, diabetes, obesity, high insulin or insulin resistance, an increased level of C-reactive protein (an indicator of inflammation), high homocysteine, high fibrinogen, and lipoprotein (a). A sedentary lifestyle also increases the risk of developing cardiovascular disease.
Conventional therapy involves controlling individual risk factors by means of diet, lifestyle, and medications. Several studies have shown that coronary and femoral atherosclerosis can be reversed to some extent either by pharmacological therapy designed to lower elevated lipid levels or by a regiment of diet or diet plus exercise .
Statin drugs like Lipitor and platelet inhibitors like aspirin and Plavix are among the most widely used pharmacological treatments. Both of these classes of medicines have been shown to be effective for prevention and for established heart disease. For some patients, these medicines can produce unwanted side effects like elevated liver enzymes, muscle pains, GI bleeding, inflammation, and cataracts.
At my clinic:
The patient with heart disease or risk for heart disease undergoes a specialized expanded lipid panel test, which looks at genetics as well as metabolic and nutritional markers for heart disease. I also do a food allergies panel test to rule out food allergies as a possible contributing factor. A Mediterranean Diet is prescribed and customized in terms of calories or portions based on the individual caloric expenditure. Emphasis is placed on whole foods, including fruits, vegetables, whole grains, nuts, seeds, soy and other lentils and beans. Avoiding refined sugar, fructose in sodas and juices, white flour, chlorinated water, and trans fatty acids (read the label on your packaged foods) is advised. In addition, avoid too much browning, broiling, frying. Use alcohol in moderation. A subset of supplements are prescribed for most and then certain specific supplements are added depending on the specifics of your medical history and lab results.
Dietary Factors:
Meal frequency: Eating small frequent meals, as opposed to larger less frequent meals, may improve serum cholesterol or lipid levels and glucose tolerance. In an observational study, the prevalence of heart disease was significantly lower in men who consumed 5 or more meals per day, than in those who ate 3 or fewer meals per day.
Cooking and Storage: During cooking, a number of harmful compounds are formed that can lead to heart disease. Oxidized cholesterol, lipid peroxides, and advanced glycation end products (AGE’s). Oxidized cholesterol and lipid peroxides can form spontaneously during storage of foods especially if exposed to air or not refrigerated. AGE’s are produced during the heating of common foods, particularly when the foods are cooked at high temperatures or in the absence of moisture. Hence, boiling, poaching, and stewing is better than frying, broiling, and roasting, by reducing AGE’s by 50%
Chlorinated Water: Chlorine is found in municipal water to kill microorganisms. It is also an oxidizing agent that may promote the oxidation of LDL (bad cholesterol) or cause oxidative damage to the arteries. Chlorination of water became widespread around 1912, shortly before heart disease became common. American soldiers in the Korean War were given water that was said to be so heavily chlorinated that it was virtually undrinkable. 75% of the soldiers killed in battle (average age was 22) were found to have advanced atherosclerosis. Chlorine can be removed from tap water by water filters or by boiling or adding a pinch of vitamin C crystals to the water.
Sucrose (Sugar) and Fructose: These products are found in excessive amounts in juices, sodas, and sweet snacks and cereals. Consumption of large amounts by humans may cause adverse changes in various cardiovascular disease risk factors, including an increase in levels of triglycerides, insulin, and uric acid, blood pressure, platelet stickiness, and a decrease in HDL (good cholesterol) levels. (Please see my blog on sugar)
Dietary Cholesterol: The prevailing point of view is that heart disease prevention programs should restrict dietary cholesterol and saturated fat. However, not all dietary cholesterol is harmful. I have a patient that has celiac disease and cannot eat any grains. She eats raw meat and vegetables only. Her cholesterol level was 300, but when I checked for heart disease markers in her blood and via a coronary calcium CT score, there was no evidence of heart disease whatsoever! So, the effect of cholesterol containing foods on heart disease risk may therefore depend as much or more on how the foods are prepared than the amount of cholesterol they contain. For example breaking the egg yolk in the frying pan oxidizes the cholesterol in the egg yolk, which is potentially more harmful than poaching or boiled. Butter left exposed to room air is presumably more harmful than butter kept refrigerated and covered. Oxidized cholesterol is found in the following foods: dried egg products, powdered milk, grated cheeses, french fries, processed meats, butter oil, heated butter, heated lard. Dried egg products are found in pancake mixes, bakery products, baby foods, cake mixes, salad dressings, noodles, and military rations.
Saturated Fat: The effect of saturated fat intake on serum cholesterol is less pronounced than is commonly believed. Saturated fat per se is not necessarily atherogenic. A Study done on Polynesians whose intake of saturated fat is very high and in the form of coconut oil have a low incidence of heart disease. A Meta analysis of 21 studies looking at 347,747 subjects found no significant association between saturated fat consumption and incidence of heart disease.
Eggs: Although eggs contain a substantial amount of cholesterol, most studies have found that regular consumption of eggs up to 28 per week did not have a significant effect on serum cholesterol levels. For diabetics however, consumption of 1 or more eggs per day as compared with less than 1 egg per week was associated with a significant increase in cardiovascular disease risk. Eggs contain a number of beneficial nutrients like choline, lutein, and a high-quality protein. I do not restrict eggs in my patients unless they are diabetic and eating eggs produces a marked elevation in cholesterol. Boiling or poaching is recommended over scrambled.
Olive oil and Monounsaturated Fats: Olive oil is a major source of monounsaturated fatty acid and is an important component of the Mediterranean diet, consumption of which appears to reduce the risk of heart disease. Consumption of monounsaturated fats results in the incorporation into the LDL, which renders the LDL more resistant to oxidation. Virgin olive oil, as opposed to refined olive oil, is rich in monounsaturated fats and several phenolic compounds found to be useful for prevention of heart disease.
Trans Fatty Acids: The epidemic of heart disease began around 1920, about 8 years after the introduction of large amounts of trans fats in the U.S. Hydrogenated vegetable oil or trans fat was introduced to the U.S. as a means to increase shelf life and marketed as a healthy alternative to butter. High consumption of trans fatty acids has been found to raise LDL cholesterol, CRP (an inflammatory marker), and risk of heart disease. Naturally occurring trans fats in yogurt, cheese and milk may or may not be harmful; the jury is out.
Nuts: Consumption of nuts has been reported to lower serum cholesterol levels. Observational studies revealed nut consumption was associated with reduced risk of both heart disease-related mortality and nonfatal heart attacks. Even though they are high in fat, they may be included as part of a cardio protective diet. Please see my blog on nuts.
Whole grains: As compared to refined or processed grains or flours, whole grains contain high amounts of cardio-protective substances including magnesium, trace minerals, B-vitamins, essential fatty acids, and fiber. Increasing consumption of whole grains was associated with a lower incidence of heart disease, heart disease-related deaths, and overall all death rates in general. Brown rice, Quinoa, Kamut, and Millet are examples of whole grains.
Soy: The well-documented cholesterol lowering effect of soy makes it an ideal part of the cardio-protective diet. The protein Genistein found in soy has been found to increase resistance of LDL to oxidation and reduced lipid peroxides.
Dietary Fiber: Higher intake of dietary fiber was associated with a decreased risk of coronary heart disease and heart attack. Examples of fiber include, fruits, vegetables, whole grains, legume, and nuts.
Fruits and Vegetables: Substances with cardio-protective effects found in fruits and vegetables include vitamin-C, flavonoids, vitamin-E, potassium, magnesium, essential fatty acids, and fiber. Numerous observational studies have found that higher intake of fruits and vegetables is associated with a lower risk of heart disease.
Purple Grape Juice: Rich in flavonoids, grape juice inhibits platelet stickiness. Refrigerated (not unrefrigerated) grape juice inhibited LDL oxidation. Ingestion of grape juice for 2-8 weeks improved endothelial function in patients with coronary artery disease. However, you should be cautious of sugar consumption.
Pomegranate Juice: Rich in antioxidants like polyphenols, tannins, and anthocyanins, pomegranate juice consumption may be of benefit in reducing the thickness of the intima-media. However, the results are conflicting.
Garlic: Garlic may reduce the risk of cardiovascular disease by lowering serum cholesterol and triglyceride levels, decreasing blood pressure, inhibiting platelet stickiness, reducing fibrinogen levels, decreasing the susceptibility of LDL oxidation, and increasing fibrinolytic activity. Clinical trials using certain garlic preparations in patients with coronary artery disease, demonstrated a reduction or reversal of the plaque. There has been some concern raised with intake of garlic that it could increase risk of bleeding in patients taking warfarin or platelet inhibitors but such an interaction has not been clearly demonstrated.
Alcohol: Based on available evidence, moderate alcohol consumption (up to 2 drinks per day for men and up to 1 drink per day for women) does not increase and may decrease, the risk of heart disease. However, for the non-drinker, it is not recommended that he/she start drinking for the purpose of decreasing their risk of heart disease. Alcohol is toxic to the heart, and, excessive drinking is a major cause of cardiomyopathy.
Salt: High sodium intake can cause hypertension, which is a risk factor for heart disease. High intake of salt may increase risk of developing enlargement of heart. In a 4-year prospective study of patients on medication for hypertension, restricted salt intake was associated with increased risk of heart attack. So based on all the available evidence, it is prudent for most people (with the exception of men with drug-treated hypertension) to avoid high salt intake.
Mediterranean diet: In addition to olive oil, the Mediterranean diet emphasizes salads, lentils and beans, whole wheat, fruit, nuts, and garlic. In patients aged 55-80 years with heart disease risk factors, consumption of a Mediterranean diet supplemented with olive oil or nuts was more effective than a low-fat diet for improving cardiovascular risk factors, including blood glucose, systolic blood pressure, lipid levels, and (for the olive oil group) C-reactive protein.
Food Allergy
In some but not all studies, circulating levels of antibodies or immune complexes against cow’s milk proteins, egg proteins, or gliadin (a marker of gluten intolerance) were elevated in patients with atherosclerosis or a history of heart attack. Consumption of allergenic foods can lead to the production of immune complexes, which can trigger an inflammatory response and possibly promote the development of atherosclerosis. Please see food allergy and sensitivities section in your condition.
Nutritional Supplements
Many supplements have been studied and found to be beneficial only for some, and across the board for everyone, depending on the specific supplement.